27/12/2016 HARDtalk


27/12/2016

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have been arrested following the attack. Now, on BBC News it is time

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for HARDtalk. Imagine you are a patient about to

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undergo brain surgery. If it goes well, it could save your life, if it

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goes wrong, you could end up paralysed or dead. You want to

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believe your surgeon is infallible, a superhero but he is not, he is all

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too human, just like you. That emerges from the extraordinary

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honest writing from Henry Marsh, giving us a rare insight into the

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mind of the doctor. Is that reassuring or troubling?

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The very job description, "brain surgeon",

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I think in most people it prompts a sense of awe

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and maybe a little bit of fear, as well, and certainly mystery.

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But you've decided to lift the veil on what it is really

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I was subject to that myth of brain surgery myself

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when I decided to become a neurosurgeon many years ago.

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I suppose I was drawing attention to oneself,

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as any writer is doing when writing a book,

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I have been drawing attention to myself from an early age,

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I wanted to convey that medicine is a very uncertain,

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When I became a doctor, 35 years ago, doctors

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Doctors were not really held to account for what they did.

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That has changed profoundly, at least in this country,

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you cannot open newspapers without seeing the latest medical

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It is the tabloid headlines that are driving

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to change things in what is basically a very excellent health

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service that we have in this country.

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I wanted to show that medicine is not my going into a shop,

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ways much more difficult than people realise,

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people think neurosurgery, brain surgery is very

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but it is not, once you know what you are doing.

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But the really difficult thing is the decision-making.

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But the really difficult thing is the decision-making and dealing

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with the patients and all the human problems that arise,

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Well, by conveying that and focusing on the difficulty and sometimes

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on the fallibility of both yourself and colleagues, isn't the danger

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

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No, I don't think so, if, if you thought it through, if...

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You have to go and see a doctor, if you could only choose one

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quality: steady hand, famous reputation, nice website...

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..nice smile, honesty, what would you choose?

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No, if you do dangerous surgery, which neurosurgery certainly is,

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the mistakes in my experience all arise in the decision-making,

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Very occasionally, purely manual errors occur.

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But actually it is very, very unusual.

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And in my career, looking at my own mistakes, and colleagues,

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it is in the decision-making where things go wrong, that is all

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Indeed, and I guess that when you decided to go

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into brain surgery, you knew you were going into a field

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of medicine which came with enormous pressure.

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There aren't so many branches of medicine where everything

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that you do could lead to the most catastrophic...

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as I said in my book, because surgery is a blood sport, in a way,

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but that is not inconsistent with caring for your patient,

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because what makes the operation exciting

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That is interesting, because it's about the patient,

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but I want to focus on something about you.

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Do you have to have a supreme self-confidence bordering

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The answer is the balance, as all of these things.

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Power corrupts, and absolute power corrupts absolutely.

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And as surgeons we have an inordinate amount of power,

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and it is very easy to become arrogant.

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I guess you need to be insensitive to some extent.

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This is the whole challenge of all medicine, visible and acute

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in something like brain surgery, finding the balance

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between compassion and professional detachment.

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One way of illustrating that is to say, obviously,

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the only ethic in medicine is we should only treat patients

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as we would wish ourselves or our family to be treated.

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But it's almost impossible to operate on somebody you know well,

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Finding the balance between compassion and

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Compassion and detachment is one element but also

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Do No Harm, and your other writings about the work over many decades,

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you, as you have gained an experience and reputation,

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have actually become more self doubtful.

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you master the purely technical skills of operating,

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where mistakes arise is in the decision-making.

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partly because I am in the latter years of my career,

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that other people are better at seeing my mistakes than I am.

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It is a profound truth that applies to all of us,

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we are very bad at seeing our own mistakes.

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There is a problem in medicine of finding a balance

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ditto, you need the arrogance and self belief to do the operating

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but it is critical that you have a good working

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relationship with your colleagues as well.

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So that they can criticise you and you can criticise them.

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Actually that is very difficult to get doctors to do on the whole.

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Let's get specific and talk about a case, that you have

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It's a troubling case, early in your career.

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I think he was a teacher, a man in his late 50s,

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who came to you with a huge brain tumour, and you were appalled by it.

