Do No Harm: Stories of Life, Death and Brain Surgery - as seen on 'life-changing' BBC documentary Confessions of a Brain Surgeon

This is a truly remarkable book written by a recently retired consultant neurosurgeon in London. He is a most perceptive character and reflects on his work and patients’ lives. A constant theme throughout the book is the difficulty in making decisions which will have very profound effects on the patient and weighing up the risks and benefits and how to relay these. I did work as a neurosurgery SHO for a while before turning to general practice. It was all far too alarming for me with operations regularly lasting longer than a complete Wagner Ring Cycle but with fewer intervals. I believe Henry Marsh is more reflective than most neurosurgeons I ever came across. As he describes his early life, he originally went into the Arts at university and seems to have been inspired to become a neurosurgeon whilst being exposed to this area in his work in the hospital as a porter. He describes many of the issues faced by all doctors at all levels and enjoys a healthy scepticism of hospital administration which is probably quite widespread amongst clinical staff and gives a few side-swipes to petty bureaucracy. The book is divided into chapters often with a pathological diagnosis. This is fully explained and is perfectly readable by the non medically qualified. Certainly all doctors and medical students should read this book. Is there anyone who should not read this book? Yes – anyone who is about to undergo a neurosurgical procedure. It will scare the living daylights out of them. You certainly appreciate from the operative descriptions the grave consequences of even the most minor slip or error and Henry Marsh is only too aware of this. He describes his successes as well as his failures and reflects on how these impacted the patient and the doctor. This is a beautiful example of how to write an e-portfolio learning log. He describes vividly his first mistake as a junior doctor on the wards and not appreciating the patient knew something was wrong but the doctor ignored it. The ups and downs of a day are described: miraculously saving the sight of a pregnant woman with a pituitary tumour but another patient died after a bleed post operatively. There are many references to Henry Marsh being aware of his personal failings, not least with his ability to become annoyed and fearing he may lose his temper. This seems more in relation to staff and colleagues than patients. He seems relieved at times to have kept his cool. There is an interesting reflection on psychosurgery which was probably losing favour by the time Marsh was entering his career but he makes some interesting points about this in the chapter entitled “Leucotomy”. There is a lot on breaking bad news (as you may expect in neurosurgery) and in some stories this is done in more detail than others. What does come across is Marsh not enjoying this (who would) but sees it as a very necessary time to invest with his patients. Not needing to say much, silence, answering questions. In the chapter Medulloblastoma, Marsh describes the harrowing tale of a child dying on the table during surgery, the silence, the reaction of staff and the parents’ reaction or rather his fears about how they would react. Small things to carers can become a big issue and worth attending to the details. The chapter Neurotmesis describes supervision of a junior doctor who got things badly wrong. Those doctors involved in training constantly have to weigh up how much exposure to give trainees and whether they are capable but having to take the consequences if things go wrong. I enjoyed the way he questioned his junior staff to think beyond the obvious and question what they were doing and why. The morning meetings to look at the day’s admissions and scans seem to have been particularly beneficial. Marsh also describes his own life and health issues. This includes managing the death of his own mother, his own child requiring neurosurgery. His marriage clearly broke down but although there are a few comments suggesting work may have played a part, there is little detail about this. Happily however he found a new wife, Kate. There is the interesting relationship between healthcare professionals when one has to take up the sick role. Are we fearful of treating colleagues? Are they aware of the risks more than the average lay person? Are they more forgiving if things go wrong? He describes his own illnesses, retinal detachment which he rather ignored the warning signs of and his fears about going blind and not being able to work. He describes his ankle fracture-dislocation and his own lack of health and safety awareness or perhaps indestructibility (who would cycle to and from work on a push bike in central London without a crash helmet – a neurosurgeon of course). His description of his own doctor’s reactions to him is very interesting especially to those of us who have to treat colleagues. He recognises the importance of having a space in which to reflect. He built a room at home. He bought large red sofas for the operating theatre suite at work. The chapter Akinetic Mutism deals with Marsh visiting a nursing home where patients lie in a persistent vegetative state. He recognised several by their names and brought home the results of his failures and the resultant lifetime of nursing home care with no quality of life. They had disappeared from his clinics but they were still out there, being cared for by kindly nuns and the like. What is consciousness and what constitutes a valued life. Marsh contemplates about how different patients respond to the knowledge that they are going to die, some had a very dramatic reaction and there were also the issues of how were they to be cared for. Others have a much more measured view and clearly have been able to come to terms with their situation. There is a description of patients waiting to see him and then waiting for scans desperate to know if they are going to live or die. They are being stalked by death and his job is to keep the shadowy figure as far away from them as possible. A very amusing concept is described of tonnes (we are metric now) of medical records being moved around the hospital full of paperwork related to patient’s bodily functions in nursing records like dung beetles! There is a chapter on Marsh’s involvement with NICE and acting as a clinical advisor. He clearly respected the process of the decision making and the thoroughness in which all views were considered. However he recognised he was out of his depth in the theoretical discussions about drugs for treatment. His reaction to hospital hierarchy and administrators, the odd spats with them, but at the same time respect for staff he had known a long time. As was said, he could not do their job and they could not do his. His secretary, Gayle and senior ward nurses he had great respect for and I am sure they loved him dearly. There are many interesting and thought provoking phrases in the book: • The surgeon has known heaven having come very close to hell. This relates to a procedure which was going horribly wrong but in the end it all worked out for the best and the patient was fine, very grateful, but knew nothing of the anguish the surgeon went through to get there. • The value of the doctor’s work as measured solely by the value of his/her patient’s lives. In other words the doctor’s value is only as good as the benefit patients receive from them. An interesting concept which comes from the notion of public service. Certainly reading this book Henry Marsh comes over as recognising he is equal to his patients and their world is as important as his. • The operating is easy. The difficulties lie with the decision making. This is very stark in neurosurgery where the wrong choice can have devastating consequences in terms of quality of life. However all doctors face similar choices and dilemmas every day. Perhaps they are not as immediately devastating but nonetheless require thought and an ability to balance the risks and benefits. • Love can be very selfish. This related to keeping relatives alive when really it would be best to just let them go. • If the patient is going to get damaged, let God do it, rather than you. In other words try not to harm and make things worse yourself. • Patients becoming an object of fear as well as sympathy. After doctors have made a few errors they may come to see patients as a risky entity and fearful of contact with them in case they bite back and the clinician no longer wants to play with fire. • Gratitude all patients have for their doctor when things go well. However demonising when things do not go well. • On risks and complication rates: If it all goes wrong it is 100% disaster for the patient but still only 5% risk for the surgeon. Those are the grim facts. This is an interesting reflection on the many perspectives of being a clinician written in an absorbing and humane manner.

