Reviewed by Eoin Dinneen, Academic Clinical Fellow, University College London Hospital
Do No Harm is a remarkably simple book. So much so, The Guardian (the book was short listed for The Guardian ‘First Book Award’) asks, ‘Why has no one ever written a book like this before?’ Each chapter’s starting point is a real life case. The clinical and extra-curricular vignettes recited allow the reader the privilege of being a fly-on-the-wall during moments of incredible personal and professional strain, sometimes during frank disaster, and occasionally during enormous relief and hilarity. In total, the book makes up a lean, unadorned, honest memoir of just some of the emotional thrills and surgical spills from a life spent in a busy tertiary neurosurgical unit. There is no twisting, confluent, fictional, engineered storyline because the quotidian of Marsh’s operating theatres, clinic rooms and foreign trips provides a surplus of heroes and heartache to sate the appetite of even the most demanding reader, publisher or dramaturge.
Do No Harm is beautifully written. Most impressively and intimately so when Marsh is describing what a living functioning brain actually looks like. Many doctors will have encountered cadaveric specimens as medical students, but their warm, electrochemically fizzing, ‘live’ predecessors evoke true wonder, especially when the reader (or the patient for that matter) is in the hands of Marsh and his remarkable familiarity, structurally at least, with our grey matter.
The illuminating passages detailing neurosurgery are intense and intensely bright. Time seems to slow with each passing pulsation nervously noticed. Marsh describes the clean and perfect cerebral anatomy; the glistening dark purple veins, the clear liquid crystal CSF, the flashing strands of arachnoid, the smooth yellow surface of the brain and the minute bright red blood vessels. Despite repeating modestly, both in the text and in promotional work around the book’s publication, that neurosurgery is but a simple matter of thuggish hole drilling and the such, this is brain surgery. Intricate, terrifying, compelling brain surgery. The minute topography of what lies inside the human skull under the meninges sparkles and moves almost as much for the reader as we feel it continues to sparkle and dance dangerously for Marsh. When Marsh was a student at the Royal Free Hospital, the doors to the neurosurgery theatres were closed to juniors. Now at St George’s Hospital, medical students are still not allowed into the neurosurgery clinic consultation rooms. Do No Harm briefly opens the door to the world of neurosurgery, doors traditionally closed to doctors let alone to patients.
If describing the anatomy of the brain should be considered ‘home turf’ for Marsh, what is even more remarkable is the profound illumination he pours on humanity when he turns his literary attentions to his patients as people, rather than brains. Cartesian duality complexly and complicitly underpins all the surgical stories, but on a simpler level the book is rich in revelatory illustrations of the doctor-patient relationship and of plain, complicated, sometimes nonsensical human behavior itself. As a surgical trainee myself, it has often vaguely agitated the foreground of my mind during busy days how few difficult questions prospective surgical patients ask prior to their surgery. Marsh notices this discrepancy also, but with characteristic flair and simplicity born of experience he highlights that, ‘as patients we are deeply reluctant to offend a surgeon who is about to operate on us.’
Also worth noting are Marsh’s musings on modern hospital care. When caring for his own dying mother in the family home, Marsh reflects on the difference between his mother’s death and that which is afforded the vast majority of dying patients who are ‘cared’ for in hospitals, care homes, nursing homes and palliative care centres. With trademark honesty Marsh points out that hospital workers are ‘caring professionals whose caring expressions (just like mine at work) will disappear off their faces as soon as they turn away, like the smiles of hotel receptionists.’ Marsh’s uncompromising frankness to tell it how it is makes for unsettling yet categorically undeniable reading for today’s healthcare professionals. Sadly, it may ring a bell for some of our patients too.
Amidst the achingly tense surgery and desperately sad patient case histories (so tragic that when Marsh met the producers of Holby City he dissuaded them from creating a central role for a neurosurgeon because his tales were so forlorn), there is much more to be taken from this book. Do No Harm, I suspect, will come to be seen in the future as a time capsule of the NHS of 2014. Though many of the patient and surgical anecdotes are picked from the many years of Marsh’s medical career, the book is predominantly written in the current day: the 21st century NHS with all its vaunted idealism, sheer enormity, HR directives, staff diversity, exasperating IT systems and senseless inefficiencies. Yes, the NHS we know, work in and die in. Marsh’s caustic commentary of the systemic incompetence and his grumbling subversive distrust of management will of course be familiar to many, but it is here much more cleverly penned than our daily flippant, flapping volleys.
On that note, though they provide the lightest and most sardonic moments in Do No Harm, Marsh’s thoughts on modern hospital management and individual managers is (with one notable exception involving the Chief Executive in Chapter 13) quite adversarial and sometimes pithy. Marsh is not unique in this respect; in fact his attitude again captures the prevailing mood amongst his Consultant colleagues nationwide. However, in the same way that Marsh tells us how he idolized and imitated his great bosses, we junior surgeons are highly likely to follow their lead in a similar apish process. It is not at all a surprise, therefore, when popping into the Doctors Mess, or passing even the most junior of doctors chatting in the corridor, to hear them complaining bitterly about managers they have had no real recourse to come into contact with yet. One feels that Marsh writes of his surgical mistakes in a genuine attempt to inform his successors so that such mistakes are not lost to a graveyard of long forgotten medical errors and repeated unwittingly. If the book is meant to be instructive in any respect for junior doctors, should there not also be some leadership on how to create harmonious interactions with hospital managers who are, lest we forget, our colleagues, and the people who run our hospitals and our healthcare system?
Do No Harm presents itself as a collection of parables, with Marsh himself cast in a panoply of roles, from the international surgeon superhero in Ukraine to the local friendly south London doc who cycles to work like the village vicar. He writes himself as a naughty schoolboy figure furtively struggling against the hospital establishment, and then challenges this by impatiently chastening a scruffy, insouciant junior doctor at the morning meeting like a schoolmaster from his days at Westminster College. Marsh represents an authoritative member of the modern medical milieu but also, movingly, puts himself on the ‘other side’ as a family carer.
Marsh does not dwell on religion or on God. He seems to intimate in a variety of ways that organized religion is not how he makes sense of the cosmos. After an ill-fated operation, which goes catastrophically wrong in the 18th hour of surgery, Marsh renders a young man paralyzed. When he breaks the terrible news to the waiting family, the patient’s mother beseeches Marsh to remember her now quadriplegic, mute son in his prayers. The neurosurgeon does not pray within the context of Do No Harm. Instead, a man of letters, of learning and of neuroscience, in this startlingly honest book about ‘Life, Death and Brain Surgery’, Marsh remembers his patients.
Do No Harm by Henry Marsh. London: Phoenix (an imprint of the Orion Publishing Group Ltd), 2014