:00:00. > :00:00.have been arrested following the attack. Now, on BBC News it is time
:00:00. > :00:21.for HARDtalk. Imagine you are a patient about to
:00:22. > :00:27.undergo brain surgery. If it goes well, it could save your life, if it
:00:28. > :00:31.goes wrong, you could end up paralysed or dead. You want to
:00:32. > :00:38.believe your surgeon is infallible, a superhero but he is not, he is all
:00:39. > :00:45.too human, just like you. That emerges from the extraordinary
:00:46. > :00:50.honest writing from Henry Marsh, giving us a rare insight into the
:00:51. > :01:24.mind of the doctor. Is that reassuring or troubling?
:01:25. > :01:27.The very job description, "brain surgeon",
:01:28. > :01:30.I think in most people it prompts a sense of awe
:01:31. > :01:34.and maybe a little bit of fear, as well, and certainly mystery.
:01:35. > :01:37.But you've decided to lift the veil on what it is really
:01:38. > :01:41.I was subject to that myth of brain surgery myself
:01:42. > :01:44.when I decided to become a neurosurgeon many years ago.
:01:45. > :01:46.I suppose I was drawing attention to oneself,
:01:47. > :01:49.as any writer is doing when writing a book,
:01:50. > :01:54.I have been drawing attention to myself from an early age,
:01:55. > :01:59.I wanted to convey that medicine is a very uncertain,
:02:00. > :02:03.When I became a doctor, 35 years ago, doctors
:02:04. > :02:13.Doctors were not really held to account for what they did.
:02:14. > :02:16.That has changed profoundly, at least in this country,
:02:17. > :02:18.you cannot open newspapers without seeing the latest medical
:02:19. > :02:21.It is the tabloid headlines that are driving
:02:22. > :02:29.to change things in what is basically a very excellent health
:02:30. > :02:31.service that we have in this country.
:02:32. > :02:35.I wanted to show that medicine is not my going into a shop,
:02:36. > :02:39.ways much more difficult than people realise,
:02:40. > :02:41.people think neurosurgery, brain surgery is very
:02:42. > :02:46.but it is not, once you know what you are doing.
:02:47. > :02:49.But the really difficult thing is the decision-making.
:02:50. > :02:52.But the really difficult thing is the decision-making and dealing
:02:53. > :02:54.with the patients and all the human problems that arise,
:02:55. > :02:59.Well, by conveying that and focusing on the difficulty and sometimes
:03:00. > :03:02.on the fallibility of both yourself and colleagues, isn't the danger
:03:03. > :03:08.that you plant a new and horrible seed of doubt in the patient?
:03:09. > :03:11.No, I don't think so, if, if you thought it through, if...
:03:12. > :03:15.You have to go and see a doctor, if you could only choose one
:03:16. > :03:19.quality: steady hand, famous reputation, nice website...
:03:20. > :03:22...nice smile, honesty, what would you choose?
:03:23. > :03:31.No, if you do dangerous surgery, which neurosurgery certainly is,
:03:32. > :03:35.the mistakes in my experience all arise in the decision-making,
:03:36. > :03:45.Very occasionally, purely manual errors occur.
:03:46. > :03:47.But actually it is very, very unusual.
:03:48. > :03:51.And in my career, looking at my own mistakes, and colleagues,
:03:52. > :03:54.it is in the decision-making where things go wrong, that is all
:03:55. > :04:04.Indeed, and I guess that when you decided to go
:04:05. > :04:07.into brain surgery, you knew you were going into a field
:04:08. > :04:09.of medicine which came with enormous pressure.
:04:10. > :04:11.There aren't so many branches of medicine where everything
:04:12. > :04:14.that you do could lead to the most catastrophic...
:04:15. > :04:20.as I said in my book, because surgery is a blood sport, in a way,
:04:21. > :04:22.but that is not inconsistent with caring for your patient,
:04:23. > :04:24.because what makes the operation exciting
:04:25. > :04:29.That is interesting, because it's about the patient,
:04:30. > :04:31.but I want to focus on something about you.
:04:32. > :04:34.Do you have to have a supreme self-confidence bordering
:04:35. > :04:38.The answer is the balance, as all of these things.
