• Bearing Witness to a Life in Neurosurgery

    Author: Tej Deepak Azac, MD

    Neurosurgeon and award-winning author Henry Marsh, MD, speaks to the Congress Quarterly about his New York Times bestselling book Do No Harm: Stories of Life, Death, and Brain Surgery (2014). In this frank and powerful narrative, Dr. Marsh delivers an intimate account of his life in medicine’s most difficult art. With complete candor, he reveals the joy of operating: the profoundly moving triumphs, the harrowing disasters, the haunting regrets, and the moments of black humor that characterize a brain surgeon’s life.

    Dr. Henry Marsh is senior consultant neurosurgeon at the Atkinson Morley Wing at Atkinson Morley’s/St. George’s Hospital in South London. He studied medicine at the Royal Free Medical School in London and was a fellow of the Royal College of Surgeons. In 2010, he was made a CBE (Commander of the Order of the British Empire). He has been the subject of two documentary films, Your Life in their Hands, which won the Royal Television Society Gold Medal, and The English Surgeon, an Emmy-winning film based on the problems Marsh and Ukrainian colleague Igor Kurilets encountered doing neurosurgical work in a Ukrainian hospital. He spends his spare time making furniture and keeping bees.

    Congress Quarterly: What motivated you to write Do No Harm?

    Dr. Henry Marsh: It basically is a reworked version of a daily diary I have kept ever since I was 12 years old. In effect, I’ve been writing all my life. I suppose in some ways I’ve always had a compulsion to write. My second wife, Kate Fox, prodded me. She’s a very successful writer and anthropologist, and wrote a book called Watching the English, which sold a huge number of copies. I used to read bits of my diary to her. And she said, “That needs to be a book.” I went to see her literary agent and that’s how the book came about. It is basically my diary, but written and done up in a book form.

    CQ: How long did it take to transform the book from its form as your diary into the released novel?

    HM: It was about 10 years between the decision to turn it into a book and its publication.

    CQ: Were you ever hesitant to turn this into a public work?

    HM: No, not really. I knew I was doing something unusual, but I was writing for myself, and I didn’t think about whether it would be successful or not.

    CQ: Did you have any inkling that Do No Harm would have the critical reception it has received? Do you have any theories on why it has become so widely acclaimed?

    I never thought it would become as successful as it has, but I didn’t think it would be unsuccessful either. I just didn’t think in those terms. I didn’t write it to be successful. I didn’t write it to make myself famous. It was just me writing about myself—or to myself.

    I’d have been a bit surprised if I had been told it was going to be as successful as it has been. There are now over 20 international editions and translations; it’s been a New York Times bestseller and a bestseller in England and Germany. But I didn’t really think about that. But I knew I was doing something unusual. I’ve read a fair number of medical memoirs and I never felt I’d read one which really showed what it was really like to be a surgeon doing, essentially, very dangerous surgery. We learn at a very early stage in our careers to pretend to patients that we’re more knowledgeable and more competent than we are. To a certain extent, that’s what patients want. As a young doctor, you can’t very well say, “I don’t know what I’m doing.” As you get older, you can be a bit more honest. But a lot of doctors aren’t. And those doctors who have written memoirs tend to maintain this sort of mask, this charade. So, I knew I was doing something unusual with the book, but I hadn’t thought much beyond that.

    CQ: Do you think your willingness to take off that fa?ade in your writing that so many doctors retain contributed to your book’s success?

    HM: Without a doubt. From the many reviews, letters, and emails I’ve received—it is the honesty. That’s obviously very unusual. People clearly know that doctors aren’t honest. If all doctors are technically honest, to their patients and themselves, there’d be nothing all that special about the book.

