Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from ‘A small cemetery’: death and dying in the contemporary British operating theatre Agnes Arnold-Forster­ ‍ ‍

Correspondence to Abstract achievements and innovative successes.2 Instead, Dr Agnes Arnold-F­ orster, Surgeon Henry Marsh begins his autobiography, Do No thick with emotional commentary, these recent Humanities, University of surgical memoirs integrate accounts of professional Roehampton, London SW15 Harm, with a quotation from the French practitioner René 5PU, UK; Leriche, “Every surgeon carries within himself a small and personal life and attest to the affective inten- agnes.​ ​arnoldforster@​ cemetery, where from time to time he goes to pray—a sity of modern operative practice.3 They describe roehampton.ac.​ ​uk place of bitterness and regret, where he must look for an moments of doubt, failure and regret, and ruminate explanation for his failures”. This article uses memoirs on the urgency and uncertainty of surgery. In the Accepted 11 June 2019 Published Online First and oral history interviews to enter the operating theatre first few pages of Do No Harm, Marsh reflects on 25 July 2019 and consider the contemporary history of surgeons’ the tragic mysteries of complex operations, embodied experiences of patient death. It will argue that these experiences take an under-appreciated­ emotional I lay in bed thinking about the young woman I had toll on surgeons, but also that they are deployed as a operated on the previous week. She had a tumour in her spinal cord… and—although I do not know why, narrative device through which surgeons construct their since the operation had seemed to proceed uneventful- professional identity. Crucially, however, there is as much ly—she awoke from the operation paralysed down the forgetting as remembering in their accounts, and the right side of her body… I longed for this next opera- ’labour’ of death has been increasingly shifted out of tion, the operation on the pineal tumour, to go well— the operating theatre, off the surgeons’ hands and into for there to be a happy ending, for everybody to live the laps of others. The emotional costs of surgical care happily ever after, so that I could feel at peace with remain understudied. Indeed, while many researchers myself once again.4 agree that undergoing surgery can be a troubling emotional experience for the patient, less scholarly This passage reveals a professional reckoning attention has been paid to the emotional demands with the emotional costs of care and the lasting performing surgery makes on surgical practitioners. affective impact unsuccessful surgery might have on Is detachment the modus operandi of the modern its practitioners. surgeon and if so, is it tenable in moments of emotional Memoirs in this genre try to construct the intensity—like patient death? emotional landscape of contemporary surgery by emphasising the practitioners’ capacity for empathy

and compassion. Indeed, Do No Harm’s blurb http://mh.bmj.com/ compels the reader to challenge their assumptions Introduction of neurosurgery as a ‘precise and exquisite craft, The neurosurgeon Henry Marsh begins his best- practised by calm and detached surgeons’.5 This selling autobiography, Do No Harm: Stories of Life, notion of emotional ‘detachment’ is pervasive in Death and Brain Surgery (2014), with a quotation literature and discourse about the role and identity from the French surgeon René Leriche, “Every of the doctor and the surgeon. Throughout the last surgeon carries within himself a small cemetery, century, commentators on the role and identity of on September 23, 2021 by guest. Protected copyright. where from time to time he goes to pray—a place the surgeon placed high value on detachment as of bitterness and regret, where he must look for an they believed that emotions could interfere with a explanation for his failures”.1 For a surgical memoir practitioner’s ability to effectively and efficiently that explicitly attends to compassion and candour, carry out their work. Various observers and medical this quotation is a fitting epigraph. It makes death professionals argued that doctors must maintain manifest: a weight for the surgeon to shoulder, a ‘distance’ from their patients to, ‘generate objec- map on which they can chart their personal and tivity in diagnosis and treatment’.6 This ‘detach- professional journey, and a delineated site within ment’ and maintenance of ‘distance’ requires the surgical experience. Both Leriche and Marsh surgeons to adopt and present an ‘aloofness’ from pay tribute to the emotional costs of surgery and emotional investment in their patients. centre death and regret in accounts of a profession This (un)emotional state has been transformed, for which routine care, digital interfaces and mini- however, into a caricature. There are persistent mally invasive interventions are increasingly the stereotypes of the surgeon that represent him © Author(s) (or their norm. as almost exclusively male, overconfident and employer(s)) 2020. Re-­use The candid and compassionate surgical memoir, unfeeling. This stereotype is prone to unpredictable permitted under CC BY. like Do No Harm, is a relatively new genre. Twenty outbursts of anger. He is volatile, insistent and even Published by BMJ. years ago, you would be hard-­pressed to find a abusive. He cuts first, asks questions later—and he To cite: Arnold-­ single published autobiographical account by a is never in doubt. He is good at hard surgeries but Forster A. Med Humanit surgeon. Those that you might uncover were narra- bad at ‘soft’ skills like compassion and communi- 2020;46:278–287. tive accounts of biographical detail, professional cation. Academically brilliant, he lacks emotional

278 Arnold-­Forster A. Med Humanit 2020;46:278–287. doi:10.1136/medhum-2019-011668 Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from intelligence. This trope is embodied by the fictional surgeon Sir bestsellers have narrated the experiences of neurosurgery or Lancelot Spratt (played by James Robertson Justice), star of the cardiac surgery rather than the more quotidian stories of hip 1954 film Doctor in the House (and its six sequels). Spratt, a replacements and cataract removal. Moreover, the bestselling detached, dispassionate demagogue, strode down hospital corri- autobiographies have mostly been written by white men.14 Thus, dors with a team of frightened trainees hurrying along behind while these memoirs provide rich source material for the subject him.7 Sixty years on, this caricature still exists and continues to of surgery and emotions, to diversify the gender, ethnicity and be influential on attitudes to surgery from within and without the subspecialty of those experiences surveyed, I have conducted profession. An article by Hill et al, published in 2014, explored oral history interviews with 21 practitioners (6 women and medical students’ stereotypes of surgical careers and found that 15 men), at multiple career stages and from a range of subspe- students described surgeons as self-confident­ and intimidating. cialties, located all over the UK.15 Their perception that surgery is a competitive and masculine Oral history is often conducted as a means of addressing field, one that requires great personal sacrifice, deterred many topics and experiences that are missing from existing archives, from following a surgical career path. 8 and its practitioners have sought to record the experiences This stereotype has also had lasting effects on the way we of the dispossessed, disempowered and marginalised.16 This write about and research surgery. While policy-makers­ and valuable tendency has meant, however, that oral history inter- medical educators have recently begun to investigate the poten- views with doctors—who have substantial social and financial tially harmful effects of the vision of the surgeon as unemotional, capital—are relatively rare.17 My corpus, therefore, constitutes