Niamh Brooks: “To be a good doctor can be painful”—career advice from Henry Marsh

What does it take to be a good doctor today?

Henry Marsh

“I don’t want to put you off,” says retired neurosurgeon Henry Marsh to a group of junior doctors and trainees at St George’s Hospital, London. “However, to be a good doctor can be painful.”

But the audience at St George’s needs no reality check. One person at his talk asks Marsh how doctors can prepare for a career that is so easily threatened by litigation. Another asks about his greatest mistake in medical practice. There’s plenty of evidence that the “pain” of being a doctor is appreciated, if not yet experienced.

In his newest book Admissions, Henry Marsh reflects on his career with pride and a sense of privilege, but also says, “I am not sure if I would take up medicine or neurosurgery now, if I could start my career all over again.” This is partly because of his preference for some of the more challenging surgical work (operating on cerebral aneurysms, for example), which has now become redundant. But he also mentions how difficult it can be for today’s doctors to find support and the amount of regulatory bureaucracy they face. Doctors are required to be empathetic and at the same time ever conscious of blame and litigation, he says.

As a young person, Marsh did not plan to go into neurosurgery, or even into medicine. After an unhappy spell at Oxford University he dropped out of a degree course in politics, philosophy, and economics and took a job as a porter at a hospital near Newcastle. “I hoped that by seeing other people suffering with ‘real,’ physical illness I would somehow cure myself,” he says. During that time he was inspired by the hospital’s general surgeon, the father of a friend, who gave him a job in the operating theatre. “I find it extraordinary that he did this,” Marsh says, “just as I find it remarkable that my Oxford college agreed that I could return after a year’s truancy.”

Marsh recognises that his experience of pursuing a medical career was very different to that of today’s UK students. “We are one of the few countries in the world that specialises so early (most students in the UK study three subjects at age 16+, with the emphasis on sciences for medicine), and yet many areas of medicine don’t require such in depth scientific knowledge,” he says. “Surgery, for example needs a very specific set of skills and the technical side is relatively straightforward to learn. It’s the decision making that’s difficult, because of the uncertainties involved.”

Instead, medicine relies on critical thinking, assessing evidence, and decision making based on probabilities rather than certainties, Marsh says. Above all, being a good doctor requires the ability to listen. Medical students and doctors are increasingly encouraged to hone their communication skills, and to put themselves in their patients’ shoes. But Henry Marsh steers clear of the word “empathy,” preferring instead “rational compassion.”

“You shouldn’t be unaffected by what your patients are going through—you do need to have the emotional needs of the patient and their family in sight—but in reality you will keep your patients and their families at bay,” he says. “If you did [empathise] at all times you’d never get your job done.”

Marsh says that the most successful doctors are those who “get on” with colleagues in all areas of their working environment, from nurses to cleaners, to senior consultants. “Gone are the days of surgeons discarding their gowns on the floor of the scrubs room for someone else to pick up.” This is especially important since higher staff turnover and shift work mean that junior doctors today are less likely to experience the camaraderie that Marsh’s generation did when they worked in one place for an extended period, or with the same group of colleagues. Junior doctors now have shorter working hours, but they have fewer opportunities to consult managers and mentors, Marsh notes. This can lead to the feeling that “you are a small cog in a big machine.”

In Admissions he recounts an incident where he rages against a nurse for refusing to follow his instruction in a patient’s postoperative care. Describing himself as “overcome with rage and almost completely out of control,” he later feels contrition and shame at his impulsive response. But the incident also highlights his frustration with the hospital’s systems, where patient care seems uncoordinated, and there is little rapport between hospital staff. It is only because one colleague has “some of the comradely atmosphere of the old hospital” that Marsh is saved from facing formal disciplinary proceedings.

Good senior leadership and an apprenticeship between junior and senior doctor will help the junior doctor learn from their mistakes, Marsh says. “And you will make many mistakes in your career. They are shattering experiences because patients expect us to be superheroes.” His advice to junior doctors is, “don’t be ashamed. Speak up—never just plough on regardless if you’re unsure about something.”

At the same time, he says in Admissions: “I wish the authorities in the UK understood just how difficult it is for a doctor to say sorry […] the General Medical Council orders us to tell patients whenever a mistake has been made, both in person and in writing—it’s usually the duty of the senior clinician responsible for the patient to do this, and to apologise, irrespective of who had made the mistake.” But (and he continues to quote the GMC), “’for an apology to be meaningful, it must be genuine.’ There is no discussion of how this contradiction can be resolved.”

Admissions describes the doctor/surgeon experience, but it is also a commentary on the NHS; on the problems of providing healthcare in countries where resources are lacking; and (perhaps unsurprisingly for a neurosurgeon) the grander themes of consciousness, memory, and mortality. In particular, Marsh describes the human brain as “hardwired for hope” and calls on doctors to tap into this facility in all aspects of patient care.

“A good doctor will speak to both the dissonant selves of a dying patient—the part that knows that it is dying, and the part that hopes that it will yet live. A good doctor will neither lie nor deprive the patient of hope, even if the hope is only of life for a few more days.”

Niamh Brooks is a technical editor at The BMJ.

Competing interests: None declared.