Transcripts For BBCNEWS HARDtalk 20161228

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. You want to believe your surgeon is infallible, a superhero but he is not, he is all too human, just like you. That emerges from the extraordinary honest writing from henry marsh, giving us a rare insight into the mind of the doctor. Is that reassuring or troubling . Henry marsh, welcome to hardtalk. The veryjob description, brain surgeon, i think in most people it prompts a sense of awe and maybe a little bit of fear, as well, and certainly mystery. But youve decided to lift the veil on what it is really like and i wonder why. I was subject to that myth of Brain Surgery myself when i decided to become a neurosurgeon many years ago. I suppose i was Drawing Attention to oneself, as any writer is doing when writing a book, and i am the youngest of four, i have been Drawing Attention to myself from an early age, if you ask my family 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 newspapers without seeing the latest medical scandal. It is the tabloid headlines that are driving the politicians often mistakenly. To change things in what is basically a very Excellent Health service that we have in this country. I wanted to show that medicine is not my going into a shop, patients are not consumers. Doctors are doing something in many ways much more difficult than people realise, people think neurosurgery, Brain Surgery is very difficult, technically, but it is not, once you know what you are doing. But the really difficult thing is the Decision Making. But the really difficult thing is the Decision Making and dealing with the patients and all the Human Problems that arise, and i wanted to convey that. Well, by conveying that and focusing on the difficulty and sometimes on the fallibility of both yourself and colleagues, isnt the danger that you plant a new and horrible seed of doubt in the patient . No, i dont think so, if, if you thought it through, if. You have to go and see a doctor, if you could only choose one quality steady hand, famous reputation, nice website. Laughter. Nice smile, honesty, what would you choose . Honesty. A steady hand might be quite nice no, if you do dangerous surgery, which neurosurgery certainly is, the mistakes in my experience all arise in the Decision Making, the idea that you drop something. It is just not like that. Very occasionally, purely manual errors occur. But actually it is very, very unusual. And in my career, looking at my own mistakes, and colleagues, it is in the Decision Making where things go wrong, that is all about thinking and psychology. Indeed, and i guess that when you decided to go into Brain Surgery, you knew you were going into a field of medicine which came with enormous pressure. There arent so many branches of medicine where everything that you do could lead to the most catastrophic. Its the excitement. You become a surgeon, as i said in my book, because surgery is a blood sport, in a way, but that is not inconsistent with caring for your patient, because what makes the Operation Exciting is you are terribly concerned they should be well. That is interesting, because its about the patient, but i want to focus on something about you. Do you have to have a supreme Self Confidence bordering on arrogance to be a brain surgeon. The answer is the balance, as all of these things. Power corrupts, and absolute Power Corrupts absolutely. And as surgeons we have an inordinate amount of power, and it is very easy to become arrogant. I guess you need to be insensitive to some extent. This is the whole challenge of all medicine, visible and acute in Something Like Brain Surgery, finding the balance between compassion and professional detachment. One way of illustrating that is to say, obviously, the only ethic in medicine is we should only treat patients as we would wish ourselves or our family to be treated. But its almost impossible to operate on somebody you know well, because youre too anxious. Finding the balance between compassion and detachment is difficult. Compassion and detachment is one element but also self belief and self doubt. It seems to me, reading your book, do no harm, and your other writings about the work over many decades, you, as you have gained an experience and reputation, have actually become more self doubtful. 0h, very much so, and once. Because i came to realise that once you master the purely Technical Skills of operating, where mistakes arise is in the Decision Making. And i believe, passionately now, partly because i am in the latter years of my career, that other people are better at seeing my mistakes than i am. It is a profound truth that applies to all of us, we are very bad at seeing our own mistakes. There is a problem in medicine of finding a balance between compassion and detachment; ditto, you need the arrogance and self belief to do the operating but it is critical that you have a good working relationship with your colleagues as well. So that they can criticise you and you can criticise them. Actually that is very difficult to get doctors to do on the whole. Lets get specific and talk about a case, that you have been very honest about. Its a troubling case, early in your career. I think he was a teacher, a man in his late 50s, who came to you with a huge brain tumour, and you were appalled by it. Appalled and excited. I was going to say, honestly, you say you were quite excited, you had never seen anything quite like it. He was sent off to see another consultant, even more senior than new, and it was pushed back more senior than you, and it was pushed back to you and they said, you know what, henry, you deal with it. It is a young mans operation. You went for it, and you were quite excited, the biggest operation you had ever undertaken. A dozen hours or more. Much longer than that. And you sucked out. And it went badly. You sucked out virtually all of this tumour, you said yourself, i think towards the end of the operation, i could stop now, but dammit, i am going to 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. And that is an example. The mistake was not severing the artery, the mistake was deciding to remove the last bit of