ramen and pickles

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Monthly Archives: April 2014

Do No Harm & The Dressing Station

I’ve just finished reading two surgical memoirs which I read back to back, switching between the two, both by surgeons trained in the British system, Jonathan Kaplan and Henry Marsh.


Jonathan Kaplan is a medical and media vagabond and his book is The Dressing Station: A Surgeon’s Chronicle of War and Medicine.  Henry Marsh is senior consultant neurosurgeon (equivalent to department chair I suppose) at a major London hospital (soon to retire), and his new book is Do No Harm: Stories of Life, Death and Neurosurgery is not widely available in the US, and I had to order it from the UK.

Structurally, the books are fairly similar.  They are both organized as a set of episodic chapters which largely stand on their own.  The Kaplan book is mostly organized around his different jobs and travels, for example a chapter or a few chapters might be dedicated to his experiences in Mozambique or his time working as a ship’s doctor on a cruise ship based in the Manilla, and they are typically titled by the country/place (e.g. Namibia or Kurdistan).  Marsh writes his chapters usually organized around a specific case or a few related cases (sometimes his own experiences as a patient) and titles his chapters around themes of disease, symptoms or situation (Glioblastoma, Medulloblastoma, Melanoma, Trauma).  Many of these chapters would stand relatively well on their own, perhaps as the sort of case reports with personal commentary that show up in places like the NY Times or the New Yorker.

As interesting side note, relatively late in the book Marsh notes two of the great advantages to being in medicine are 1) an inexhaustible supply of interesting anecdotes, sometimes amusing but often terrible and 2) a good knowledge of where to get very good healthcare for yourself and your loved ones.  Both authors certainly take advantage of their supply of anecdotes, but terrible and amusing in these books.

There are some similarities between the authors.  Kaplan grew up white and privileged in apartheid South Africa to a long line of physicians and surgeons.  Marsh grew up privileged in England (white as well), although his family were more of the humanities side of things, such as the law.  Kaplan fled South Africa after medical school to avoid mandatory military service for the oppressive apartheid regime and goes to the UK for his clinical training (the part that corresponds to residency in the US), so they both had training (house office, registrar, etc.) in the old British system.  They are both surgeons with literary interests.  Both are interested in improving medical care in the developing world.   Both are critical of the modern NHS (the British socialized health system).  Both are somewhat irreverent and anti-authoritarian.

They both have done international work, much of Kaplan’s career has been in the remote regions of the world, many areas of ongoing conflict.  Not for him is the safe life of organizations like Medecins san Frontieres, instead he joined up with much, smaller more wild outfits running into regions with active conflict, much of the time not even working primarily as a physician, but often being a journalist or documentarian.  He covered such topics at the slaughter of elephants during the many African wars he witnessed, their ivory pillaged to buy weapons, although often even on these non-medical jobs, he has been involved in providing medical care to refugees, accidental trauma victims, or those intentionally injured by warfare and conflict.  Much of this work in the developing world is without renumeration, so in between dangerous adventures, he seems to try to recover from PTSD of the horrors of wartime surgery and artillery shells exploding nearby by taking up various temporary medical posts such as cruise ship doctor, medical supervision/escort of patients being airlifted around the world, and even the occupational health of highly stressed bankers in London.

The international work of Marsh has been in several countries, but most of it has been focussed in the Ukraine.  In many ways it is much less dramatic, certainly less dangerous, as he has worked to improve neurosurgical care in post Soviet Ukraine by training their physicians, bringing them supplies, and treating some of their most difficult cases.  I originally became familiar with him through the documentary The English Surgeon which mostly focusses on his work in Ukraine.  It’s a good movie, which I enjoyed a lot:

