Dr Henry Marsh HARDtalk


Dr Henry Marsh

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Welcome to HARDtalk. Imagine you are a patient about to undergo brain

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surgery and if it goes well it could save your life, if it goes wrong,

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you could end up paralysed or dead. Of course you want to believe your

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surgeon is infallible, a superhero, but he is not, he is all too human,

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just like you. And that simple truth emerges from the extraordinary

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honest writing of my guests to date, one of Britain's leading rein

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surgeons, Henry Marsh. He has given us where insights into the mind of

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the doctor. Is that reassuring or troubling?

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Henry Marsh, welcome to HARDtalk. Thank you. The very job description

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brain surgeon, for most people it prompts a sense of all and maybe

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fear as well. And certainly mystery. To have decided to lift the veil on

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what it is really like and they wonder why. I have been subject to

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that of brain surgery myself. When I became a neurosurgeon many years

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ago. I am the youngest of four and I have been drawing attention to

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myself from an early age. I wanted to convey that medicine is a very

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uncertain, imprecise business. When I became a doctor, doctors buried

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their mistakes. There was deference and trust. Doctors are not really

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held to account for what they did. That has changed profoundly, at

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least in this country. You cannot open the newspapers without the

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medical scandals. It is the tabloid headlines that drive the politicians

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could the mistakes that they can change things in what is a very

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excellent health service. Patients are not consumers. Doctors are doing

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something in many ways much more difficult than what people realise.

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People think brain surgery is difficult technically. It is not,

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actually. The really difficult thing is the decision-making and dealing

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with the patients and all the human problems that arise. I wanted to

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convey that. By conveying that and focusing on the difficulty and

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sometimes the fallibility of yourself and colleagues, isn't the

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danger that you plant a new and horrible seed of doubt in the

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patient? I do not think so. If you had to go and see a doctor and you

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could only choose one quality, steady hands, famous reputation,

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nice bedside manner, nice smile, we would all go with honesty. If you do

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dangerous surgery, which neurosurgery certainly is, the

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mistakes all arise in the decision-making. It is not about

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dropping something, it is not like that. Occasionally surely manual

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errors occur, but it is very unusual. It is in the

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decision-making where things go wrong. That is all about thinking

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and psychology. When you've decided to go into brain surgery, you knew

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you were going to a field of medicine that came with enormous

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pressure. There are so many branches of medicine where anything you could

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do could lead to the most catastrophic... You become a surgeon

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because surgery is a blood sport in a way. That is not inconsistent with

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caring for your patience. What is making it exciting is being worried

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your patient should do well. You have to have supreme confidence,

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maybe bordering on arrogance to become a brain surgeon? It is all

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about balance. Absolute power corrupts absolutely. We have an

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enormous amount of power and it is easy to become arrogant. You need to

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be insensitive to some extent. This is a challenge of all medicine. It

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is acute in brain surgery. I the balance between compassion and

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professionalism. We should only treat patients as we wish ourselves

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or our family to be treated. But it is almost impossible. Finding that

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balance between compassion and detachment is difficult. Also self

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belief and self-doubt. It seems to me reading your book and other

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writings about the work you have done, as you have gained an

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experience and reputation, you have become more self doubtful. Very much

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so. Because I came to realise that once you master the technical skills

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of operating, mistakes a rise in the decision-making. I believe now that

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other people are better at seeing my mistakes than I am. That is a truth

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that applies to all of us, we are very bad at seeing our own mistakes.

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You need the arrogance and self belief to do the operating, but it

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is critical to have a good working relationship with your colleagues as

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well so they can criticise you and you can criticise them. That is

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difficult to get doctors to do. Let us get specific and talk about a

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case that you have been very honest about. Earlier in your career, he

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was a man in his late 50s who came to you with a huge brain tumour and

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you were appalled by it. Appalled and excited. He was sent off to see

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another consultant even more senior than you. He pushed it back to you

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and said, Henry, you do it. It is a young man's operation. Exact. And

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you were quite excited. It was a dozen hours or more. And it went

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badly. You said yourself, I could stop now, but I will get every

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single trace of this tumour out and before you finished, you have

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accidentally separate a branch of an artery and the man never recovered.

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The mistake was not severing the artery, it was deciding to remove

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that last bit of tumour. The answer is all neurosurgeons have terrible

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disasters and periods of despair. When I first became a consultant, my

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first few bad results I felt quite sick and miserable for weeks on end.