unfeeling and antisocial in the uptake of surgical career paths and one of the only existing collections of semistructured inter- the gender disparities evident in the profession, few have taken views with British surgeons.18 The oldest participant was born a historical view of how this surgical caricature was shaped, in 1938, and so the interviews cover surgical experiences from maintained and on occasion undone.9 Moreover, the emotional c.1950 to the present day. A semistructured interview is open, costs of surgical care remain understudied. Indeed, while many relatively freeform and allows new ideas to be brought up researchers agree that undergoing surgery can be a troubling during the interview process.19 I began by asking participants emotional experience for the patient, less scholarly attention has about medical experiences in childhood, before moving chron- been paid to the emotional demands performing surgery makes ologically through their lives according to a predetermined on surgical practitioners.10 This blind spot is particularly true (although flexible and responsive) framework of themes. We of the twentieth and twenty-­first centuries as recent histories discussed their decisions to embark on a medical career path, of Victorian medicine have problematised accounts of barba- their early exposure to anatomical dissection, their first experi- rous surgeons insensitive to the cries of un-­anaesthetised patient ences on the hospital ward, their own experiences of ill-­health, suffering.11 why they were drawn to surgery as a specialty, and their rela- However, historians have not paid similar levels of investi- tionships with their colleagues, patients and families. The inter- gative attention to the place of emotions in twentieth-century­ views each lasted for approximately an hour and were recorded and twenty-­first-­century surgery. We know little about what and then transcribed. My theoretical approach to the analysis happened to surgical experience and identity and how those of the interviews is primarily historical and draws on the professional standards—dispassion, detachment and masculine ample literature on reflexivity, trauma, and forgetting in oral stoicism—were challenged or maintained in the intervening history and autobiography to explore surgeons’ attitudes to, 20 century since the end of Queen Victoria’s reign. Is detachment and narrations of, patient death. In particular, I deploy ideas http://mh.bmj.com/ still the modus operandi of the modern surgeon and if so, is it about ‘forgetting’ and in line with historians such as Naomi tenable in moments of emotional intensity—like patient death? Norquay suggest that like remembering, forgetting is an ‘active To answer these questions—at least in part—this article uses process’ that is key to identity-­formation and the construction memoirs and oral history interviews to enter the emotional of coherent personal and professional narratives.21 Thus, I pay landscape of the British hospital and consider the contempo- as much attention to the questions they cannot answer, as to rary history of surgeons’ experiences of patients dying under the those they can, and stay attuned to how they say something, knife. not just what they say. on September 23, 2021 by guest. Protected copyright. Much has changed over the course of the twentieth century This article will draw on these surgeons’ responses to my and the surgeon–patient relationship has been profoundly altered questions to argue that patient death takes an under-­appreciated by social, cultural and technological shifts. Surgery has become emotional toll on surgeons, but also that they deploy it as a much safer and today your risk of an ‘intraoperative death’ is narrative device through which they construct their professional minimal, although not non-­existent. While in 1900 you had a identity. Crucially, there is as much forgetting as remembering in 50% chance of dying during or soon after an operation, today, their accounts, and the ‘labour’ of death has increasingly been you have a 3.6% chance of dying within 2 months of surgery shifted out of the operating theatre, off the surgeons’ hands, and and only between 1 and 30 in every 100 000 patients die on onto intensive care physicians, palliative care professionals and the table itself.12 As a result, some surgeons may go their entire nurses. Thus, death is a useful and provocative subject for discus- career without ever witnessing such an event. A recent question- sion because it is emotionally intense and laden with cultural naire survey in the British Medical Journal reported that only baggage, and also because surgical experiences of patient death 53% of orthopaedic surgeons had ever experienced an intraop- have changed substantially over the last 60 years. I will begin by erative death.13 Of course, different subspecialties will be more exploring some of the narratives surrounding death and dying or less likely to witness intraoperative death. Cardiac surgeons that emerged from my interviews and are recounted in surgical in their dealings with large blood vessels and brain surgeons in memoirs, before analysing the shape of these narratives and their involvement with the delicate structures inside the skull asking why some deaths are remembered and others forgotten. are more likely than their plastic or orthopaedic counterparts Finally, this article will conclude with some reflections on the to preside over death on the operating table. It is, therefore, emotional landscape of British surgery and the systems, struc- perhaps unsurprising that specialties with the potential for melo- tures and support networks in place to alleviate feelings of grief, drama dominate the autobiography market—the recent surgical loss and trauma.

Arnold-­Forster A. Med Humanit 2020;46:278–287. doi:10.1136/medhum-2019-011668 279 Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from My first death body. And you might never have seen a dead body, and this is your I asked each surgeon to recall their first death because I found first time. You’re supposed to shine a light in their pupils, so you’ve that it prompted participants to reflect on their earlier or earliest got to look into their eyes… You’ve got to touch them and feel for a 28 experiences of operative practice. For many, patient deaths pulse… There’s a lot of time for reflection. that took place at the beginning of their careers were pivotal In this narrative, the certification of patient death becomes a moments and prominent parts of their professional narrative. meditative process. Universally acknowledged signs of life (both They often marked the commencement of their clinical identi- clinical and cultural)—breath, eye contact, heartbeat—become ties—a transitional point through which everyone must pass to signs of death that you must sit with, wait with, until you are acquire their ‘medical selfhood’ and belong to a new community sure. In his autobiography, Henry Marsh recalled a similar of practitioners.22 As anthropologists of medicine have acknowl- experience, edged, the medical profession forces its participants to endure an intensive, rigorous and emotionally demanding apprentice- In my first year as a doctor… I would often be summoned, usually 23 ship. This is a process of socialisation that inculcates them into out of bed in the early hours, to certify the death of a patient… I the values of the profession and cultivates the ‘medical identity’ would walk along the empty, anonymous corridors of the hospital, that provides practitioners with status in both the medical and young and healthy and wearing a doctor’s white coat, to enter a dark non-­medical world. Patient deaths are a key component of that ward and be directed by the nurses to a bed around which the cur- ‘apprenticeship’ and were frequently framed as opportunities tains had been drawn.29 for learning, whether that learning was part of a process of acclimatisation to the process