:04:39. > :04:40.Power corrupts, and absolute power corrupts absolutely.
:04:41. > :04:43.And as surgeons we have an inordinate amount of power,
:04:44. > :04:45.and it is very easy to become arrogant.
:04:46. > :04:48.I guess you need to be insensitive to some extent.
:04:49. > :04:51.This is the whole challenge of all medicine, visible and acute
:04:52. > :04:53.in something like brain surgery, finding the balance
:04:54. > :04:58.between compassion and professional detachment.
:04:59. > :05:01.One way of illustrating that is to say, obviously,
:05:02. > :05:04.the only ethic in medicine is we should only treat patients
:05:05. > :05:08.as we would wish ourselves or our family to be treated.
:05:09. > :05:11.But it's almost impossible to operate on somebody you know well,
:05:12. > :05:14.Finding the balance between compassion and
:05:15. > :05:17.Compassion and detachment is one element but also
:05:18. > :05:23.Do No Harm, and your other writings about the work over many decades,
:05:24. > :05:26.you, as you have gained an experience and reputation,
:05:27. > :05:31.have actually become more self doubtful.
:05:32. > :05:42.you master the purely technical skills of operating,
:05:43. > :05:45.where mistakes arise is in the decision-making.
:05:46. > :05:50.partly because I am in the latter years of my career,
:05:51. > :05:55.that other people are better at seeing my mistakes than I am.
:05:56. > :05:57.It is a profound truth that applies to all of us,
:05:58. > :06:00.we are very bad at seeing our own mistakes.
:06:01. > :06:03.There is a problem in medicine of finding a balance
:06:04. > :06:08.ditto, you need the arrogance and self belief to do the operating
:06:09. > :06:11.but it is critical that you have a good working
:06:12. > :06:13.relationship with your colleagues as well.
:06:14. > :06:19.So that they can criticise you and you can criticise them.
:06:20. > :06:23.Actually that is very difficult to get doctors to do on the whole.
:06:24. > :06:26.Let's get specific and talk about a case, that you have
:06:27. > :06:29.It's a troubling case, early in your career.
:06:30. > :06:32.I think he was a teacher, a man in his late 50s,
:06:33. > :06:37.who came to you with a huge brain tumour, and you were appalled by it.
:06:38. > :06:41.you say you were quite excited,
:06:42. > :06:43.you had never seen anything quite like it.
:06:44. > :06:46.He was sent off to see another consultant, even
:06:47. > :06:52.more senior than you, and it was pushed back
:06:53. > :06:56.to you and they said, you know what, Henry, you deal with it.
:06:57. > :07:00.You went for it, and you were quite excited,
:07:01. > :07:02.the biggest operation you had ever undertaken.
:07:03. > :07:08...You sucked out virtually all of this tumour,
:07:09. > :07:13.towards the end of the operation, I could stop now, but dammit,
:07:14. > :07:16.I am going to get every single trace of this tumour out.
:07:17. > :07:20.you had accidentally severed a branch of an artery
:07:21. > :07:25.The mistake was not severing the artery, the mistake
:07:26. > :07:27.was deciding to remove the last bit of tumour.
:07:28. > :07:35.The answer is, all neurosurgeons have terrible periods...
:07:36. > :07:38.terrible disasters and terrible periods of despair.
:07:39. > :07:40.When I first became a consultant,
:07:41. > :07:45.I felt quite ill and sick and miserable for weeks on end
:07:46. > :07:49.You have to go on working because you do,
:07:50. > :07:53.Does it change the way that you work, we have
:07:54. > :08:00.talked already about about confidence, and self-doubt...
:08:01. > :08:04.You need to deceive yourself to some extent.
:08:05. > :08:08.I mean, it is one of the ironies of medicine, that a lot
:08:09. > :08:12.It is something you learn very early on as a young doctor,
:08:13. > :08:16.patients do not want a doctor who says, "I don't know what to do,
:08:17. > :08:20.We want our doctors to be experienced and competent,
:08:21. > :08:23.and by my stage, that is easy, because I am experienced,
:08:24. > :08:26.but when you are a young doctor you are not experienced.
