The hands. It always starts with the hands.
It’s funny, really. A child might be at death’s door. As far as the parents are aware, I am the person who stands a chance of bringing their bundle of joy back from the brink. I’ve been doing this my entire adult life. I’ve saved hundreds of children with the exact same symptoms. But sometimes it doesn’t cross their minds to check that. They don’t ask for my CV. They don’t enquire about past success rates. They stare at my hands.
Does he have the hands of someone who could save our child?
I get it. I’m going to be putting my fingers inside their baby’s skull. Touching its brain, most likely. They want assurances that I’m worthy, that I’m not shaking, that I’m clean. We scrub our hands thoroughly before we operate, and of course we wear gloves for all procedures. There was a short-lived attempt to suggest that we only needed to do a full ‘surgical scrub’ – the kind you see on the telly – in the morning, and then just a simple handwash between each case that day. It didn’t happen, despite the evidence that was presented to us. Some things can’t be changed – surgeons and nurses have their routines, and we need to do them to keep our anxiety at bay. But it’s all about appearances. And appearances where desperate parents are concerned count for more than you think. It’s a lesson I’ve learned over more than fifteen years as a consultant and almost double that time as a doctor.
And yet not everyone sets great store on such things. Not everyone even notices what parents think. Some people, in fact, couldn’t care less. Which is why I am the man I am today and why I choose to work with children. And which is why I try to go the extra mile and place myself in not just the parents’ shoes, but those of my patients. How would I feel in their position? What would make my already horrific ordeal that bit better?
I like to think that I do what I can, and should, for my patients. But it wasn’t always like that. And it certainly wasn’t what I was always taught.
At the age of eighteen I went off to medical school. I chose St Mary’s in Paddington, London. I had thought about Oxford – my biology teacher said that this was clearly where I should go – but after having visited it, I felt that it seemed too quiet, too provincial for the teenage me. I wanted the grubby highlights of the big smoke. Interesting how this view was to change later on in my life. Six years of medical school is a long time, but you soon realize after qualification that even half a century of study would have left you feeling you had gaps in your knowledge. All these years later I’m still learning. Of course, that’s with the benefit of hindsight. At that age you think you know it all.
I was bright-eyed and bushy-tailed, full of enthusiasm and enough confidence to think I could change the world. A typical eighteen-year-old, in other words. It was a bit of a shock to learn that the whole profession had slightly lower aspirations. The father of modern medicine, Hippocrates himself, summed it up in a nutshell: ‘Do no harm.’ (Well, he didn’t actually make it up, but let’s not quibble – it simply paraphrased his ‘oath’ that doctors love so much.) In other words, don’t screw up. That’s it. That’s all doctors were expected to do. Don’t make things worse. Anything better than that is a bonus. Surely, we must have moved on from there?
Reality check aside, the course covered everything, and as much as it makes me sound nerdy, I liked it all. Whichever topic we covered that week became my new life’s ambition. I was like a kitten chasing beams of light. Ooh, sparkly. Ooh, new! Want it, chase it, want it.
It was only as we went through year five that I decided upon my future speciality. Or so I thought. In your penultimate year of being a medical student, essentially after nearly six years of hard slog and excessive drinking, they throw you a bone. You’re asked to do a three-month specialism with the bonus of the powers-that-be letting you choose where to do it. Most people pick Jamaica or Thailand or Australia, basically somewhere to chill.
I chose the National Hospital for Neurology and Neurosurgery in Queen Square in London. Just down the road. What a loser.
In my defence, they had a great reputation for my new favourite topic: neurology, the medical side of brain disorders. The passion had been growing for some time. Lots of people have a model of that phrenology bust on their shelves – the human head with the various parts of the brain marked off like prime cuts on a picture of a cow. You’d be forgiven for thinking that it is an accurate representation of what’s under the hood – and certainly in the early 19th century most experts did – but it’s largely inaccurate. Having said that, as incredible as it sounds, there are some areas of the brain that were successfully associated with specific functions as far back as ancient Egyptian times.
An American collector of antiquities called Edwin Smith discovered an almost 4,000-year-old papyrus containing a fantastic collection of descriptions of what are clearly neurosurgical wounds alongside explanations of what should be done to make them better. Things like: ‘If the man has a wound to his temple, and cannot speak, this is a wound that cannot be treated’, because they obviously knew that the speech centres were in these areas. It lists different presentations of spinal injuries and gives a spookily accurate assessment of the prognosis for each. There are lots of nuggets like these, all born thousands of years ago from, one imagines, observations of people with battle injuries. It’s fascinating to consider the physicians working independently, but all their information has been pulled together over time. One doctor would look at a patient and say, ‘Okay, you can’t move. There’s a hole in this part of your head, so they must be connected.’ He would write that down and over time people would build on that knowledge.