of death and dying (what a dead In both cases, the body was shrouded by drapes and secluded body looks or feels like and sometimes framed as a process that from the ward. There are various reasons why junior doctors are cultivates ‘detachment’), or whether they provided more specific called on to do this job. It is low status and low stakes—there is clinical lessons. The routine management of death and dying little prestige associated with successfully certifying a dead body, is, after all, one of the critical experiences that sets medically and while mistakes might prove embarrassing, the potential for trained people apart from the rest of the population. It is also an patient harm is minimal (although not without its costs to the experience that has remained relatively constant over the course dignity of the patient and their family). It offers, therefore, an of the NHS’ lifetime. opportunity for new doctors to familiarise themselves with death In the oral history interviews, I asked participants about their and dying. It prepares them (perhaps unintentionally) for those experiences of medical school and their encounters with death times when there is so much more at stake. while still studying. Students’ first interaction with the dead is Common across both published memoirs and interviewed usually in the anatomy theatre where they first dissect bodies surgeons is the idea that patients are capable of accurately and parts of bodies. Almost all the surgeons reflected on that predicting their own deaths. When the surgeons I interviewed experience as being a positive one, something crucial to their witnessed these prognostications early in their careers, these intellectual development. One female consultant surgeon said, events influenced later perceptions of patient credibility. A female “We had a huge amount of anatomy… we had six to a dissecting consultant surgeon remembered her experiences as a surgical table, we just did it ourselves, from top to bottom… I really house officer in 1991. She spoke about a patient who, “had an really enjoyed that” 24 absolute premonition of doom and I didn’t know how to [um] . She denied ever feeling ‘squeamish’ or unsettled and 30 http://mh.bmj.com/ alleviate that”. The patient died soon after predicting her own instead said, “I’ve always felt it’s an enormous privilege that death, “she literally turned her face to the wall and died”.31 The we’re allowed to do that… we were very respectful”.25 That surgeon reflected on how this experience affected her emotion- respect was partly due to constant reminders of the personhood ally and influenced her later practice, “I could not shake her and individuality of the body being dissected, premonition… I completely believe patients when they have that 32 Now and again something would remind you. The weird thing is the feeling”. Henry Marsh made a similar observation, “It used to

hair. As the body shrinks the hair looks like its growing, like stubble, be called angor animi—the anguish of the soul—the feeling that on September 23, 2021 by guest. Protected copyright. and that’s weird. Or there’ll be something that suddenly brings you some people have, when they are having a heart attack, that they back like a tattoo or a surgical scar or something like that and sud- are about to die. Even now, more than thirty years later, I can see 26 denly you’ll be jolted back to this was someone. very clearly the dying man’s despairing expression as he looked at me as I turned away”.33 She went on to say that despite these reminders, she was never Some have argued that the regularity of death and dying in the ‘upset’ by the experience, “because you know that you’re doing hospital—and the frequency with which surgeons are called on it, you’re not mucking around, you’re learning how to do this to commune with dead bodies—serves to detach practitioners 27 for real”. She saw anatomical dissections as an essential part from the emotional costs of surgical care. However, for many of clinical education and crucial for the development of surgical surgeons, emotional detachment is partial or incomplete, and skill. some do not aspire to detachment as a professional standard In the first few foundation years after completing their medical at all. I interviewed a retired paediatric oncology surgeon who degrees, junior doctors are frequently called on to certify patient rejected the notion that practitioners should remain detached death and, for many, this process constitutes their first expo- and emotionally distant when their patients died, sure to the dead and the materiality of their bodies. A female surgeon reflected on her experience of certifying deaths as a I don’t think parents [of his paediatric patients] regarded it as a nega- junior doctor in the early 1990s. In her interview, she described tive when they saw that I got upset. I think some people think you’ve the intimacy of the process, got to remain very detached and objective at all stages. I couldn’t do that, I was sometimes very involved with a particular child and the They’ve got the curtains round, and you get ushered in. And then parents could see how upset I was. I don’t think any of those parents they all disappear and leave you with your stethoscope, and you’ve thought the less of me for it or thought it was a bad thing. But I do got to spend a minute listening to the chest and watching this dead know doctors who think you shouldn’t really show your emotion.

280 Arnold-­Forster A. Med Humanit 2020;46:278–287. doi:10.1136/medhum-2019-011668 Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from But I don’t agree with that really. I basically couldn’t hide it really, so pre-mortem”,­ and on the ward, while the patient was still alive, I didn’t have a choice.34 “he opened up her abdomen and put his hand in”. The woman died, and in her interview, the surgeon reflected on why this In his book, Admissions: A Life in Brain Surgery, published in particular patient had stayed with her, “I just remember that as 2017 as a sequel to Do No Harm, Marsh reflects on the progres- being really horrific. Because I’d known her and been talking to sive disintegration of detachment as he aged and approached her and we’d been expecting to operate and she’d just gone blue retirement, “But now that my surgical career was coming to an at the edges and unresponsive. It was awful”.42 Often recalled end, I could feel the defensive psychological armour that I had with dread and regret, early experiences of patient death take worn for so many years starting to fall away, leaving me as naked 35 their toll and discourses of emotional detachment barely feature as my patients”. in the interviews at all. However, from Do No Harm, we can see that Marsh’s ‘psycho- However, the interviewees’ willingness to discuss painful logical armour’, rather than once being intact, had always had moments in their professional history with candour does not its gaps. Specific conditions of patient death made it impossible reflect surgeons’ general tendency to reflect emotionally on their for him to disregard the emotional consequences of surgical practice. In a podcast made by the Royal College of Surgeons practice, of England (RCS) on End of Life Care, consultant orthopaedic surgeon and former President of the RCS Dame Clare Marx As a casualty officer, I would have to certify death in some poor soul who had collapsed and died in the street. On these occasions I would suggested that, “as a profession we have been risk averse about 43 find their corpse fully dressed on a trolley, and having to undo their having this conversation [about patient death]”. It is possible, clothing to place my stethoscope on their heart was a profoundly therefore, that my interviewees do not reflect most current and different experience from certifying death in the hospital inpatients recently retired surgical practitioners in their attitudes towards in their anonymous white gowns. I felt that I was assaulting them, emotional detachment. Rather, they could instead represent a and I wanted to apologise to them as I unbuttoned their clothes, self-selecting­ group of surgeons attracted by my research, and even though they were dead. It is remarkable how much difference by the opportunity to speak more frankly about their feelings. 