by Henry Marsh
‘I’m giving you advance warning of a meeting you are to have with me in the New Year,’ he announced.
‘But what’s it about?’ I asked, immediately anxious.
‘That will have to wait until the meeting.’
‘For Christ’s sake – why are you ringing me up now then?’
‘To give you advance warning.’
I felt frightened and confused and could only assume this was the desired effect of the phone call.
‘What am I supposed to make of that? Advance warning about what? I’ve just about had enough of working here,’ I said pathetically. ‘I feel like resigning.’
‘Oh we can’t have that,’ he replied.
‘Well, tell me what the problem is then!’ I cried.
‘It is about a recent Complaints meeting, but it will have to wait until the meeting.’
He refused to tell me any more and the conversation ended.
‘Happy Christmas,’ I said to my mobile phone.
The meeting was scheduled for early January and I spent much of Christmas brooding over it. I may appear to others to be brave and outspoken but I have a deep fear of authority, even of NHS managers, despite the fact that I have no respect for them. I suppose this fear was ingrained in me by an expensive English private education fifty years ago, as was a simultaneous disdain for mere managers. I was filled with ignominious dread at the thought of being summoned to meet the chief executive.
In the event, a few days before I was to meet him I suffered a haemorrhage into my left eye and had to undergo emergency surgery for a retinal detachment. Perhaps because of my impaired eyesight I then fell down the stairs at home a few weeks later and broke my leg. Once I had recovered from that I then suffered a retinal tear – a lesser problem than a detachment – in my right eye which required further treatment. By the time that I was back at work it seemed that the chief executive had forgotten about me, as had I our conversation on the telephone. I made one of my regular trips to Ukraine and shortly afterwards I was sitting in my office catching up on the paperwork that had accumulated while I had been away.
‘You’re in trouble again!’ Gail shouted through the doorway between our offices. ‘The chief executive’s secretary telephoned. You’ve been summoned to a meeting with the chief executive and the director of surgery tomorrow at eight.’
On this occasion I knew well enough what the meeting was going to be about. Two days earlier, after running up the stairs to the second floor on my way to the morning meeting I was taken aback to find that the doors to the female neurosurgical ward had an enormous three-foot by four-foot poster stuck to them. On it there was a huge No Entry sign in ominous red and black with the grim instructions beneath: ‘DO NOT ENTER UNLESS YOUR VISIT IS ESSENTIAL. SOME PATIENTS ON THIS WARD HAVE AN INFECTIOUS ILLNESS.’
I turned away in disgust and went in to the X-ray viewing room for the morning meeting. The juniors were discussing the poster. Apparently there had been an outbreak of norovirus on the ward – an unpleasant but usually harmless virus that used to be called winter flu. My colleague Francis marched into the room waving the poster in his hand, which he had clearly pulled off the ward doors.
‘How fucking ridiculous can you get?’ he shouted. ‘Some moron from management has stuck this up on the door to the women’s ward. Are we supposed to stop going to see our patients?’
‘You’re a naughty boy!’ I said. ‘You’ll be in trouble with the management for removing it!’
After the meeting I went down to my office and sent an email to the hospital’s director of infection control complaining about the poster. No doubt I was now blamed for its removal.
At eight o’clock next morning, feeling apprehensive and defensive, I made my way along endless corridors to the labyrinth of managerial offices in the heart of the hospital. I passed the doors for the Manager and Deputy Manager for Corporate Strategy, the Interim Manager for Corporate Development, the Director of Governance, the Directors for Business Planning, for Clinical Risk, and for many other departments with names I cannot remember, almost certainly all created as a result of expensive reports by management consultants. The Department for Complaints and Improvements, I noted, had been renamed yet again and was now the Department for Complaints and Compliments.
The chief executive’s office was a suite of rooms, with a secretary in the outer room and a large room beyond with a desk at one end and a table with chairs around it at the other. Just like the offices, I thought a little sourly, of all the ex-communist apparatchiki and professors I have dealt with in the former Soviet Union. The chief executive, however, was not going to use the bullying and bluster of some of his post-Soviet counterparts and instead welcomed me enthusiastically and offered me coffee. (On the other hand, some of the nicer post-Soviet professors would welcome me in the morning with vodka.) We were joined shortly afterwards by the director of surgery, who said little throughout the meeting, his expression one of irritation and exasperation with me, and of deference to the chief executive. After the usual niceties, the question of the infection control poster came up.
‘Just for once,’ I said, ‘I followed the proper channels. I sent an email to the director of infection control.’
‘It caused great offence. You compared the hospital to a concentration camp.’
‘Well, I wasn’t the one who copied it to everybody in the Trust,’ I retorted.
‘Did I say that you did?’ the chief executive replied in a stern and headmasterly tone.
‘I regret saying “concentration camp”,’ I said with some embarrassment. ‘It was silly and a bit over the top. I should have said “prison”.’
‘But didn’t you remove the poster?’ asked the chief executive.