:08:27. > :08:28.If you don't take on the difficult cases,
:08:29. > :08:33.You face this ethical problem right from the start,
:08:34. > :08:36.the moment you qualify as a doctor, suddenly you have to start lying
:08:37. > :08:39.to patients, to some extent, you have to pretend a greater degree
:08:40. > :08:42.of competence and confidence than you really feel you have.
:08:43. > :08:45.And the best way of deceiving other people is deceiving yourself.
:08:46. > :08:48.It is a necessary self belief, self-deception, to help one cope.
:08:49. > :08:54.But as you get older, perhaps you can start trying to dispense
:08:55. > :08:59.I wonder whether that incident, and others like it, you very
:09:00. > :09:02.honestly say come you went to a hospital that specialised
:09:03. > :09:09.And others, and you said, you saw for five people on this ward,
:09:10. > :09:11.who you operated on, and they were, in essence,
:09:12. > :09:16.I'm just wondering whether the threshold of risk
:09:17. > :09:22.that you are prepared to take, changed over time?
:09:23. > :09:25.It goes up and down, is the answer, after that
:09:26. > :09:29.case that you mentioned, I became, in a sense,
:09:30. > :09:33.over conservative, but again reflected the working environment
:09:34. > :09:40.Over the years I discover that the way to do these
:09:41. > :09:42.really difficult cases, and they are really rare,
:09:43. > :09:46.you only see a handful, is to do them with another colleague.
:09:47. > :09:51.When I was working in Nepal recently,
:09:52. > :09:55.we had one or two cases like that, and my colleague was on his own,
:09:56. > :09:58.he runs his own hospital, he said how wonderful
:09:59. > :10:02.I think a more collaborative way of working is very
:10:03. > :10:11.to take on the risk of a very difficult operation, which you know
:10:12. > :10:14.has a serious risk of, as you put it sometimes,
:10:15. > :10:17."catastrophic consequences", or whether it is more
:10:18. > :10:21.difficult to tell a patient, who is desperate for you to operate,
:10:22. > :10:24.even though you have explained all the risks, that in your view,
:10:25. > :10:27.it is simply not the right decision and that nature has
:10:28. > :10:35.That you feel there is nothing more you can give them.
:10:36. > :10:39.It depends to some extent on the nature of the problem.
:10:40. > :10:45.It is harder to say, go away, live with it,
:10:46. > :10:53.Sometimes, sometimes you say that death is the better outcome.
:10:54. > :10:56.And with experience you learn, and I see this with my younger
:10:57. > :11:00.colleagues, I see them operating on cases which I would have done,
:11:01. > :11:04.which I did at my stage in their career,
:11:05. > :11:12.I no longer do emergency work in this country but when I was
:11:13. > :11:15.you are often telephoned at night by the junior doctors
:11:16. > :11:18.I should add that emergency neurosurgery
:11:19. > :11:34.Is it removing blood cots, it isn't difficult.
:11:35. > :11:36.But the decision-making, whether it is worth operating or not,
:11:37. > :11:40.These are people with head injuries and strokes where,
:11:41. > :11:43.in simple and strokes, in simple terms, if you don't operate,
:11:44. > :11:47.they will die, if you do operate, they may survive that they may be
:11:48. > :11:51.And it's a bit like Nero at the Roman games,
:11:52. > :11:54.if I say thumbs up, operate, I get back to sleep.
:11:55. > :11:57.If I say, let them die, I don't, because I worry that
:11:58. > :12:01.There is a built-in asymmetry which always forces us to overtreat
:12:02. > :12:04.Is it important for you to get to know your patients before
:12:05. > :12:09.Well, I used to think it was, that is an interesting question,
:12:10. > :12:13.my son had, as I say in my book, my son had a brain gym
:12:14. > :12:17.my son had, as I say in my book, my son had a brain tumour
:12:18. > :12:25.he's not necessarily the reason I became a Paediatric brain surgeon.
:12:26. > :12:28.I don't know what other doctors are like, but I always felt it
:12:29. > :12:38.gave me a certain understanding and sympathy of what my patients
:12:39. > :12:40.were going through, because I have been through it myself.