"It's not brain surgery" is up there with "It's not Rocket Science" as a way to make something seem simple, because the alternatives are generally viewed as the pinnacle of difficulty. This book grabbed me because it's by a man who does Brain Surgery every day and very honest about the difficulty of being a human being doing something so difficult. In here you'll find cases of near miraculous recovery, nigh impossible operations that go well restoring those with no hope to health, but also seemingly simple cases that go wrong, sometimes with life-ending (at least life-limiting) results. The writer is honest, too, in describing the cases where he feels the fault was his, either in engendering false hope or in something going wrong. I can only imagine the trauma of those who his 'mistakes' impacted, but equally someone has to be prepared to take these chances for the ones successfully treated to recover. What came through for me is that it's a fine line between success and failure, that, often, Brain Surgery IS incredibly complex and difficult, and that it takes a huge amount of courage to risk the guilt of failing when you have before, but that you are one of only a tiny few have the skills to succeed. An uplifting, heart-breaking, sobering, euphoric read - One of the most unexpected pleasures (and traumas all in one) I've had from a book in recent years.

My favourite book is Cervantes's 'Don Quixote', because it tells us timeless truths about humanity. This is my second favourite, it adds to that project. No kidding. Marsh was late into science but did the quick conversion course for prospective medics at the Royal Free. Before training as a doctor he worked as a nurse on a male geriatric ward and saw the reality of the underbelly of medicine. An early experience as a young doctor gave him a strong wish to devote his time to neuro-surgery. He went on to become one of the best. The book is beautifully organised. We are taught new terms and get to understand complex procedures in some detail. He never talks down to us. He shares both his triumphs and disasters. Throughout, there is a commitment to complete honesty. He revisits the people he has successfully repaired and sometimes those he has damaged. He explains how NHS medicine has changed over the last forty years and how these changes have often made for a more bureaucratic and less intelligent and intelligible system of care. He wonders at the stoicism of his patients and the stupidity of his Trust managers. This book made me cry at times, yet there are periods of exquisite irony and dark humour, as when he must pretend to be another consultant in order to access his patients' brain scans. Marsh is a most human and humane surgeon. We learn much about neuroscience and the mysteries of personal identity and consciousness. This book is simply brilliant. I have bought five copies and given them to friends. All are agreed that this irascible and gifted man is both a wonderful writer and remarkable clinician.