‘No, I didn’t,’ I said.
He looked surprised and the room was quiet for a while. I had no intention of sneaking on my colleague.
‘And there was a problem with a Complaints meeting last year.’
‘Yes, your Trust’s Complaints office managed to arrange the meeting on the anniversary of the patient’s death.’
‘Not “your Trust” Henry,’ said the chief executive. ‘Our Trust.’
‘The anniversary of a death is the worst possible date for such a meeting. Have you ever come across so-called “Anniversary Reactions”? Grieving relatives are particularly difficult to handle on these occasions.’
‘Well, yes. We did have one of those recently, didn’t we?’ he said, turning to the director of surgery.
‘Nor was there any meeting with me beforehand – with your Trust’s staff about the basis of the complaint,’ I added.
‘Our Trust,’ he corrected me again. ‘But it’s true that the procedure is that there should have been a meeting beforehand . . .’
‘Well the procedure wasn’t followed but I’m sorry if I handled the meeting badly,’ I said. ‘But you try sitting opposite the parents of a patient who has died and who are convinced you killed their child. It’s even more difficult when the accusation is absurd, even though I did get the diagnosis wrong and he was subjected to an unnecessary operation.’
The chief executive was silent. ‘I couldn’t do your job,’ he said at last.
‘Well, I couldn’t do yours,’ I replied, filled with sudden gratitude for his understanding. I thought of all the government targets, self-serving politicians, tabloid headlines, scandals, deadlines, civil servants, clinical cock-ups, financial crises, patient pressure-groups, trades unions, litigation, complaints and self-important doctors with which an NHS chief executive must deal. The average time for which they serve, not surprisingly, is only four years.
We looked at each other for a few moments.
‘But your Communications Office is crap,’ I said.
‘All I’m asking is that you use your undoubted abilities for Our Trust,’ he said.
‘We want you to f
ollow established procedures . . .’ the director of surgical services added, feeling obliged to contribute to the meeting.
After the meeting I made my way back out of the labyrinth and returned to my office. Later that day I emailed the Communications Department my suggestions for a better poster. ‘We need your HELP . . .’ it began, but I never received a reply.
The chief executive left the Trust a few weeks later. He had been re-directed to another Trust with financial difficulties, where no doubt he was to wield the axe again on behalf of the government and the civil servants in the Treasury and Department of Health. I heard a rumour a few months later that he was on sick leave from his new Trust because of stress and, slightly to my surprise, I felt sorry for him.
14
NEUROTMESIS
n. the complete severance of a peripheral nerve. Complete recovery of function is impossible.
On the first day of June, the weather suddenly hot and humid, I cycled to work for the morning meeting. Before setting off I had gone into my small back garden to inspect my three bee hives. The bees were already hard at work, shooting up into the air, probably heading for the flowering lime trees that grow along one side of the local park. As I pedalled to work I thought happily of the honey I would be harvesting later in the summer. I arrived a few minutes late. One of the senior house officers was presenting the cases.
‘The first case,’ she said ‘is a sixty-two-year-old man who works at one of the local hospitals as a security man. He lives on his own and has no next of kin. He was found confused at home. His colleagues had gone round to look for him because he hadn’t turned up for work. There were many bruises on his right side and his colleagues said that he had had increasing difficulties with talking over the previous three weeks.’
‘Did you see him when he was admitted?’ I asked her, knowing that the house officers presenting the cases at the morning meeting will rarely have seen the patients they present because of their short working shifts.
‘Well, actually I did,’ she said. ‘He was dysphasic and had a slight weakness on the right side.’
‘So what’s the diagnosis going to be?’ I asked.
‘It’s a short history of a progressive neurological deficit. It involves speech,’ she replied. ‘The bruises on the right side of his body suggest he’s falling to the right so he’s probably got a progressive problem on the left side of his brain, probably in the frontal lobe.’
‘Yes, very good. What sort of problem?’
‘Maybe a GBM, or maybe a subdural.’
‘Quite right. Let’s have a look at the scan.’
As she worked at the computer keyboard the slices of the poor man’s brain scan slowly appeared. It showed what was obviously a malignant tumour in the left cerebral hemisphere.
‘Looks like a GBM,’ somebody said.
There were two medical students that morning in the audience. The SHO turned to them, probably enjoying the fact that there was somebody even lower in the strict medical hierarchy than herself.
‘A GBM,’ she said in a knowledgeable tone of voice, ‘is a glioblastoma multiforme. A very malignant primary brain tumour.’
‘These are fatal tumours,’ I added for the benefit of the students. ‘A man his age with a tumour like this has only a few months – maybe only weeks – to live. If he’s treated, which means partial surgical removal and then radiotherapy and chemotherapy afterwards, he’ll only live a few months longer at best and he probably won’t regain his speech anyway.’
‘Well, James,’ I said, turning to one of the registrars, ‘the SHO has been spot on with the diagnosis. What is the management of this case? And what are the really important points here?’
