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.

I graduated from St. George’s Hospital Medical School in 1991 and well remember doing a neurosurgical attachment at Atkinson Morley’s Hospital in Wimbledon, where Mr. Marsh was a consultant before the hospital moved to the St. George’s site. I found the experience horrifying and the visions of people lying in rows of beds on the old Nightingale wards, shattered psychologically, physically and neurologically, reminiscent of a field hospital at Sevastopol, has stayed with me. This outstanding book is somehow reassuring to me because it shows that the existential awfulness of neurosurgical illnesses and treatments is not lost on all neurosurgeons and Mr. Marsh gives us a page-turning series of vignettes which get to the heart of what it is to be a neurosurgeon (and by extension a doctor of any kind) dealing with these kinds of conditions. Although they are experienced in sharpest relief day in and day out in neurosurgery, this book teases out the dilemmas facing all doctors who deal with life and death illnesses. It is clear that the author’s experience prior to medical school as a geriatric nurse, teacher in Africa and Oxford student of PPE has furnished him with the literary tools and perspective to be able to portray these impossible situations in an eloquent fashion and he brings us uncomfortably close to the anxiety, doubt and equivocation which must affect anyone doing this job who has an ounce of sensitivity. Lest this sound too much like a hagiography, it must be stated that although he comes across as a man of great compassion and sensitivity, the book reveals Mr. Marsh to have more than a few elements of the old school, irascible, patrician consultant surgeon about him. These make for great anecdotes, of course, and he will no doubt be long remembered by his trainees for that, but it is not difficult to see why he is unpopular with some of the more junior surgical consultants who function as NHS apparatchiks, nor with their controllers, the ever burgeoning plethora of new-style NHS managers. Both these groups will be ecstatic to see him retire. Mr. Marsh’s contempt for the idiotic, self-serving bureaucracy, blithe and uncaring of patients’ needs, which the NHS has become is well-expressed and will be shared by many of his generation and those a little younger. He’s a prickly dinosaur, alright, but one with his heart in the right place who has much to say and says it in a compelling way. Buy this book if you are: Interested in life and death. Interested in medicine. Interested in neuroscience and the roots of consciousness. Interested in what it is to be a doctor. Interested in what it is to be a person. Interested in the search for meaning. Interested in the philosophy of healthcare. Interested in a thought-provoking, entertaining read, which you won’t be able to put down. Don’t buy it if you: Are feeling psychologically fragile. Are unable to deal with paradox, nuance and not having a clear answer. This book deserves to become a bestseller and to reach a broad audience, both due to its content and the quality of its writing. I don’t know if it will or not, but it is certainly a profound addition to the corpus of human literature. (Disclosure: I am a GP, recently moved to practise abroad, partly because I couldn’t stand the NHS any more. I haven’t seen Mr. Marsh since 1990 and he wouldn’t know me from Adam. He wouldn’t have known me from Adam then, so I’m certainly not puffing the book through any personal connection.)

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.

Life and death decisions every day leaves the reader in awe. There are a vast array of brain injuries and diseases that a neurosurgeon needs to know – aneuriysms, haemangioblastoma, tic doloureux, angor animi, meningioma, leuctomy – the names themselves are other worldly. But the scope of this book is far deeper than the technicalities of brain surgery, impressive though they are. It covers the whole experience of brain damage both from the patient and surgeon’s perspective. Terry Marsh paints a vivid picture of the daily case discussions among the surgical teams, the difficult decisions they have to make , not just on likely success of the operations, but on the subsequent quality of life of the patients. But as Terry Marsh explains “its one of the painful truths of neurosurgery that you only get good at doing the really difficult cases if you get lots of practice , but that means making lots of mistakes at first and leaving of many injured patients behind you”. He describes his mistakes as well as his successes and juxtaposes the reverence and gratitude of his patients with successful outcomes with the angst and legal wrangles of his mistakes. Marsh has made many patients very happy with successful operations but there have been many terrible failures and he contends that most neurosurgeons’ lives are punctuated by periods of deep despair. His language is vivid: “the idea that my sucker is moving through thought itself, through emotion and reason, that memories, dreams, reflections should consist of jelly is simply too strange to understand” or “aneurysm surgery is akin to bomb disposal, though bravery required is of a different kind as it is the patient’s life that is at risk and not the surgeon’s”. Or “to a man with a hammer , it is said, all things look like nails. When brain surgeons look at a brain scans they see things that they think requires surgery and I am, alas, no exception.” He sounds an exacting and outspoken consultant – I imagine very difficult to work with – very ready to critiscise his registrar surgeons and take over when he is not happy with their work. But when you are dealing with life and death how can you tolerate less than the best? With his nursing staff he appears courteous and appreciative – he describes Vince Hurley, a West Indian charge nurse as one of the most impressive people he met in his long medical career. To work on that ward, with its hopeless cases, to treat them with such kindness and tact was remarkable”. He comes across as devoted to explaining and dealing with the personal anguish of his patients and their relatives – well beyond the call of duty. He holds that surgeons must always tell the truth but rarely, if ever, deprive patients of all hope. It can be very difficult to find the balance between optimism and realism. He has trenchant, unsympathetic views about the management of the National Health Service and the remoteness of the management from the day to day surgery, but he describes a very positive and fascinating inside account of how NICE, the National Institute of Clinical Excellence, works. A humbling and graphic 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!