Like so many advancements in science and technology today, the driving factor has been the effects of war rather than a thirst for health. But the ancient Egyptians weren’t the only ones on record to dabble in neurosurgery. There’s evidence from over 3,000 years ago in Central and South America, where they used to trepan – in other words, drill holes in skulls to let out the evil humours. It’s almost inconceivable that there was neurosurgery going on back then, but the fact that there was further sold it to me as a worthwhile career.
The great thing about any neurological condition, though, and this is why I was drawn to it, is that it takes a lot of thought. It’s a very deductive speciality. You examine patients, and you have to work out where the problem lies, at what level and which part of the function of that person is affected. It’s like doing a cryptic crossword. The clues are there, but can you make sense of them? You’re Dr Watson and Sherlock Holmes rolled into one. I absolutely loved it. It spoke to me. Challenged me. And, I guess, didn’t exactly hurt my ego.
It’s not for everyone. Many of my friends were drawn to orthopaedics. I wasn’t going to judge them, but where was the challenge in that? ‘You’ve got a broken leg. Here’s an X-ray, it shows me the leg is broken. Job done.’
Of course, now I know that orthopaedics can be incredibly intricate and challenging, but I didn’t see that side of these specialities back then – you only get two to three months at most, and sometimes much less, at medical school.
I didn’t want something that would give me answers on a plate. I wanted to have to sit and think and work stuff out. Be a calculator rather than a robot on the production line. But, I began to wonder, would that be enough?
The thing about Sherlock, of course, is that while he was the greatest deductive detective, he was also, like the Dark Knight, no slouch at the old fisticuffs. He could handle the practical as well as the theoretical side of crime-solving. Whereas I, in neurology, was being benched whenever the going got good. The problem with neurology as a discipline is that although it’s really good for all that deductive reasoning, the treatment options can be limited. I felt slightly powerless in that I was going to be giving patients some medicine and seeing if the medicine helped, rather than me helping personally. I may as well have been standing on that weird raised step in a pharmacy doling out ibuprofen for all the input I thought I’d be giving. It didn’t feel like I was actually part of the treatment – just a conduit for the drugs. I think it was all part of a rather youthful desire to be the centre of everything.
But, I reasoned, so what if I rarely break a sweat? This is the area I want to specialize in.
By the third month, however, it had got to me. I was in the dining hall at Queen Square queuing for something with chips, whatever the day’s special was, and I remember ranting to a couple of friends about the shortcomings of the area.
‘I never feel like I do anything. I got into medicine to help people, not read books. I want to get my hands dirty.’ I was talking to a group of neurology hopefuls, so I wasn’t going to get any sympathy from them. Nor, it turned out, from anyone else.
‘Stop fucking whingeing,’ said a voice from behind me. I turned to see that, according to his name tag, it was one of the university’s senior trainee neurosurgeons. ‘If you really want to get your hands dirty then stop moaning and do something about it. Join us. Be a brain surgeon. Ditch these losers. Become one of the elite.’
I don’t think I moved for about a minute as I was so shocked at being sworn at like that by a stranger. By the time I did, the lunch queue had shifted around me and the guy was already at the till. I was torn between grabbing the chilli option and running after him. In the end I tried to do both. Clutching my food, I chucked a fiver at the cashier and legged it after my new mentor. So what if he eavesdropped on other people’s conversations? I liked the cut of the guy’s jib. He had this arrogance I’d never seen in doctors before. It was intoxicating. It spoke to me. He was exactly everything I wanted to be.
‘Do yourself a favour,’ he said, barely looking at me when I caught up. ‘Come and see what we do. You’ve either got it or you haven’t.’ He explained that he was operating the following day and I was welcome to attend.
Eighteen hours later, I was watching him cut into a young woman’s head. I needed to become one of these guys. Of course I did. It was so obvious. This guy wasn’t just deducing the problem and prescribing a few pills. He was nailing the diagnostic bit and then providing the solution with his own two hands.
He’s not just dishing out the medicine. He is the medicine.
My future was fixed at that very moment. But before I got there, despite what it said at my graduation ceremony about being qualified, I needed to learn to become a real doctor.
