Henry Marsh

One of my most favorite writers is Henry Marsh, longtime brain surgeon of the NHS before his retirement in 2015.

Little did I realize the double entendre of the book title when I first picked up his memoir Admissions. Once you have read the book yourself, you will know it isn't just narrative of patient admission under his care; Henry Marsh is making confessions or admissions of himself. And he had even been admitted to a psychiatric ward as a patient.

He didn't pretend to be perfect. He has his flaws as doctor and as human. Like most doctors, he has made his share of mistakes, hurt more people than we should have, and, at times, behaved not so properly. He was probably considered to be one of the worst offenders by the hospital managers. One good example is the sin of his wearing suits and ties to work, for which Henry Marsh considered a sign of courtesy to his patients, but then condemned as a breach of infection control in the NHS.

The next error picked up by the managers is his disinterest in diagnostic coding when patients were discharged. The penalty doubled when Henry Marsh didn't make sure that his juniors completed the computerized work. I don't have to tell you how the increasingly depersonalized health care system frustrated Henry Marsh.

If there is one lesson I learn well from his story, it is the way sick patients were handled in Nepal. One sixty-something man was brought to hospital with fixed and dilated pupils, after a catastrophic bleeding inside his brain. The scan showed an undoubtedly fatal bleed. Henry Marsh agreed. When the family was told there was no treatment, they took the brain-dead patient home, squeezing a respiratory bag connected to his lungs. The unusual hand-bagging story struck Henry Marsh as a very humane solution: "He could die with some dignity within the family home, with their loved ones around him, rather than in the cruel impersonality of the hospital."

I can't agree more.

Uncertainty

Medicine is a science of uncertainty, and an art of probability.

Each time I met a patient with not-so-straightforward diagnosis I would remind myself and my junior this teaching by Sir William Osler at the turn of the last century.

Lub dub, lub dub, lub dub. Lub dub, lub dub, lub dub. That's what I heard with my stethoscope yesterday when I examined a gentleman coming to emergency room after feeling breathlessness for two days. Out of pride I refused to rush through the case as that will inflate my chance of failing to crack the puzzle. It wasn't pleasant to miss the additional sound after the usual "lub dub" heart sound, not least after my reading of a medical journal article The Art of Constructive Worrying yesterday morning. I made sure I'd heard that "lub dub whirr, lub dub whirr, lub dub whirr" melody.

Diagnosis resembles a jigsaw puzzle. We are supposed to find the pieces first, then fit them together. One by one. Before the full picture.

My patient clearly had a problem with his heart. What puzzled me is which piece I should focus at the emergency room. Was it because his heart turned oversized after wear and tear from clogged coronary arteries? I didn't have long to reflect on the counterargument that the gentleman neither smokes nor complains of crushing pain of heart attack. A glance at his ECG showed more jigsaw pieces than that of a leaking heart valve; I spotted abundant premature heart beats. Those frequent extra beats, if too frequent, could have caused what we call arrhythmia-induced cardiomyopathy.

Simply put, I was nowhere. There was one possibility after another. Two or three at a time, the possibilities were weighed, and discarded. Other possibilities then cropped up. A good talk with my patient revealed his story of multiple surgery procedures for removing lumps in his neck, torso and legs. I could also palpate some, one of them lurking behind his right calf, not yet operated. By the time I checked his computer record I was pretty sure that he was suffering from a plethora of nerve tumours with a funny name schwannoma. To be honest I don't recall seeing a case of Carney complex, but that could have been the first case in front of my eyes. In short, that's an exceptionally rare inherited anomaly in the human anatomy, with numerous spongy schwannoma and even a tumour inside the heart. Rare, but it can happen.

I don't think I have yet solved the puzzle, but I learned the essence of constructive worrying. Thinking and worrying about the jigsaw pieces that matter most and making plans based on this worrying.

Multitasking

Think about the last time you were multitasking. Are you proud of your versatility and efficiency?

I used to be so. This is even more so when I was attending a true tour-de-force outpatient clinic, in which I had to see twenty to thirty patients within a half day. Everyone is in a rush, and I am no different. After recent installation of dual monitor computer in my clinic, I could scan and call the second patient's name before I finished seeing the first patient. I've lost track of how many patients had entered my consultation room when it was still occupied by the previous patient.

"I've never been in your embarrassing situation, because I never multitask," my mentor shrugged, apropos of my dual monitor story.

I was thrown by this.

But it didn't take me long to figure out why I should not multitask.

An article published in Teaching and Teacher Education titled "The myths of the digital native and the multitasker" highlights that cognitive multitasking simply doesn't exist. What happens in reality is "task switching," indicative of a break in concentration. It strikes me that the human brain is single core; such architecture of cognitive system only allows for switching between different tasks. Switching between tasks, in turn, is not more efficient than carrying out one single task or a series of single tasks consecutively.

Psychological refractory period (bottleneck in switching tasks) is the key, interference the result, and shrinking productivity the ROI.