tumour. How can you live with that . Well. The answer is, all neurosurgeons have terrible periods. Terrible disasters and terrible periods of despair. When i first became a consultant, my first few bad results, i felt quite ill and sick and miserable for weeks on end afterwards. You have to go on working because you do, in a sense you accept it. Does it change the way that you work, we have talked already about about confidence, and self doubt. And if the self doubt. You develop blinkers. You need to deceive yourself to some extent. I mean, it is one of the ironies of medicine, that a lot of medicine is an act. It is something you learn very early on as a young doctor, patients do not want a doctor who says, i dont know what to do, i have never done this before. We want our doctors to be experienced and competent, and by my stage, that is easy, because i am experienced, but when you are a young doctor you are not experienced. If you dont take on the difficult cases, how will you ever get any better . You face this ethical problem right from the start, the moment you qualify as a doctor, suddenly you have to start lying to patients, to some extent, you have to pretend a greater degree of competence and confidence than you really feel you have. And the best way of deceiving other people is deceiving yourself. It is a necessary self belief, self deception, to help one cope. And so it is not a bad thing. But as you get older, perhaps you can start trying to dispense with some of it and treat patients more as equals. I wonder whether that incident, and others like it, you very honestly say come you went to a hospital that specialised in long term care. I saw this patient years later. And others, and you said, you saw for five people on this ward, who you operated on, and they were, in essence, brain dead or in a vegetative state. Im just wondering whether the threshold of risk that you are prepared to take, changed over time . And whether your calculation. . It goes up and down, is the answer, after that case that you mentioned, i became, in a sense, over conservative, but again reflected the working environment i was in, 25 years ago. Over the years i discover that the way to do these really difficult cases, and they are really rare, you only see a handful, is to do them with another colleague. When i was working in nepal recently, we had one or two cases like that, and my colleague was on his own, he runs his own hospital, he said how wonderful it was to share an operation. I think a more collaborative way of working is very important in modern surgery. Heres a thought that i have. I wonder if its more difficult to take on the risk of a very difficult operation, which you know has a serious risk of, as you put it sometimes, catastrophic consequences, or whether it is more difficult to tell a patient, who is desperate for you to operate, even though you have explained all the risks, that in your view, it is simply not the right decision and that nature has to take its course. That you feel there is nothing more you can give them. Which is harder . It depends to some extent on the nature of the problem. I think it is harder to do nothing. Do you . I think so. It is harder to say, go away, live with it, go away and die. Go away and die. That is very, very different. Sometimes, sometimes you say that death is the better outcome. And with experience you learn, and i see this with my younger colleagues, i see them operating on cases which i would have done, which i did at my stage in their career, but now i wouldnt. I no longer do Emergency Work in this country but when i was you are often telephoned at night by thejunior doctors about emergencies. I should add that Emergency Neurosurgery is actually very simple, the actual operating is very easy. Is it removing blood cots, it isnt difficult. But the Decision Making, whether it is worth operating or not, it is often very difficult. These are people with Head Injuries and strokes where, in simple and strokes, in simple terms, if you dont operate, they will die, if you do operate, they may survive that they may be left terribly disabled. And its a bit like nero at the roman games, if i say thumbs up, operate, i get back to sleep. If i say, let them die, i dont, because i worry that im wrong. There is a built in asymmetry which always forces us to overtreat and overoperate. Is it important for you to get to know your patients before you operate on them . Well, i used to think it was, that is an interesting question, my son had, as i say in my book, my son had a brain gym my son had, as i say in my book, my son had a brain tumour when he was very young. He was a baby, a few months old. And i was doing general surgery, hes not necessarily the reason i became a paediatric brain surgeon. I dont know what other doctors are like, but i always felt it gave me a certain understanding and sympathy of what my patients were going through, because i have been through it myself. Therefore i felt it was an essential part to be actually quite close to the patients and their families. Although that is partly selfish, if you are close to them, if things go wrong, they are likely, they are less likely to lose their trust. It is selfish and unselfish, because it also means you are more invested in the case, emotionally. And therefore it is more hurtful and damaging. When i was working in nepal, admittedly, my colleague and his team, because of the language barrier, were doing all the talking with the patients, so i was ending up operating on patients i had not seen before, and scarcely saw afterwards. Which in the past to me would have been complete anathema. It did not make any difference. I was just as focus and intense and anxious about the operating. So that was the surprise to me. I was better than i expected. Let me switch focus a little bit and talk to you about the brain itself. This most may amazing organ of ours, it is so complex, it is so mysterious in so many ways. And yet you approach it with, sometimes drills, saws, knives and suckers, and there is some thing quite bizarre about what you are involved in. It is utterly bizarre, it is. Something i took for granted when i was younger 