:12:41. > :12:44.Therefore I felt it was an essential part to be actually quite close
:12:45. > :12:49.Although that is partly selfish, if you are close to them,
:12:50. > :12:51.if things go wrong, they are likely, they are less likely
:12:52. > :12:55.It is selfish and unselfish, because it also means
:12:56. > :12:59.And therefore it is more hurtful and damaging.
:13:00. > :13:02.When I was working in Nepal, admittedly, my colleague and his
:13:03. > :13:05.team, because of the language barrier, were doing all the talking
:13:06. > :13:09.with the patients, so I was ending up operating on patients I had not
:13:10. > :13:12.seen before, and scarcely saw afterwards.
:13:13. > :13:15.Which in the past to me would have been complete anathema.
:13:16. > :13:20.I was just as focus and intense and anxious
:13:21. > :13:30.Let me switch focus a little bit and talk
:13:31. > :13:36.This most may amazing organ of ours, it is so complex,
:13:37. > :13:45.And yet you approach it with, sometimes drills, saws,
:13:46. > :13:50.and there is some thing quite bizarre about what
:13:51. > :13:59.Something I took for granted when I was younger but for various
:14:00. > :14:04.reasons, as I get older, I am more and more amazed by this
:14:05. > :14:07.fundamental mystery, everything you and I are thinking
:14:08. > :14:16.and feeling at the moment, is electric.
:14:17. > :14:18.It doesn't feel like electric chemistry, it feels
:14:19. > :14:21.But we are the product of the electrical chemical
:14:22. > :14:27.What is fascinating, modern science, we cannot even begin to explain how
:14:28. > :14:30.thoughts and feelings and consciousness arises,
:14:31. > :14:39.Your career has spanned 35 years or so, in brains.
:14:40. > :14:42.You saying to me that in those 35 years, in brains,
:14:43. > :14:45.are you saying that in those 35 years you have learned very little
:14:46. > :14:48.more about how the electrochemistry is works, and how...
:14:49. > :14:51.It is like saying we know how a brick is made.
:14:52. > :14:54.It doesn't tell us anything about the house made by the bricks.
:14:55. > :14:57.So although there is a huge amount of neuroscience going on,
:14:58. > :14:59.what really interests us, as human beings,
:15:00. > :15:05.is ourselves, our own feelings and consciousness.
:15:06. > :15:13.We cannot experiment upon it, you see, either.
:15:14. > :15:16.You write lyrically about this, at one point you write
:15:17. > :15:18.about being struck during an operation,
:15:19. > :15:28.that you sucked jelly out of the brain with,
:15:29. > :15:31.you say - "My sucker is moving through thought itself,
:15:32. > :15:34.through emotion, and that reason, memory and dreams should consist
:15:35. > :15:36.of this jelly is simply too strange to understand."
:15:37. > :15:42.Literally, how dare you suck out all of this jelly when you might be
:15:43. > :15:44.sucking out people's imaginations or thoughts or dreams?
:15:45. > :15:48.The answer to that is the illness you are trying to treat is even
:15:49. > :15:49.worse than the operation, so to speak.
:15:50. > :15:53.Coming back to the question, how do surgeons cope with bad
:15:54. > :15:55.results and convocation, well, you think of the good result,
:15:56. > :16:00.and you know that most of the time, things go well, and for all the poor
:16:01. > :16:02.patients who have not done well in my hands,
:16:03. > :16:04.hopefully there will be hundreds, if not thousands
:16:05. > :16:09.That is ultimately what the balance is about.
:16:10. > :16:12.It is terribly important, maybe it is partly my personality,
:16:13. > :16:14.but success is corrupting, success makes us
:16:15. > :16:21.The worst surgical crime for me is complacency.