36 clothing makes. It is difficult to tell whether other surgeons, otherwise taciturn, would offer up similarly emotional reflections if given the time, But it was not just clothes that could penetrate his self-­ space, and justification to do so. protection, “I hated post-­mortems and usually tried to avoid While many participants recalled emotionally intense instances them. My detachment had its limits”.37 of patient death from early in their careers, many could not recall Detachment was particularly fragile in cases of patient death their ‘first deaths’ and some could not, or would not, reflect on when surgeons said they felt responsible or if they doubted patient death at all. One responded to my question with, “This whether they had provided the best possible care. Many of is a long time ago. I don’t think I remember the first time”.44 Marsh’s early experiences of patient death stayed with him However, while my prompts about death and dying were not throughout his career, especially when his efforts had been in always answered with accounts of loss, trauma and grief, there vain, “I have seen people die… I remember working all night is little evidence to suggest that this ‘forgetting’ was the product trying, and failing, to save one man, fully awake and suffering of emotional detachment. For some, the realisation that they horribly, who looked into my eyes as he bled to death from could not remember the first patient (or any subsequent ones) 38 oesophageal varices”. Indeed, the affective demands placed who died under their care was unnerving. They commented on http://mh.bmj.com/ by a death that is your responsibility as a doctor (even if the how ‘terrible’ their forgetfulness was and fretted over what I surgeon was not at fault in any legal or even medical capacity) (the interviewer) must think of them.45 While we might expect are profound. This type of patient death can have complex and surgeons to recall early moments of emotional intensity vividly, lasting emotional consequences on the presiding surgeons. About it should come as no surprise that remembering and forgetting 25%–30% of the paediatric oncology surgeon’s patients died. are not automatic processes. However, this leads us to the ques- When interviewed, he described the agonies of their parents, tion: why are some moments of patient death remembered and “The suffering they go through, is something that you just can’t others forgotten? on September 23, 2021 by guest. Protected copyright. help saying I hope this doesn’t happen to me”.39 Throughout the How and whether you remember an event depends on a range interview, he referenced his own children and his experiences as of variables, and not least your emotional state during the event a parent, “I’ve got children and going back to the ‘70s, when my itself. Memory is influenced by the actual events it records and youngest children were small, I’d always come back from work also by other knowledge, experiences, expectations, interpreta- and I would always go straight upstairs and go to their bedrooms tions, perceptions and feelings. When we store a memory, we and see if they were all right”.40 While all of these deaths had not only record all sensory data—what we see, hear and smell, emotional consequences, he felt some more keenly than others. we also store our mood and emotional state. Emotionally intense He recounted his feelings of guilt and regret, “There are patients experiences—like witnessing or being involved in a patient I still have nightmares about because I feel I let them down and death—might be more likely to be remembered. And, of course, could have done better. Those will be with me until the day I memories are not necessarily permanent. They can deteriorate die”.41 over time, otherwise known as the concept of ‘transience’. He was not alone in recalling some patient deaths with horror. Participants could struggle to remember such negative memories When asked to describe a specific death, a female surgeon said, without the correct cues which may be absent from the setting “I remember a dramatic one. There are a lot of deaths”. Her and circumstances of an oral history interview. In what follows, narrative was hurried and jumped back and forward in time, I pose a few suggestions as to why some experiences of patient “I do remember a horrific death when I was a houseman of death might be remembered or forgotten, and reflect on the someone who we were planning to operate on. This looks really role played by these experiences in the construction of surgical bad she’s all blue she looks terrible. Is she bad enough to call the identity. cardiac arrest team? There was a prolonged arrest and she ended It is worth pointing out that from my interviews there does up in intensive care…” The consultant said, “We’ll have to do a not seem to be any identifiable change over time or any clear

Arnold-­Forster A. Med Humanit 2020;46:278–287. doi:10.1136/medhum-2019-011668 281 Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from gendered or age-based­ responses. As many women as men ‘Two Patients Who Determined My Career’, suggesting that ‘forgot’ their first deaths, and while we might expect older this experience played a vital role in the development of his surgeons to be more reticent about emotions, I observed no such professional interests and identity. correlation. Rather, there seems to be a range of emotional land- In cardiac surgeon Stephen Westaby’s memoir, Fragile Lives, scapes in any given place and time. However, some surgeons he begins by describing himself as a medical student watching an reflected on the changing responsibilities and specialisation of operation in Charing Cross hospital. The young woman on the practitioners and suggested that might have effected their expe- table has a heart damaged by rheumatic fever. This was Westa- riences of patient death. I deal with this shift in the section on by’s first death, and while he did not wield the scalpel himself, the ‘Restructuring of healthcare’. the experience clearly affected him. It opens his memoir and began his surgical life. He describes the materiality and tactility of the surgery in vivid detail, Senses of death Patient death is a sensory experience as well as an emotional Then, as if in slow motion, the cannula site in the aorta gave way. one. Those deaths that were remembered tended to be ones that Whoosh! Like a geyser erupting, a crimson fountain hit the operating had imprinted themselves on the bodies as well as the minds lights, spraying the surgeon and soaking the green drapes. Someone of the surgeons being interviewed. The senses have the capacity murmured, ‘Oh, shit.’ An understatement. The battle was lost. Before a finger could plug the hole the heart was empty. Blood dripped from for bringing the past into the present at any time—unbidden, the lights and red rivulets streamed across the marble floor. Rubber involuntarily—but they can also be deliberately foregrounded in 46 soles stuck to it. The anaesthetist frantically squeezed bags of blood the more formal setting of an oral history interview. Indeed, into the veins, but to no avail. Life was fast ebbing away. As the inject- it is well known that senses can act as a mnemonic device or a ed slug of adrenaline wore off, the turgid heart simply blew up like a 47 memory trigger . Oral historians have used smells, tastes and balloon and stopped. Stopped forever.53 materials to prompt participants to recall distant memories or to 48 direct the conversation. Scholars such as Mark Paterson claim The surgical registrar came to close over the wound, ready to that, “it is through touch that we engage with the materiality of move the body to the mortuary. Again, Westaby devotes para- the world and it can invoke powerful memories involving other graphs to describing the materiality of the body, senses”.49 Precisely how the senses operate with memory is, so far, an imperfectly understood area by both neuroscientists and The young woman would be sliced open again from neck to pubis, psychology. However, recognising the multisensory character so there was no point closing the breastbone or bringing together the of memory is crucial, “The unthinking dominance of the visual different layers of the chest wall. He took a big needle and some thick braid, and sewed her up like a mailbag. The wound edges still gaped in accounts of the social limits our imagination and ignores the 54 equally crucial role that other senses play in our experience and and oozed serum. Mail bags were much neater. understanding of the world”.50 It is perhaps unsurprising that senses other than sight— He reflects explicitly on his capacity to remember this specific and particularly touch—play a crucial role in the remem- death. bering of surgical events. Surgery is a manual profession, Auxiliary nurses came with mops and buckets to erase the last traces draws on haptic skill, and surgeons frequently express their 51 of her—her blood now dry on the floor around the operating ta- identity in terms of their craft-­like practice. When asked to ble, the bloody footprints heading towards the door, the blood on http://mh.bmj.com/ recount their encounters with dead bodies and their experi- the anaesthetic machine, the blood on the operating lights. Blood ences of patient death, descriptions of textures, smells and everywhere—now meticulously wiped up… But one spot of blood sounds dominate the interviews. When asked how she ‘felt’ remained on top of the light where no one could see. Adherent and about anatomical dissection, one female consultant surgeon black, it said part of me is still here. Remember me.55 immediately responded with thoughts on smell, “The first feeling is nausea, actually, because the smell of formalin is There are many reasons why Westaby might have opened his overwhelming and it sticks to clothes so you take it home autobiography with this story. It serves various narrative func- on September 23, 2021 by guest. Protected copyright. with you”. She commented explicitly on the importance of tions: it is dramatic, draws us into the memoir, and it evokes smell in memory and recollection, “Recently I had the expe- sympathy and compassion from the reader. It causes us to reflect rience of going back to the fourteenth floor of the medical on the rapid transformation of medical science and surgical effi- school for another reason… but you go out of the lift and cacy even within one person’s lifetime (few Londoners will die that smell just took you back, right back to 1985”. from the complications of rheumatic fever today) and reveals the In 1996, a retired clinical physiologist and community changing nature of surgery. It also shows how surgical death— physician recalled his first experience of the operating and particularly cardiac surgical death—has the capacity to etch theatre as a 17-­year-old­ son of a surgeon, working during itself on the practitioners’ memory. the Second World War. Writing in the British Medical The woman’s visceral, viscous blood marked Westaby’s early Journal, his description of this memory attests to the impli- experiences of surgery, and her mortal remains implored him cation of senses and the emotions in remembering clinical to recall her, even 50 years later. The role played by senses in experiences.52 The 17-­year-old­ accompanied his father who surgeons’ accounts of patient death also problematise the ideas had been called into the local children’s hospital to deal about detachment set out in the introduction. Detachment is with two emergency night-­time admissions. One patient, a supposed to be a skill you cultivate—a process by which prac- 3-­year-old­ unconscious girl with a crushed skull, was oper- titioners deliberately become capable of distancing themselves ated on in a crowded theatre. As his father withdrew the from the emotional intensity of patient care in order to be able trephine, he had to staunch the bleeding with his left thumb. to perform effectively and objectively. The cases outlined above The surgeon called on his son to scrub in and help, “My suggest that detachment is unevenly applied and subject to the finger had to replace his on the skull and I still recollect the whims of circumstance and the variety of senses and emotions sensation”. The girl died on the table. The article is entitled experienced in the operating theatre.

282 Arnold-­Forster A. Med Humanit 2020;46:278–287. doi:10.1136/medhum-2019-011668 Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from Paradigm of surgery “alive one min, dead within seconds”.67 However, as I have Just as the notion of the ‘medical self’—or surgical identity—can established, dying on the operating table is increasingly rare. explain why early experiences of patient death can prove pivotal, The same surgeon who commented on the ‘paradigm’ of surgery it might also explain why some surgeons do not remember these also said, “We’re lucky, we’re privileged in surgery, because if we episodes. Halbwachs characterises memory as a filter that tends can’t fix the problem, usually, someone else looks after them”, to preserve only those images that support the group or indi- and in doing so identified another key reason why surgeons vidual’s present sense of identity.56 Moreover, oral history can might be unwilling to discuss patient death. As the health service both destabilise and affirm a personal narrative.57 The stereo- is restructured and increasingly specialised—and as surgery has typical surgical identity is constructed from a group of traits become safer—surgeons encounter death less frequently. Thus, that are traditionally considered masculine, such as ‘boldness of the ‘labour’ of death is increasingly shifted out of the operating action’ and a ‘take-charge­ machismo’.58 For some, this might be theatre, off the surgeons’ hands and into the laps of others.68 about conforming to a detached or disinterested ideal. In these These ‘others’ include intensive care physicians, nurses and palli- cases, recalling individual patients and their deaths might disrupt ative care professionals as well as the patients’ friends, families models of professionalism that privilege emotional distance. In a and carers. Kerri Thomas said that she did not “think it’s always surgical textbook, published in 1965, the author wrote that the at all the surgeon’s role to have an advanced care planning ‘typical surgeon’ must have “a rather more than normal degree discussion”.69 of common sense which will enable him in his early stages of his Death in the operating theatre has become highly unlikely, and career to inhibit his emotional responses to the sometimes tragic some subspecialties are very unlikely ever to preside over patient situations which confront him and get on with the job which death. I asked an orthopaedic surgeon, “Do you feel you have needs to be done”.59 much to do with death?” She responded, “Not generally any For others, patient death might be troubling (and there- more. The good thing about orthopaedics is that we don’t gener- fore forgotten) because it disrupts what various practitioners ally make people ill—we don’t invade a body cavity. [Death] is interviewed called the ‘paradigm’ of surgery—the attribute an infrequent occurrence now—thank goodness”.70 Orthopaedic that attracted them to the profession in the first place—that surgery is perhaps unusual in that respect, but across the surgical surgery, unlike medicine, is a practice of ‘doing’ and ‘fixing’.60 board, diseases that kill people are increasingly circumscribed by One surgeon put it thus, “The thing I loved about surgery, the specialists, “There’s