I just finished Do No Harm, a book authored by a freshly retired British neurosurgeon. If you’re not maxed out on your summer reading list, add this one.
In one sense, the book is a bit depressing. Dr. Marsh works for the National Health Service and chronicles more defeats than victories. He writes about his complications. The text is raw. His confessions authentic.
Neurosurgery is hard. And many patients have difficult conditions. Some of these conditions will progress regardless of the treatment. In such cases, doing little or nothing may make the most sense. That is one of Dr. Marsh’s primary points – a point echoed by Dr. Atul Gawande in his book Being Mortal.
When a patient has surgery for some condition, he is taking on near-term risk for future benefit. But, if the future benefit is marginal, then near-term risk makes little sense. As a neurosurgeon with 30 years of experience, Dr. Marsh explained he was more aggressive earlier in his career. But, long term follow-up prodded him to question the wisdom of his early choices.
As he matured, he would often talk patients out of surgery. He might leave small pieces of tumor next to vital structures (to avoid potential harm). Don’t let perfect be the enemy of the good. These are smart choices made by someone who has appropriately checked his ego at the door.
He also described the challenges of teaching residents. Dr. Marsh took care of one patient whose passion was cycling. The patient had a large disc herniation causing unrelenting pain; pain that did not improve with conservative treatment. Surgery was offered and the patient agreed. While Dr. Marsh was putting out a fire with an administrative bureaucrat, he tasked his resident with starting the case. He believed his resident was just opening the wound.
Turns out the resident was much further along. Dr. Marsh poked his head in and saw clear fluid and a long piece of spaghetti. The resident was lost and had opened the dura causing a CSF leak. Further, that piece of spaghetti was a sliced nerve root. Dr. Marsh quickly scrubbed in and did what he could. Post-op the patient had an expected foot drop which likely cut short his cycling passion. Dr. Marsh did not say what happened to the patient long-term. He lamented that while the resident made the error, he alone would bear the burden of responsibility. He had to speak to the patient. He had to speak to the family. He would be the person to see this patient in follow-up. All true. Residents move on. The attending stays put.
Finally, the book quotes a doctor stating there are only two compelling reasons to be a doctor. Over your career, you’ll have a collection of great stories. And you’ll know from whom to seek care when you become ill.
By the end of the book, I had hoped Dr. Marsh would have given more reasons. After 30 years, surely there must have been more.
It’s Dr. Henry Marsh. On iBooks. Good read!
I wholeheartedly agree with both of the reasons given. I’ll let you know when ~my~ book comes out. But for me, there are at least two more reasons:
1) When I did surgery (Retired from that nearly two years ago), if I had a difficult case that no standard treatment was working on, I almost always found a way to ad lib a solution. This was especially true when I would travel to moonlight at distant locations where the equipment (consumables–coils, emboli and the like) were very different from and not as good as mine. But I usually cobbled a solution together that worked well. It was like designing a fighter jet, then flying it into combat and winning. It’s hard to overstate how good that feels.
2) When I was in med school, one of the parasitology profs, Jack Eslinger, had a plaque on his desk. It read “The rich can make you famous, but the poor can make you a hero.” All patients who are suffering are poor in that sense. When I relieved suffering, they thought I hung the moon. Not quite as good as item 1 above, but damn close.
I still take care of friends and family (not surgically) and therefore also friends of friends and friends of family, so I still get item 2 goodies, just not as often as before.
[For calibration, watch the vulgar youtube of Lenny Bruce’s “thank you masked man” bit. It hasn’t come to that. Yet.]
From an outsider’s point of view I know just enough about the art of surgery to know that certain specialties are murderously difficult and in many cases, ultimately depressing. Neurosurgery fills both of those characteristics in spades. When it comes to “job satisfaction” which I think Dr. Marsh is writing about, you would probably pick a group of procedures or patients that “typically” have a good outcome.
I would assume that discovering and decompressing a subdural hematoma (in time to prevent brain damage) fulfills the goals for a truly satisfying surgery. But there are probably more. You would hope that at least some of your procedures fall into that category. Ultimately I suspect that few do in actuality.
Most surgeons have procedures that have a good outcome as a rule. I know I had some. But when it comes to patients who have massive brain injuries or highly invasive tumors, you are in the forced position of cobbling together the best possible outcome out of a deep well of profound permanent disability, pain and early death. How do you go back to your family and friends and enjoy a nice dinner, drinks and friendly banter after such a day/night? I’m damned if I know.
You are doing work that only a tiny percentage of the population has the intelligence, drive or ability to even consider. You climbed through so many academic and training obstacles that your entire life was consumed by incredible hard work and accomplishment. To me as an outsider, you not only deserve the praise of the public and politicians, but even some adulation. I mean it. You earned it.
Our politically liberal population has lost reverence for people of high accomplishment and massive skills. They take you for granted. I’m not asking for politicians to bow when you enter the room, but at the least, you disserve applause. That should be a large part of your job satisfaction. I hope it is.
Michael M. Rosenblatt, DPM
“You are doing work that only a tiny percentage of the population has the intelligence, drive or ability to even consider. You climbed through so many academic and training obstacles that your entire life was consumed by incredible hard work and accomplishment. To me as an outsider, you not only deserve the praise of the public and politicians, but even some adulation. I mean it. You earned it.” Michael M. Rosenblatt, DPM on 17 Jul 2015 at 10:01 pm
In addition to the above outstanding quote I wonder what might happen if those “Administrative Types,” who Critique us, Regulate us, and perhaps even Look Down on Us had to, “Walk some miles in our shoes?” Dare I, Dare we wonder if such types had to follow us through our days (and evenings), (and nights) eating only when we ate, sleeping only when we slept, taking breaks only when we took a break (albeit rarely) etcetera etcetera; might that facilitate some element of respectful communication and perhaps even respectful appreciation of exactly who we are and exactly what we do? With humility…I am only inquiring…
Thank you Dr. Grossman. When the grandson/granddaughter of a member of Congress does a header over his/her bicycle/motorbike and comes to the ER with unequal pupils, vomiting, loss of consciousness, GCS of 3.2 hemiparesis and violent headache, their parents will remind the hospital staff that they are related to a Congressperson.
They will demand the very best neurologist to evaluate and neurosurgeon to operate the kid. Their legislative grandparents at that time will not consider the Stark Laws they enacted to restrict the income/opportunities of the treating doctors. In fact, this won’t even occur to them.
Michael M. Rosenblatt, DPM