The Duty of Candour

Each of us has been to a doctor we didn’t like: either they botched up a case, didn’t have enough time to listen to our complaints, weren’t compassionate enough, or simply didn’t meet the physical criteria we had in our heads for what doctors should look like. Yes, the last one is actually true. A friend once came up to me, telling me how disappointed she was by her doctor’s visit. When I asked her why, she mournfully said, “Em toh he solved my problem perfectly, pan bow batko che,” hoping that for the three thousand rupees she had paid, she would have met George Clooney.

In today’s digital jet age, doctors are expected to respond to our text messages instantly, and this is made even scarier with the auto-correct function because patients can die of inadvertent typos! Physicians have to be available to interpret WhatsApp images of different body parts sent to them at odd hours of the day and reply with a smiley face. A dermatologist friend of mine told me that patients send such zoomed in close-ups of their anatomy that it’s impossible to distinguish between body parts, and he once prescribed an oral ulcer cream for haemorrhoids; thankfully, it wasn’t the other way around. Doctors also need to sound chirpy when you call them even when they are in a completely different time zone. They need to be the perfect combination of youth and experience, woo you with their charm, and baffle you with their brilliance.


I think it is relatively easy to do all of the above. Most average surgeons are fairly competent and produce decent results. They look good (especially the Parsi ones), are charismatic, and can engross you with stories of their heroics. However, what they don’t always open up about are their failures, and sometimes rightly so; no patient wants to hear that someone with the exact same tumour they have died just a week ago!


In my opinion, the hardest thing for a surgeon to do is be honest. When every day is filled with either a soaring triumph or a shattering tragedy, what you see is not always what you get, and often, the tragedies are swept under a carpet of triumphs. Unfortunately, the doctor-patient relationship is all about trust because medical treatment is dangerous and uncertain, and almost never comes with a guarantee; good doctors understand that and never take this trust for granted.


I recently had the pleasure of meeting with Dr. Henry Marsh, a British neurosurgeon whose memoir, Do No Harm: Stories of Life, Death and Brain Surgery, dares to reveal the raw and tender humanity behind brain surgery. In his book, he peels back the meninges to reveal the glistening, harrowing, and utterly confounding world of neurosurgery. While I sat and listened to him openly recounting painfully honest mistakes that had wrecked several lives over the course of his career, I could not imagine what I was getting into, just at the beginning of mine—even though, during my residency, I had witnessed every single complication that could possibly occur in the human brain. I have had illusions of coming out of an operating room like an angel with wings delivering news to rejoice for, and here I was, listening to soul-bearing stories of catastrophe.


In his book, Dr. Marsh writes with rare and unflinching honesty. “Neurosurgical disasters can be cruel. A patient can wake up and appear healthy only to die, a few days later, of a stroke or a haemorrhage that’s related, in ‘some unknowable way’, to the operation. And some patients can live on for years despite severe brain damage. Nobody, nobody other than a neurosurgeon, understands what it is like to have to drag yourself up to the ward and see, every day—sometimes for months on end—somebody one has destroyed and face the anxious and angry family at the bedside.


“So, why is it difficult and unusual for doctors to be honest with patients?” he asks. When we are ill, we want to be given hope; some of us are frightened and fear learning the truth. Doctors learn to pretend to do both: please their patients and avoid having painful conversations. And the best way to deceive others is by deceiving yourself first. As surgeons, if we don’t take on the more challenging cases, how will we become better surgeons? How many of you have been referred to another, supposedly more experienced surgeon by the surgeon you first went to because he was not ready to take your case or do such an operation at that stage of his career?


There are also other hidden truths that we seldom speak of. There is power and greed. In a cutthroat (surgical pun intended) society, where power corrupts and absolute power corrupts completely, no doctor will let go of his/her patients. This being said, I like to believe that there still exist doctors of nobility and grace between us, who practice medicine not as a means to an end but as a divine rendition of their life’s primary purpose and duty. At the bottom of my heart, I know these doctors exist and walk amongst us, and one must never lose faith in humanity at the cost of the general plethora; I know I’m too young to be jaded so early on in my clinical and surgical endeavours.


We all make mistakes. As surgeons, we learn more from our mistakes than from our successes. Mistakes can be errors of clinical judgment or pure carelessness. Brain surgery is slow and dangerous, and removing a tumour is like defusing a bomb; the only difference is, here, the bomb is at risk and not the diffuser. “Often, surgeons look through a microscope and use long-handled, fine-tipped instruments to pull the tumour away from the brain before removing it with a sucker. A quarter of the body’s blood courses through the brain’s veins and arteries, and if one of them tears during the surgery, it may result in bleeding and/or a stroke. It’s also quite possible to remove important parts of the brain by accident, because brain tissue and tumour tissue look pretty much the same. Unlike the rest of the body, the brain and the spinal cord rarely heal; if a neurosurgeon makes a mistake, the damage is often permanent,” explains Dr. Marsh.


The next time you visit a surgeon, do consider the psychological realities he/she is dealing with. Medicine is built on mistakes, because doctors, like the rest of us, learn by making blunders. The French surgeon René Leriche said, “Every surgeon carries about him a little cemetery, in which from time to time he goes to pray, a cemetery of bitterness and regret, of which he seeks the reason for certain of his failures.” Or in the words of Dr. Marsh, we all struggle to find the balance between “hope and reality,” “optimism and realism,” “detachment and compassion.”


Like Hippocrates once said, “Life is short, and Art long; opportunity fleeting, experience misleading and decision difficult. It is the duty of the physician not only to provide what he himself must do, but to enable the patient, the attendants and the external circumstances to do their part as well.”


And that’s true for everyone, not just surgeons.