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  I am not sure, however, if I would take up medicine or neurosurgery now, if I could start my career all over again. So many things have changed. Many of the most challenging neurosurgical operations – such as operating on cerebral aneurysms – have become redundant. Doctors are now subject to a regulatory bureaucracy that simply did not exist forty years ago and which shows little understanding of the realities of medical practice. The National Health Service in England – an institution I passionately believe in – is chronically starved of funds, since the government dares not admit to the electorate that they will need to pay more if they want first-class health care. Besides, there are other, more pressing problems now facing humanity than illness.

  As I returned to Newcastle with my new-found sense of having a future, I read the first issue of a magazine called The Ecologist. It was full of gloomy predictions about what was going to happen to the planet as the human population continued to grow exponentially, and as I read it I wondered whether becoming a doctor, healing myself by healing others, might not be a little self-indulgent. There might be more important ways of trying to make the world a better place – admittedly less glamorous ones – than by being a surgeon. 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.

  A few weeks later, back at work as a theatre technician, I watched a man undergoing surgery to his arm. He had deliberately pushed his hand through a window in a drunken rage and his hand had been left permanently paralysed by the broken glass.

  The other woman who quite unintentionally played a pivotal role in my life – at the end of my neurosurgical career – was the medical director of my hospital. She was sent one day by the hospital’s chief executive to talk to the consultant neurosurgeons. I believe that we had the reputation of being arrogant and uncooperative. We were too aloof and not playing our part. I was probably considered to be one of the worst offenders. She came into our surgeons’ sitting room – the one with the red leather sofas that I had bought some years previously – accompanied by a colleague who was called, I think, the Service Delivery Unit Leader (or some similarly absurd title) for the neurosurgery and neurology departments. He was a good colleague and on several occasions had saved me from the consequences of some of my noisier outbursts. He was suitably solemn on this occasion, and the medical director was looking perhaps a little anxious at the prospect of disciplining eight consultant neurosurgeons. She sat down and carefully placed her large pink handbag beside her on the floor. Our Service Delivery Unit Leader made a little introductory speech and handed over to the medical director.

  ‘You have not been following the Trust dress code,’ she declared. Apparently this meant that the consultant neurosurgeons had been seen wearing suits and ties. I had always thought that dressing smartly was a sign of courtesy to my patients, but apparently it now posed a deadly risk of infection to them. A more probable, albeit unconscious, explanation for the ban – which came from high up the NHS hierarchy – was that the senior doctors should not look any different from the rest of the hospital staff. It’s called teamwork.

  ‘You have not been showing leadership to the juniors,’ the medical director continued. This meant, she told us, that we had not been making sure that the junior doctors had been completing the Trust computer work on time when patients were discharged. In the past we had had our own neurosurgical discharge summaries, which had been exemplary, and I had always taken some pride in them, but they had now been replaced by a Trust-wide, computerized version of such appallingly poor quality that I, for one, had lost all interest in making sure that the juniors completed them.

  ‘If you do not follow Trust policies, disciplinary action will be taken against you,’ she concluded. There was no discussion, no attempt to persuade us. The problem, I knew, was that the hospital was about to be inspected by the Care Quality Commission, an organization that puts great store by dress policy and the completion of paperwork. She could have said that she knew this was all rather silly, but could we please help the hospital, and I am sure we would all have agreed – but no, it was to be disciplinary action. She picked up her pink handbag and left, followed by the Service Delivery Unit Leader, who looked a little embarrassed. So I sent off my letter of resignation the next day, unwilling to work any longer in an organization where senior managers could demonstrate such a lack of awareness of how to manage well, although I prudently postponed the date of my departure until my sixty-fifth birthday so that my pension would not suffer.

  It is often said that it is better to leave too early rather than too late, whether it is your professional career, a party, or life itself. But the problem is to know when that might be. I knew that I was not yet ready to give up neurosurgery, even though I was so anxious to stop working in my hospital in London. I hoped to go on working part-time, mainly abroad. This would mean that I would need to be revalidated by the General Medical Council if I were to remain a licensed doctor.

  Aircraft pilots need to have their competence reassessed every few years and, it is argued, it should be no different with doctors, because both pilots and doctors have other people’s lives in their care. There is a new industry called Patient Safety, which tries to reduce the many errors that occur in hospitals and which are often responsible for patients coming to harm. Patient Safety is full of analogies with the aviation industry. Modern hospitals are highly complex places, and many things can go wrong. I accept the need for checklists and trying to instil a blame-free culture, so that mistakes and errors are identified and, hopefully, avoided. 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. Passengers will almost certainly survive the flight, whereas patients will often fail to leave the hospital alive. Passengers do not need constant reassurance and support (apart from the little charade where the stewardesses and stewards mime the putting-on of life jackets and point confusingly to the emergency exits). Nor are there anxious, demanding relatives to deal with. If the plane crashes, the pilot is usually killed. If an operation goes wrong, the surgeon survives, and must bear an often overwhelming feeling of guilt. The surgeon must shoulder the blame, despite all the talk about blame-free culture.

