Author: Gabriel Weston
With an intriguing narrative style and a refreshingly unpretentious prose, this book is undoubtedly the pinnacle of story-telling. It is an account of the author’s challenging experience as a female trainee in a male-dominated surgical specialty, a situation that frequently pitted her lofty ideals against her attempts to conform to a stereotypically aggressive surgical culture. Deploying many engaging stories, the book illustrates a range of harmful behaviours that degrade medical practice, and an equally diverse variety of admirable traits that elevate it. The author’s engrossing stories frequently illustrate the subtle conflicts that arise when the personal objectives of the doctor clash with the overriding concerns of the patient. By exploring several related themes in diverse contexts, the author cleverly extolls the virtues of selfless patient care, just as she gently warns against the perils of an insensitive clinical mindset. All the stories are relayed in an uplifting and contemplative prose, and abound with exceptional lessons for all aspects of medical practice.
If there is a major theme in the book, it is about the qualities that denigrate surgical practice. A key factor in this context is the danger that surgical hubris poses to patient safety, a point the author illustrated with the story of how she lacerated an artery during an operation, an error she attributed to her desire to show off her speedy surgical skills. Describing how her ‘aversion to slowness‘ and ‘keenness to be quick‘ overcame her better judgement, she represented the whole episode as ‘absurdity and hubris‘ (pages 5-9). She specifically deplored the arrogance that drives surgeons to undertake risky operations, pointing out that the ‘awareness of one’s own limits may prove more life-saving than any knife‘, epitomising this insight with the classical surgical aphorism that ‘a good surgeon knows how to cut‘, but ‘a really good surgeon knows how not to’ (page 80). Conversely, she depicted what she views as the epitome of excellent surgical practice with an operation she assisted in; characterising it as ‘surgery at its moral best‘, it was distinguished by ‘a full and transparent understanding between doctor and patient’, and it was ‘conducted in comfort, with all the right equipment, and with no time pressure’ (page 160).
Empathy was an equally important theme of the book, and the author repeatedly asserted the preeminence of compassion such as when she said that the most important aspect of medical care is ‘protecting the interests of those you are lucky enough to be looking after’ (page 90). She was particularly dismissive of the popular characterisation of the surgeon as technically competent but emotionally detached; she rather contended that ‘a good surgeon also needs to know how to be gentle‘ and ‘to subdue the toughness which becomes such an indelible part of our professional persona’. She condemned the unsympathetic attitude of many surgeons, pointing out that they fail their patients who look to them ‘in the most terrifying moments of their lives as the only available source of human comfort‘ (page 150). Discussing the ways that doctors can project compassion to their patients, she pointed to very simple measures such as just listening to them. In this context, she highlighted the detrimental impact of turning a deaf ear to patients when she said ‘we doctors may deny our patients a voice through the unconscious but still brutal act of just not listening to it’. In her inimitable style, she drew an analogy between the disempowering effect of not listening to patients, to the devastating disability that accompanies the physical loss of ‘the power of speech‘ (pages 50-51).
Pleasantly surprising for a book set in a surgical specialty is the dominant and recurrent theme of emotions. Of the diverse feelings the author portrayed, shame and guilt were particularly prominent especially pertaining to the regrettable clinical decisions she made without putting the concerns of her patients over her own (pages 84 and 90). It is telling that this trait usually emerged when she attempted to project a sense of competence to her colleagues and seniors; such was the case when, afraid that she would lose professional pride before her fellow trainees, declined to admit a woman with haemorrhoids, rather opting to treat her expeditiously in the emergency department (page 84). The author repeatedly depicted the harmful consequences of such self-serving attitudes, such as when she narrated the touching story of a 10 year old boy with a brain tumour to whom she withheld her sympathy. She subsequently realised that all he required was ‘whatever small amount of my heart’s warmth I could afford’, but this was ‘a need to which he was too young to give a voice‘. She regretted that her lack of empathy meant ‘he was unable to find this comfort in me’ (pages 141 and 150).
The theme of compassion was also central to the book’s treatment of the subject of death. The author particularly focused on the contradictory attitude of the medical profession to mortality, describing it as ‘the consequence of disease prevailing over medical and surgical industry‘, and as ‘the ultimate point of failure‘ (page 25). She described the ethical dilemma many surgeons face when, confronted with the reality that their patient is dying, prefer to offer futile surgical solutions in place of the compassion they are unable or unwilling to convey. She depicted this conflict as a detrimental clash between the expediency of surgery, and the human interests of the patient. She highlighted the danger posed by this predicament when she said, ‘in the process of acting in a patient’s best surgical interests, we may sometimes make the final moments of their life more terrible then they would ever have been had we left them alone’ (page 64). On the contrary, she advocated an approach to the dying which entails the doctor accepting a loss of control, and adopting a ‘sense of smallness‘ at the deathbed (pages 34-35).
A most inspiring feature of the book is how the author managed to maintain her human instincts and ethical judgement as she negotiated the difficult terrains of surgical practice. An example is how she coped with several empathy-sapping episodes during her training rotation through the emergency department; describing this setting as ‘a sort of departure lounge in which every patient had come to say goodbye to someone or something’, she was nevertheless able to look beyond ‘all the loss and the doom‘ to focus on the ‘frills of kindness in the violent scenes’, and on the ‘shreds of goodness that persisted through the bad’ (pages 91-97). She relied on this philosophical attitude to overcome other emotionally charged circumstances, such as when she grappled with the romantic feelings she developed for a patient; she however reflected positively on this experience, concluding that ‘one of the most difficult things is learning how to manage sexual matters in hospital life’ (pages 10-20).
With perhaps some of the best prose of any book written by a physician, this relatively small book is a pleasurable read. The author has a compelling unique writing style not reminiscent of any other author. Notwithstanding the absence of stated themes, the book still projected many fundamental lessons for good clinical practice. Whilst the subject matters appeared disparate, the book explored subjects that have important clinical implications, condemning, as it did, poor clinical practice, and promoting high ethical standards. Each of the book’s chapters expounds a fundamental surgical principle or practice which the author illustrates with striking clinical scenarios. Humanity, often depicted as deficient in routine surgical practice, shines throughout the book.
This excellently written book is perfused with key clinical lessons and deep insights. The diverse themes, from clinical competence to surgical compassion, are weaved into touching stories. Beyond routine surgical practice, the author explores a range of emotional and ethical issues that may impact the patient-doctor relationship, and she crafts this in a way that makes the lessons striking. The author’s advocacy for humane clinical practice was paramount, and I highly recommend the book to all doctors.
Publisher, Place, Year: Vintage Books, London, 2009
Number of chapters: 14
Number of pages: 181
Star rating: 5