28/12/2016 HARDtalk

Now it's time for HARDtalk.

Welcome

Welcome to

Welcome to HARDtalk.

Welcome to HARDtalk. I

Welcome to HARDtalk. I am

Welcome to HARDtalk. I am Stephen

Welcome to HARDtalk. I am Stephen Sackur.

Imagine you are a patient about to undergo brain surgery.

If it goes well it could save your life, if it goes wrong you could end

up paralysed or dead.

Of course you want to believe your surgeon is infallible,

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

just like you.

And that simple truth emerges from the extraordinary honest

writing of my guest today, one of Britain's leading brain

surgeons, Henry Marsh.

He has given us rare insight into the mind of the doctor.

Is that reassuring or troubling?

Henry Marsh, welcome to HARDtalk.

Thank you.

The very job description brain surgeon, for most people it prompts

a sense of awe and maybe fear as well.

And certainly mystery.

You have decided to lift the veil on what it is really

like and I wonder why.

I have been subject to that myth of brain surgery myself.

I became a neurosurgeon many years ago.

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

from an early age.

I wanted to convey that medicine is a very uncertain,

imprecise business.

When I became a doctor 35 years ago, doctors buried their mistakes.

There was deference and trust.

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

That has changed profoundly, at least in this country.

You cannot open the newspapers without seeing the latest medical

scandal.

It is the tabloid headlines that drive the politicians to believe

mistakenly that they can change things in what is a very

excellent health service.

Patients are not consumers, it's not like a shop.

Doctors are doing something in many ways much more difficult

than what people realise.

People think brain surgery is difficult technically.

Well, it is not actually.

The really difficult thing is the decision-making and dealing

with the patients and all the human problems that arise.

I wanted to convey that.

By conveying that and focusing on the difficulty and sometimes

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

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

I do not think so.

If you had to go and see a doctor and you could only choose one

quality, either steady hands, famous reputation, nice website,

nice smile, we would all go with honesty.

If you do dangerous surgery, which neurosurgery certainly is,

the mistakes all arise in the decision-making.

It is not about dropping something, it is not like that.

Occasionally purely manual errors occur, but it is very unusual.

In my career, looking at my colleagues, it is in

the decision-making where things go wrong.

That is all about thinking and psychology.

When you decided to go into brain surgery, you knew

you were going to a field of medicine that came

with enormous pressure.

There aren't many branches of medicine where anything

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

You become a surgeon because surgery is a blood sport in a way.

That's what I say in my book.

That is not inconsistent with caring for your patience.

What is making it exciting is being worried your patient

should do well.

That's fine, but focussing on you.

Is it fair to say you have to have supreme confidence,

maybe bordering on arrogance to become a brain surgeon?

It is all about balance.

Absolute power corrupts absolutely.

We have an enormous amount of power and it is easy to become arrogant.

You need to be insensitive to some extent.

This is a challenge of all medicine.

It is visible and acute in something like brain surgery.

Finding the balance between compassion and detachment.

The only ethic in medicine, some say, is we should only treat

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

But it is almost impossible.

Finding that balance between compassion and detachment

is difficult.

That's one element of it, but also self belief and self-doubt.

It seems to me reading your book and other writings about the work

you have done, as you have gained an experience and reputation,

you have become more self doubtful.

Very much so.

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

of operating, where mistakes arise is in the decision-making.

I believe now that other people are better at seeing my mistakes

than I am.

That is a divine truth that applies to all of us,

we are very bad at seeing our own mistakes.

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

but it is critical you have a good working relationship

with your colleagues as well so they can criticise

you and you can criticise them.

That is difficult to get doctors to do.

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

very honest about.

It's a troubling case.

Earlier in your career, there was a man in his late 50s

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

Appalled and excited.

You said you'd never seen anything like it.

He was sent off to see another consultant even more

senior than you.

He pushed it back to you and said, Henry,

you do it.

It is a young man's operation.