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you say you were quite excited,

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you had never seen anything quite like it.

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He was sent off to see another consultant, even

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more senior than you, and it was pushed back

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to you and they said, you know what, Henry, you deal with it.

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You went for it, and you were quite excited,

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the biggest operation you had ever undertaken.

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..You sucked out virtually all of this tumour,

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towards the end of the operation, I could stop now, but dammit,

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I am going to get every single trace of this tumour out.

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you had accidentally severed a branch of an artery

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The mistake was not severing the artery, the mistake

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was deciding to remove the last bit of tumour.

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The answer is, all neurosurgeons have terrible periods...

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terrible disasters and terrible periods of despair.

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When I first became a consultant,

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I felt quite ill and sick and miserable for weeks on end

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You have to go on working because you do,

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Does it change the way that you work, we have

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talked already about about confidence, and self-doubt...

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You need to deceive yourself to some extent.

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I mean, it is one of the ironies of medicine, that a lot

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It is something you learn very early on as a young doctor,

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patients do not want a doctor who says, "I don't know what to do,

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We want our doctors to be experienced and competent,

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and by my stage, that is easy, because I am experienced,

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but when you are a young doctor you are not experienced.

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If you don't take on the difficult cases,

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You face this ethical problem right from the start,

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the moment you qualify as a doctor, suddenly you have to start lying

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to patients, to some extent, you have to pretend a greater degree

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of competence and confidence than you really feel you have.

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And the best way of deceiving other people is deceiving yourself.

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

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But as you get older, perhaps you can start trying to dispense

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I wonder whether that incident, and others like it, you very

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honestly say come you went to a hospital that specialised

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And others, and you said, you saw for five people on this ward,

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who you operated on, and they were, in essence,

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I'm just wondering whether the threshold of risk

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that you are prepared to take, changed over time?

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It goes up and down, is the answer, after that

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case that you mentioned, I became, in a sense,

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over conservative, but again reflected the working environment

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Over the years I discover that the way to do these

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really difficult cases, and they are really rare,

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you only see a handful, is to do them with another colleague.

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When I was working in Nepal recently,

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we had one or two cases like that, and my colleague was on his own,

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he runs his own hospital, he said how wonderful

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I think a more collaborative way of working is very

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to take on the risk of a very difficult operation, which you know

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has a serious risk of, as you put it sometimes,

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"catastrophic consequences", or whether it is more

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difficult to tell a patient, who is desperate for you to operate,

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even though you have explained all the risks, that in your view,

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it is simply not the right decision and that nature has

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That you feel there is nothing more you can give them.

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It depends to some extent on the nature of the problem.

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It is harder to say, go away, live with it,

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Sometimes, sometimes you say that death is the better outcome.

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And with experience you learn, and I see this with my younger

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colleagues, I see them operating on cases which I would have done,

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which I did at my stage in their career,

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I no longer do emergency work in this country but when I was

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you are often telephoned at night by the junior doctors

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I should add that emergency neurosurgery

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Is it removing blood cots, it isn't difficult.

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But the decision-making, whether it is worth operating or not,

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These are people with head injuries and strokes where,

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in simple and strokes, in simple terms, if you don't operate,

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they will die, if you do operate, they may survive that they may be

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And it's a bit like Nero at the Roman games,

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if I say thumbs up, operate, I get back to sleep.

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If I say, let them die, I don't, because I worry that

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There is a built-in asymmetry which always forces us to overtreat

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Is it important for you to get to know your patients before

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Well, I used to think it was, that is an interesting question,

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my son had, as I say in my book, my son had a brain gym

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my son had, as I say in my book, my son had a brain tumour

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he's not necessarily the reason I became a Paediatric brain surgeon.

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I don't know what other doctors are like, but I always felt it

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gave me a certain understanding and sympathy of what my patients

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were going through, because I have been through it myself.

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Therefore I felt it was an essential part to be actually quite close

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Although that is partly selfish, if you are close to them,

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if things go wrong, they are likely, they are less likely

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It is selfish and unselfish, because it also means

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And therefore it is more hurtful and damaging.

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When I was working in Nepal, admittedly, my colleague and his

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team, because of the language barrier, were doing all the talking

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with the patients, so I was ending up operating on patients I had not

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seen before, and scarcely saw afterwards.

