Honoring Henry Marsh's 75th Birthday
Celebrating the birthday of an extraordinarily sensible neurosurgeon and his seminal memoir, Do No Harm
Harm is often mentioned as a disembodied statistic. Perhaps, a footnote beneath a belabored list of flowery benefits. Even under the spotlight it deserves, the visceral reality of harm is euphemized. We tiptoe around the topic, careful to avoid admission to our own errors.
There is a lot of discussion of harm on Sensible Medicine. It can originate from poorly designed studies, bad regulators, and conflicts of interest. These issues, of course, are important to discuss. Yet, anyone committed to the alleviation of suffering should also be aware of their own capacity to cause harm. Though proximal origins of harm – like arrogance or hubris – are within our capacity to mitigate, it is easy to recognize these faults in others before ourselves.
Recognizing, and coping with, the harm we cause is not easy.
Fortunately, we have Henry Marsh to learn from. Marsh is a British neurosurgeon whose nuanced relationship with harm is fascinating and instructive. Today, we celebrate his 75th birthday, and his vision for honest, sensible medicine.
On multiple occasions, Dr. Cifu has promoted Henry Marsh’s memoir, Do No Harm and called it one of his favorite books of the 21st century. The book was nominated for numerous awards and received high praise from The Economist, Financial Times, and The New Yorker.
In the spirit of Sensible Medicine, I will appraise this critical acclaim.
Portrait of a Fascinating Neurosurgeon
Henry Marsh is a British neurosurgeon who lives in London. He has also worked in Ukraine for three decades, undeterred by Russian invasion. In his later career, he wrote successful books: Admissions, Do No Harm, as well as his latest, And Finally. He is also featured in a documentary film.
In writing, Henry Marsh is able to transform ordinary experiences into transcendent observations:
Sometimes, if the dissection is particularly difficult and intense, or dangerous, I will pause for a while, rest my hands on the arm-rests, and look at the brain I am operating on. Are the thoughts that I am thinking as I look at this solid lump of fatty protein covered in blood vessels really made out of the same stuff? And the answer always comes back – they are – and the thought itself is too crazy, too incomprehensible, and I get on with the operation.
Yet, Henry Marsh minces no words when describing workplace politics, the electronic health record, useless training sessions, and administrative initiatives. His distaste for hospitals combined with dry humor, make for a vindicating read.
The humor and prose of Do No Harm are enjoyable and necessary. They complement the severe and unrelenting criticism that he reserves for one specific target: himself.
Marsh describes a grave mistake operating on a large petro-clival meningioma in a chapter titled “Hubris”. A more experienced consultant told Marsh the case was a “young man’s operation”. Early in the procedure, the atmosphere was jovial, accompanied by music ranging “from Bach to Abba to African music”.
Inspired by the clean brain scans presented at conferences, Marsh whittled away at the last bits of tumor, despite the growing risk of proceeding. Everything went fine until he nicked the basilar artery. The result was a devastating stroke that left the man comatose.
What followed was a painful reevaluation of his place in medicine. He became skeptical of the post-op images presented at conferences, which showed clean margins. And he grew wary of senior consultants pawning off difficult surgeries to those with less experience. The depth of his atonement is revealed by his lost appetite for music while operating.
Henry Marsh’s humility while recalling his own mistakes is unlike anything I've ever encountered. And it appears he is as honest with readers as he was with patients. In another chapter, he recalls advising a patient’s family to pursue a lawsuit against himself. He admitted a mistake was simply indefensible.
What makes Henry Marsh a great storyteller is that he revels in the ambiguity of medicine. He finds troubling nuance in seemingly mundane cases.
Few people outside medicine realize that what tortures doctors most is uncertainty … It is easy enough to let somebody die if one knows beyond doubt that they cannot be saved – if one is a decent doctor one will be sympathetic, but the situation is clear. This is life, and we all have to die sooner or later. It is when I do not know for certain whether I can help or not, or should help or not, that things become so difficult.
Why We Need Henry Marsh
We need healers that publicly and constructively reconcile their shortcomings. In all of medicine, harm is inevitable. Yet, there is a range of possible responses to it. On one end, we have “Doobie” who went viral for quitting neurosurgery after ten years of independent practice, citing pressure to perform unnecessary procedures. On the other end, we have Christopher Duntsch, whose reputation for maiming patients led to his incarceration and the Dr. Death podcast.
Both stories are tragic. In the first case, a well-seasoned surgeon turns away from the profession when he is unable to honor his wariness of causing harm. In the second case, a neurosurgeon is forced out due to his inability to mitigate harm.
Neither of these high-profile cases inspire a clear-eyed approach to medicine. We need role models who examine their potential to cause harm while staying devoted to the craft of healing. Henry Marsh fills this void.
A Path Forward
Henry Marsh reveals that our relationship with medicine does not need to end in extremes. Enlightenment can't be found in agony nor ignorance, alone. He embodies the necessary struggle to make sense of suffering, as difficult as that might be. He begins his book quoting French practitioner René Leriche:
Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.
Most of us could go further to identify, document, and testify to the mistakes we make. We should normalize admission to errors. And we should encourage trainees to demonstrate humility instead of a facade of infallibility.
All of us fail.
This is why Henry Marsh’s meticulous exploration of harm is admirable.
His testimony makes him a hero.
Wil Ward, MD is a family medicine physician working in Iowa. On Sensible Medicine, he previously wrote about unintended harm that arose after routine depression screening. He also writes on his own Substack.
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He’s my age and I can relate. My overall best experiences were with the families - I’ve written about that in a Substack. Wait. Did I publish that?
Although I made it through 35 years of Critical Care this piece reminds me, once again, that my most vivid memories are of my failures, some small and of little consequence, some catastrophic. Fortunately there aren’t many in 35 years of active practice but they, to this very moment, are indeed my most vivid recollections.
After each one I reported myself to Quality, possibly as an act of confession but more just to let my colleagues knew that I was AWARE. Too often I was told whatever happened was “within the standard of care” and, while that kept my record “clean”, I knew better and it was of little comfort.
And, after each one I tried to understand what went wrong and the decision which led me down the wrong road. One thing stood out: I was always 100% sure what I was doing was the correct course. After a few years I learned that when I’m “100% sure” that’s a red light, not a green light. Eventually, like Dr. Marsh, I stopped at that point and reconsidered, ran it by the patient’s nurse, or asked a colleague. There’s a time and place in Medicine for ego.
Making that mistake is the loneliest place in the world. You are alone with God in those moments. No one on Earth can make you feel better about it. There is no quota of rationalization or blame-shifting that suffices. In the end you know it was you writing that order, or placing that chest tube. And you know you’ll feel that until you don’t feel that way anymore.
And, ultimately, you have to get up the next day and see 12 patients again. And do it better.
I read the last quote and translated it as "Every human carries within himself a small cemetery..."
I kneel at the graves in my cemetery perhaps too often.
While physicians should heed the call to humility, so should patients and caregivers. Each one of us, by the time we are decades into life, would, if we could, repair errors that have grievously harmed others.