The actual literature of this book is easy to read. It's well-written and flows well, don't worry, you won't get bogged down in medical terms. He balanced it well, it's not too heavy on his own biographical life, it doesn't pompously talk too much about his own career, it doesn't become a long list of surgical anecdotes, each quite short chapter doesn't strictly follow a repetitive format. He mixes it well. On the emotional side though, this book is pretty heavy. Which isn't the author's fault it's simply the very nature of the topic. Each time a patient is introduced to the reader you're wondering whether it's going to be an uplifting ending or a drastic outcome. Each time I was guided out the other end of this turmoil I almost dreaded beginning the next chapter knowing I was going to have to do it all again. The author writes bluntly with brutal honesty, almost making you wince at times. It's strange how the book is so often very light-hearted even though the context is heavy. You even forgive yourself for a chuckle here and there. It gives a very clear insight into the surgical world and one thing is for sure, I can conclude I would never like to do this man's job. The things he deals with on a day-to-day basis are the types of things we all hope to never encounter once in our lives, let alone numerous times daily. Looking back, each chapter could probably read individually in any order you choose, there's no real chronology or connection between them. This makes the book easy to pick up and put down. It's very interesting, give it a read.

Avant-Garde Politician: Leaders for a New Epoch In imperial Portuguese statecraft rulers and their advisors often viewed themselves as medical healers of the body politic. Some contemporary thinkers impressively continue this tradition, such as "Dr. Politico" (Dr. Luis Enrique Alcala) in Venezuela. And, indeed, this fascinating book, as well as in the literature on medical training and practice as a whole, presents issues salient to political leaders, subject to careful application. Thus: "Much of what happens in hospitals is a matter of luck (p. ix),"[but it also is] a question of balancing risks, sophisticated technology, experience and skill (p. 41), while political leaders face much more uncertainty without being equipped by study and experience to handle it well; "the self-importance [produced by being a neurosurgeon] (p. 14) is all the more a danger accompanying political leadership, while being much less subjected to peer control and other safeguards; "Doctors like to talk of the `art and science' of medicine. I...prefer to see [it] as a practical art...that takes years to learn" (p. 31), but nearly all political leaders sorely lack the extensive knowledge, systematic study and supervised learning from practice essential for fulfilling their missions well; "Doctors need to be held accountable, since power corrupts" (p. 180), but this is relatively easy when results become soon visible and statistical quality control can be applied, while political leaders easily cover up errors, or are held responsible by simplistic publics for what does not depend on them. And so on. Politics and medicine are in many respects radically different. Thus, there is a model of a "healthy person", a catalogue of the more frequent diseases, and evidence-supported "best practices," however changing with time. Nevertheless, one overall critical lesson from the history of medicine fully applicable to politics is provided by the progression from "Feldscherers" (a term going back to barbers engaged in surgery, first used around 1877 and then applied to fields surgeons lacking serious qualifications), to highly professional medical specialists. Extensive study of political leaders as well as observation of many of them in action leads me to the bitter conclusion that most of them are in in the stage of Feldscherers, lacking most of the qualifications needed for coping with the fateful issues increasingly facing humanity. Democratic elections are essential in most countries, but the truth must be confronted: they are far from assuring the quality of successful candidates, all the more so when big money and political marketing cover up the real traits of candidates. Therefore, as discussed in my most recent book, radically upgrading of the qualities of political leaders is essential. In my reading this book raises implicitly the fateful question how to assure that political leaders have the required moral and cognitive qualities, thus adding to its merits as being fascinating to read. Professor Yehezkel Dror The Hebrew University of Jerusalem

Ebook stupendo, fluido anche per i non addetti al lavoro. Ho guardato video di ogni intervento/capitolo per comprenderlo al meglio. è raro riuscire a combinare in maniera così sublime scienza e umanità. L'autore ha fatto davvero un ottimo lavoro. Il desiderio di leggerlo ha vinto anche il fatto che la traduzione non fosse ancora disponibile. Mi risulta che l'IBS abbia rilasciato da qualche giorno invece la versione in italiano per cui non ci sono davvero più scuse per non acquistarlo.

This book was written by a neurosurgeon in the UK and relates his experiences and seemingly many failures in performing brain surgery. It is forthright and honest and when you read this, you just hope you never have to go into the hospital to have your brain worked on. This was published in 2014 so we have about 15 years of possible advances in the interim.. Yet even the 'experts' just have minimal understanding of the organ and mistakes when operating are higher than you might think. No matter how exacting the surgeon. This is a sobering but no less interesting recounting of a neurosurgeon's journey through the medical system in England along with his stints in the Ukraine. Not to be missed.

I'm a medical student who was seriously considering to become a neurosurgeon but thanks to this book I realized that it isn't for me and I am not for it. However, the experiences that Dr. Marsh share are not only useful for neurosurgeons or physicians in general, but also for every person who has the life of another one way or the other (be it engineers, chemists, etc) Highly recommended book for everyone!

This was interesting to read The author made it very easy to read Being a neurological surgeon is not always rewarding but then it's a dangerous j9b at best

Excellent. Catches the nervousness and excellence of the branch at the same time