Henry Marsh, Do No Harm: Stories of Life, Death, and Brain Surgery (2014) — a book review

15 July 2016

Do No Harm is quietly magnificent

Neurosurgeon Henry Marsh’s — Do No Harm: Stories of Life, Death, and Brain Surgery (St. Martin’s Press, 2014) — presents a very British philosophical perspective on neurosurgery.

As such, the book is probably not for reality-defying optimists, meaning folks who have difficulty admitting the frequently uncomfortable wander that Life is.

On the other hand, the book’s anecdotes address core issues in medicine and medical delivery systems:

When I visit American hospitals and see the extremes to which treatment can sometimes be pushed, I wonder whether the doctors and patients there have yet to understand that the famous dictum that in America death is optional, was meant as a joke.

I have also worked in countries such as Ukraine and Sudan that have very impoverished health care systems compared to America. You realize quite quickly . . . that despite the very great differences . . . many things are the same.

Our vulnerability and fear of death . . . know no national boundaries, and the need for honesty and kindness from doctors . . . is equally universal.

My readiness to admit my fallibility is perhaps rather English . . . .

Let’s structure this review backwards — by taking some of Amazon’s negative customer reviews as an initial framework

The below-listed negative Amazon assessments conclude, in sum, that the allegedly profane Dr. Marsh’s memoir was:

(i) too personal,

(ii) textually both too much and too little medically detailed,

(iii) simultaneously arrogant and humble,

(iv) overly concerned with organizational inefficiencies,

and

(v) inadequate in patient follow up (for story telling purposes).

I present this array of opinions because each is substantively reasonable, but arguably misses the book’s point and worth.

If you do not want to bother with this Amazon amble, please skip to the next section.

“KH” was disappointed with Dr. Marsh’s character and medical information provision:

I purchased this book looking for some professional insight from a neurologist that would help me understand what a family member went they when diagnosed with a brain tumor, who survived, but is now more handicapped than preservers, confined to a wheel chair, eyesight and speech significantly impaired and who will need personalized care for the rest of her lift.

Frankly I think that Dr. Marsh is an arrogant physician or should I say primadonna who is more concerned about himself than his patients. Very disappointed in the book that really gave me no comfort or much understanding regarding her condition.

“Tatty Head” was both offended and bored:

This book was not exactly riveting.

I never completed reading it although if it hadn’t been for the bad language that popped up here and there I probably would have finished it. Disappointing how even eminent surgeons these days can’t express themselves without expletives!

The doctor was candid and humble about his feelings and his mistakes but all in all this book struck me as flat.

“Hate to Say This” evidently missed the point that memoirs are personal:

Just so-so…I admire this surgeon but this book leaves much to be desired; some of the patient’s stories are just left hanging, and there is way too much personal stuff unrelated to the medicine, IMHO.

And “K” was irritated with the author’s too honestly conveyed perspectives and unlikeable character:

The surgical parts were interesting, if not scintillating, but the arrogance, supposedly forgivable in surgeons according to other readers, was a bit much. He misses the days when senior doctors could bully juniors.

He lost me at last when he referred to morbidly obese patients at his hospital as “small whales being rolled around on gurneys”.

[T]o admit to thinking them with no acknowledgement that you realize that they are mean, cruel or downright wrong, makes you too self-important an observer for me to enjoy reading.

I couldn’t find enough interest in the tales and rather sparse medical ephemera – which is something I usually love – to want to put up with the unfortunately unlikeable author.

Curiously, “BNewby” slammed Marsh’s supposedly too condensed surgical descriptions:

I am very involved with the practice of medicine . . . I thought would make me an ideal candidate to LOVE this book.

Put bluntly, I did not.

Dr. Henry Marsh’s accounts are very dry as he explains extremely detailed aspects of his surgeries while simultaneously leaving out key information for a layman to understand them.

I was only able to follow Dr. Marsh because of previously obtained knowledge in the field and seeing the same surgeries first-hand.

[T]he book would be better if it expanded on his personal triumphs and failures . . . rather than incompletely outlining why his procedures were so difficult.

“RIley 1” thought that Dr. Marsh’s concerns about British medical bureaucracy getting in the way of patient care were too emphasized:

I usually love these kind of books but I started skimming the book because I was so tired of him endlessly griping about the medical community changes.

We get it there are not enough beds and too much red tape but come on already. I don’t want to start and end each chapter detailed every abuse.

In rebuttal

First, a memoir is intended to be personal. As such, it presents the writer’s perspectives, framed in his and her own sense of what it important. It is arguably foolish to criticize Marsh for expressing his sense (arrogant, misplaced, or not) of his profession and what it emotionally takes out of him.

Indeed, Marsh seamlessly integrates bits of his personal life into his anecdotes. Readers get an impression of what it is like having to switch gears from one patient to the next, or from himself and his wife to his patients. I have never read anyone who more skillfully portrays a day’s high and low professional and personal interactions.

Marsh’s abiding point is that you bring who you are, and what you’ve been through, to what you do. Without reprieve or respite.

Second, Marsh’s frustration with too few beds, non-working computers, and over-technologized brain scan data banks is justified. Government nonsense (portrayed in a wide array of short anecdotes) gave me a more detailed impression of Britain’s public and private healthcare system in operation than I have ever gotten from scholarly reviews.