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Which in the past to me would have been complete anathema.

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I was just as focus and intense and anxious

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Let me switch focus a little bit and talk

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This most may amazing organ of ours, it is so complex,

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And yet you approach it with, sometimes drills, saws,

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and there is some thing quite bizarre about what

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Something I took for granted when I was younger but for various

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reasons, as I get older, I am more and more amazed by this

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fundamental mystery, everything you and I are thinking

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and feeling at the moment, is electric.

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It doesn't feel like electric chemistry, it feels

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But we are the product of the electrical chemical

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What is fascinating, modern science, we cannot even begin to explain how

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thoughts and feelings and consciousness arises,

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Your career has spanned 35 years or so, in brains.

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You saying to me that in those 35 years, in brains,

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are you saying that in those 35 years you have learned very little

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more about how the electrochemistry is works, and how...

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It is like saying we know how a brick is made.

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It doesn't tell us anything about the house made by the bricks.

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So although there is a huge amount of neuroscience going on,

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what really interests us, as human beings,

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is ourselves, our own feelings and consciousness.

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We cannot experiment upon it, you see, either.

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You write lyrically about this, at one point you write

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about being struck during an operation,

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that you sucked jelly out of the brain with,

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you say - "My sucker is moving through thought itself,

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through emotion, and that reason, memory and dreams should consist

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of this jelly is simply too strange to understand."

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Literally, how dare you suck out all of this jelly when you might be

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sucking out people's imaginations or thoughts or dreams?

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The answer to that is the illness you are trying to treat is even

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worse than the operation, so to speak.

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Coming back to the question, how do surgeons cope with bad

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results and convocation, well, you think of the good result,

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and you know that most of the time, things go well, and for all the poor

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patients who have not done well in my hands,

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hopefully there will be hundreds, if not thousands

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That is ultimately what the balance is about.

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It is terribly important, maybe it is partly my personality,

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but success is corrupting, success makes us

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The worst surgical crime for me is complacency.

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You mustn't dwell permanently on your complications

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It is terribly important to remain as humble and modest as you can,

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even though you must present as more confident and assured

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Before we go back to practical matters of health care,

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one more question on the more philosophical side of what you do,

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you just said to me, I believe in science with a S,

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but you know, for centuries, philosophers, scientific

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thinkers, have posited the notion that in the end, our mind,

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our soul is separate from the physical reality of this

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Are you telling me that you are absolutely convinced

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there is no possibility of that being true?

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I find that infinite mystery rather reassuring.

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We all know the macrocosm of the Big Bang, all this stuff

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recently about the anniversary of Einstein's theory of relativity,

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each of us within our own head and our own consciousness is sitting

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on a mystery as great as the Big Bang.

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I'm sure that you have read the science papers which address

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near death experiences, and under scientific conditions can

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recollect experiences they have had when nominally the machinery has

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near death experiences are well recognised as a phenomenon.

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But they come out of the electrochemistry of the brain,

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Back to health care, we have talked about you,

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as an individual doctor, surgeon, and how you have approached

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a career dealing with the most terrible sort of challenges

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is exist within a vast health care system, one small cog,

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Seems to me that you have become very disillusioned

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You have to look at the NHS internationally,

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first thing, and if you look at the NHS...

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There is a lot of criticism in England, you cannot read

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the newspapers without seeing, some mistake in a hospital and

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As if it's the responsibility of the NHS as a whole.

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The National Health Service provides, by international

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standards, very good health care in terms of overall outcomes

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Do you still believe in "socialised medicine",

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I believe passionately in socialised health care,

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because I have worked and visited so many countries where

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medicine is commercial and it is terrible, because...

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But it comes back to the fact that medicine is not

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like going into a shop and buying something.

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A, the patients are not in a good position to judge

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what is good for them, and B, a lot of the decision-making is very

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And if you look at countries like America, sure, American health

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care at its best is fantastic, but it is extravagant.

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All countries in the world, health care costs are rocketing

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above the rate of inflation, and, I'm afraid, if doctors

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have a financial interest in what they are doing,

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they tend to do more and a lot of it is unnecessary.