:16:22. > :16:23.You mustn't dwell permanently on your complications
:16:24. > :16:30.It is terribly important to remain as humble and modest as you can,
:16:31. > :16:32.even though you must present as more confident and assured
:16:33. > :16:38.Before we go back to practical matters of health care,
:16:39. > :16:41.one more question on the more philosophical side of what you do,
:16:42. > :16:45.you just said to me, I believe in science with a S,
:16:46. > :16:47.but you know, for centuries, philosophers, scientific
:16:48. > :16:50.thinkers, have posited the notion that in the end, our mind,
:16:51. > :16:53.our soul is separate from the physical reality of this
:16:54. > :17:03.Are you telling me that you are absolutely convinced
:17:04. > :17:08.there is no possibility of that being true?
:17:09. > :17:25.I find that infinite mystery rather reassuring.
:17:26. > :17:28.We all know the macrocosm of the Big Bang, all this stuff
:17:29. > :17:30.recently about the anniversary of Einstein's theory of relativity,
:17:31. > :17:34.each of us within our own head and our own consciousness is sitting
:17:35. > :17:38.on a mystery as great as the Big Bang.
:17:39. > :17:42.I'm sure that you have read the science papers which address
:17:43. > :17:44.near death experiences, and under scientific conditions can
:17:45. > :17:47.recollect experiences they have had when nominally the machinery has
:17:48. > :18:03.near death experiences are well recognised as a phenomenon.
:18:04. > :18:06.But they come out of the electrochemistry of the brain,
:18:07. > :18:12.Back to health care, we have talked about you,
:18:13. > :18:18.as an individual doctor, surgeon, and how you have approached
:18:19. > :18:20.a career dealing with the most terrible sort of challenges
:18:21. > :18:29.is exist within a vast health care system, one small cog,
:18:30. > :18:35.Seems to me that you have become very disillusioned
:18:36. > :18:41.You have to look at the NHS internationally,
:18:42. > :18:43.first thing, and if you look at the NHS...
:18:44. > :18:51.There is a lot of criticism in England, you cannot read
:18:52. > :18:54.the newspapers without seeing, some mistake in a hospital and
:18:55. > :18:59.As if it's the responsibility of the NHS as a whole.
:19:00. > :19:01.The National Health Service provides, by international
:19:02. > :19:03.standards, very good health care in terms of overall outcomes
:19:04. > :19:10.Do you still believe in "socialised medicine",
:19:11. > :19:13.I believe passionately in socialised health care,
:19:14. > :19:16.because I have worked and visited so many countries where
:19:17. > :19:21.medicine is commercial and it is terrible, because...
:19:22. > :19:27.But it comes back to the fact that medicine is not
:19:28. > :19:29.like going into a shop and buying something.
:19:30. > :19:32.A, the patients are not in a good position to judge
:19:33. > :19:36.what is good for them, and B, a lot of the decision-making is very
:19:37. > :19:40.And if you look at countries like America, sure, American health
:19:41. > :19:43.care at its best is fantastic, but it is extravagant.
:19:44. > :19:45.All countries in the world, health care costs are rocketing
:19:46. > :19:48.above the rate of inflation, and, I'm afraid, if doctors
:19:49. > :19:51.have a financial interest in what they are doing,
:19:52. > :19:54.they tend to do more and a lot of it is unnecessary.
:19:55. > :19:56.Your message seems to be, taking the British case,
:19:57. > :20:07.of a socialised system which is free at the point of delivery,
:20:08. > :20:10.but politicians have to be more honest that at a time of rising
:20:11. > :20:12.health care costs and ageing populations, politicians
:20:13. > :20:16.need to say to people, you can have this but you are going
:20:17. > :20:19.to need to pay more tax, or you have to accept greater
:20:20. > :20:24.It is basic economics, if you have a good that is free
:20:25. > :20:28.at the point of delivery and scarce supply, you end up with queues,
:20:29. > :20:30.and having all of these targets, introduced by the previous
:20:31. > :20:31.government, can be counter-productive.
:20:32. > :20:37.I don't think they are OK but you have to prioritise and deal
:20:38. > :20:40.with the emergencies first, if you give equal priority
:20:41. > :20:42.to nonurgent cases, then urgent work suffers.