Exactly.

And you were quite excited.

It was a dozen hours or more.

It was longer than that and it went badly.

You said to yourself, I could stop now, but I will get

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

you had accidentally severed a branch of an artery

and the man never recovered.

The mistake was not severing the artery, it was deciding

to remove that last bit of tumour.

How do you live with that?

The answer is all neurosurgeons have terrible disasters

and periods of despair.

When I first became a consultant, my first few bad results I felt

quite sick and miserable for weeks on end.

You have to go on working.

In a sense you accept it.

Has it changed the way you work?

We have talked about confidence and self-doubt.

You develop blinkers.

You need to deceive yours elf to some extent.

One of the ironies of medicine is a lot of medicine is an act.

Very early on as a young doctor you learn the patient does not want

the doctor to say, I do not know what to do.

We want our doctors to be experienced and confident.

In my case, that is easy, because I am.

But younger doctors are not.

If you do not take on the difficult cases, how will you get better?

You face an ethical problem from the moment you become a doctor,

you have to start lying to patients.

You have to pretend you are confident.

You must deceive other people in order to deceive yourself.

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

It is not a bad thing.

As you get older, you can try to dispense with some of it

and treat patients more as equals.

I wondered with that incident and others like it,

you are very honest, you went to a hospital that

specialised in long-term care.

I saw that patient years later.

You operated on people who were in essence brain damaged.

I wonder what threshold of risk you are prepared to take

changed over time?

It goes up and down, is the answer.

After the case you mentioned, I became over conservative.

But it again reflected the working environment I was in 25 years ago.

Over the years, I discovered the way to do really difficult cases,

they are very rare, so you only see a handful.

When I was working in Nepal recently we had a couple of cases like that.

My colleague was on his own, he runs his own hospital.

My colleague said, how wonderful of you to share an operation.

A more collaborative way of working is very important in modern surgery.

A thought, I wonder if it is more difficult to take on the risk

of a very difficult operation which you know has a serious risk

of sometimes catastrophic consequences.

But whether it is more difficult to tell a patient who is desperate

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

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

to take its course.

And you feel there is nothing more you can do for them.

Which is harder?

It depends on the nature of the problem.

I think it is harder to do nothing.

Do you?

It is harder to say, go away and die.

That is very difficult.

Sometimes you say it is the better outcome.

Yes, you learn with experience.

I see my younger colleagues operating on cases which I did

at that stage of my career which now I wouldn't.

I no longer do emergency work, but when I was I was often

called about emergencies.

Emergency neurosurgery is actually very simple.

It's not the lazy consultant refusing to get out of bed.

The actual operating is very easy.

It is based on moving blood clots.

But the decision on whether it is worth operating is very difficult.

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

If you do operate, they may survive, but they might be left disabled.

It's like the Roman games, If I say, thumbs up,

operate, I get back to sleep.

If I say thumbs down, I do not.

There's a symmetry.

Is it important for you to get to know your patience before operating?

I used to think it was.

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

He was a few months old.

I was doing general surgery.

That is not why I became a brain surgeon myself.

It gave me a certain understanding and sympathy of what my patients

were going through.

They say an essential part of the operating was to be quite

close to the patients and their families.

That is partly selfish.

If you are close to them and things go wrong,

they are less likely to lose trust in you.

It is selfish and not selfish because you are more invested

in the case emotionally.

In Nepal my colleague and his team were doing all the talking

because of the language barrier.

I was operating on patients I hadn't seen before

and would scarcely see after.

In the past it would have been complete anathema.

It did not make a difference.

I was just as focused and intense about the operating.

That was a surprise to me.

I was better than I expected.

Let me switch focus and talk to you about this most amazing

organ of ours.

It is so complex, it is so mysterious in many ways.

And yet you approach it with sometimes drills,

saws, knives and suckers and there is something quite

bizarre about that.

And yet you approach it with sometimes drills, saws,

knives and suckers and there is something quite bizarre about that.