    The other reason, in a sense, almost unconsciously, is zeitgeist, the spirit of the age. In England and in the United States, too, doctors are working in an increasingly critical, if not hostile, environment. A huge contrast to when I went into medicine 40 years ago. And I don’t see this as necessarily a bad thing. I’ve always felt one should treat patients as equals, as you’d wish to be treated yourself. If patients want to be treated as adults, they must understand that doctors are human as well. There’s always been a tendency for patients to regress to child-like roles with doctors; they’re frightened of doctors as patients. I’m always telling my trainees, “Your patients are frightened of you.” You think you’re this nice, kind, philanthropic, competent guy. But your patients are frightened—particularly of surgeons. It’s a very unequal relationship. I think the idea of having a profession, which has taken big knock certainly in this country (England), is the idea of trust. You trust people, you assume they’re honest. So in one sense, by saying I’ve often made serious mistakes and I’m often very anxious and frightened, I’m being honest. Perhaps patients respect and trust me more as a result, instead of being a god-like figure who never makes a mistake.

    CQ: Has your writing ebbed and flowed with your life? Or has it been a constant presence?

    HM: It’s changed, it’s changed. When I was a teenager, it was a load of morbid, narcissistic navel-gazing. Later in my medical career, one sees the most wonderful and terrible things as a doctor. Particularly as a brain surgeon. And there is this deep and fundamental mystery about the brain and how physical matter generates consciousness. And we haven’t a clue! We haven’t even begun to explain it. You’re dealing with extraordinary life and death mysteries, dramas and tragedies. And when you go and work in countries like Ukraine and Nepal and Albania, you have a very interesting life.

    One of the problems with being a doctor is that you’re always trying to damp down the excitement. It’s the asymmetry of our relationship with our patients. For our patients, their encounter with us is among the worst experiences of their life. For us, it’s another day at work. Anxiety is contagious; we don’t like anxious patients, so we try to play down the drama. But at the same time, it is the drama and it is the incredible importance of medicine which makes it so attractive. With writing, particularly in my later years, I didn’t want it to slip through my hands. I wanted to try to describe with words what I feel and do. It was for myself.

    CQ: Is writing an outlet that verbal communication isn’t?

    HM: Certainly with patients, there are lots of things you don’t communicate. What one writes in a book is going to be quite different. This book is only one I could have written toward the end of my career. I couldn’t have written or published this book years ago. I would have felt far too vulnerable. Because I’m very senior, I can, in a sense, take the risk of writing a book like this and be respected for it, rather than demolishing myself with it. For me the book is not a confession; a confession is something you feel guilty about. This is trying to understand why I got things wrong, trying to understand myself, and also trying to set an example for other doctors to realize how easy it is to make mistakes. When I was a young consultant and had my first disasters, either through mistakes or bad luck, I found it quite reassuring to remember some of the guys who trained me, whom I greatly respected. I’d seen them make mistakes occasionally, and I found that quite helped me cope with the overwhelming sense of guilt I experienced. In recent years, when things went badly and I blamed myself for it, I still felt awful about it, but only for a few days. When I was younger, I’d feel terrible for weeks on end, although one went on working in the way one does.

    I was very struck after the American edition came out. I got quite a large number of letters or emails from very senior guys, like the late John Jane, and they really liked the book. I was amazed; I thought the Americans would say he’s just another incompetent limey. He doesn’t know what he’s doing. Most of the letters I got from surgeons were from people after they retired. Only when you’ve retired can you let the defenses down a bit and admit just how emotionally difficult the work can be. And a lot of the time you have to pretend to yourself in order to cope with the bad side of things. Again, in a very high visibility, superficially glamourous specialty like brain surgery, the triumphs are only triumphs because there exist disasters. If the operations always went well, never went wrong, there’d be nothing very special about it. You can’t have one without the other. Both to keep patients happy and to keep doctors’ egos happy, the tendency is to hide the bad side of things. As with everything in life, particularly in medicine, we learn much more from mistakes than we do success. Success is dangerous; success makes us complacent and corrupts us. You know, it is very difficult to admit to mistakes, even to one’s self. As doctors, the consequences of our mistakes are so bad and horrible, it is very tempting to say things like, “The operation was a success, but the patient died.” It’s being a bit more honest, at least to one’s self.