All the theory in the world can’t prepare you for what lies outside the college doors. After qualifying, you used to do a year’s basic medicine and surgery, basically a bit of everything, before you could even think of sub-specializing. In other words, you’re let loose on the public. Again I eschewed the glamour spots of the world for Ealing Hospital. Like all newbies, I thought I had all the answers. Like all newbies, I was soon put in my place. I knew nothing.
There was six months of general surgery and another six of general medicine. That’s really when you learn how to be a doctor. And it’s a steep learning curve. During my first ‘on-call’ shift as a doctor, I was asked to ‘write up’ some paracetamol. There happened to be a box near me in the drug cupboard, so I broke a couple of tablets out and handed them over.
‘What are you doing, lad?’ the nurse in charge asked. ‘You can’t just hand out medicine. You have to prescribe it.’
‘Okay,’ I said, and I duly wrote down ‘two paracetamol’. ‘There you go.’
She rolled her eyes and laughed. ‘You can’t write “two tablets”. You have to write “one gram”.’
‘Really? Six years and no one told me that?’
‘That’s why you’re here.’
Measuring tablets in weight was just the start of it. There were so many idiosyncrasies not covered in the textbooks and of course the only way to learn was to have first-hand experience. I examined hundreds of patients, processed thousands of blood tests, listened to countless heartbeats. It was baffling how so many people of the same species suffering the same conditions could have such different bodies. At med school all the practice dummies looked the same. Still, all part of the learning process.
The lack of time and resources in the NHS means there’s no room for slowcoaches. As nice as most people were, carrying a newbie passenger wasn’t something anyone enjoyed. They made that clear enough. And why not? They’d had to get up to speed sharpish back in the day. There was no reason I shouldn’t either.
You had to learn quickly. There just wasn’t the time for anything else. I was basically only shown anything once. If it didn’t stick, you didn’t dare ask again. The whole culture was summarized succinctly by one of the doctors in the following words: ‘See one, do one, teach one.’ That was workable when you were writing out prescriptions. When we moved onto the surgery half of the year, the risks got a little higher and Hippocrates’ words finally made sense. You’re dealing with someone’s internal organs. It’s not Lego, it’s not Stickle Bricks. If anything it’s Jenga. One slip and you can wreck everything. Surgeons aren’t magicians. As one of them said, ‘We don’t deal in miracles. If in doubt, do nothing at all.’
Do no harm.
Every fledgling doctor has to pass the whole year. Whether you’re aspiring to become a GP, a gynaecologist or the future of oncology, it all begins with this cold immersion into reality. These days it’s spread out over two years. Even double that, I would suggest, couldn’t begin to prepare you comfortably for the world outside.
The surgery aspect only confirmed my decision to focus on neurosurgery, but I still had two more years of hurdles to overcome before I could even begin. Now promoted to Senior House Officer, ‘Dr Jay’ was expected to turn his hand to everything at the hospital of his choice and I elected Kingston in Surrey.
My first stint was in A&E. If I thought doling out painkillers was an ordeal, then this was something else. If you’ve ever gone into A&E and thought the treating doctor looked a little scared, you’re right. I honestly didn’t know what I was doing quite a lot of the time. If you gave me rare and seemingly random symptoms as part of an exam, I’d ace it. ‘Erratic behaviour in a patient with sweet-smelling urine and ear wax? That must be a metabolic condition known as branched-chain ketoaciduria. I think that patient is suffering from Maple syrup urine disease, sir.’ (That’s a real thing, by the way.)
But staring into the eyes of a real-life human being at 1 o’clock on a Sunday morning, trying to unpack the truth from the confused guesses the patient has made about his or her condition, the pressure was slightly different. So many variables, so many red herrings. Thankfully, there are the nurses. These people saved my backside countless times, and are the absolute backbone of the department. An experienced A&E nurse is worth more than sleep – and that was something I was sorely lacking.
A&E really is the front line of medicine. You’re firefighting all the time. It’s a really worthy part of the system, but it wasn’t where I wanted to be. Nor was general surgery nor orthopaedic surgery, even after six months doing each. No, I thought, my future is in neurosurgery. I want to be a ‘Mr’.
It’s a weird quirk of UK medicine – certainly it’s viewed as weird by international colleagues and, if I’m honest, most of my patients – that once you qualify as a surgeon you are elevated beyond the soubriquet of ‘doctor’. As a breed we’re quite passionate about the origins of the tradition. Like so many British oddities it has its roots in snobbery.
To be a doctor in the 1700s required a medical degree. In theory, this was a sign of erudition. In practice, degrees were often acquired by charlatans cheaply, abroad or by post. It didn’t matter, as it bestowed upon them the title of ‘Dr’ and the right to prescribe medicines, albeit from a rather narrow range, and charge bills. Big bills.