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 electric. It doesnt feel like electric chemistry, it feels free and insubstantial. But we are the product of the electrical chemical activity of those cells. What is fascinating, modern science, we cannot even begin to explain how thoughts and feelings and consciousness arises, we just dont know. Your career has spanned 35 years or so, in brains. You saying to me that in those 35 years, in brains, are you saying that in those 35 years you have learned very little more about how the electrochemistry is works, and how. It is like saying we know how a brick is made. It doesnt tell us anything about the house made by the bricks. So although there is a huge amount of neuroscience going on, what really interests us, as human beings, is ourselves, our own feelings and consciousness. We cannot experiment upon it, you see, either. You write lyrically about this, at one point you write about being struck during an operation, that your sucker, your hoover thing, that you sucked jelly out of the brain with, you say my sucker is moving through thought itself, through emotion, and that reason, memory and dreams should consist of this jelly is simply too strange to understand. It is the last great mystery literally, how dare you suck out all of this jelly when you might be sucking out peoples imaginations or thoughts or dreams . The answer to that is the illness you are trying to treat is even worse than the operation, so to speak. Coming back to the question, how do surgeons cope with bad results and convocation, well, you think of the good result, and you know that most of the time, things go well, and for all the poor patients who have not done well in my hands, hopefully there will be hundreds, if not thousands who have done well. We know that is true. That is ultimately what the balance is about. It is terribly important, maybe it is partly my personality, but success is corrupting, success makes us complacent and spoils us. The worst surgical crime for me is complacency. You mustnt dwell permanently on your complications but you must never forget them. It is terribly important to remain as humble and modest as you can, even though you must present as more confident and assured outside to the patients. Before we go 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 believe in science with a s, but you know, for centuries, philosophers, scientific thinkers, have posited the notion that in the end, our mind, our soul is separate from the physical reality of this thing between our ears. Are you telling me that you are absolutely convinced there is no possibility of that being true . I think it is highly unlikely deeply improbable. The brain is everything . We dont understand how it works. Maybe we never will. I find that infinite mystery rather reassuring. We all know the macrocosm of the big bang, all this stuff recently about the anniversary of einsteins theory of relativity, each of us within our own head and our own consciousness is sitting on a mystery as great as the big bang. Im sure that you have read the Science Papers which address near death experiences, and under scientific conditions can recollect experiences they have had when nominally the machinery has told us that they are brain dead. But you think that is a mirage . It is a complicated area. Brain dead is rather different, near death experiences are well recognised as a phenomenon. But they come out of the electrochemistry of the brain, is what it comes down to. Back to health care, we have talked about you, as an individual doctor, surgeon, and how you have approached a Career Dealing with the most terrible sort of challenges in the brain. But that is one part of what you do. Another part of what you have done is exist within a vast health care system, one small cog, component, in a huge machine. Seems to me that you have become very disillusioned with that machine. Yes and no. You have to look at the nhs internationally, first thing, and if you look at the nhs. The national Health Service. There is a lot of criticism in england, you cannot read the newspapers without seeing, some mistake in a hospital and the headlines say, shames the nhs. As if its the responsibility of the nhs as a whole. The national Health Service provides, by international standards, very Good Health Care in terms of overall outcomes for healthy life expectancy. Do you still believe in socialised medicine, as the americans call it . I believe passionately in socialised health care, because i have worked and visited so many countries where medicine is commercial and it is terrible, because. It is not if you can pay for it but it comes back to the fact that medicine is not like going into a shop and buying something. A, the patients are not in a good position to judge what is good for them, and b, a lot of the Decision Making is very unclear and very great. And if you look at countries like america, sure, American Health care at its best is fantastic, but it is extravagant. All countries in the world, Health Care Costs are rocketing above the rate of inflation, and, im afraid, if doctors have a financial interest in what they are doing, they tend to do more and a lot of it is unnecessary. Your message seems to be, taking the british case, of a socialised system which is free at the point of delivery, but politicians have to be more honest that at a time of rising Health Care Costs and ageing populations, politicians need to say to people, you can have this but you are going to need to pay more tax, or you have to accept greater rationing in terms of waiting times. It is basic economics, if you have a good that is free at the point of delivery and scarce supply, you end up with queues, and having all of these targets, introduced by the previous government, can be counter productive. So you think queues are ok . I dont think they are ok but you have to prioritise and deal with the emergencies first, if you give equal priority to nonurgent cases, then urgent work suffers. A lot of people have made the point about the organisations and the chaos in the system, but it seems to be another interesting point about you, coming back to a word i used