Admissions, Henry Marsh

We develop what psychologists call ‘cognitive dissonance’, where we entertain entirely contradictory thoughts. (Location 70)

‘the example of disinhibition loved by doctors is the man who pisses in the middle of the golfing green. But the frontal lobes are where all our social and moral behaviour is organized. You get a whole variety of altered social behaviours if the frontal lobes are damaged – almost invariably for the worse. Sudden outbursts of violence and irrational behaviour are among the commonest. (Location 228)

The person with frontal-lobe damage rarely has any insight into it – how can the “I” know that it is changed? It has nothing to compare itself with. (Location 231)

As I have got older, I have instead come to realize that we have no idea whatsoever as to how physical matter gives rise to consciousness, thought and feeling. (Location 256)

I know that some neurosurgeons believe in a soul and afterlife, but this seems to me to be the same cognitive dissonance as the hope the dying have that they will yet live. (Location 264)

The patient can die after the operation from ‘coning’: (Location 298)

I lay on the red leather sofa in the neurosurgeons’ sitting room, slightly anxious, as I always am when waiting to operate, longing to retire, to escape all the human misery that I have had to witness for so many years, and yet dreading my departure as well. (Location 311)

I left my predictable professional career path to work as a hospital theatre porter in a mining town north of Newcastle. I hoped that by seeing other people suffering with ‘real’, physical illness I would somehow cure myself. My subsequent life as a neurosurgeon was to teach me that the distinction between physical and psychological illness is false – at least, that illnesses of the mind are no less real than those of the body, and no less deserving of our help. (Location 452)

I knew that I had now found a sense of purpose and meaning. (Location 463)

I have never entirely escaped the view that being a doctor is something of a moral luxury, by which doctors are easily corrupted. We can so easily end up complacent and self-important, feeling ourselves to be more important than our patients. (Location 474)

But surgery has little in common with flying an aircraft. Pilots do not need to decide what route to fly or whether the risks of the journey are worth taking, and then discuss these risks with their passengers. Passengers are not patients: they have chosen to fly, patients do not choose to be ill. (Location 509)

The feeling that there was something special about being a doctor had disappeared – it was just another job, I was just a member of a team, many of whose members I did not even know. I had less and less authority. I felt less and less trusted. I had to spend more and more time at meetings stipulated by the latest government edicts that I felt were often of little benefit to patients. (Location 582)

The first rule of microscopic surgery, I tell my trainees, is to be comfortable, (Location 650)

He did a very good job of it and it was only when I later learned that he was a dalit that I understood why he at first looked awkward and embarrassed when I politely greeted him each morning as I passed his open workshop. (Location 781)

I have come to enjoy crossing the road – there is a feeling of achievement each time I get across it safely. (Location 802)

The young doctors I am trying to train are so painfully polite that I am never sure what they really think. I do not know whether they understand the burden of responsibility that awaits them if they ever become independent neurosurgeons. Nor do I know what they feel about their patients, or how much they care for them, as their English is limited and I cannot speak Nepali. What I do know is that most of them want to leave Nepal if they possibly can. Their pay and professional prospects here are poor compared to what they can find in wealthier countries. It is a tragedy affecting many low-income countries such as Nepal and Ukraine – the educated younger generation, the countries’ future, all want to leave. (Location 816)

I often longed to return home, to my family and friends, and wondered why I had abandoned them. I thought of how I had always put work first, ahead of my wife and Children, when I was younger, and now I was doing it all over again. But the deep contentment I experienced each day as I walked to the hospital in the low morning sunlight never faded. (Location 887)

I have noticed they never describe the patient’s occupation, which is supposed to be a normal part of presenting a patient’s history, although in Nepal it seems that everybody is either a farmer, a driver, a shopkeeper or a housewife. Mentioning the patient’s occupation is important: not so much for the traditional reason, which is to alert us to possible occupational diseases, but more to remind us that the patient is a person, an individual, and has a life and a story beyond being a mere anonymous patient with a disease. (Location 906)

swells and severe brain swelling kills you. Helping a patient survive a stroke with this operation of ‘decompressive craniectomy’ is perhaps justifiable if the stroke is on the right side of the brain (so that they do not lose the ability to communicate, speech usually being on the left side) (Location 932)

But it is also because, as the French surgeon René Leriche observed, we all carry cemeteries within ourselves. They are filled with the headstones of all the patients who have come to harm at our hands. We all have guilty secrets, and silence them with self-deception and exaggerated self-belief. (Location 970)

‘When I was the Minister of Health under the last king – before the Maoists abolished the monarchy – I saved more lives by making crash helmets for motorcyclists compulsory than I will ever save as a neurosurgeon. (Location 1002)

There has always been a tension at the heart of medicine, between caring for patients and making money. (Location 1017)

They are the peacocks’ tails of health care. (Location 1185)

I used to feel critical of surgeons if they were remote and detached from their patients but now, very late in my career, I was forced to recognize that some of this had perhaps been vanity on my part, and simply yet another attempt to feel superior to other surgeons. (Location 1215)

The brain cannot feel pain: (Location 1242)