very little [bone] cancer work that’s done thing I still love about surgery, is that people come to you with in a district general hospital. If we think something is malig- a problem, [er], which you diagnose and fix… That paradigm of nant we refer it to a specialist centre”.71 This surgeon also no sorting out problems, fixing them, moving on, I really responded longer worked on acute trauma. Similarly, her colleagues who to, I thought it was great”.61 In the RCS podcast on End of Life performed hip fracture repairs on elderly patients were then Care, Professor Keri Thomas, said that the ‘default position’ is transferred to ortho-­geriatricians who are experts in end-of­ -­life to save life and that from a surgeon’s point of view “actually care. appreciating that people die goes against the grain”.62 Dame In this way, the emotional labour of dealing with death is Clare Marx said, “as a group of people we are pro-active”­ and transferred out of the operating theatre, off the shoulders of so coming to terms with patient death is particularly challenging surgeons and onto other healthcare practitioners. We see this to the surgical identity.63 Self-effic­ acy is a vital component of the process taking place in Westaby’s account of the heart surgery at mental training necessary for surgical performance and, there- the beginning of his memoir, http://mh.bmj.com/ fore, death as the ultimate ‘failure’ of efficacy fits uneasily into any personal or professional narrative. Only the scrub nurse lingered. Then she was joined by the anaesthetic nurse who had comforted the patient in the anteroom. They took off There is a pervasive perception that the surgeon’s (and, their masks and stood silently for a while, unconcerned by the sticky indeed, the doctor’s) role is to be responsible, to protect patients blood that covered every surface and by the chest still splinted open. from themselves, and ultimately to cure disease and delay death. The anaesthetic nurse searched for the patient’s hand beneath the Uncertainty, error and doubt are, therefore, fundamentally prob- drapes and held it. The scrub nurse pulled away the blood-­soaked lematic for a surgeon’s persona and sense of self: “a lot of doctors covering from the face and stroked it.72 on September 23, 2021 by guest. Protected copyright. think that death is failure”.64 One surgeon said to me, “For me, I became a surgeon to fix people. Plus, I know, in myself, that In this case, the surgeons leave the dead body behind, and only I have only a finite amount of emotional energy to go around. the nurses remain to perform any kind of emotional work in the So, when someone dies… I put them in a box, marked ‘I can’t aftermath of death. This differentiation of emotional labour is, fix you any more’. Then I take a deep breath and try and fix of course, highly gendered. This operates along disciplinary lines the things I can fix”.65 As oral historian Naomi Norquay argues, with nurses—who tend to be female—taking on the care of the “what we do not remember, what we omit, and what we deem as dying just as surgeons—who tend to be male—absent themselves not worth remembering is as important to identity construction from such efforts, engagements and relationships. The gendered as what we do remember, what we do include, and what is worth dynamics of the emotional labour of death could also operate remembering”.66 within the surgical profession—as female surgeons shoulder the bulk of the affective burden whereas male practitioners might find it easier to avoid. It is worth noting, however, that the Restructuring of healthcare male surgeons I interviewed were as likely, if not more likely, to In some ways, surgeons are the closest of all healthcare profes- reflect in emotional terms about their patients and professional sionals to death. They hold their patients’ lives, quite literally, in experiences. their hands and this visceral connexion to death is less common The decreasing likelihood that surgeons will preside over among other doctors. Physicians are unlikely to have had an patient death is a product of many manifestly positive develop- experience that can match, ‘for sheer horror’, their patient dying ments in healthcare. End-­of-­life care has become professionalised on an operating table. Surgeon Kevin J H Newman offered and there are now teams and individuals with specific exper- aortic aneurysm surgery as one of the more graphic examples: tise about caring for those approaching death. Moreover, and

Arnold-­Forster A. Med Humanit 2020;46:278–287. doi:10.1136/medhum-2019-011668 283 Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from as shown above, surgery has become safer and intraoperative because they were maintained by a sense of comradery and death increasingly rare. However, Dame Clare Marx suggested mutual understanding. Many of the surgeons lamented the loss that this shift was not necessarily a good thing, “Most doctors of the ‘family-­like’ structure of the NHS in days-gone-­ ­by. don’t see a lot of death. Nurses see death. Carers see death… I’m One surgeon interviewed, who was born in 1944 and first qual- not sure that a little more exposure to death and the different ified in the early 1970s, told me about how 100 hours working ways people die might be a good thing”.73 This suggestion can weeks were normal. He reflected on how different the working be interpreted as a recommendation for a subtle shift in the culture of the NHS had become and remarked that he was “quite ‘surgical paradigm’ and a move away from what Professor Keri happy that [he] lived through that old era”.82 In this ‘old system’. Thomas called the ‘default position’ to save life.74 Which is not he said that “you very much felt like you were part of a firm… to say that that should not be the primary goal of surgical inter- Whatever you were doing… you were definitely working within vention, but rather that there should be an acknowledgement of, the team and that gave a very strong feeling of belonging and and a more candid conversation about, the presence of death in commitment”.83 However, histories of surgery and hospital care twenty-­first-­century healthcare and the emotional costs it levies in the 1960s, 1970s and 1980s reveal a very different vision at practitioners. of the emotional landscape of the NHS—a hierarchical, male-­ dominated and exhausting system that relied on nepotism and the wives who performed the household labour and childcare Emotional support required to allow their consultant husbands to work uninter- Despite the emotional intensity of the surgical experiences rupted.84 The ‘firm’ system—while lauded by many—was also described in memoirs and interviews, only rarely did participants critiqued by several surgeons I interviewed and particularly by or authors comment on that emotional intensity being recognised female practitioners who argued that it was a macho culture with by their colleagues and employers. The interviews reveal a lack little time or space for emotional reflection, women or family of formal or systematic emotional or mental health support for life. It also reveals a recurring pattern of initiatives to try and surgeons, “There was never any formal support anywhere I improve the emotional resources available to practitioners. From worked for as surgeon”.75 Instead, practitioners filled that space the foundation of the NHS to the late 1970s, articles published with their own ad hoc and informal versions of comfort and care. in the medical press repeatedly call for the preservation of social For example, one paediatric surgeon offered his own form of spaces in the hospital dedicated to doctors, the protection of bereavement counselling to the parents of his patients who had surgeons’ lunch hours, and the provision of psychoanalytic died and in doing so built and maintained a mutually beneficial and therapeutic support for staff.85 These articles suggest that relationship, “When a child has died I