    CQ: You mention that it was often retired surgeons, or those toward the end of their careers, who wrote to you about their agreement with the book. Do you think it’s possible for a surgeon in the peak of their career to step back and “let the defenses down” as you mention?

    HM: I think it’s very difficult. But I think some insight into one’s self is surely a good thing. Because we learn from mistakes and we all make mistakes, however good we are. The best surgeons are very experienced, and experience is about making mistakes and learning from them. It is normal to make mistakes, and one shouldn’t feel too bad about it. The important point is to learn from it, and if you’re a senior doctor, to make sure your trainees don’t make the same mistakes. In other words, set an example by being open and honest. In principle, that happens in M&M meetings, but in my experience, M&M meetings are often pretty meaningless. They can be quite good, depending on who’s running them. But they often don’t really have an impact. While we subscribe in theory, as surgeons, to this belief in open discussion, it doesn’t always happen.

    CQ: Neurosurgery captures the attention of the public, even though it is a field that very few will ever truly know.
    HM: There’s this huge myth about brain surgery. People think it’s terribly difficult—the steady hands thing. I think most surgeons would admit that operating is the easy bit, once you know what you’re doing. The problems are all psychological; problems with decision-making, problems with dealing with bad results. The public are right to think neurosurgery is difficult, but they’re wrong as to why.

    CQ: Do you think neurosurgeons have any obligation to help others understand our field?

    HM: I think we all have an obligation to explain and educate as best we can. It is often very difficult, particularly if you work in very uneducated, very poor countries. For instance, in Nepal, where there’s no understanding of the brain, the families of the patients don’t understand the idea of brain damage. They think of it like any other illness, and that all operations are the same. It’s very difficult when there are deeply ingrained cultural values and beliefs.

    CQ: Has any of the correspondence you’ve received really stuck with you?

    HM: I’ve received quite a lot of email from previous patients. Sometimes it seems I beat myself up more than the patient’s family did when things went badly. They were less critical of me than I was myself.

    CQ: Could you describe how you’ve grown and developed as a writer?

    HM: After starting the process of writing the book, it was looked at by my agent, editor, and publishers. I showed it to members of my family and friends, and got lots of comments and criticism. When I look at books nowadays, particularly the acknowledgements, people are always thanking many people. It really is very important to show what you’re writing to other people. I’ve learned a huge amount, especially from my wife, who’s a very good writer and a very good critic. So, my writing has gotten a lot better because of lots of benign criticism. There are two rules in trying to write well. One is to show, not tell. I try to show things, describe things, rather than pontificate and preach. The other is to never use two words when one will do. Always try to keep things as simple as possible.

    CQ: Are there authors you look to, that you particularly enjoy?

    HM: I come from a very bookish family. I read an awful lot and have done so since I was a child. I think it’s very hard to be a good writer if you haven’t read a lot. I think reading a lot is very important. If you ask for particular names, they’re rather obscure. I like writers who write in a rather simple manner. There was an English travel writer, Normal Lewis, who is a great stylist and writes beautifully. I love his books. There are many people’s books I read.

    CQ: Are there any similarities between writing and operating?

    HM: That’s difficult to answer, as they’re both aspects of the same person. At first glance, there are not too many similarities beyond the importance of lucidity and clarity—knowing where you’re going is invaluable in both. I do woodworking and keep bees, and I’m a very practical person. I see parallels there with operating, but those are quite different from writing.

    There is a tone I’m trying to get in my writing, which I found in Norman Lewis’s writing, of both compassion and detachment. This is reminiscent of the balance I sought as a surgeon. As a writer, you’re trying to describe things because you’re involved, but you struggle to remain detached and to write objectively.

    CQ: What advice would you give to a neurosurgeon who wants to start writing?

    If you want to write, you have to sit down and start writing. Show it to other people who are good critics. Don’t keep it to yourself, discuss it. People go to creative writing courses, and what that largely consists of is sitting in a room with other people and reading what you’ve written to see what they say. Exposure of what you write is very important.

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