It is utterly bizarre.

It is something, in a sense, when I was younger, I rather took for

granted but, for various reasons, as I get older, I am more and more

amazed by this fundamental mystery.

Everything you and I are thinking and feeling at

the moment is electricochemistry.

It doesn't feel like electricochemistry.

It feels free and insubstantial but we are the product of the electrical

chemical activity of nerve cells.

And although I'm a complete believr in science with

a capital "S," what is fascinating is that modern science...

we cannot even begin to explain how thoughts and feelings,

our consciousness arises We just do not know...

Your career has spanned 35 years or so, in brains - are you saying

to me that in those 35 years you have learnt very little more about

how the electrochemistry works?

Yes.

How thought, consciousness...

We know how a brick is made but it is not tell us anything

about the house made by the bricks.

So although there's a huge amount of neuroscience going on,

what really interests us as human beings is ourselves,

our feelings and consciousness.

You can't experiment on it, you see, either.

You write lyrically about this.

At one point you write about being struck, during

an operation, that your sucker, as you call it, your kind of Hoover

thing that you suck jelly out of...

You say, "my sucker is moving through thought

itself, through emotion and that reason, memories and dreams

should consist of this jelly is simply too strange to understand."

It is the last great...the great mystery.

My question is, how dare, how, literally, dare you suck out all

of this jelly when you might be sucking out people's imaginations

or thoughts or dreams!

Well, the answer to that is the illness

you're trying to treat is even worse than the operation, so to speak.

I mean, coming back to the question, how do surgeons cope with

their bad results and complication?

Well, you think of the good results and you know that

most of the time things go well.

For all the poor patients who have not done well in my hands,

there are, hopefully, made hundreds or even thousands who have.

I think we know that's true.

That is what ultimately the balance is about.

Sure.

But it is terribly important...maybe

it's partly my personality..

But, you know, success is corrupting.

Success makes us complacent and spoils us.

The worse surgical crime, for me, is complacency.

I'm not saying...you

mustn't dwell constantly on your complications -

you must never forget them.

You tend to forget them but it is terribly important to

remain as humble and modest as you can even though you must

present a more confident and assured outside to the patient.

Before we get back to practical matters of health care,

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

You just said to me, "I'm a scientist.

I believe in science with a capital S."

But you know, for centuries, philosophers and scientific thinkers

have posited the notion that, it the end, our mind, our soul, maybe, is

separate from the physical reality of this thing between our ears.

Are you telling me you absolutely are convinced there is no

possibility of that being true?

I think it is highly unlikely.

(LAUGH).

One way to put it.

Deeply improbable.

The brain is everything.

We do not understand how it works and maybe we never will.

I find that infinite mystery actually reassuring.

We all know the macrocosm of the big bang - all this stuff

recently about the anniversary of Einstein's general relativity.

Each of us, with our own head, our own consciousness, is sitting on

a mystery as great as the big bang.

So...I'm

sure you have read the science papers that address

near-death experiences and the notion that people credibly

and under scientific conditions can recollect experiences they've had

when normally the machinery has told us that they are brain dead.

But you think it is a mirage?

It is a complicated area.

Brain-dead is rather different.

Near-death experiences are a well recognised phenomenon ...pfft...

But they come out of...

CROSSTALK.

Back to healthcare.

We have talked about you as an individual doctor,

surgeon and how you have approached a career dealing with the most

terrible challenges in the brain.

That's one part of what you do.

Another part of what you've done for years is exist within a vast

health-care system, beeing one small cog component in a huge machine.

It seems to me you have become disillusioned with that machine?

Yes and no.

You have to look at the NHS internationally,

firstly and if you look...

CROSSTALK

There is a lot of criticism in England about the NHS.

You can't read the newspapers without them saying, you know

some mistake in a hospital.

And the headlines say, "Shame the NHS."

That it's the responsibility of the NHS.