I learnt about this book when it was read out on Radio 4 “Book of the Week” programme - the bit that I heard was about the cognitive dissonance about facing our own mortality and as this is a topic I have thought about I was interested to read of Henry Marsh’s perspective. The book records the author’s experience as a neurosurgeon helping patients with different brain conditions and I can’t say it makes for pleasant reading in that sense, but it is an education and fascinating at the same time: it shows how vulnerable we all are - any of these diseases could happen to anyone at any time. We’re all in the same boat - and in that sense it makes the reader come to accept their own mortality whatever age they are. The author himself expresses his own fear of illness and death, and his thoughts about it which was somewhat comforting as you think you’re the only one who thinks thoughts like that. I had to summon up a certain amount of courage to face reading about these nasty conditions, but I also enjoyed the author’s honesty and forthrightness which made me want to read his sequel “Admissions”. Even though Mr Marsh was an eminent surgeon, I found him to be very authentic and could relate to his humanity, even though I am poles apart from him socially (me being from a working class background). There are now quite a lot of books about end of life on the market and I am working my way through several of them, and this book I found was a very interesting read even though it was dealing with death at the coal face.

As a junior neurosurgical trainee this book has been an unexpected delight. It has provided another entity to help contextualise my future learning before I become a more senior neurosurgical trainee and in time a consultant neurosurgeon. Having heard Mr. Marsh speak at conferences, once standing on a bar top in Bratislava at a Eurpoean neurosurgical meeting, it is all too easy to form an impression that he comes from a line of privilege and that neurosurgery was almost pre-ordained. But indeed on reading this book it wasn't and that is what makes this book even more special. His humility is incredible in this book (although this is easy to say as a junior neurosurgical trainee that has not worked under him and therefore this observation is through a book from a distance). There are too many parts to this book to compose a proper review in a mere few lines. But the overwhelming triumph in this book is that he is retiring and can therefore blast out loud his distaste for how things go. This is not isolated to him but sadly reflects a good number of senior trainees and junior colleagues, e.g. him almost getting a ticket during a certain scenario is ludicrous and the rampant hospital policies that management think safeguard patients act enormously to smash out morale that actually puts patients at risk. I once asked a prominent MP in 2004 if the brain drain in science and engineering could affect doctors and the NHS. He proudly declared no as doctors in Britain are committed to the NHS. Well at one point one third of my social circle of doctors left Britain and most are not coming back. On a more inspirational note his constant desire to seek out Ukraine, to help colleagues out there to ultimately help people has acted in concert to other books, e.g. the Dressing Station, that I might have to explore working overseas in improverished places in combination to pursuing my NHS career to make the most of my surgical and individual experiences. A sueprb read, full of humour, anecdotes, sarcasm and ultimately a very personal account of the grim realities of neurosurgery: that it dares to reset often irreversible disease processes that have the all too common potential to irreversibly change who we are as a person. This is one of the best surgical accounts I have read in the popular press and I have encouraged all my colleagues and friends and family to read it.

I was first aware of this book when I saw a friend mark it as read at the end of last year. The title stuck with me, having had neurosurgery myself only a few months before, and it came up on a 99p Kindle deal recently so snapped it up. This is a fascinating look into neurosurgery and life as a neurosurgeon, written by such a surgeon at the end of his career. As often seems to be the case with life's strange coincidences Marsh's son suffered from a brain tumour as a little boy, his wife developed epilepsy late in life, and he himself has had a few surgeries (although nothing related to the brain specifically) so his stories are not only from the surgeon's viewpoint, but also from that of the patient and the frightened family member. We all on some level know that doctors are only human and all surgery comes with some level of risk, but it was refreshing to really hear that from the surgeon's experience. One of the biggest surprises for me was the observation that most surgeons can cope relatively well with patients who are beyond saving, the certainty that surgery won't help and the patient will definitely die being easy to come to terms with. It's the cases where you can't be sure whether operating will help or not that are the most difficult. It makes sense when you think about it, uncertainty is always the hardest thing to cope with, but I'd never thought about it that way before. Also fascinating was learning all about different types of brain tumours and other afflictions. Having never known anyone closely with a brain tumour, it was an education to learn how many types there are and how they differ in terms of symptoms, surgery and other treatments. Overall the memoir felt honest and it was definitely quite humble which is not the stereotypical depiction of a surgeon who we are often led to believe have something of a God-complex! As a surgeon who worked in the NHS and some private practice for several decades it was interesting to see how things had changed, both in surgery and in the wider world of secondary care. Unfortunately it did lead to quite a few chapters including a lamentation on lack of beds, but that's a sad truth of the NHS these days and so probably hard to avoid. Definitely a great read for pretty much anyone, unless you are squeamish at detailed descriptions of surgery!

