The Conscience of a Brain Surgeon

I FELL IN LOVE with neurosurgery at first sight, almost 40 years ago, when I first saw an aneurysm operation.

Aneurysms are fragile blowouts only a few millimeters wide, growing off the major cerebral arteries. They can rupture without warning, causing death or a major stroke. The surgeon puts a microscopic clip across the aneurysm to prevent such a rupture. But if the surgeon bursts the aneurysm while trying to clip it—a small but very real risk—the patient can die or suffer a catastrophic stroke, causing the very harm that you are trying to prevent. The operation combined exquisitely difficult, microscopic surgery with all the excitement of bomb-disposal work, without any risk to the surgeon.

A career in neurosurgery appealed to my competitive, alpha-male nature, as well as to my deep intellectual fascination with the brain. What could be more glorious than being a brain surgeon? I signed up for the specialty more or less the next day.

Now, facing retirement, I am still in love with neurosurgery, but my view of it has changed profoundly. I soon came to understand that brain surgery is very crude relative to the microscopic intricacy of the brain. Our main tool is a small sucker, two millimeters in diameter, 50 times as large as the average brain cell—a low-tech device in the face of such complexity.

Worse, the brain has only a limited capacity to recover; it doesn’t heal like bone, muscle or other tissues. So brain surgery is particularly dangerous, risking not only death, paralysis or blindness but also changes to our intellect and personality—our very being.

The difficulty of neurosurgery lies not so much in the operating as in the decision-making. Surgeons must balance the risks and benefits of surgery against the risks and benefits of not operating. These are probabilities, not certainties, and they are easy to misjudge.

Overtreatment is a major problem in modern medicine, especially in the U.S. The patient may be perfectly well after an operation that was actually a mistake—one in which a less biased or emotional assessment would have shown that the probable risks of not operating were less than the probable risks of operating. My worst mistakes—the times patients came to harm at my hands—have almost always stemmed from bad decision-making on my part.

Other people are always better at seeing our blunders than we are. Only toward the end of my career did I fully grasp the importance of having good colleagues willing and able to criticize me.

In a safe surgical department, the senior surgeons get on well and don’t feel threatened by each other. This often doesn’t happen. Surgical egos are large. One cannot carry out high-risk surgery if one suffers from low self-esteem. Teamwork doesn’t—and to some extent shouldn’t—come naturally to surgeons.

It is also dangerously easy to become corrupted by your patients’ gratitude, which can often verge on adulation (although it is, of course, grounded in fear). You can be rude with patients, but if their operation goes well, they will still think you are wonderful. And if the patient “does badly,” we have many ways of exculpating ourselves. We can blame the pathology, the anesthetist, the equipment or the postoperative care, all of which lets us continue to see ourselves as the infallible, Godlike creature that our poor, frightened patients want us to be.

As the French surgeon René Leriche put it, all surgeons carry within themselves an inner cemetery containing the headstones of the patients who came to harm at our hands. The triumphs are triumphant only because disasters also occur.

Complacency, I have learned, is the worst of all surgical sins. All doctors face the central challenge of balancing professional detachment with painful compassion. You can care too much for your patients and become overwhelmed—because however skillful and diligent you are, some of your patients will suffer and die.

But if you fail to suffer with them to at least some extent, you will have lost not only your humanity but also your drive to do better. I still love the struggle to find this balance—and to justify the respect and confidence that our patients have little choice but to place in us.

Dr. Marsh is the author, most recently, of “Admissions: Life as a Brain Surgeon,” which will be published by St. Martin’s on Oct. 3.

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