The author’s stories about infuriating administrative bumbling were organizationally informative and emotionally telling. He illustrates each bureaucratic obstacle with its negative effect on deeply suffering patients. Each of his short, mild rants is focused on a different bureaucratic knife twist.

Third, the author’s honesty in confessing his character flaws — which he admits fall into the arrogance and judgmental camps — is refreshing. As with human anatomy, abrasive “assholes” are apparently a necessary part of our survival. Marsh indicates that self-confidence, emotional separation from patients, and occasional excessive self-regard are all necessary — if the job is to be effectively done.

Fourth, with respect to the allegedly inadequate medical descriptions in the book, Do No Harm was not intended to be a surgical textbook. Nor is it aimed at the “isn’t this interesting” genre that neurologist Oliver Sacks so capably contributed to.

Do No Harm is about a neurosurgeon’s perceptions of his profession. The book will most appeal to people already in, or considering medicine as a career. For the rest, Marsh presents enough explained detail to orient his readers to the technical and emotional challenges that he and his patients faced.

Writing samples

A good example of Marsh’s anecdotal style — here in extracts:

Pineal tumours are very rare. They can be benign and they can be malignant.

The malignant ones can be treated with radiotherapy and chemotherapy but can still prove fatal.

This particular patient had found it very hard to accept that he had a life-threatening illness and that his life was now out of his control.

The tumour was obstructing the normal circulation of cerebro-spinal fluid around his brain and the trapped fluid was increasing the pressure in his without. Without treatment he would go blind and die within a matter of weeks.

He laboriously typed everything I said into his smartphone, as though typing down the long words . . . would somehow put him back in charge and save him.

His anxiety, combined with my feeling of profound failure ab out an operation I had carried out a week earlier, meant that I faced the prospect of operating on him with dread.

When I talk to my patients the night before surgery I try not to dwell on the risks . . . which I will already have discussed in detail at an earlier meeting. I try to reassure them and lessen their fear, although this means that instead I make myself more anxious.

It is easier to carry out difficult operations if you told the patient beforehand that they operation is terribly dangerous and quite likely to go wrong — I will perhaps then feel a little less painfully responsible if it does.

As soon as an operation begins, I usually find that any such morbid fear disappears.

Regarding his character flaws:

I joined a long [supermarket] queue of people at the checkout.

‘And what did you do today?’ I felt like asking them, annoyed that an important neurosurgeon like myself should be kept waiting after such a triumphant day’s work. But then I thought of how the value of my work as a doctor is measured solely in the value of other people’s lives, and that included the people in front of me . . . .

So I told myself off and resigned myself to waiting. Besides, I had to admit to myself that soon I will be old and retired and then I will no longer count for much in the world. I might as well start getting used to it.

On medicine (and probably everything else):

‘The operating is the easy part, you know,’ he said. ‘By my age you realize that the difficulties are all to do with the decision-making.’

It’s quite easy to lie if things go wrong with an operation. It would be impossible for anybody to know . . . in what way it had gone wrong. You can invent plausible excuses . . . .

Doctors need to be held accountable, since power corrupts.

‘You can’t stay pleased with yourself for long in neurosurgery,’ my colleague said. ‘There’s always another disaster waiting round the corner.’

On appreciation of those with differing perspectives:

The devout Catholic staff did not accept the grave lesson of neuroscience — that everything we are depends upon the physical integrity of our brains. instead, their ancient faith in an immaterial human soul meant that they could create a kind and caring home for these vegetative patients and their families.

Regarding shifting perspectives — at the transition from life to death:

Healthy people, I have concluded, including myself, do not understand how everything changes once you have been diagnosed with a fatal illness. How you cling to hope, however false, however slight, and how reluctant most doctors are to deprive patients of that fragile beam of light in so much darkness.

With respect to ambiguity’s psychic torture:

[W]hat tortures doctors most is uncertainty . . . .

It is easy enough to let somebody die if one knows beyond doubt that they cannot be saved . . . .

It is when I do not know for certain whether I can help or not, or should help or not, that things become so difficult.

The book’s most painfully revealing chapter is its 22^nd

Here, Marsh recounts his arguably medically mistaken attempt to save an 11-year old Ukrainian child. He faces the torment that she and her mother underwent in the process.

At the end of the chapter, he writes (in his characteristic ruminating style) — here in excerpts:

Tanya’s grave had a six-foot-high headstone from which her carved face appeared — odd, perhaps to western eyes, but beautiful.

The sun was shining, the artificial flowers glittered and shook in the light wind and in the distance I could hear the chickens in the local village. The snow had melted and only a little was left . . . .

There was birdsong everywhere.

Most of the people buried here would have lived through the most terrible times . . . .

At least a quarter of the population of Ukraine died violently in the twentieth century.

[I]t seemed to me that they looked back at me as though to say, ‘We are dead. You are still alive. And what are you doing with the time that you have left?’

Life in Ukraine is not easy.

The moral? — This book is a quietly delivered masterpiece

Do No Harm is, in my judgment, a “must read” for anyone intending to become a thoughtful medical provider.

PeteFree.com

Henry Marsh, Do No Harm: Stories of Life, Death, and Brain Surgery (2014) — a book review