I have even had the left visual cortex – the part of the brain responsible for seeing things on the right-hand side – looking at itself. You feel there should be some philosophical equivalent of acoustic feedback when this happens, a metaphysical explosion, but there is nothing, although one patient, having looked at his speech cortex, as I brushed it with a sucker and told him that was what was talking to me, commented: ‘It’s crazy.’ (Location 1278)

Does one good result justify all the suffering caused by many bad results? And who am I to decide the difference between a good result and a bad result? We are told that we must not act like gods, but sometimes we must, if we believe that the doctor’s role is to reduce suffering and not just to save life at any cost. (Location 1302)

We sat in silence for several minutes. It is very important not to try to fill these sad silences with talking too much. I find it very difficult, but have got a little better at it over the years. (Location 1342)

Sometimes, if you are to make the right decision, you have to accept that you might be wrong. You may lose one patient with a good outcome but save a far greater number – and their families – from great suffering. It’s a difficult truth that even now I find hard to accept. (Location 1353)

Who has not felt contradictory impulses within themselves? The more you learn about the brain, about our true selves, the stranger it becomes. (Location 1405)

‘All pain is in the brain,’ (Location 1572) Neurosurgery

our closest evolutionary relatives, which shows that they have compassion and kindness, a sense of fairness and console each other over pain – at least for their own group. They have not been told to do this by priests or philosophers or teachers, it is part of their genetic nature, and it is reasonable to conclude that the same applies to us. (Location 1585)

For most of us, when we become doctors, we have to suppress our natural empathy if we are to function effectively. Empathy is not something we have to learn – it is something we have to unlearn. (Location 1588)

In poor countries such as Sudan and Nepal, there has been an explosion of private clinics and hospitals. The professional associations, largely based on the old British model, have become sidelined, and there is less and less effective maintenance of professional standards. Money and medicine have always gone together: what could be more precious than health? But patients are infinitely vulnerable, from both ignorance and fear, and doctors and health-care providers are easily corrupted by profit-seeking. (Location 1866)

The faults of socialized health care are ultimately less than the extravagance, inequality, excessive treatment and dishonesty that so often come with competitive private health care. (Location 1872)

a large, lopsided bandage hiding my rough stitching. I thought of how difficult it is to believe in a benign deity intervening in human life when you have to witness suffering like this. Unless, of course, in the words of the famous Victorian hymn, there really is a friend for little Children, above the bright-blue sky, who will right all the wrongs we suffer in this life on earth in an afterlife in heaven. (Location 1892)

But it is very easy to underestimate the importance of endless practice with practical skills. You learn them by doing, much more than by knowing. It becomes what psychologists call implicit memory. (Location 2294)

To learn is to restructure your brain. (Location 2299)

True craftsmanship, like surgery, does not need to advertise itself. A good surgeon, a senior anaesthetist once told me, makes operating look easy. (Location 2334)

Psychologists talk of the ‘endowment effect’ – that we are more concerned about losing things than gaining them. Once we own something, we are averse to losing it, even if we are offered something of greater value in exchange. (Location 2349)

it was some time before I learnt that usually the families would take the patients home, hand-bagging them if necessary, so that they could die with some dignity within the family home, with their loved ones around them, rather than in the cruel impersonality of the hospital. It struck me as a very humane solution to the problem, although sadly unimaginable back home. (Location 2395)

As far as I can remember, I never believed in God, not even for a moment. (Location 2607)

‘Not good. Poor peasant in a remote village. Can’t afford insulin. Diabetes is still a fatal disease here for many people. But we’ve told her husband to take her to the nearest big hospital. They may be able to help.’ (Location 2774)

My inability to speak any language other than English is the deepest of all my regrets. (Location 2786)

The government, driven as always by the latest tabloid headlines, has set up an increasingly complex system of bureaucratic regulation based on distrust of the medical profession and its professional organizations. Of course doctors need regulating, but they need to be trusted as well. It is a delicate balance and it is clear to me that in England the government has got it terribly wrong. (Location 3041)

There is nothing more frightening for a patient than a doctor, especially a young one, who is lacking in confidence. (Location 3168)

But as we get older, and become genuinely experienced and competent, it is something we must start to unlearn. (Location 3173)

Safe medicine, I told them, is largely about having good colleagues who feel able to criticize and question us. (Location 3190)

Doctors are frequently accused of playing God but, in my experience, the opposite is more often the case. (Location 3402)

in the developed world, 75 per cent of our lifetime medical costs are incurred in the last six months of our lives. (Location 3445)

But I do not believe in an afterlife. I am a neurosurgeon. I know that everything I am, everything I think and feel, consciously or unconsciously, is the electrochemical activity of my billions of brain cells, joined together with a near-infinite number of synapses (or however many of them are left as I get older). (Location 3458)

For those who believe in an afterlife, must we suffer as we lie dying, if we are to earn our place in heaven? (Location 3476)

If euthanasia is legalized, this question of how we can have a good death, for those of us who want it, with pointless suffering avoided, can be openly discussed, and we can make our own choice, rather than have it imposed upon us. (Location 3481)