Do No Harm

1. Neurosurgery is inherently dangerous and uncertain.

Despite all this technology neurosurgery is still dangerous, skill and experience are still required as my instruments sink into the brain or spinal cord, and I must know when to stop.

High stakes. Operating on the brain or spinal cord is inherently risky, even with advanced technology like computer navigation or evoked potentials. The consistency of brain tissue is like jelly, making precise movements difficult. Surgeons must constantly decide when the risks of intervention outweigh the risks of doing nothing.

Technology's limits. While tools like operating microscopes and specialized instruments enhance precision, they don't eliminate danger. Surgeons must rely on skill, experience, and knowing when to stop to avoid causing irreversible damage to "eloquent" brain areas responsible for vital functions.

Luck plays a role. Despite preparation and skill, outcomes can be influenced by chance. Unexpected bleeding, anatomical variations, or how a tumor behaves during removal can turn a routine case into a disaster, highlighting the unpredictable nature of the work.

2. Surgeons carry the heavy emotional burden of failure.

Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.

Profound regret. Surgical failures, especially those causing patient harm or death, leave lasting emotional scars. These experiences accumulate over a career, forming a metaphorical "cemetery" of past mistakes and regrets that surgeons revisit.

Personal responsibility. Unlike other professions, a surgeon's errors can have catastrophic, irreversible consequences for another human being. This intense responsibility leads to deep anxiety before difficult cases, particularly after a recent failure.

Coping mechanisms. Surgeons learn to accept intense anxiety as part of the job, but the pain of causing harm is profound. While the immediate grief may fade, the memory of damaged patients becomes a permanent scar, added to the internal list of disasters.

3. Honesty and empathy are difficult but essential.

Doctors will sometimes admit their mistakes and “complications” to each other but are reluctant to do so in public, especially in countries that have commercial, competitive healthcare systems.

The challenge of truth. Discussing risks with patients is difficult, especially when the potential outcomes are severe. Surgeons may struggle to balance honesty with the need to reassure anxious patients and their families.

Patient vulnerability. Patients facing life-threatening conditions are often terrified and look to doctors for reassurance and hope. They may invest surgeons with superhuman abilities, making it harder for doctors to admit uncertainty or fallibility.

Learning empathy. Experiencing illness or being a patient oneself provides invaluable insight into the patient's perspective. This personal vulnerability fosters deeper empathy, although it can also make the emotional burden of the job heavier.

4. Hospital bureaucracy hinders patient care.

Years ago, I would have stormed off in a rage, demanding that something be done, but my anger has come to be replaced by fatalistic despair as I have been forced to recognize my complete impotence as just another doctor faced by yet another new computer program in a huge, modern hospital.

Systemic frustrations. Modern hospitals are often plagued by inefficient systems, bureaucratic rules, and a lack of resources like beds. These issues cause delays, cancellations, and frustration for both staff and patients.

Loss of control. Surgeons, despite their critical role, feel increasingly powerless against the dictates of management and ever-changing protocols. Simple tasks become complicated by new computer systems or arbitrary rules, diverting energy from patient care.

Impact on patients. Bureaucratic hurdles directly affect patients, leading to cancelled operations, long waits, and a sense of being lost in the system. The focus shifts from individual patient needs to meeting targets and following procedures, often at the expense of compassionate care.

5. The complex, often fraught, surgeon-patient bond.

Anxious and angry relatives are a burden all doctors must bear, but having been one myself was an important part of my medical education.

Trust and expectation. Patients place immense trust in their surgeons, often viewing them as heroes or even gods. This trust is vital for the surgeon but also creates pressure and fear of disappointing or harming the patient.

Shifting roles. When complications occur, the surgeon's role shifts from potential savior to perpetrator or incompetent. Facing a patient one has harmed is emotionally agonizing, making it difficult to maintain professional detachment.

Gratitude and detachment. Successful outcomes bring profound gratitude from patients and families, a powerful reward for the surgeon. However, the most successful outcomes are often those where patients recover completely and no longer need the surgeon, moving on with their lives and leaving the experience behind.

6. Confronting death and the limits of intervention.

death is not always a bad outcome, you know, and a quick death can be better than a slow one.

Accepting inevitability. Surgeons must confront death regularly, often recognizing when further intervention is futile or would only prolong suffering. Deciding when to stop treatment is one of the most difficult ethical challenges.

Beyond cure. For patients with incurable conditions, the goal shifts from saving life to ensuring a good death. This may involve difficult conversations with families who cling to hope, even when it is unrealistic.