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In a sense you access it. Has it changed the way you work? We have

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talked about confidence and self-doubt. You develop lingos. You

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need to perceive yourself to some extent. A lot of medicine is an act.

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Very early on as a young doctor, the patient does not want the doctor to

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say, I do not know what to do. We want to do is to be experienced and

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confident. In my case, that is easy, because I am. But younger doctors

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are not. If you do not take on the difficult cases, how will you get

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better? You face an ethical problem from the moment to become a doctor,

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you have to start flying to patients. You have two pretend you

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are confident. You must deceive other people and you must deceive

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yourself. It is a necessary self-deception to help one cope. It

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is not a bad thing. As you get older, you can try to dispense with

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some of it and treat patients as equals. I wondered with that

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incident and others like it, you are very honest, you went to a hospital

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that specialised in long-term care. You said to fight -- operated on

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people who were in essence brain damage. I wonder what threshold of

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rescue are prepared to take changed over time. It goes up and down, is

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the answer. After the case you mentioned, I became group are

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conservative. But it reflected the working environment I was in 25

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years ago. Over the years, I discovered a way to do really

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difficult cases. They are very rare, so you only see a handful. When I

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was working in the poll recently we had a couple of cases like that. My

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colleague said, how wonderful a view to share in operation. A more

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collaborative way of working is very important in modern surgery. I

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wonder if it is more difficult to take on the risk of a very difficult

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operation which you know has a serious risk, sometimes catastrophic

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consequences. But whether it is more difficult to tell a patient who is

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desperate for you, even though you have explained all of the risks,

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that it is not the right decision and it is right for nature to take

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its course. Which is harder? It depends on the nature of the

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problem. I think it is harder to do nothing. It is harder to say, go

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away. That is very difficult. Sometimes you say it is the better

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outcome. Yes, you learn. I see my younger colleagues operating on

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cases which I did at my stage of that career. Now they wouldn't. I no

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longer do emergency work, but when I was your often called about

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emergencies. Emergency neurosurgery is actually very simple. The actual

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operating is very easy. It is based on moving blood clots. But the

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decision on whether it is worth operating is very difficult. You

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have strokes where if you do not operate they will die. If you do

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operate, they might survive, but they might be left disabled. If I

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say, thumbs up, operate, I get back to sleep. If I say thumbs down, I do

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not, because I am worried I was wrong. Is it important for you to

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get to know your patience before operating? I used to think it was.

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My son had a brain tumour when he was very young. He was a few months

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old. I was doing general surgery. That is not why I became a brain

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surgeon myself. I do not know what other. As are like, but it gave me a

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certain understanding and sympathy of my patients were going through.

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An essential part of the operating was to be quite close to the

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patients and their families. That is partly selfish. If you are close to

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them and things go wrong, they are less likely to lose trust in you. It

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is selfish and not selfish because you are more invested in the case

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commercial league. -- emotionally. My colleague and his team were doing

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all the talking because of the language barrier. In the past it

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would have been complete anathema. It did not make a difference. I was

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just as focused and intense about the operating. That was a surprise

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to me. I was better than I expected. Let me switch focus and talk to you

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about this most amazing organ of pounds. It is so complex, it is so

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mysterious in many ways. And yet you approach it with sometimes drills,

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saws, knives and the suckers and there is something quite bizarre.

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It is utterly bizarre. When I was younger, I took it for granted. As I

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get older, I am more and more amazed about this fundamental mystery. What

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I thinking or feeling is electric chemistry. It feels free and

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insubstantial but we are the product of the electrical chemical activity

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of nerve cells. What is fascinating is that modern science... We cannot

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even begin to explain how thoughts and feelings arise. We just do not

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know... Your career has spent 35 years, are you saying you have

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learnt little more about the electro chemistry works? We now how a brick

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is made but it is not tell us anything about the house made by the

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bricks. What really interests asked as human beings is ourselves, our

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feelings and consciousness. We cannot experiment on it either. You

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write about being struck, during an operation, that your sucker, the

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Hoover thing you suck jelly out of, is moving through thought and

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emotion and that memories and dreams should consist of this jelly is

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simply too strange... It is the last great mystery. You might be sucking

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up peoples imaginations or thoughts or dreams! The answer to that is the

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illness you trying to treat is even worse than the operation. The right

