Author: Henry Marsh
This is perhaps the most brutally honest portrait of medicine one is likely to come across. It is written by a neurosurgeon who is unafraid to speak his mind, and who infuses every chapter with candour and disdain for convention. The author is as hard on himself as he is scathing of medical authorities. His motivation for writing the book is the influence of human error on clinical practice. He says ‘doctors are human, just like the rest of us…’, and ‘…much of what happens in hospitals is a matter of luck, both good and bad’. He sees both success and failure as ‘out of the doctor’s control…’, and says ‘…knowing when not to operate is just as important as knowing how to operate…’ (page ix).
The author’s inspiration is Thinking Fast and Slow by Daniel Kahneman, the book which encouraged him to reflect on his clinical mistakes. He acknowledges that surgeons ‘…find it difficult to admit to making mistakes, to themselves as well as to others…’ (page 155). The reflection made him recollect numerous mistakes which ‘…rose to the surface, like poisonous methane stirred up from a stagnant pond‘ (page 155). Victims of his mistakes include the young mother he paralysed (page 10), and the man whose stroke he mistook for a brain tumour (page 156). He accepts that some of the many decisions he makes every day may go wrong with ‘terrible consequences’. He is however determined that this does not deter him from making tough choices; this is because ‘my patients desperately need to believe in me, and I need to believe in myself as well’ (page 157).
The book gives a broad account of neurosurgery, a specialty the author describes as ‘dangerous’. He says ‘…like all surgeons all I want to do is operate…’ (page 131), and his book offers an excursion of how he tackles brain lesions such as aneurysms, ependymoma, glioblastoma, and pineocytoma. We learn that haemangioblastoma is the only tumour that must be removed ‘en bloc’ (page 41), and that meningiomas may expand rapidly in pregnancy (page 49). He describes the intricate steps of many neurosurgical procedures; we see, for example, the application of lumbar puncture, the use of the Gigli wire saw, the removal of a bone flap, and the use of a retractor, all in a single operation to expose a meningioma (page 53-55). The author brilliantly conveys the pervading sense of uncertainty and risk that lay siege on every surgical procedure, and this is significant enough for the author to say ‘…every time I divided a blood vessel I shook a little with fright…’ (page 8).
The book is sprinkled with the author’s honest self-reflection about several medical subjects. For example, he described how the ‘simple altruism’ he had as a medical student was replaced by the anxiety and stress that come with responsibility (page 83). He ruminated on the impact of modern technology on neurosurgical practice; on one hand, technology has rendered obsolete his ‘slowly and painfully acquired’ skills of aneurysm surgery (page 15). On the other hand, he revelled in the ecstasy of using an operating microscope, an act which makes him ‘…feel like a medieval knight mounting his horse and setting off in pursuit of the mythical beast…’ (page 25). We experience his anxiety of complaint letters (page 157), and his pleasure in the gratitude of his patients, something which makes him feel ‘…like a conquering general after a great battle‘ (page 33). Some of the self-reflection is painful, such as when he admits to lacking the legendary characteristics of a good surgeon: nerves of steel, the heart of a lion, and the hands of a lady (page 31).
Patient conversations, a core medical activity, permeates the book. The author discusses the hardship of delivering distressing news, and of asking families to make life-threatening choices. He says ‘…surgeons must always tell the truth but rarely, if ever, deprive patients of all hope. It can be very difficult to find the balance between optimism and realism…’ (page 142). He reflects on his own communication skills, wondering how effectively they have served him. He gives several examples of losing control within his team such as when his assistant severed a nerve during a spinal operation: he said ‘I threw the forceps onto the floor and flung myself away from the operating table…’ (page 171). This perhaps reflects the temperament of many surgeons working under the pressured and risky environment of the operating theatre.
The author, in many places, demonstrated his irritation with the endless political decisions which impact on clinical practice. He says ‘the stream of initiatives and plans and admonishments from the government and management…feels like a game of musical chairs…’ (page 113). He is disapproving of hospital management, and he shows many instances of this, such as when he deletes management emails without reading them (page 133). He satirises the behaviour of new hospital chief executives who ‘…do rounds of the hospital departments when they are appointed and then one never sees them again, unless one is in trouble…’ (page 159).
This is a fascinating read with graphic anecdotes of surgical successes and failures. It is written for professionals and the public alike, and the author took care to use lay language throughout, and to explain medical conditions clearly. An example is his description of aneurysms as small, balloon-like blowouts (page 13). In contrast to the detailed account he gave of his professional work, his personal life story was disappointingly sketchy; he only furnished tantalising snippets of how he was traumatised by unrequited love, how he abandoned university to work as a hospital porter, and how he faced personal tragedies. This aside, there was very little to criticise about the book.
This is a great contribution to the public understanding of medicine, and a lesson for all doctors in humility. It debunks the dangerous medical myth of the confident and infallible expert, and it lays bare the human frailties that influence medical practice at all levels. The author reflects the painful reality of medical practice, and he openly acknowledges the uncertainties that underlie patient care. This, rather than erode the public’s confidence in the profession, opens a window for realism and common sense to guide the doctor-patient relationship. It is an important and refreshing book and I highly recommend it to all doctors.
Publisher, Place, Date: Weidenfeld & Nicholson, London, 2014
Number of chapters: 25
Number of pages: 277
Star rating: 5 stars