The Right Stuff?

There are doctors who work in war zones. There are doctors who spend their lives in laboratories. There are doctor managers, doctor novelists, doctor comedians. A medical training can lead you almost anywhere. The trick is finding the niche which suits you.

The most high-octane branch of medicine in Britain is probably neurosurgery. The stakes are high and the risks, even of an apparently straightforward operation, are intimidating. Neurosurgeons can transform patients’ lives, curing their brain tumour or rendering them a vegetable. Or both in the same operation. In general practice, every day there are things we could have done better, but we don’t have to live with such catastrophic failures. How can anyone bear a lifetime on such a roller-coaster?

Henry Marsh knows. He’s a neurosurgeon on the verge of retirement, and his memoir, “Do no Harm”, tells us what it’s like.

Neurosurgeons need nerves of steel. If something goes wrong inside the patient’s cranium you have to make split second decisions. If you need time to make up your mind, take up dermatology.

We all live with guilt or shame about patients who suffered through our treatment, but it requires a particular resilience to walk through a care home recognising the names of patients who have been wrecked by your surgery and then go back to the operating theatre.

As well as failure, doctors have to bear uncertainty. Even if the diagnosis is obvious – and that doesn’t happen as often as medical soap operas suggest – the management of the problem is frequently less straightforward, despite all the protocols. “Heal the sick, comfort the dying, and don’t get them mixed up” doctor-novelist Colin Douglas was told many years ago by his consultant. Good advice, but the dividing line is often less clear now than it was then. And patients, and their families, may hold a different view of whether heroic treatment is still appropriate. Neurosurgeons may relish risk, but they have to navigate this quagmire as sensitively as do oncologists.

Every day clinicians walk a tightrope. Most of us stop noticing the drop, at least until we find ourselves up before the GMC. But some doctors leave clinical medicine because they cannot keep their balance over the abyss.

Patients still put doctors, particularly heroic surgeons, on a pedestal. But, like statues of Lenin, at any moment we may be pulled down and smashed. Henry Marsh has been criticised by readers for admitting to irritation in the supermarket queue. Maybe you need that touch of arrogance if you are to delve into someone else’s brain. Better a bit of high-handedness if that hand has more skill and is willing to take on the difficult cases that a timid surgeon would turn down. GPs have less to be to arrogant about, but which of us hasn’t felt frustrated when queuing to pay for our groceries, especially behind trolleys filled with junk food?

“You don’t know what it’s like” is a common criticism of doctors. It is another way of saying “You haven’t shown me that you understand”. Do doctors need to suffer what the patient is experiencing in order to understand? Henry Marsh’s infant son had a brain tumour. It taught him what parents go through while he operates on their child. But personal experience doesn’t guarantee empathy. It’s easy to think “I put up with it, so can my patients.”

Alternative practitioners don’t have personal experience of every dis-ease, any more than doctors do, but they attract high approval ratings. Surely not because of their remedies. It’s because their patients feel heard. What training do homeopaths have in consultation management, and why can’t we doctors match them? Does the first year on the wards crush the learning from all those communication skills modules? Do we need more training in being nice? Or do we need more time to be nice?

Few alternative practitioners’ consultation skills are tested by having to break terrible news. GPs break terrible news every so often, neurosurgeons every week. There is no right way to do it, just less bad ways, and however ruthless you are with a scalpel, to be a good doctor you must accomplish this most difficult of tasks with sensitivity and humility.

Of course patients want the perfect doctor. The GMC has compiled a daunting list of the virtues expected of us. But in the messy real world, everyone – government, patients, we ourselves – has to remember that perfection doesn’t exist, and that what makes a doctor a good-enough brain surgeon is not what makes a good-enough GP.

There isn’t one model for a good GP. The investment banker with sinusitis doesn’t want his GP to probe his psyche, while for the downtrodden woman sinusitis is a ticket to a supportive listener. And we all have to learn. Someone has to be the first patient a trainee operates on or we wouldn’t have doctors with the experience to tackle difficult cases.

The first thing doctors in clinical roles need is an interest in people. If you have that, doesn’t all the rest follow? Add a smile and an analytical mind. So that you know when the patient needs tea and sympathy, and when it is time for coffee and a kick in the pants.

Do No Harm: Stories of Life, Death and Brain Surgery Henry Marsh, W&N 2014 ISBN-13: 978-0297869870

Judith Harvey

Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.

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