Admissions: Life as a Brain Surgeon

Abstract

When the eminent British neurosurgeon Henry Marsh’s celebrated first memoir titled Do No Harm: Stories of Life, Death, and Brain Surgery was published in 2014,1 the English novelist and screenwriter Ian McEwan commented, “Neurosurgery has met its Boswell in Henry Marsh.” I would argue that Marsh’s second memoir, Admissions: Life as a Brain Surgeon, is even more insightful, introspective, and compelling than his first given its more expansive and probing reflections on the man rather than the surgeon. In this thoughtful, disarming, and elegantly written book, the author reveals poignant admissions (truths) about his admissions (patients).Henry Marsh was the youngest of four children, born in 1950, to a German mother and an English father who was a storied academic lawyer at Oxford University. Young Henry read politics, philosophy, and economics at Oxford before studying medicine at the Royal Free Hospital in London, graduating with honors from both institutions. He became a Fellow of the Royal College of Surgeons in 1984. In 1987, he was appointed Consultant Neurosurgeon at Atkinson Morley’s, St. George Hospital in London, where he worked until his abrupt retirement, triggered by a fit of anger and frustration related to administrative, bureaucratic, and regulatory miasma, in 2014. Marsh, who introduced and popularized awake craniotomy under local anesthesia in England, was made a Commander of the British Empire in 2010.Henry’s brilliance and enviable pedigree did not shelter him from life’s vicissitudes. He briefly rebelled against his well-meaning and kindly father, temporarily abandoning his university studies to work as a hospital porter in a mining town north of Newcastle. Subsequently, he developed psychologic issues, was transiently suicidal, and was hospitalized for psychiatric care. It was, however, his experience as a theater porter, watching surgeons operate, that led him to become a surgeon. Newly motivated, Marsh reapplied himself to his studies with focus and enthusiasm. After becoming a surgeon, Marsh’s personal challenges included dealing with his son’s (successful) surgery for a brain tumor diagnosed at age 3 months, an acrimonious divorce with its attendant disorientation and recalibration, his own retinal detachments, his mother’s terminal cancer, and his father’s eventual dementia resulting in death at age 96 yr.Admissions affords an intriguing glimpse into the life of a neurosurgeon, who is also a deeply thoughtful, searingly honest human being. What sort of person has the requisite fearlessness, boldness, and confidence to cut into and manipulate the physical substrate of consciousness? Marsh represents himself as an impatient, irascible, and sometimes arrogant neurosurgeon. With rigorous, unflinching candor, he reveals his own medical/surgical errors and miscalculations. He also exposes and sharply scrutinizes his failings as a human being.The author underscores the difficulties of working in a profession that deals in probabilities, not certainties. Although he does not use the term “second victim,” he revealingly writes, “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.”Marsh tangentially suggests that the technical details of neurosurgery are less difficult to master than acquiring and exercising the judgment needed to know when not to operate. He worries that in some situations, the destructive consequences of surgery might be worse than death itself. He does not avoid these difficult conversations with his patients and their families, attempting to help them realize that palliative measures might be more humane than prolonging suffering. Marsh observes, “We are told we must not act like gods, but sometimes we must, if we believe that a doctor’s role is to reduce suffering and not just to save life at any cost.” (Parenthetically, Marsh is a vocal advocate of physician-assisted suicide in circumstances when a competent person has persistently expressed his or her wish for that intervention.)Generally speaking, when anesthesiologists are asked to list personality traits of their neurosurgical colleagues, humility is not top of mind. Yet genuine humility is pervasive in this pitch-perfect memoir. Marsh is profoundly grateful for the contributions his colleagues make to safe and compassionate patient care. He is specifically appreciative of anesthesiologists, noting, “The relationship between anesthetist and surgeon is critical, especially if there is going to be trouble, and having colleagues who are friends is all-important.” Marsh is appropriately generous in highlighting the vital role anesthesiologists have, particularly during an awake craniotomy when their kindness, sensitivity, and communication skills are invaluable. He writes, “I always relied on my anaesthetists, in particular Judith Dinsmore, whose highly skilled and reassuring manner never failed to keep the patients calm and cooperative.”Marsh spent approximately 30 yr doing pro bono neurosurgical work in both Nepal and Ukraine, a service he continued into retirement. No doubt the reader will find his observations about the challenges of practicing medicine in regions with language barriers, limited resources, and suboptimal infrastructure, as well as in cultures where clinical practice is “eminence-based” rather than evidence-based, illuminating. The author firmly believes that health care systems reflect the societies they serve, and he shows no diffidence in criticizing both the British National Health Service and the American system.Although Henry Marsh is a lifelong atheist who holds no belief in an afterlife, this memoir has a spiritual feel that is difficult to explain. Perhaps it is because the book is suffused with deep gratitude for all the opportunities and privileges afforded the author, as well as his genuine compassion for struggling people and his intense respect for human dignity.Querulously likeable in spite of himself, the author is as gifted with the pen as the scalpel. This exquisitely quilted cache of memories, opinions, and trenchant observations seen through the eyes of an accomplished neurosurgeon is a gem. I enthusiastically recommend this captivating memoir to all but the terminally queasy. Nonetheless, Admissions will have particular resonance for medical students, trainees, clinician–educators, and retirees who are determined to retain their identity and sense of purpose in life. Sadly, Henry Marsh was diagnosed with advanced metastatic prostate cancer in 2021, but we can look forward to his next book, titled And, Finally, which is scheduled for release in early 2023.