always offer the parents twentieth-­century surgeons have not always been detached and the opportunity to come back, as soon as they wanted, as often past practitioners found value in affective as well as technical as they wanted. And some of them came back quite regularly just to talk it all through… I have parents who came back to see expertise. me years later, just to talk it all through”.76 Surgeons also often Despite the nostalgia that obscures contemporary surgeons’ sought emotional support from friends and family, “The wife vision of the past, there is nonetheless a pervasive sense that prac- and family could sometimes see I was upset when I got home and titioners today are profoundly dissatisfied with the emotional if I wanted to talk to them about it I would”.77 Moreover, clin- support available to them and particularly in instances of intra- operative death.86 Professor Sir Alfred Cuschieri argued that, “a ical systems could be repurposed for emotional support. Weekly http://mh.bmj.com/ morbidity and mortality meetings—designed to discuss clinical death on the operating table of a patient is a harrowing expe- issues—“usually served as sort of a de-brief­ really”.78 rience for a surgeon. In my view, the surgeon is emotionally However, various interviewees commented on how informal and mentally not in the frame of mind to continue to operate 87 support networks within the surgical profession and the hospital that day”. In response, Sheriff Albert Sheenan recommended had, over the past 30 years, collapsed. Nostalgia frequently that surgeons should not operate for 24 hours after the intra- 88 inflected these conversations.79 When asked about the emotional operative death of an elective surgical patient. There are also costs of care, and their working conditions, and their experi- various initiatives that endeavour to provide the therapeutic on September 23, 2021 by guest. Protected copyright. ences of patient death, almost all hark back to the halcyon days resources so many surgeons require. For example, Schwartz before the introduction of the European Working Time Directive Rounds offer a space and time in a busy working day where (EWTD). The EWTD 48 hours working week entered law in all staff come together regularly to discuss the aspects of their European countries in 1998. A phased approach to implementa- jobs. Rounds follow a standard model and adhere to a pre-­ tion was agreed for doctors in training in the UK, which steadily determined structure. They take place regularly—usually once reduced working hours to 58 in 2004, 56 in 2007 and 48 in a month for an hour at a time. A round can either be based 2009.80 A key component of the EWTD was that the maximum on a single case, or explore a theme such as ‘when things go period of work for a resident without rest is 13 hours. Surgeons wrong’ or ‘when I made a difference’. A panel, composed of have argued that these shorter sessions of work have led to three staff, share their experiences for the first 15–20 min, and complex rotas and frequent handovers. The frequent handovers for the remainder of the hour, trained facilitators ask partici- have made it difficult to maintain continuity of care with impli- pants to share their thoughts and reflections on the stories and cations for patient safety and professional well-being­ alike.81 lead an open discussion. Rounds are confidential, in which Indeed, the changing shape of surgical training and work was a patient and staff identities are protected, and can help staff feel thread running throughout all the interviews, intersecting with a more supported in their jobs by allowing them the time and range of issues, including patient death. Prior to the introduction space to reflect on their roles. I have attended several Rounds of the EWTD and the MMC (Modernising Medical Careers)— as an observer on the condition that I do not use the material surgeons trained as part of a ‘firm’—a hierarchical structure of in my research. Patient death is a frequent topic of conversation senior and less-­senior practitioners. Many of those interviewed in Schwartz Rounds. The clinical authors in an article on the attested to the supportive nature of this team approach—and introduction of Rounds to the Royal Brompton and Harefield argued that they could cope with 120 hours working weeks Hospital Trust reflected,

284 Arnold-­Forster A. Med Humanit 2020;46:278–287. doi:10.1136/medhum-2019-011668 Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from Many of us were brought up in an age when the metaphorical stiff Data availability statement There are no data in this work. upper lip still held sway. While we were allowed to have ‘feelings’ Open access This is an open access article distributed in accordance with the we were discouraged from ‘wearing them on our sleeve’. As busy Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits practising physicians, anaesthetists and surgeons, we inevitably have others to copy, redistribute, remix, transform and build upon this work for any taken on the treatment of extremely sick patients whose time in hos- purpose, provided the original work is properly cited, a link to the licence is given, pital, despite very high levels of effort, ended with the death of the and indication of whether changes were made. See: https://​creativecommons.​org/​ patient… By taking time to debrief as a team and discuss what the licenses/by/​ ​4.0/.​ experience of caring for a critically-ill­ patient was like, we can guard ORCID iD against the long-­term effects of the stress of such challenging situa- Agnes Arnold-Forster­ http://orcid.​ ​org/0000-​ ​0002-8153-​ ​3217 tions.89

Quantitative evidence shows that staff who attend rounds feel Notes less stressed and isolated.90 For practitioners to maintain their 1. Henry Marsh, Do No Harm: Stories of Life, Death and Brain Surgery. London: Hachette, 2014. own emotional health and provide compassionate care to their 2. Reginald Murray, Surgical Roots and Branches. London: Wiley Blackwell, 1990. patients, staff must feel supported in their work and have outlets 3. Paul Kalanithi, When Breath Becomes Air. London: Random House, 2016; Stephen that allow them to deconstruct limiting notions of detachment Westaby, Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating and dispassion. Table. London: Harper Collins, 2017; Gabriel Weston, Direct Red: A Surgeon’s Story. London: Random House, 2009. Conclusion 4. Henry Marsh, Do No Harm, 4. 5. Ibid. This article has used memoirs, oral history interviews, and other 6. Natalie J Lewis et al, “Emotional intelligence medical education: measuring the sources to enter the emotional landscape of the British hospital unmeasurable?”, Adv Health Sci Educ 10, no. 4 (2005): 339–55. and consider the contemporary history of surgeons’ experiences 7. Ralph Thomas, Doctor in the House, (1954). of patient death. I have argued that while the experience of 8. Elspeth J R Hill et al, “Can I cut it? Medical students’ perceptions of surgeons and patient death is central to the formation of surgical professional surgical careers”, Am J Surg 208, no.5, (2014): 860–7. identity and medical selfhood, it takes an under-appreciated­ 9. Erin Dean and Erin, “The gender pay gap in surgery”, The Bulletin of the Royal College emotional toll on surgeons. Moreover, these moments of ill-­ of Surgeons 99, no.1 (2017): 12–14; Kim Peters and Michelle Ryan, “Machismo in managed emotional intensity coalesce into a broader feeling that surgery is harming the specialty”, BMJ 348, (2014); Kevin J H Newman, “A surgeon’s practitioners are inadequately supplied with the time, space and view of excising the ’surgeon ego’ to accelerate progress in the culture of surgery”, BMJ 364, no. 158 (2019). support necessary to process the emotional costs of care in the 10. Ellen M Redinbaugh et al, “Doctors’ emotional reactions to recent death of a patient: modern NHS. And yet, my prompts about death and dying were cross sectional study of hospital doctors”, BMJ 327, no. 7408, (2003): 185–9; Sofia not always answered with accounts of loss, trauma and grief. C Zambrano et al, “How do surgeons experience and cope with the death and dying Instead, there was as much forgetting as remembering in the of their patients? A qualitative study in the context of life-limiting­ illnesses”, World surgeons’ accounts, and I have tried to suggest some explana- Journal of Surgery 72, (2013): 935–44. tions for this apparent amnesia. As I have shown, however, there 11. Michael Brown, “Surgery and emotion: the era before anaesthesia”, in Thomas Schlich is little evidence to suggest that this ‘forgetting’ was the product (ed.), The Palgrave Handbook of the History of Surgery, (London: Palgrave Macmillan, of emotional detachment. 2017), 327–48. Indeed, this case study—patient death—problematises the 12. Rupert M Pearse et al, “Mortality after surgery in Europe: a 7 day cohort study”, The