  To revalidate doctors is important but not easy, and it took the General Medical Council in Britain many years to decide how to do it. As well as being ‘appraised’ by another doctor, I had to complete a ‘360-degree’ assessment by several colleagues, and one by fifteen consecutive patients. I was tempted, when instructed to provide the names of colleagues, to name ten people who disliked me (alas, not very difficult), but I chickened out, and instead listed various people who would be unlikely to find great fault with me. They ticked the online boxes, saying how good I was, and how I achieved a satisfactory ‘work–life balance’, and I returned the favour when they sent me their 360-degree forms.

  I was provided with fifteen questionnaires to hand out to patients. The exercise was managed by a private company – one of the many profitable businesses to which much NHS work is now outsourced. These companies prey off the NHS like hyenas off an elderly and disabled elephant – disabled by the lack of political will to keep it alive.

  I was told to ask the patients to complete the lengthy, two-sided form after I had seen them in my outpatient clinic and to have them return the forms to me. Not surprisingly, I was on my best behaviour. Besides, the patients would probably have been reluctant to criticize me to my face. My patients obediently filled in the forms. It seemed to me that whoever would be examining them might well suspect that I had fraudulently completed them myself, as all the completed forms were both eulogistic and anonymous. I was tempted to do this but to accuse myself of being im
patient and unsympathetic – in short, of being a typical surgeon – and see if this made any difference to the absurd charade.

  My first neurosurgical post had been as a senior house officer in the hospital where I had trained as a medical student. There were two consultant neurosurgeons, the younger one very much my mentor and patron. The senior surgeon retired shortly after I started working in the department. He rang me once at night when I was on call, seeking advice about a friend of his who had passed out at home, asking whether this might be due to his blood-pressure drugs. It was fairly obvious that the friend was himself. I remember once standing with him in front of an X-ray screen looking at an angiogram – an X-ray that shows blood vessels – of a patient with a difficult aneurysm, and him telling me to ask his younger colleague to take over the case.

  ‘By my age, aneurysm surgery is not good for the coronaries,’ he said. I knew that recently one of the senior neurosurgeons in Glasgow had clipped an aneurysm and then immediately collapsed with a major heart attack.

  My senior consultant’s career ended gloriously with a successful operation on a large benign brain tumour in a young girl. She recovered perfectly and a few days later, still in her hospital gown and with a shaven head, came to his retirement party to present him with a bouquet of flowers. I believe that he died a few months afterwards. My own surgical career, thirty-four years later, was to end ignominiously.

  I had two weeks left before retiring and I was looking at a brain scan with my registrar, Samih.

  ‘Fantastic case, Mr Marsh!’ he said happily, but I did not reply. Until recently, I would have said exactly the same myself. The difficult and dangerous operations were always the most attractive and exciting ones, but as my career approached its end I was finding that my enthusiasm for such cases, and for the risk of disaster, was rapidly diminishing. The thought of the operation going badly, and of my leaving a wrecked patient behind me after my retirement, filled me with dismay. Besides, I thought, as I am soon to give all this up, why must I go on inflicting it on myself? But the patient had been referred to me personally by one of the senior neurologists. Suggesting that one of my colleagues do the operation instead was out of the question: it was just not compatible with my self-esteem as a surgeon.

  ‘It should separate away from all the vital bits,’ I said to Samih, pointing to the tumour on the scan. The tumour was growing at the edge of the foramen magnum. Damage to the brainstem or the nerves branching off it can be catastrophic for the patient, including paralysis of swallowing and coughing. This can lead to fluid in the mouth getting into the lungs and causing a very severe form of pneumonia that can easily be fatal. At least the tumour appeared benign. It did not look as though it would be stuck to the brainstem and spinal nerves so, at least in theory, it should be possible to remove the tumour without causing severe damage. But you can never be certain.

  It was Sunday evening and Samih and I were sitting in front of the computer at the nurses’ station on the men’s ward. We both regretted the fact that our work together was soon to end. The close relationship you can have with your trainees is one of the great pleasures of a surgeon’s life.

  It was early March, and it was dark outside but the sky was clear; there was a very bright full moon, low over south London, which I could see through the ward’s long line of windows. There had been a scent of spring in the air as I had bicycled in to work, along the back streets, the moon cheerfully racing along beside me over the slate roofs of the terraced houses.

  ‘I haven’t met him yet,’ I said. ‘So we had better go and talk to him.’

  We found the patient in one of the six-bed bays, the curtains drawn around the bed.

  ‘Knock, knock,’ I said, drawing the curtain aside.

  Peter was sitting up. There was a young woman in the chair beside the bed. I introduced myself.