When reading the Kaplan book I was struck by the lack of a coherent sense of something accomplished or some greater truth learned.  He has certainly saved many lives, helped many people, but he himself admits a few times to feeling like it was not a great contribution and contrasts his work to an engineer providing clean water in Iraq who saves thousands of lives in a very short period of time.  He readily admits that many of his best skills are really suited for things like operating a surgical trauma center in a hotspot in the developing world and don’t often transfer over to medical life in places like the US or England.  I am somewhat struck with getting a feeling of an unfulfilled life.  Despite all his amazing adventures, I didn’t get a sense reading it like he really enjoyed things or felt much achievement.  I’m not sure if that sense of restlessness is what drives him on his adventures, but in his writing it seemed to be there.  There is a sense of being a bit burnt out on human suffering and the burnt out on the lack of empathy and response; he thinks of the Western World as being disinterested and callous about human interests stories on things like just more “War in Africa”, and I guess he is right.  I was also surprised that the book had no pictures.  I know from some video interviews I have seen that he takes very interesting and compelling photography (below).  Part of his travels he was producing documentaries or new stories for the British or Dutch media, so he should have a lot of photographic evidence.  Maybe some of it is someone else’s copyright, but he must have some material to include.

The Kaplan book also has a lot of of the socio-political history of various conflicts in the 70’s-90’s.  I sent me off into several forays into Wikipedia to learn about things like FRELIMO.  On reflection, the book might have benefited from some maps.  I did not go into this book being very familiar with things like geography of Eritrea or Burma, so even just a simple map of his rambling adventures might have helped put things into better context.

Overall, one gets the sense reading the book that he has seen a tremendous amount of human suffering (starting from his early days being aware of the conditions in South Africa), and has done a lot of work to help ameliorate it, but perhaps feel like someone who has taken a few little scoops of water out of the ocean.  There are interesting, exciting stories, but it is somewhat discouraging to think about doing this sort of work.  He tries to end some of his most serious stories with with a happy story encountering a patient he had saved in a makeshift trauma hospital, recovering well later in a bar.  However, he robs this a bit of the uplifting message by somewhat cynically noting that the journalists he is with enjoy it as being a happy ending to a story of their time in Eritrea.  Some of these experiences have pictures, shown in this video interview:

Kaplan is a bit critical of the modern NHS, but Marsh takes it much further and is incredibly critical of the current NHS, which comes off as being absurdly bureaucratic, authoritarian, and barely functional.  He cites numerous examples of the top down driven system making all sorts of policies and the medical equivalent of papal bulls on all manner of aspects of medical care, some of them seemingly absurdly picayune (rules forbidding doctors from wearing wristwatches when seeing patients) to bizarre results of their rules such as sending a CD of medical images in one taxi and a piece of paper with the password in the other to comply with privacy concerns.

Marsh is very open about his surgical errors, writing very openly about judgment errors and mistakes (with a great shout out to Kahneman-Tversky  style biases), including going through a major liability settlement against him.  He talks about one of the serious, major realities of neurosurgical practice being that often patients are left alive, but severely compromised (paralyzed, brain damaged, in a persistent vegetative state).  However, he does rejoice on some difficult cases with good outcomes, patients saved from a death sentence from brain tumor or the chronic pain of trigeminal neuralgia.   He has worked to improve the infrastructure and training program at his hospital, but one also gets something of a feeling of defeatism, as he is happy to be resigning from his post as he is pessimistic of the path the NHS is taking and where it is going.

Both authors write pretty openly about their personal lives.  Kaplan includes some of his sexual escapades, although he seems to remain unmarried without serious interpersonal relationships, other than some comrade-in-arms type close friendships from his adventures (in the video he mentions a girlfriend).  Indeed, it might be hard for someone who has seen so much trauma to relate with many other people.  Marsh’s workaholism led to a divorce from his first wife, but he does seem happy in his current relationship.  He also talks about some of his experiences being the parent of a child with a brain tumor, as his son needed neurological surgery early on in Marsh’s training.   The books both have a lot of introspection about the meaning of what they do and the meaning of their craft and their own personality quirks.

Overall both authors provide very interesting stories about lives spent in the service of others.   I imagine them most tremendously and hope that I can emulate some of their tireless efforts of service.  I would recommend them to anyone interested in global health, medical ethics, and/or the profession of surgery.







To be skilled or to feel skilled – which is more important?