‘He’s got a malignant tumour we can’t cure,’ James replied. ‘He’s disabled despite steroids. All we can do is a simple biopsy and refer him for radiotherapy.’
‘Yes, but what’s really important about the history?’
James hesitated but before he could reply I said that what was important was that he had no next of kin. He’d never get home. He’d never be able to look after himself. He had only a few months of life left whatever we did – and since he had no family he was likely to spend what little time he had left miserably on a geriatric ward somewhere. But I told James he was probably right – it would be easier to get him back to his local hospital if we established the diagnosis formally, so I said that we had better get a biopsy and bounce him off to the oncologists. We could only hope that they’d be sensible and not prolong his suffering by treating him. The fact of the matter was that we already knew the diagnosis from the scan and any operation would be something of a charade.
I pulled out a USB stick from my pocket and walked up to the computer at the front of the viewing room.
‘I’ll show you all some amazing brain scans from my last trip to Ukraine!’ I said but I was interrupted by one of my junior colleagues.
‘Excuse me,’ he said, ‘but the manager responsible for the junior doctors’ working hours has very kindly agreed to come and talk to us about the new rota for the registrars and she can’t stay beyond nine o’clock since she has another meeting to go to afterwards. She’ll be here in a minute.’
I was annoyed that I was not going to be able to show some enormous Ukrainian brain tumours but clearly I had no choice in the matter.
The manager was late, so while we waited for her to arrive I walked round to the operating theatres, to see the only patient for the day’s operating. He was waiting in the anaesthetic room, lying on a trolley, a young man with severe sciatica from a simple disc prolapse. I had seen him six months earlier. He was a computer programmer but also a competitive mountain biker and had been training for some kind of national championship when he developed excruciating sciatic pain down his left leg. An MRI scan had shown the cause to be a slipped disc – ‘a herniated intervertebral disc causing S1 nerve root compression’ in medical terms. His disc prolapse had prevented him from training and he had had to drop out of the mountain biking championships, to his bitter disappointment. He had been very frightened by the prospect of surgery and decided to see if he would get better on his own which, I had told him, often happened if one waited long enough. This had not happened, however, and he had now reluctantly decided to undergo surgery.
‘Good morning!’ I said, my voice full of surgical reassurance – genuine reassurance since the planned operation was a simple one. Most patients are pleased to see me before their operation, but he looked terrified.
I leant forward and lightly patted his hand. I told him that the operation really was a very simple one. I explained that we always had to warn people of the risks of surgery but promised him that it really was most unlikely that things would go wrong. If I’d had sciatica for six months I would have the op, I said. I wouldn’t be happy about it, but I’d have it although, like most doctors, I am a coward.
Whether I managed to reassure him or not, I do not know. It really was a simple operation, with a very low risk, but my registrar would have consented him earlier that morning and the registrars – especially the American ones – tend to go over the top with informed consent, and terrorize the poor patients with a long list of highly unlikely complications, including death. I mention the main risks as well but stress the fact that serious complications with simple disc prolapse surgery, such as nerve damage and paralysis, are really very rare.
I left the anaesthetic room to go to the meeting with the EWTD compliance manager.
‘I’ll come back and join you,’ I said to my registrar over my shoulder as I left the theatre, though I thought that would scarcely be necessary as he had done such operations before on his own. I went back to the meeting room where my colleagues were waiting with the manager.
She was a large and officious young woman with hennaed hair in tight curls. She spoke imperiously.
‘We need your agreement to the
new rota,’ she was saying.
‘Well, what are the options?’ one of my colleagues said.
‘If they are to be compliant with the European Working Time Directive your registrars can no longer be resident on-call. The on-call room will be taken away. We have examined their diary cards – they are working far too much at the moment. They must have eight hours sleep every night, six of it guaranteed uninterrupted. This can only be achieved if they work in shifts like the SHOs.’
My colleagues stirred uncomfortably in their seats and grumbled.
‘Shifts have been tried elsewhere and are universally unpopular,’ one of them said. ‘It destroys any continuity of care. The doctors will be changing over two or three times every day. The juniors on at night will rarely know any of the patients, nor will the patients know them. Everybody says it’s dangerous. The shorter hours will also mean that they will have much less clinical experience and that’s dangerous also. Even the President of the Royal College of Surgeons has come out against shifts.’
‘We have to comply with the law,’ she said.
‘Is there any choice?’ I asked. ‘Why can’t we derogate? Our juniors want to opt out of the EWTD and work longer hours than forty-eight hours a week and can do this by derogating. Everybody in the City opts out of the EWTD. My medical colleagues in France and Germany say that they take no notice of the EWTD. Ireland has derogated for doctors.’
‘We have no choice,’ she replied. ‘Anyway, the deadline for derogation was last week.’
‘But we were only told last week about the possibility of derogation!’ I said.
‘Well it’s irrelevant anyway,’ came the reply. ‘The Trust has decided nobody will derogate.’