  ‘I’m so pleased to see you at last,’ he said, looking much happier than most of my patients when I first meet them. ‘The headaches have really been getting awful.’

  ‘Have you seen the scan?’ I asked.

  ‘Yes, Dr Isaacs showed it to me. The tumour looked huge.’

  ‘It’s not that big,’ I replied. ‘I have seen many bigger, but then one’s own tumour always looks enormous.’

  Samih had pulled along one of the new mobile computer stations from the corridor and placed it at the end of Peter’s bed. He summoned up the brain scan while we talked.

  ‘That’s a centrimetric scale there,’ I explained, pointing to the edge of the scan. ‘Your tumour is four centimetres in diameter. It’s causing hydrocephalus – water on the brain – it’s acting like a cork in a bottle and trapping the spinal fluid in your head where it is supposed to drain out at the bottom of your skull. Without treatment – although I apologize for terrorizing you – you only have a few weeks to live.’

  ‘I can believe that,’ he said. ‘I’ve been feeling really lousy, though the steroids Dr Isaacs started me on helped a bit.’

  We talked for a while about the risks of the operation – death or a major stroke were possible but unlikely, I said, and he might have difficulty swallowing. He nodded and told me that in recent weeks he had sometimes choked when eating. We talked also about his work, and about his children. I asked his wife what they knew about their father’s illness.

  ‘They’re only six and eight,’ she said. ‘They know their Daddy is coming to hospital and that you are going to make his headaches better.’

  While we talked, Samih filled up the long consent form and Peter signed it quickly.

  ‘I’m not at all frightened,’ he said, ‘and I’m really glad I’ve got you to do it just before you retire.’ I let this pass – patients want to think their surgeon is the best and don’t particularly like it when I tell them that I am not and that I am dispensable. Samih noted his wife’s phone number down on the edge of the consent form.

  ‘I’ll ring you after the op,’ I said to Peter’s wife. ‘See you tomorrow.’ I waved to Peter and slipped out between the curtains. There were five other men in the room who looked up at me as I left – no doubt they had all listened to the conversation with great interest.

  As I cycled to work next morning, I reflected on the strange fact that almost forty years of working as a surgeon were coming to an end. I would no longer have to feel constantly anxious, with my patients so often on the edge of disaster, yet for almost forty years I had never had to worry about what to do each day. I had always loved my work, even though it was often so painful. Every day was interesting; I loved looking after patients, I loved the fact that I was – at least in my own little hospital pond – quite important, indeed my work had frequently felt more like a glorious opportunity for adventure and self-expression than mere work. It had always felt profoundly meaningful. But in recent years this love had started to fade. I attributed this to the way in which working as a doctor felt increasingly like being an unimportant employee in a huge corporation. 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. We spent more time talking about work rather than actually working. We would often look at brain scans and decide whether the patient should be treated or not without any of us having ever seen the patient. Like almost all the doctors I knew, I was becoming deeply frustrated and alienated.

  And yet despite this, I was still burdened with an overwhelming sense of personal responsibility for my poor patients. But perhaps my discontent was because I had less and less operating to do – although I was lucky compared to many other surgeons in that I still had two days of operating a week. Many of my colleagues are now reduced to a single day each week; you may well wonder what they are supposed to do for the rest of the week. Recent increases in the number
of surgeons have not been matched by any increase in the facilities we need in order to operate. Or then again, perhaps it was simply because I was getting old and tired and it was time to go. Part of me longed to leave, to be free from anxiety, to be master of my own time, but another part of me saw retirement as a frightening void, little different from the death, preceded by the disability of old age and possibly dementia, with which it would conclude.

  There had been fewer emergency admissions than usual over the course of the weekend and there were empty beds on the ITU, so I was told that my list could start on time. The anaesthetist, Heidi, had been away on prolonged leave to look after her young son and was now back at work part-time. We were old friends and I was relieved to see her. The relationship between anaesthetist and surgeon is critical, especially if there is going to be trouble, and having colleagues who are friends is all-important. I walked into the anaesthetic room where Heidi and her assistants had Peter already asleep. The ODA – the operating department assistant, whose job is to help the anaesthetist – was stretching a wide band of Elastoplast across his face to keep the endotracheal tube – the tube which Heidi had inserted through his mouth, down his throat and into his lungs – in place. His face now disappeared beneath the Elastoplast, and the process of depersonalization that starts as the intravenous anaesthetic takes effect and the patient becomes unconscious was now complete.

  I have watched that process thousands of times – it is, of course, one of the miracles of modern medicine. One moment the patient is talking, wide awake and anxious – although a good anaesthetist like Heidi will be soothing and reassuring – and the next instant, as the intravenously injected drug travels up the veins of the arm via the heart to the brain, the patient sighs, the head falls back a little, and he or she is suddenly and deeply unconscious. As I watch, it still looks to me as though the patient’s soul is leaving the body to go I know not where and all I now see is an empty body.