Is it better (more important?) to be really good at something or to feel like you are really good at something?  To be very good at something or is it important to be the best around?  A decent sized fish in a big ocean or the biggest fish in a small pond?

Malcolm Gladwell gave an interesting talk at the Google Zeitgeist conference (video link below) last year on this topic.   He was presenting some of the ideas from his latest book, David and Goliath, which has drawn relatively sharp criticism from Esquire and the New Republic, the latter of which called him “American’s best paid fairy tale writer”, so caveat emptor.

Caveats aside, he talks about a few different things, but one element is issues in what causes college students to switch out of STEM majors, which seems to be relative performance to local peers.  For example, even if you are one of the top 10 performing students (say as measured by an exam) in the world, but you are at a school with the 9 people in the world who rank above you, then there is a good chance you will give up, despite being better at your chosen discipline than everyone else in the world except the other people in your local group.   An example of why this is important (if you think money is important) is that being in a STEM major seems to be one of the major determinants of future income, as highlighted by the latest PayScale report, and although there is some dependence on where you went to school, the choice of major seems to be a much more important factor.   So one thought is that if you are studying something really difficult, and you seem to be the worst at it around, it may be in your long term best interest to stick it out, even if immediately you feel horrible.  As an aside, I have heard this joke: “What’s the graduate of Harvard Medical School with the worst grades called?  Doctor.”

However, Gladwell goes into some research on publication success of economists, and how that the same effect seems to be at work here as well. I guess I have seen very talented people at elite universities sort of “intimidated” out of academia because of their peers, despite being incredibly talented on their own, so maybe there is something to it. However, there is also the important aspect that you need to be challenged by talented people and cooperate with talented people to drive success. In some of his (Gladwell’s) other work he has talked about pockets of high achievers appearing in different areas, supporting the idea of the advantage of a critical mass of people all challenging and driving each other toward excellence, so there is a flipside and an advantage to finding a very good group to work with and not looking for a small pond to be the big fish. I have certainly found that I am most productive when I’m working with the smartest people I can find.

I have heard boxing coaches (maybe this was just in a movie about boxing though, I can’t remember, so take this anecdote with that in mind) talking about how to support the career of a new boxer. You have to have the new boxer move up through bouts progressively. If they go up against the champ right away, they get intimidated and basically ruined. However, they also need to be challenged by progressively more difficulty opponents so they improve their abilities as they go along. Incidentally, that’s how video games work to be wildly addictive.  Relatedly, certainly people have written about why winning a bronze medal can be psychologically more satisfying than winning a silver medal.

I think it is important to recognize the importance or being an expert or leader at something in your life for your happiness. Robert Sapolsky (one of my heroes) has talked about this before with regards to stress reduction. There seems to be an emotional need to feel like you have prestige and competence in one area, and I think that’s a good thing (as long as that thing is a pro-social area). If everyone can have different aspects of life in which they have a lot of prestige, then everyone can be happy at having their own little bay where they can retreat to and be the big fish, but also swim in the larger ocean most of the time to flex their fins. To paraphrase the Lego Movie, “Everyone is the Special”.

Anyway, I certainly feel (or at least think I feel) like it’s more important to be really good at something for the sake of working hard and trying to be good at something, independent of what anyone else is doing.  There is a certain reward to progressive improvement at a task all on its own.

Good luck out there!





How long is an average PhD thesis?

There is a great blog post over on http://beckmw.wordpress.com/2013/04/15/how-long-is-the-average-dissertation/ looking at dissertation length.  It is definitely a standard based upon discipline, as we can see from this figure.



There is some great R code over there to show how to analyze the data from the U of Minnesota’s digital storage of dissertations and create the figures.

Mine was a total of 112 pages, and probably the closest academic discipline on the chart is biostatistics, so I guess it was very close to “industry standard”.   However, a lot of mathematics theses are notoriously brief.

John Nash‘s thesis is about 26 pages of content, has two references (one to Von Neumann, and one self-cite), and led to a Nobel Prize in Economics (1994).  That is efficiency.

John Nash is an interesting dude.

Did you do a dissertation?  How long was it?