Occasionally, their diagnosis would require some bloodletting or bone-cutting, which is where the surgeon would come in. Except in those days, surgeons weren’t considered medical men. Far from it. They were butchers or, more accurately, barbers.
If you needed a bladder stone removed or a tooth yanked out, you’d be sent along to the same place where you got your hair cut. This is why, if you look outside barbershops today, you’ll often see a pole of red-and-white stripes. It signifies the blood and bandages of their forefathers’ ‘other’ jobs.
It was considered such a ghastly side of health care that doctors weren’t going to perform surgery themselves. All that blood and gore was considered beneath them. Not only were surgeons not required to have qualifications as doctors, all they really needed was muscle, something no man of learning would possess. If a doctor diagnosed a gangrenous foot, for example, then your local Vidal Sassoon would basically stick a leather strap in your mouth and four big blokes would hold you down while the barber got the saw out. Doctors wanted absolutely nothing to do with it.
It was only in the 1800s, with the advent of antisepsis and some element of anaesthetic, that surgery began to lose its tag of human torture and people would voluntarily go to the surgeon and say, ‘I think there’s something wrong with me.’ As it evolved as an occupation and became more skilled and more licensed – and less deadly – the medical profession made moves to bring this former black sheep of the family under its own roof, which of course made sense. But even as they became ‘legit’ members of the industry, surgeons wanted nothing to do with those quacks who’d once treated them like dog mess on their shoes, so they refused the title of ‘Dr’. And which is why, out of solidarity with our predecessors, surgeons in the UK still do the same today. Myself included.
After six years of struggle to become a ‘Dr’, I couldn’t wait to get rid of it.
It was at a hospital in leafy Wimbledon where I finally got my chance to practise neurosurgery and, from the moment I passed my junior surgeon exams, my title changed as well. It gave me an inordinate amount of pleasure to ask people to ‘Call me “Mister”.’ It sounds really childish, but this title had cost me so much time and effort, and all the surgeons I knew got a kick out of this name change.
I worked with half a dozen neurosurgeons, some more closely than others. They were a mix of consultants and senior trainees who were basically at the end of their training. They all had their strengths and weaknesses. Some would let me do more than run errands and watch them in theatre, but they might be unpleasant personally. Others were charm personified, but always, I felt, holding me back from contributing anything worthwhile. What they all had in common, however, was this unerring belief that they were operating – pun intended – at the top of the medical profession. The swagger wasn’t just reserved for the guy at Queen Square who’d helped to change my career path. They all had it coursing through them. As one of them admitted to me during an operation, ‘All doctors have a God complex – but we’re the only ones who deserve it.’
I could see what they meant. Your heart is important but, at the end of the day, it’s basically a pump. A fancy irrigation system. Whereas the brain is network control. You want anything done, speak to the brain – oh wait, you can’t because the brain controls speech.
I admit it. I was falling for the hype hook, line and sinker. In the meantime, my big brother was training to be a heart surgeon. We had a vague sort of competition going on between our specialities. He never gave an inch. Never doubted his side of the great divide. And, when we both experienced one of his colleagues close up, I could see why.
I still remember the day I got the call from my dad telling me that he required a triple heart bypass. He was youngish, relatively fit and had never smoked, so it was a shock. Despite all three of us being in the medical game, the waiting list for Dad’s operation was some months after they predicted he would likely suffer a heart attack. That seemed a bit back to front. Fortunately, Dad had health insurance. I’d never understood why a doctor would get insurance but, given the waiting-list issues, it was all suddenly clear – he knew exactly what pressures the NHS was under and, given the predictions, we all knew this was the only way to go. So, given that we were paying, my cardiac surgery trainee brother knew exactly who he wanted to conduct the operation.
On the morning of the operation, my brother and I were at the hospital to give moral support to my mum. Dad was in bullish spirits and, as he was wheeled away, so was I. As the hours passed, that confidence began to slip. Despite all my training, the thought of a stranger with his hands inside our dad’s chest was unsettling.
I remember asking my brother, ‘I know you were his registrar, but are you sure about this guy?’
‘I’ve told you,’ he said. ‘He’s the best. You wouldn’t want anyone else.’
‘Let’s hope you’re right.’
It was a long and painful five hours of waiting and waiting. I must have covered every inch of the floor in the first sixty minutes alone. Apart from a quick dash down to the supermarket in the lobby, the rest of the time I’d spent gazing absent-mindedly out of the window. Eventually, though, I had to ask, ‘What’s taking so long?’