The National Health Service provides,

by international standards, very good healthcare in terms of overall

outcomes in life expectancy...

The Americans would call it socialist healthcare...

Passionate!

Passionate in socialized healthcare.

I have worked and visited so many countries where medicine is

commercial and it is terrible...

It is not if you can pay for it.

It comes back to the fact that medicine is not like going

into a shop and buying something.

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

what's good for them.

B, a lot of the decision-making is very unclear and very grey.

If you look at countries like America - sure,

at its best it is fantastic - but it is incredibly extravagant.

In all countries, healthcare costs are rocketing

above the rate of inflation.

I'm afraid if doctors have a financial interest in what they

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

Taking British case of a socialised system which is free

at the point of delivery, politicians have to be more honest

that at a time of rising healthcare costs and an ageing population,

politicians need to say to people, you can have this system...

..but

you need to pay more.

Pay more tax or accept greater rationing.

Exactly.

It is basic economics.

If you have a good which is free at the point od delivery but is

in scarce supply, you end up with queues.

Having all these targets, introduced by the previous government,

can be counterproductive.

You think queues are OK?

No, I don't think they're OK.

But you have to prioritise and deal with the emergencies first.

If you give equal priority on urgent cases, the emergency work suffers.

A lot of people have made points about the organisation, and you

call it the chaos, in the system.

But it seems to me there's another interesting point about you

and it comes back to the word I used earlier, arrogance.

Yes.

You do not like being told what to do by managers.

Exactly.

You do not like being told to can't wear a tie

or a wristwatch, you get angry that your car park has been taken...

I do not drive a car I ride a bicycle everywhere so I don't

have that particular problem.

You are right.

Some of the reviewers of my book comment on my arrogance

but, again, that criticism is probably fair to some extent but

there is this fundamental tension in medicine what patients want...

They want individual care from a doctor.

They want a sense of personal responsibility from an individual.

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

responsibility for our patients and for their lives and their death.

If you are treated as just another minor cog in the machine,

it produces a lot of tension.

Psychologists will say many times one of the most stressful situations

- lab rats or human beings - to have a position

of responsibility with no power.

And that's very stressful.

You have escaped the confines of NHS.

A lot of your work is done abroad abroad - Ukraine, Nepal.

I want to end by asking you this, having worked for

so long with sick people, with terrible health challenges of

the brain, are you now frightened of your brain and deterioration?

Oh, yes, I am.

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

Dementia is an increasing problem in wealthy countries

and it bothers me greatly.

I much more worried about dementia than dying.

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

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

ultimately.

You are committed to keeping on doctoring.

You said an ageing doctor is a better doctor because

if the wheels start to fall off you have more empathy.

You are more sympathetic, yes.

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

Everything in life has a life itself.

Best to leave too early rather than too late.

We began by talking about...

I'm not ready to stop yet..

We began by talking about whether you wanted an honest doctor

or a doctor with a steady hand.

I mean, I don't wish to be sort of rude but, as you age, as I age,

your hand gets a bit unsteady, your eyesite isn't quite so good.

Do you think about these things?

I have been thinking about it quite a lot when I was

operating in Nepal - I was mainly there to teach but I ended up doing

a lot of major operating, more than I would do in this country,

in fact - and I felt two things.

One, I was pretty sure that purely manually I was as good as I was.

My operating is done with a microscope

so eyesight isn't an issue.

But I felt increasingly ashamed and embarrassed at how crude

the operating I was doing was compared to what I increasingly

understand about the brain.

It's from neuroscience books not from neurosurgical medicine.

That struck me.

I need to gradually withdraw from operating, clearly but not yet.

Not yet, please.

I hope you keep going for quite sometime.

I still totally in love with it.

Dr Henry Marsh, it has been a pleasure.

Thank you.

Thank you very much indeed.

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

parts of the British Isles.

Certainly in England and Wales.

But my major concern is the density of the fog.

Quite a widespread issue as we start the new day.