earlier, arrogance, you dont like being told what to do by managers, you dont like being told that you cant wear a tie during surgery and you cant wear a wristwatch, you get angry that your Car Park Space has been moved. I dont drive a car, i ride a bicycle, i dont have that particular problem that many of my colleagues do. You are right, some of the reviews of the book commented 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 their lives and their deaths. And then if you are treated as though you are just another minor cog in the machine it produces a lot of tension. Psychologists have found that many times, one of the most stressful situations that lab rats can be in and human beings can be in is to have a position of responsibility with no power, that is very stressful. Youve escaped the confines of the national Health Service in the uk, because a lot of your work is done abroad, in ukraine, in nepal, and other countries as well. But 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 yourown brain, and deterioration . I am, i think it is something that haunts most people of our age, most of us have had one or two demented parents to care for. Dementia is an increasing problem in wealthy countries. It bothers me greatly. Im much more worried about dementia than dying. The evidence is fairly clear, keeping busy, physical exercise, things like that, are very important, to try to keep it at bay. We cannot keep old age at bay. Interestingly, you are committed to keeping up doctoring, you said once, an ageing doctor is a better doctor, as the wheels start to fall off, you have more energy. You are more sympathetic. Having said that, you need to know where to stop. As with everything in life as with life itself, best to leave too early than too late but im not ready to stop working yet we began by talking about whether you wanted an honest doctor or a doctor with a steady hand, i dont wish to be rude, but as you age, as i age, your hand becomes unsteady, eyesight is not quite so good. Do you think about these things . I think about it. I was thinking about it quite a lot when i was doing a lot of very major operating in nepal. I was mainly there to teach, but i ended up doing a lot of very major operating, more than i would do in this country. And i felt two things one, i was pretty sure that purely manually, i was as good as i was. All this operating is done with a microscope, eyesight is not an issue because everything is magnified. The other thing that struck me, which was curious, i felt increasingly ashamed and embarrassed at how crude the operating i was doing, compared with what i increasingly understand about the brain. What i understand about the brain is from reading popular neuroscience books, not from neurological medicine. That is what struck me. I need to gradually withdraw from operating, clearly. Not yet. Not yet, please thats the thought i want to end with. I hope you keep going for quite some time. Im still totally in love with it. Henry marsh, its been a pleasure. Thank you very much forjoining us on hardtalk. Hello. 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. Not so much in the south west. We will have had enough breeze overnight to keep the atmosphere that little bit more mixed. But where things have really settled, that is where the fog will have popped up. Central and eastern parts of wales, through the midlands to east anglia, down into the south east and up towards the vale of york. Further north, the fog a good deal more patchy, and so too the frost, but here, more in the way of cloud and breeze. An ever present feature throughout the day across the western isles. Close by to a Weather Front, may produce the odd spot of rain. Wind really quite a feature here. We are not without the chance of some sunshine. The borders of scotland, north of england, western side of wales and south west of england. Here, the temperatures having a chance to respond. 7 10 degrees or so. But, and it is a significant but, if that fog lingers with you, and it may well do in some locales, certainly through the midlands, east anglia and parts of the south east, it will really put a dent in the temperatures as well as your visibility. That is not such an issue for the Scottish Premiership matches. There are four through the course of wednesday evening. But if you are journeying for this particular feature, southampton taking on spurs, there could well be a fog issue for your travels. If you lose the fog, it may well reform from Wednesday Night Into thursday. We will do it all over again. The Weather Front still a player over northern and western parts of scotland. Further south, leaden skies for the most part. Again, if you happen to keep the fog for any length of time during the course of the day, the temperature could be closer to 1 2 degrees rather than 4 7. Thursday into friday, that Weather Front coming more towards the North Western quarter of the british isles. The isobars beginning to tighten up. Fog less of an issue as we start friday. Mild air streaming in across scotland, the Western Fringes of wales through Northern Ireland into the south west of england. The last of the chilly conditions hanging on across east anglia. Towards the weekend, out of the old year into the new, a significant change in the weather. The front comes further south and the isobars stream in from the north, and with it much colder weather. So a change to cooler conditions, certainly, and near that front, quite wet too. Welcome to bbc news. My names mike embley. Our top stories 75 years on, japans Prime Minister shinzo abe makes a historic visit to pearl harbor, offering condolences to victims of the attack. Translation we must never repeat the horrors of war again. This is the solemn vow we, the people of japan, have taken. Somebody get this Walking Carpet out of my way. An outpouring of tributes. Carrie fisher, The American Actress who played the feisty Princess Leia in star wars, has died at the age of 60. Argentinas former president , Cristina Fernandez de kirchner, is charged over corruption allegations. Make no bones about it, scientists believe evolution may be to blame forjoint pain, and it could get even worse