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.