‘I’m sure everything is fine,’ my brother said. ‘They’re just being thorough.’
‘Yeah, I suppose you’re right. You wouldn’t want them to rush – hey! Wait a minute.’ I called him over to the window. ‘Is that who I think it is?’
A few floors down below was the unmistakable figure of my father’s surgeon, climbing into a car. ‘What the hell’s he doing out there?’ I asked.
‘He must have finished,’ he replied.
‘And he didn’t bother to come and tell us how it went? You were his fucking registrar!’
Despite his defence of the guy, my brother was just as offended as I was that no contact had been made. We’d been waiting for nearly six hours and literally didn’t know where our dad was, alive or not. I’d had enough. I went running down the hall and was just about to give someone a piece of my mind when the anaesthetist from the operation walked out. He too had been handpicked.
‘There you are,’ he said. ‘I was just coming to find you.’
‘Is Dad all right?’ I asked.
‘Should be fine. The next twenty-four hours, as you know, are crucial, but the op itself went like clockwork.’
‘Thank you,’ I replied. ‘Although it would have been nice to hear that from the surgeon.’
‘Oh, don’t worry about that,’ the guy said, ‘he’s not so good with families. All that matters is what he does in theatre, right?’
‘Yeah,’ I said, ‘I guess.’ But for the first time in my career, I wasn’t so sure.
As it turned out, Dad developed renal failure the following day. Nothing to do with the level of skill shown by our errant surgeon – he’d been brilliant, you’d have to say. Not that I could ever tell him that. Never once during the following days did he show his face anywhere near us or even my dad. The anaesthetist, by contrast, was in and out like a nosy neighbour.
My brother was as worried as I was, obviously, but he wouldn’t let a word be said about his former boss. An attack on the surgeon was an attack on the whole cardiac family.
‘Your lot are just the same,’ he insisted. ‘Probably worse.’
‘You don’t know what you’re talking about,’ I said. ‘I’ve never known a neurosurgeon care so little about his patient or their family.’
He laughed. ‘Well, you will, I’m sure of it.’
And, unfortunately, it wasn’t long before he was proved right. What this did teach me was about how it feels to be sitting on the cheap sofa, drinking crap coffee and sweating – in other words, being the relative. It was bad enough with my dad as the patient. The amplified terror of it being your baby – you wouldn’t want to experience that too often in your life. I knew that part of my job was going to involve trying to manage that fear in other people whenever I could.
Surgery is very much an apprenticeship. You can’t learn that much from a book, hence the seemingly never-ending training. At the start, as a junior trainee you spend time examining patients – lots and lots of them – taking care of all the ward work, basically getting to grips with how things are done as much as anything. You’re allowed in the operating theatre, but it’s a fairly ‘no touching’ deal. It is a rude demotion compared to the level of operating we did as juniors in other specialities. I was able to do a fair few abdominal procedures almost single-handed, but neurosurgery training puts you right back down again.
After a year of that, you start contributing to some procedures, learning how to close wounds, operating the suction, getting a bit more hands-on. It’s very low risk. There’s always either a senior trainee or the consultant surgeon – often both – guiding every move. You’re nervous as hell the first time you do anything and, though they don’t admit it, so are your bosses. But you get through it and the next time they only watch you with one eye.
It was late at night. I was the designated dogsbody on duty, basically there to answer the bleep in case of emergency. But as it turned out, there was an emergency and I duly called the senior trainee who was on call with me. He took the patient to theatre. The whole process worked as smoothly as could be hoped. But then the bleep rang again. I took the verbal history and results over the phone from a harassed registrar in some other hospital, no doubt harassed to the extreme also.
I phoned out again to run through the details with my boss, as the senior registrar was busy. Consultants are on call on top of their full-time day duties – so they are at home and are available for advice and assistance. I fully expected him to say, ‘Check the patient over – I’m coming in.’ But he didn’t.
‘You’ve seen this procedure before?’ he said.
‘Yes.’
‘Good, I think you will manage to do this quite fine.’
‘Do this? You mean on my own?’
‘You want to be a surgeon, don’t you?’
‘Then he’s yours. Let me know how you get on.’
I hung up the phone in shock. At last. It was happening. After all the years of dreaming and waiting, I was finally being allowed to work on my own patient. I was so excited. So ready for my big moment. So determined that this person – this fellow human being – whose life had been placed in my hands, was about to benefit from surely the greatest surgeon the UK would ever see!
I was prepared. I was confident.
Perhaps too confident.