A few months ago I was walking through a large teaching hospital with one of the consultants, a surgeon of some eminence, when he turned to me and asked: ‘Why do you want to write a book about heart surgeons? We’re all psychopaths.’
Although tempted to reply, ‘Precisely because you’re all psychopaths,’ I just laughed; while this affable man had an impressive ability to monopolise any conversation, I was pretty sure he was no psychopath. And after spending many hours in the company of cardiac surgeons, both in their operating theatres and in more unguarded moments, the one thing that struck me about them was how difficult they were to pigeonhole. True, I’d met one or two who spoke fluently and with a startling lack of modesty about their own achievements, deftly sidestepping any questions that threatened to take us into neutral territory. But others were diffident almost to a fault, more comfortable talking about their mentors and patients than about themselves. Then there were those who were simply fascinated by the minutiae of their craft, happily explaining techniques and procedures to me at length until an exasperated secretary put a head round the door to shoo them off to a more important engagement. Most seemed to be normal and well adjusted – more blessed with self-confidence than most of the population, perhaps, but also friendly and compassionate, and manifestly devoted to helping their patients get better.
So at first I dismissed the surgeon/psychopath association as a self-deprecating joke. But why had he said ‘psychopaths’? ‘Egotists’ or ‘narcissists’ would have been just as funny, and probably more accurate, I thought. And then I stumbled across a study in the Bulletin of the Royal College of Surgeons of England which asked simply: ‘Are surgeons psychopaths?’1 The authors assessed 172 doctors for the traits typical of psychopathy, including ‘Machiavellian egocentricity’, ‘social potency’ and ‘cold-heartedness’. Surgeons scored particularly highly on this scale, exceeded only by paediatricians in their psychopathic tendencies.fn1 The most commonly identified personality traits in surgeons were stress immunity and fearlessness – qualities which, the researchers noted, are ‘beneficial or even essential’ when providing care in difficult situations.
Not long afterwards I spent a day in the operating theatre of Marjan Jahangiri, a charismatic surgeon based at St George’s Hospital in Tooting. Standing next to the anaesthetist at the head of the table, I had the best possible view as Professor Jahangiri prepared to replace a diseased heart valve. The first part of the procedure had already been completed, the patient’s chest lay open and I could clearly see his motionless and empty heart, temporarily relieved of its work by the heart-lung machine a few feet away, which was now oxygenating his blood and circulating it through his body. Professor Jahangiri picked up a pair of scissors and in one smooth motion severed the aorta, the artery that normally carries oxygenated blood from the heart to the rest of the body. Involuntarily I took a large gulp of air: I was taken aback by the insouciance with which she had cut the heart loose from its moorings, somehow transforming it from an integral part of the human machine into a distinct and isolated viscus.
Why was this moment so shocking? It was only later, as I watched her replace the man’s diseased aortic valve and then reconstruct his aorta with a tubular graft of synthetic fabric, that I understood. It was the point at which there could be no turning back, when the patient became entirely reliant on the skill of an experienced surgeon to ensure that he left the operating theatre alive and with his heart beating once more. Only somebody with absolute confidence in their abilities could pick up those scissors and be happy to continue. This, I realised, was the fearlessness that all cardiac surgeons need in order to do their job.
Every contemporary heart surgeon has lost a patient, and all need to confront the sobering fact that a single mistake may be all that separates life and death. But the truth is that cardiac surgery today is safer than it has ever been: there is a wide repertoire of operations which have become routine, and so safe that the vast majority of patients make an excellent recovery. Many surgeons walk into theatre expecting every patient to pull through; it is the rarity of death that makes it all the more shocking. So what must it have been like to be a member of the profession in the early years, when death was not merely an occasional visitor but the cardiac surgeon’s constant companion?
Surgeons were so convinced of the unique fragility of the heart that they scarcely dared touch it until the last years of the nineteenth century. The first successful operation on the beating heart took place in 1896, but for almost forty years the only interventions possible would remain simple suture repairs for stab or bullet wounds. Specialists were sure that the scalpel would one day provide relief from many other cardiac conditions – and they were right – but achieving that progress took many decades and entailed a shocking loss of life. The only way of establishing the efficacy of a new procedure was to test it on a patient, and the few plausible candidates for such experimental surgery would usually be so sick that their death was likely whatever happened. For some new operations, therefore, surgeons were braced for the possibility that few, if any, of their patients would make any sort of recovery. And it was not just human lives at stake: virtually every major cardiac procedure was first tested on rabbits, dogs, apes, calves or pigs, many thousands of them – indeed, far more experimental animals died during the twentieth century than did patients.
Pioneers in such a brutal field required perseverance and an extraordinary degree of emotional resilience. Unsurprisingly, many of those attracted to this unforgiving occupation were powerful characters, with strong opinions and unshakeable faith in their own abilities. This was a true medical elite: it is easily forgotten that fifty years ago heart surgeons were the most glamorous and best paid professionals in the world, celebrities who were photographed for the cover of Time magazine and became the friends of royalty and film stars. Some made colossal fortunes which they spent on property empires or fleets of luxury cars; others donated their considerable surgical income to the hospitals for which they worked. Many were tyrants, impossible men who worked seven days a week and expected the same of their juniors, and bitter rivalries were commonplace. And they were usually men: for years this was an almost exclusively male club, a bastion of inequality which did not begin to admit women in significant numbers until the turn of the millennium.
Much else has changed. If cardiac surgeons were quasi-deities in the 1960s, it was partly because there were so few of them, a select number willing and able to tamper with an organ traditionally seen as the repository of the soul. Today there are close to fifty centres of cardiac surgery in the UK alone, and every developed nation has hundreds or even thousands of highly trained surgeons. There is no longer such mystique surrounding the profession, and (with few exceptions) the surgeon has willingly stepped down from his pedestal. In some hospital departments, treatment is now overseen by a multi-disciplinary ‘heart team’, in which anaesthetists, surgeons, cardiologists and medical-imaging specialists all play an equal role, and discussion of a case may only take place if the patient is present.2 The dictator has become a member of a democratic assembly.
Though the body count in this story is high, it is also full of unexpected recoveries, exhilarating moments of discovery, and celebrations of human ingenuity. Its heroes and heroines are not just those who held the surgical instruments, but also the armies of nurses, physiologists, engineers, biochemists and inventors who made their work possible; and of course the many patients, and their families, who willingly allowed their bodies to be used as glorified laboratory specimens. This is not a comprehensive history of the subject, and I have had to be highly selective in which operations and individuals to include; many other important contributions were made which, with regret, I was unable to acknowledge. At times progress was driven by competitive individuals, at others it was a team effort; but what they achieved was miraculous, and I hope readers will share my admiration for these brave pioneers.