:19:52.:19:54.

Your message seems to be, taking the British case,

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of a socialised system which is free at the point of delivery,

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but politicians have to be more honest that at a time of rising

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health care costs and ageing populations, politicians

:20:11.:20:12.

need to say to people, you can have this but you are going

:20:13.:20:16.

to need to pay more tax, or you have to accept greater

:20:17.:20:19.

It is basic economics, if you have a good that is free

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at the point of delivery and scarce supply, you end up with queues,

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and having all of these targets, introduced by the previous

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government, can be counter-productive.

:20:31.:20:31.

I don't think they are OK but you have to prioritise and deal

:20:32.:20:37.

with the emergencies first, if you give equal priority

:20:38.:20:40.

to nonurgent cases, then urgent work suffers.

:20:41.:20:42.

A lot of people have made the point about the organisations

:20:43.:20:45.

and the chaos in the system, but it seems to be another

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interesting point about you, coming back to a word I used

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earlier, arrogance, you don't like being told what to do

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by managers, you don't like being told that you can't wear

:20:55.:20:57.

a tie during surgery and you can't wear a wristwatch, you get

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angry that your car park space has been moved.

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I don't drive a car, I ride a bicycle, I don't have that

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particular problem that many of my colleagues do.

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You are right, some of the reviews of the book commented

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on my arrogance, but again, that criticism is probably fair

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to some extent but there is this fundamental tension

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in medicine, what patients want, they want individual care,

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from a doctor, they want a sense of personal responsibility

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As a doctor, most of us have this overwhelming sense of personal

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responsibility for our patients and their lives and their deaths.

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And then if you are treated as though you are just another minor

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cog in the machine it produces a lot of tension.

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Psychologists have found that many times, one of the most

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stressful situations that lab rats can be in and human beings can be

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in is to have a position of responsibility with no power,

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You've escaped the confines of the National Health Service

:21:53.:21:55.

in the UK, because a lot of your work is done abroad,

:21:56.:21:58.

in Ukraine, in Nepal, and other countries as well.

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But I want to end by asking you this - having worked

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with terrible health challenges of the brain,

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are you now frightened of your own brain,

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I am, I think it is something that haunts most people of our age,

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most of us have had one or two demented parents to care for.

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Dementia is an increasing problem in wealthy countries.

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I'm much more worried about dementia than dying.

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

:22:32.:22:34.

things like that, are very important, to try to keep it at bay.

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Interestingly, you are committed to keeping up doctoring,

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you said once, an ageing doctor is a better doctor,

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as the wheels start to fall off, you have more energy.

:22:46.:22:51.

Having said that, you need to know where to stop.

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As with everything in life as with life itself,

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best to leave too early than too late!

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But I'm not ready to stop working yet!

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We began by talking about whether you wanted an honest

:23:06.:23:08.

doctor or a doctor with a steady hand, I don't wish to be rude,

:23:09.:23:11.

but as you age, as I age, your hand becomes unsteady,

:23:12.:23:14.

I was thinking about it quite a lot when I was doing a lot of very

:23:15.:23:24.

but I ended up doing a lot of very major operating,

:23:25.:23:29.

more than I would do in this country.

:23:30.:23:31.

And I felt two things - one, I was pretty sure that purely

:23:32.:23:35.

All this operating is done with a microscope,

:23:36.:23:39.

eyesight is not an issue because everything is magnified.

:23:40.:23:42.

The other thing that struck me, which was curious,

:23:43.:23:44.

I felt increasingly ashamed and embarrassed at how crude

:23:45.:23:47.

the operating I was doing, compared with what I increasingly

:23:48.:23:49.

What I understand about the brain is from reading popular

:23:50.:23:53.

neuroscience books, not from neurological medicine.

:23:54.:23:55.

I need to gradually withdraw from operating, clearly.

:23:56.:24:01.

That's the thought I want to end with.

:24:02.:24:09.

I hope you keep going for quite some time.

:24:10.:24:12.

Thank you very much for joining us on HARDtalk.

:24:13.:24:40.

It looks as though Wednesday will start on a cold note for many

:24:41.:24:47.

But my major concern is the density of the fog.

:24:48.:24:51.

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