This is a truly remarkable book written by a recently retired consultant neurosurgeon in London. He is a most perceptive character and reflects on his work and patients’ lives. A constant theme throughout the book is the difficulty in making decisions which will have very profound effects on the patient and weighing up the risks and benefits and how to relay these.
I did work as a neurosurgery SHO for a while before turning to general practice. It was all far too alarming for me with operations regularly lasting longer than a complete Wagner Ring Cycle but with fewer intervals. I believe Henry Marsh is more reflective than most neurosurgeons I ever came across. As he describes his early life, he originally went into the Arts at university and seems to have been inspired to become a neurosurgeon whilst being exposed to this area in his work in the hospital as a porter. He describes many of the issues faced by all doctors at all levels and enjoys a healthy scepticism of hospital administration which is probably quite widespread amongst clinical staff and gives a few side-swipes to petty bureaucracy.
The book is divided into chapters often with a pathological diagnosis. This is fully explained and is perfectly readable by the non medically qualified.
Certainly all doctors and medical students should read this book.
Is there anyone who should not read this book? Yes – anyone who is about to undergo a neurosurgical procedure. It will scare the living daylights out of them. You certainly appreciate from the operative descriptions the grave consequences of even the most minor slip or error and Henry Marsh is only too aware of this. He describes his successes as well as his failures and reflects on how these impacted the patient and the doctor. This is a beautiful example of how to write an e-portfolio learning log.
He describes vividly his first mistake as a junior doctor on the wards and not appreciating the patient knew something was wrong but the doctor ignored it.
The ups and downs of a day are described: miraculously saving the sight of a pregnant woman with a pituitary tumour but another patient died after a bleed post operatively.
There are many references to Henry Marsh being aware of his personal failings, not least with his ability to become annoyed and fearing he may lose his temper. This seems more in relation to staff and colleagues than patients. He seems relieved at times to have kept his cool.
There is an interesting reflection on psychosurgery which was probably losing favour by the time Marsh was entering his career but he makes some interesting points about this in the chapter entitled “Leucotomy”.
There is a lot on breaking bad news (as you may expect in neurosurgery) and in some stories this is done in more detail than others. What does come across is Marsh not enjoying this (who would) but sees it as a very necessary time to invest with his patients. Not needing to say much, silence, answering questions. In the chapter Medulloblastoma, Marsh describes the harrowing tale of a child dying on the table during surgery, the silence, the reaction of staff and the parents’ reaction or rather his fears about how they would react. Small things to carers can become a big issue and worth attending to the details.
The chapter Neurotmesis describes supervision of a junior doctor who got things badly wrong. Those doctors involved in training constantly have to weigh up how much exposure to give trainees and whether they are capable but having to take the consequences if things go wrong. I enjoyed the way he questioned his junior staff to think beyond the obvious and question what they were doing and why. The morning meetings to look at the day’s admissions and scans seem to have been particularly beneficial.
Marsh also describes his own life and health issues. This includes managing the death of his own mother, his own child requiring neurosurgery. His marriage clearly broke down but although there are a few comments suggesting work may have played a part, there is little detail about this. Happily however he found a new wife, Kate. There is the interesting relationship between healthcare professionals when one has to take up the sick role. Are we fearful of treating colleagues? Are they aware of the risks more than the average lay person? Are they more forgiving if things go wrong?
He describes his own illnesses, retinal detachment which he rather ignored the warning signs of and his fears about going blind and not being able to work. He describes his ankle fracture-dislocation and his own lack of health and safety awareness or perhaps indestructibility (who would cycle to and from work on a push bike in central London without a crash helmet – a neurosurgeon of course). His description of his own doctor’s reactions to him is very interesting especially to those of us who have to treat colleagues.
He recognises the importance of having a space in which to reflect. He built a room at home. He bought large red sofas for the operating theatre suite at work.
The chapter Akinetic Mutism deals with Marsh visiting a nursing home where patients lie in a persistent vegetative state. He recognised several by their names and brought home the results of his failures and the resultant lifetime of nursing home care with no quality of life. They had disappeared from his clinics but they were still out there, being cared for by kindly nuns and the like. What is consciousness and what constitutes a valued life.
Marsh contemplates about how different patients respond to the knowledge that they are going to die, some had a very dramatic reaction and there were also the issues of how were they to be cared for. Others have a much more measured view and clearly have been able to come to terms with their situation. There is a description of patients waiting to see him and then waiting for scans desperate to know if they are going to live or die. They are being stalked by death and his job is to keep the shadowy figure as far away from them as possible.
A very amusing concept is described of tonnes (we are metric now) of medical records being moved around the hospital full of paperwork related to patient’s bodily functions in nursing records like dung beetles!
There is a chapter on Marsh’s involvement with NICE and acting as a clinical advisor. He clearly respected the process of the decision making and the thoroughness in which all views were considered. However he recognised he was out of his depth in the theoretical discussions about drugs for treatment.
His reaction to hospital hierarchy and administrators, the odd spats with them, but at the same time respect for staff he had known a long time. As was said, he could not do their job and they could not do his. His secretary, Gayle and senior ward nurses he had great respect for and I am sure they loved him dearly.
There are many interesting and thought provoking phrases in the book:
• The surgeon has known heaven having come very close to hell. This relates to a procedure which was going horribly wrong but in the end it all worked out for the best and the patient was fine, very grateful, but knew nothing of the anguish the surgeon went through to get there.
• The value of the doctor’s work as measured solely by the value of his/her patient’s lives. In other words the doctor’s value is only as good as the benefit patients receive from them. An interesting concept which comes from the notion of public service. Certainly reading this book Henry Marsh comes over as recognising he is equal to his patients and their world is as important as his.
• The operating is easy. The difficulties lie with the decision making. This is very stark in neurosurgery where the wrong choice can have devastating consequences in terms of quality of life. However all doctors face similar choices and dilemmas every day. Perhaps they are not as immediately devastating but nonetheless require thought and an ability to balance the risks and benefits.
• Love can be very selfish. This related to keeping relatives alive when really it would be best to just let them go.
• If the patient is going to get damaged, let God do it, rather than you. In other words try not to harm and make things worse yourself.
• Patients becoming an object of fear as well as sympathy. After doctors have made a few errors they may come to see patients as a risky entity and fearful of contact with them in case they bite back and the clinician no longer wants to play with fire.
• Gratitude all patients have for their doctor when things go well. However demonising when things do not go well.
• On risks and complication rates: If it all goes wrong it is 100% disaster for the patient but still only 5% risk for the surgeon. Those are the grim facts.
This is an interesting reflection on the many perspectives of being a clinician written in an absorbing and humane manner.
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Top reviews from United Kingdom
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- Reviewed in the United Kingdom on 20 June 2017
Top reviews from other countries
- YvesReviewed in Mexico on 11 November 2023
It helped me to decide not to be a neurosurgeon
- Mohit KumarReviewed in India on 6 March 2022
Absolutely brilliant and the narrative is just so gripping.
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GabrielaReviewed in Spain on 3 September 2015
Muy interesante, de fácil lectura y extraordinariamente humano