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bad results and complications but you think of the good results and

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most of the time things go well. -- there are. For all the patients are

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done badly, there are thousands that did well. That is the balance. But

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it is terribly important. Success is corrupting. Success makes us

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complacent and spoils us. The worse surgical crime is complacency. You

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must never forget the complications but it is terribly important to

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remain as humble and modest as you can even do you must present a

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confident and assurance to the patient. One more question on the

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more philosophical side of what you do. You said you believe in science

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with a capital S. But for centuries, philosophers have posited the notion

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that, it the end, our mind, our sole, maybe, is separate from the

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physical reality from the thing between our ears. Are you telling me

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you are absolutely could win the there is no possibility of that

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being true? Deeply in probable. We do not understand how it works. I

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find that mystery reassuring. We know the macrocosm of the big bank,

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the anniversary of Einstein's the Wii of relativity. But we are

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sitting on a mystery as great as the big bang. You have read the papers

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that address and near death experiences and some that we collect

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experiences when normally the machinery has told us they are brain

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dead. But you think it is a mirage? It is a complicated area. Brain-dead

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is rather different. Near death experiences are recognised phenomena

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in... Bad... -- Butt. Back to healthcare. We have talked about you

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as an individual dog and a surgeon and how you have approached a career

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dealing with the most terrible challenges in the brain. Another

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part of what you do is exist with a vast health-care system, one small

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cog component in a huge machine. It seems to me he had become

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disillusioned with that? Yes and no. You have to look at the NHS

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internationally, firstly and if you look... There is a lot of criticism

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in England about... Some mistake in the hospital. And the headlines are

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shamed to the NHS. The national health service provides by

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international standards very good healthcare in terms of overwrought

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outcomes in terms of life expectancy... The Americans would

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call it socialist healthcare... I have worked and visited so many

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countries where it is terrible... It is not if you can pay for it. It

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comes back to the fact that medicine is not like going in to a shop and

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paying for it. A lot of the decision-making is very unclear and

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the grave stop if you look at countries like America, at its best

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it is fantastic but it is incredibly extravagant. In all countries,

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healthcare costs are rocketing. I afraid doctors have a financial

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interest in what they are doing, they tend to do more. Taking the

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Nitish case of a socialised system -- British. At a time of ageing

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population and rising costs,... You need to pay more. Pay more tax or

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accept greater rationing. Exactly. It is basic economics. If it is in

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scarce supply, you end up with queues. Having all these targets can

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be. You think queues are OK? Note that you have to prioritise and deal

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with emergencies first. A lot of people have made points about the

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organisation, and you call it the chaos, in the system. Arrogance...

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You do not like being told what to do I manage us. You do not like

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being told to come wear a tie or a wristwatch or your car space has

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been taken... I do not drive a car I ride a bike everywhere. You are

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right. Some comment on my arrogance but, again, that criticism is

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probably fair to some extent but what patients want... They want

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individual care from a dog. They want a sense of responsibility from

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an individual. -- from a doctor. We have responsibility for their lives

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and deaths. If you are treated as a minor cog, it produces a lot of

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tension. So colleges will say that under stressful situations, to have

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a position of responsibility with no power. You have escaped the confines

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of NHS. You work abroad. Having worked. Long with sick people, with

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terrible health challenges of the brain, are you now frightened of

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your brain and deterioration? Oh, yes, I. Most of us have had one or

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two demented parents to care for. Dementia is an increasing problem in

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wealthy countries and I much more worried about dementia than dying.

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The evidence is a fairly clear that keeping busy, physical exercise, a

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very important to keep it at a but we cannot keep old age at bay,

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ultimately. You are committed to keeping on doctoring. You said an

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ageing dog is a better dog... You are all sympathetic. -- dog. --

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Doctor. We began by talking about where that you want an honest

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doctor... As you age, your hands are not as steady... I have been

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thinking about that a lot. I was operating in Nepal, and I felt two

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things. I felt sure that physically I was as good as I have been. But I

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felt increasingly ashamed and embarrass and help crude the

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operating I was doing compared to what I increasingly understand about

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the brain. That struck me. I need to gradually withdraw from operating,

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clearly but not yet. Please. I hope you keep going for quite sometime. I

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still totally in love with it. Dr Henry Marsh, it has been a pleasure.

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Thank you. Thank you very much indeed.

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