Personal mortality. As surgeons age, their own vulnerability becomes more apparent, blurring the lines between doctor and patient. This can lead to deeper empathy but also makes confronting the limitations of medicine and the inevitability of death more personal.

7. Experience brings wisdom, but also painful lessons.

Most neurosurgeons become increasingly conservative as they get older – meaning that they advise surgery in fewer patients than when they were younger.

Learning from mistakes. Surgical skill and judgment improve with experience, but this often comes at the cost of past failures. Difficult cases that seemed daunting early on become manageable, but the memory of times things went wrong remains.

Increased caution. Older surgeons tend to be more conservative, less likely to operate on marginal cases where the risks are high and the potential benefit limited. This stems from a more realistic understanding of surgery's limitations gained over years of practice.

Balancing risk. Deciding whether to operate involves weighing the risks of surgery against the risks of doing nothing. Experience helps refine this judgment, but the decision remains fraught with uncertainty, particularly in complex or rare cases.

8. Healthcare disparities highlight universal vulnerability.

Our vulnerability and fear of death when we are patients know no national boundaries, and the need for honesty and kindness from doctors—and the difficulty at times in giving these—is equally universal.

Global contrasts. Working in vastly different healthcare systems, from well-funded Western hospitals to impoverished facilities in Ukraine or Sudan, reveals stark differences in resources and technology. However, the fundamental human experience of illness and fear of death remains constant.

Shared humanity. Regardless of location or access to advanced care, patients share the same vulnerability and need for compassionate, honest communication from their doctors. The challenges doctors face in providing this care are also universal.

Beyond technology. While modern equipment is crucial, the core of medical care lies in the human connection between doctor and patient. Kindness, honesty, and acknowledging shared vulnerability transcend technological disparities.

9. Hope's double edge: solace and self-deception.

Life without hope is hopelessly difficult but at the end hope can so easily make fools of us all.

The power of hope. Hope is essential for patients facing serious illness, providing solace and motivation. Doctors often try to foster hope, even when the prognosis is poor, as it is a vital psychological support.

Unrealistic expectations. Hope can become unrealistic, leading patients and families to demand futile treatments that only prolong suffering. This creates a difficult dynamic where doctors must balance compassion with honesty about the limits of medicine.

Clinging to life. The human instinct to cling to life makes accepting death incredibly difficult. Hope, even false hope, can delay this acceptance, sometimes leading to more suffering in the final stages of illness.

10. The physical and psychological cost of the profession.

Terrible job, neurosurgery. Don’t do it.

Intense pressure. Neurosurgery is demanding, requiring long hours, intense concentration, and constant readiness for emergencies. The physical strain is compounded by the immense psychological pressure of making life-or-death decisions.

Emotional toll. Dealing with suffering, death, and the consequences of mistakes takes a heavy emotional toll. Surgeons must develop a degree of detachment to cope, but this can lead to feelings of alienation or burnout.

Personal sacrifice. The demands of the job can impact personal life, relationships, and well-being. Maintaining a balance between the all-consuming nature of neurosurgery and personal happiness is a significant challenge.

11. Learning from mistakes is a lifelong, painful process.

I feel an increasing obligation to bear witness to past mistakes I have made, in the hope that my trainees will learn how not to make the same mistakes themselves.

Acknowledging fallibility. Surgeons inevitably make mistakes, but admitting them, especially publicly or to patients, is incredibly difficult due to fear of blame and litigation. However, acknowledging errors is crucial for learning and improving.

The cost of learning. Gaining experience in complex surgery often involves a period where mistakes are more likely. This creates a moral dilemma, as the surgeon's learning comes at a potential cost to patients.

Bearing witness. Sharing past mistakes, though painful, serves as a vital lesson for future generations of surgeons. It highlights the human element of the profession and the importance of humility and continuous learning.

12. The mystery of consciousness and the brain.

The idea that my sucker is moving through thought itself, through emotion and reason, that memories, dreams and reflections should consist of jelly, is simply too strange to understand.

Awe and wonder. Operating on the brain, the seat of consciousness, thought, and emotion, is a source of profound awe. The physical reality of brain tissue contrasts starkly with the abstract nature of the mind it produces.

The mind-brain problem. Neuroscience reveals that consciousness arises from the electrochemical activity of neurons, a fact that remains deeply mysterious and counterintuitive. This challenges traditional notions of a separate soul or immaterial mind.

Beyond understanding. Despite scientific advancements, the fundamental question of how matter gives rise to subjective experience remains unanswered. This mystery underscores the complexity and wonder of the human brain.

Last updated: May 15, 2025