“DO NO HARM,’ BY HENRY MARSH

By JEROME GROOPMAN

My closest friend from medical school is a neurosurgeon, and I recently attended the wedding of his daughter. I was seated at a table with his associates when the conversation turned to our respective careers. I asked why they had chosen neurosurgery. A young member of the group said: “When you enter the brain, you’re seeing the soul. It’s amazing.” A senior neurosurgeon shook his head and disagreed. “It’s psychiatrists who see the soul — not us.” Later I posed the question to my friend. “The brain is the organ of cognition, perception, consciousness. When you operate, the stakes couldn’t be higher.” Not even for cardiac surgery? “The heart is just a muscle,” he replied.

Reading “Do No Harm,” Henry Marsh’s frank and absorbing narrative of his life in neurosurgery, it was easy to imagine him at the table. The men, and increasingly women, who slice back the scalp, open the skull and enter the brain to extract tumors, clip aneurysms and liberate nerves, share a certain ego required for such work. They typically are bold and blunt, viewing themselves as emperors of the clinical world. Marsh adds irony to this characterization, made clear in the opening line of the book, “I often have to cut into the brain and it is something I hate doing.”

The first cut Marsh describes involves the removal of a pineal tumor. In the 17th century, Descartes speculated that the pineal gland was the site of the soul, but like the senior neurosurgeon at the wedding, Marsh notes: “The idea that my sucker is moving through thought itself, through emotion and reason, that memories, dreams and reflections should consist of jelly, is simply too strange to understand. All I can see in front of me is matter.” Vivid descriptions bring the reader beside him in the operating room. “I am looking directly into the center of the brain, a secret and mysterious area where all the most vital functions that keep us conscious and alive are to be found. Above me, like the great arches of a cathedral roof, are the deep veins of the brain — the internal cerebral veins and beyond them the basal veins of Rosenthal and then in the midline the great vein of Galen, dark blue and glittering in the light of the microscope.”

While most cerebral aneurysms are now treated by interventional radiologists, some cases still require Marsh’s expertise. In a chapter pulsing with drama, he struggles to place a clip in the precise location, since an error of millimeters can burst the vessel. If that occurs, “the patient will usually die, or at least suffer a catastrophic stroke — a fate that can easily be worse than death.” Such risk escalates what Marsh terms the “thrill of the chase.” He dismisses the popular notion that surgery is a mix of art and science. “I have always found this rather pretentious, and prefer to see what I do as a practical craft. Clipping aneurysms is a skill, and one that takes years to learn.” This is the journeyman nature of operating, an iterative process that ultimately results in earned expertise.

Midway, “Do No Harm” begins to flag. Excessively detailed surgeries diminish the intensity of the chapters. Similarly, Marsh’s story about neurosurgeons in poorly equipped Ukrainian medical centers has little that is revelatory. Fortunately, the narrative gains a second wind when he recounts the unexpected path he took to become one of Britain’s most eminent neurosurgeons. From a privileged family, he entered Oxford to read politics, philosophy and economics, but abandoned university after being rejected in love. He imagined himself as Jack Nicholson in “Five Easy Pieces.” Instead of departing for Alaska, as Nicholson does at the end of the movie, Marsh went to the north of England and worked at a hospital in a mining town, lifting patients on and off operating tables, cleaning walls and equipment. This was his “ritual rebellion” against his “well-meaning” father who had set the course of his life. While watching surgeons operate, he found its “controlled and altruistic violence deeply appealing.” Moreover, surgery involved job security, “a combination of manual and mental skills, and power and social status.” Marsh was accepted to only one medical school, and later as a junior doctor, happened to attend an operation on an aneurysm. He was hooked.

There has been a sharp shift in the culture of medicine, particularly in America, from paternalism to “empowering” patients. Marsh takes a contrarian view. “ ‘Informed consent’ sounds so easy in principle — the surgeon explains the balance of risks and benefits, and the calm and rational patient decides what he or she wants — just like going to the supermarket and choosing from the vast array of toothbrushes on offer. The reality is very different. Patients are both terrified and ignorant. How are they to know whether the surgeon is competent or not? They will try to overcome their fear by investing the surgeon with superhuman abilities.”

Marsh sometimes skirts the truth when presenting a planned procedure. “I told him that there was a 1 or 2 percent risk of his dying or having a stroke if the operation went badly. In truth, I did not know the exact figure as I have only operated on a few tumors like his — ones as large as his are very rare — but I dislike terrorizing patients when I know that they have to have an operation. What was certain was that the risk of the operation was many times smaller than the risk of not operating. All that really matters is that I am as sure as I can be that the decision to operate is correct and that no other surgeon can do the operation any better than I can.”

If patients were “thinking rationally,” Marsh contends, they would ask their surgeon how many such operations he or she has performed, but this “scarcely ever happens.” Given ready access to health advice, particularly on the Internet, Marsh’s assertion that a patient rarely asks this question is becoming passé. Yet his insight into how a physician’s behavior can influence a person’s decision is still apt. “Would he have chosen differently if I had not made any jokes, or had not smiled?”

Britain’s National Health Service is a socialized system, and Marsh chafes at new rigid rules imposed by its administrators. He is particularly incensed by a mandatory dress code: Neurosurgeons are subject to disciplinary action for wearing a wristwatch. There is scant evidence that this item contributes to hospital infections, but he is shadowed on ward rounds by a bureaucrat who takes notes on his dress and behavior. The reign of the emperor is ending, but Marsh refuses to comply and serve as a myrmidon.

Clinical practice is becoming a theater of the absurd for patients as well. Hospital charts are filled with N.H.S. forms detailing irrelevant aspects of care. Searching for a patient’s operative note, Marsh finds documentation she passed a “Type 4 turd.” He shows her an elaborate stool chart “colored a somber and appropriate brown, each sheet with a graphically illustrated guide to the seven different types of turd. . . . She looked at the document with disbelief and burst out laughing.”

Age and a sense of his own mortality soften Marsh. He becomes more compassionate with his patients, closely attending to them even when surgery cannot remedy their plight. The heart may merely be a muscle, but by laboring in the brain, Marsh learned how to exercise it.

http://www.nytimes.com/2015/05/24/books/review/do-no-harm-by-henry-marsh.html