Lancet 380 no.9847, (2012): 1059–65. http://mh.bmj.com/ surgical image and identity and complicates any assumption 13. I C Smith and M W Jones, “Surgeon’s attitudes to intra-oper­ ative death: questionnaire that surgeons are, or must be, detached or distant from their survey”, BMJ, 322 (2001): 896–7. patients. Not only is detachment uneven, unstable and inappli- 14. Exceptions include Gabriel Weston, Direct Red: A Surgeon’s Story, London: Jonathan cable to many of the cases surgeons encounter today, efforts to Cape, 2009; and Gautam Das, Tender is the Scalpel’s Edge: Glimpses for the Casebook maintain detachment and accord to the stereotypes that domi- of a British Consultant Surgeon, London: Notion Press, 2017. nate the profession have had profoundly negative consequences 15. In 2016, women made up 11.1% of consultant surgeons in England. https://www.​ on surgeon well-being,­ professional diversity and patient care. rcseng.ac.​ ​uk/careers-​ ​in-surgery/​ ​women-in-​ ​surgery/statistics/​ (Accessed 14 Aug 2018) on September 23, 2021 by guest. Protected copyright. Detachment is a damaging fiction that does harm to the various 16. Lynn Abrams, Oral History Theory, London: Routledge, 2016, 96–7. participants of twenty-­first-century­ healthcare. There is no 17. The exception is the British Library’s ’Oral Histories of Medicine and Health benefit, I would argue, to acquiring or maintaining the type of Professionals’, https://www.​bl.uk/​ ​collection-guides/​ ​oral-histories-​ ​of-medicine-​ ​and-​ health-professionals​ (Accessed 14 Aug 2018). detachment that some surgeons claim to value. 18. Ruth McDonald et al interviewed surgeons for their 2006 article: Ruth McDonald, Finally, while my project is a historical one, I am also inter- Justin Waring and Stephen Harrison, ’Modernization and nostalgia in a hospital ested in the future of surgery. As I have noted previously, death operating theatre department’, Sociology 40, no. 6 (2006): 1097–115. on the operating theatre has become highly unlikely—and that 19. Valerie J Janesick, “Oral History Interviewing: Issues and Possibilities”, In Patricia Leavy trend will probably continue. How, then, will the surgeons of (ed), The Oxford Handbook of Qualitative Research, Oxford: OUP, 2014. the future cope when it does—inevitably—all go wrong—and 20. Wendy Rickard, “Oral history ’more dangerous than therapy’?: interviewees’ reflections they are faced with a dead or dying patient that they were not on recording traumatic or taboo issues”, Oral History 26, no. 2 (1998): 34–48; Alan prepared for? How will surgeons, highly trained in shoulder Wong, “Conversations for the real world: shared authority, self-­reflexivity, and process in the oral history interview”, Journal of Canadian Studies/Revue d’études canadiennes replacements, gallbladder removal and hernia repair, deal with 43, no. 1, (2009): 239–58. the fatal complications that have always been part of their 21. N. Norquay, ’Identity and forgetting’, Oral History Review 26, no.1, (1999): 1–21, 2 profession? 22. A recent article by Dr Clare Gerada on the question of surgical mental health, published in the Bulletin of the Royal College of Surgeons, argues that doctors have Contributors AA-­F is the sole author of this article and no one else contributed. their own ’unwritten group norms’, that are deeply engrained and have long histories. Funding This study is funded by Wellcome Trust (108667/Z/15/Z). Clare Gerada, “Clinical depression: surgeons and mental illness”, Bulletin of the Royal College of Surgeons 88, no. 8, (2017): 260–3. Competing interests None declared. 23. Simon Sinclair, Making Doctors: An Institutional Apprenticeship, London: Berg, 1997. Patient consent for publication Not required. 24. Interview with female surgeon born in 1967; interviewed by author, 24 Nov 2017. Provenance and peer review Not commissioned; externally peer reviewed. 25. Ibid.

Arnold-­Forster A. Med Humanit 2020;46:278–287. doi:10.1136/medhum-2019-011668 285 Original research Med Humanities: first published as 10.1136/medhum-2019-011668 on 25 July 2019. Downloaded from

26. Ibid. 75. Interview with male surgeon born in 1944; interviewed by author, 18 Jan 2018 27. Ibid. 76. Ibid. 28. Interview with female surgeon born in 1970; interviewed by author, 12 Jan 2018. 77. Ibid. 29. Henry Marsh, Do No Harm, 145. 78. Ibid. 30. Interview with female surgeon born in 1967; interviewed by author, 24 Nov 2017. 79. Agnes Arnold-­Forster, “Doctors’ wellbeing: learning from the past can help improve the 31. Ibid. future”, BMJ, (2018). 32. Ibid. 80. Richard Canter, “Impact of reduced working time on surgical training in the United 33. Henry Marsh, Do No Harm, 83. Kingdom and Ireland”, The Surgeon, 9 (2011): 6–7. 34. Interview with male surgeon born in 1944; interviewed by author, 18 Jan 2018. 81. Ibid. 35. Henry Marsh, Do No Harm, 21. 82. Interview with male surgeon born in 1944; interviewed by author, 18 Jan 2018 36. Henry Marsh, Do No Harm, 146–7. 83. Ibid. 37. Ibid., 146. 84. Agnes Arnold-­Forster, “Doctors’ wellbeing: learning from the past can help improve 38. Ibid. the future”. 39. Interview with male surgeon born in 1944; interviewed by author, 18 Jan 2018. 85. J H Tweedie et al, “Facilities for junior doctors in new hospitals”, BMJ 2, no. 6150, (1978): 1503; J. F. Murray, “Improving the hospital service”, BMJ 1 no. 6008, (1976): 40. Ibid. 507–8; Anon, ’The orthopaedic surgeon’, BMJ 1, no. 5698, (1970): 748–9; N. Davis 41. Ibid. and H. Stephen Pasmore, “Anxious patient and worried doctor”, BMJ 1 no. 5061, 42. Interview with female surgeon born in 1970; interviewed by author, 12 Jan 2018. (1958): 40. 43. Royal College of Surgeons, ’End of Life Podcast Part One’, Podcast, 2018, https://​ 86. Marc R de Leval, “Facing up to surgical deaths: each death should be subjected to soundcloud.com/​ ​user-385374793/​ ​eol-podcast-​ ​part-1 forensic and statistical analysis”, BMJ 328, no. 7436, (2004): 361–2. 44. Interview with female surgeon born in 1979; interviewed by author, 23 Jan 2018. 87. M Jones, ’Deaths on the operating table’, BMJ 320, no. 7238 (2000): 881. 45. Ibid. 88. I C Smith and M W Jones, ’Surgeons’ attitudes to intraoperative death: questionnaire 46. Paula Hamilton, “The Proust Effect: Oral History and the Senses”, In Donald A. Ritchie survey’, 896. (ed), The Oxford Handbook of Oral History. Oxford: OUP, 2011, 222 89. John R Pepper et al, ’Schwartz Rounds: reviving compassion in modern healthcare’, J R 47. Geoffrey Cubitt, History and Memory. Manchester: Manchester University Press, 2007. Soc Med 105, no. 3, (2012): 94–5. 48. Hamilton, “The Proust Effect: Oral History and the Senses”, 220 90. Jill Maben et al, ’A realist informed mixed methods evaluation of Schwartz Center 49. Mark Paterson, The Senses of Touch Haptics, Affects and Technologies. Oxford: Berg, Rounds in England’, Health Services and Delivery Research 6, no. 37, (2018). 2007, 8. 50. Hamilton, “The Proust Effect: Oral History and the Senses”, 220 51. 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