Henry Marsh is one of the UK’s leading neurosurgeons, and has been the subject of two award-winning TV programmes. His background is unconventional, having done a series of rather menial jobs, and taken a degree in PPE at Oxford, before starting medical training and eventually deciding to specialise in neurosurgery. Now nearing retirement, he has written this superb, compelling book about what it means to be a surgeon working in a field where every day one is required to make agonizing decisions, and where even a minor error can have catastrophic life-changing consequences for the patient. Many of the short chapters describe specific cases, from the initial consultation, through to the diagnosis, then the operation, and finally the outcome. The descriptions of the operations are given in ‘real time’ and are riveting. One can almost see the surgeon cutting his way through the brain to reach the offending material and share his elation when the operation is successful; but also his anxiety when he encounters something unexpected, and his dismay when things go wrong. Marsh does not prevaricate when this happens and honestly admits that he has made many mistakes over his long career that have ruined the lives of his patients. One such error eventually cost the insurers £6M. This openness is rare in the culture of today’s NHS. These accounts are interwoven with personal details about his own life: for example, the fears he experienced when other members of own family have become ill, the moving description of the final days of his mother, and his long-term charity work in Ukraine. Marsh is obviously ‘old school’, irascible and hierarchical, having little sympathy with NHS managers and other apparatchiks, and their political masters. Doubtless he has made enemies. His blunt question to one arrogant junior surgeon ineptly presenting a case in the morning case conference ‘What are you planning to do when you grow up?” says it all. But beneath this surface arrogance there emerges a man of great compassion and sensitivity, who cares deeply about his patients and the health service in which he has worked for all his medical career. It was a privilege to read this book.

Despite only giving this three stars that is not to say I didn't enjoy it. I liked it quite a lot but in comparison to the other two books I read while I was on holiday this was my least favourite. It is fascinating and enlightening but Henry Marsh's almost complete detachment from what he is writing left me a little bit cold. I completely understand that a lot of the time he is in a no-win situation. Operations he decrees a huge success in the realms of brain surgery can still have catastrophic consequences for the patient (ie the op was textbook but it still rendered facial paralysis for the patient which is an unavoidable side effect). I totally understand that in this situation the patient and their family would deem the op a failure (due to the paralysis) completely putting aside the fact that Mr Marsh had removed all the tumour and saved their lives! He gets no thanks for it but I suspect that that is just human nature and he, as the specialist, sees things in a totally different way to us mere mortals. We learn very little about the human side of Mr Marsh in the book - that he is married to Kate and likes to cycle to work - but I think we need to know more about him as a man. There is not enough of him in this book to actually connect with him. Maybe this is just how he is - a totally remarkable brain surgeon that keeps his personality closed to the outside world. For me though this then comes across occasionally as arrogant and I really don't think that's his aim - but you can almost imagine him having a little tantrum here and there! I know he gives credit to many a colleague he has worked with over the years and also to some exceptionally kind nurses but apart from one sentence to that effect he tells us no more. I get that surgeons are detached from their customers as they would, over time, clearly go mad with the constant emotional turmoil of dealing with successful outcomes quickly followed by those for who there is no hope. Overall and enjoyable read. A little repetitive in places but very informative. Mr Marsh is clearly an incredible man who has helped so many people over the years and does not shy away from those operations that he would agree did not quite go to plan. I think I will probably watch the award winning film that was made of Mr Marsh and his Ukranian colleague. I suspect on tv he comes across completely different to the book! If I were ever to succumb to some sort of brain disaster then I'd be very glad I'd read this book!