:20:43. > :20:45.A lot of people have made the point about the organisations
:20:46. > :20:48.and the chaos in the system, but it seems to be another
:20:49. > :20:51.interesting point about you, coming back to a word I used
:20:52. > :20:54.earlier, arrogance, you don't like being told what to do
:20:55. > :20:57.by managers, you don't like being told that you can't wear
:20:58. > :21:00.a tie during surgery and you can't wear a wristwatch, you get
:21:01. > :21:02.angry that your car park space has been moved.
:21:03. > :21:06.I don't drive a car, I ride a bicycle, I don't have that
:21:07. > :21:08.particular problem that many of my colleagues do.
:21:09. > :21:11.You are right, some of the reviews of the book commented
:21:12. > :21:15.on my arrogance, but again, that criticism is probably fair
:21:16. > :21:17.to some extent but there is this fundamental tension
:21:18. > :21:19.in medicine, what patients want, they want individual care,
:21:20. > :21:22.from a doctor, they want a sense of personal responsibility
:21:23. > :21:33.As a doctor, most of us have this overwhelming sense of personal
:21:34. > :21:36.responsibility for our patients and their lives and their deaths.
:21:37. > :21:39.And then if you are treated as though you are just another minor
:21:40. > :21:42.cog in the machine it produces a lot of tension.
:21:43. > :21:45.Psychologists have found that many times, one of the most
:21:46. > :21:48.stressful situations that lab rats can be in and human beings can be
:21:49. > :21:52.in is to have a position of responsibility with no power,
:21:53. > :21:55.You've escaped the confines of the National Health Service
:21:56. > :21:58.in the UK, because a lot of your work is done abroad,
:21:59. > :22:01.in Ukraine, in Nepal, and other countries as well.
:22:02. > :22:04.But I want to end by asking you this - having worked
:22:05. > :22:08.with terrible health challenges of the brain,
:22:09. > :22:10.are you now frightened of your own brain,
:22:11. > :22:18.I am, I think it is something that haunts most people of our age,
:22:19. > :22:21.most of us have had one or two demented parents to care for.
:22:22. > :22:24.Dementia is an increasing problem in wealthy countries.
:22:25. > :22:31.I'm much more worried about dementia than dying.
:22:32. > :22:34.The evidence is fairly clear, keeping busy, physical exercise,
:22:35. > :22:37.things like that, are very important, to try to keep it at bay.
:22:38. > :22:42.Interestingly, you are committed to keeping up doctoring,
:22:43. > :22:45.you said once, an ageing doctor is a better doctor,
:22:46. > :22:51.as the wheels start to fall off, you have more energy.
:22:52. > :22:56.Having said that, you need to know where to stop.
:22:57. > :23:01.As with everything in life as with life itself,
:23:02. > :23:03.best to leave too early than too late!
:23:04. > :23:05.But I'm not ready to stop working yet!
:23:06. > :23:08.We began by talking about whether you wanted an honest
:23:09. > :23:11.doctor or a doctor with a steady hand, I don't wish to be rude,
:23:12. > :23:14.but as you age, as I age, your hand becomes unsteady,
:23:15. > :23:24.I was thinking about it quite a lot when I was doing a lot of very
:23:25. > :23:29.but I ended up doing a lot of very major operating,
:23:30. > :23:31.more than I would do in this country.
:23:32. > :23:35.And I felt two things - one, I was pretty sure that purely
:23:36. > :23:39.All this operating is done with a microscope,
:23:40. > :23:42.eyesight is not an issue because everything is magnified.
:23:43. > :23:44.The other thing that struck me, which was curious,
:23:45. > :23:47.I felt increasingly ashamed and embarrassed at how crude
:23:48. > :23:49.the operating I was doing, compared with what I increasingly
:23:50. > :23:53.What I understand about the brain is from reading popular
:23:54. > :23:55.neuroscience books, not from neurological medicine.
:23:56. > :24:01.I need to gradually withdraw from operating, clearly.
:24:02. > :24:09.That's the thought I want to end with.
:24:10. > :24:12.I hope you keep going for quite some time.
:24:13. > :24:40.Thank you very much for joining us on HARDtalk.
:24:41. > :24:47.It looks as though Wednesday will start on a cold note for many
:24:48. > :24:51.But my major concern is the density of the fog.