Direct Red: A Surgeon's Story
by Gabriel Weston
192pp, Jonathan Cape, £16.99
Taking the Medicine
by Druin Burch
336pp, Chatto & Windus, £20
Direct Red is Gabriel Weston's memoir of the years she spent pursuing a surgical career. In the chapter titled "Beauty", Weston recalls a night as a medical student during the 1990s. She was sent to examine a patient in his late 60s who had been diagnosed as having a kidney stone. This was purely for Weston's benefit, one of the thousands of encounters by which students incrementally gather experience: neither Mr Cooke, nor his wife sitting beside his A&E trolley, stood to gain from it. Weston's awkward superfluousness was unexpectedly relieved: it transpired that the patient was a retired professor of English, which had been Weston's first degree. The discovery sparked the Cookes into clearly comforting banter over the comparative merits of Augustan versus Romantic poetry. For a short time, that curtained-off casualty cubicle was enlivened. Worries about bodies, and the myriad ways they can fall ill and fail, were, briefly, set aside.
Weston never declares herself, but one suspects her sympathies lie more with the Augustan camp. She is alive to the sensuousness of the world yet renders it in spare, arresting prose. Here is the moment when paramedics crash through heavy swing doors, with a seriously injured girl on a stretcher: "The smell and look of constructively harried humans. The snaking of cold air, brought in from outside, working its way into the over-warm corners of the children's A&E. The hyperacoustic noise of new voices, clanking metal, and the squeaking of rubber wheels and shoe soles. Foremost in this din ... the cries of a child."
Weston is acutely aware, too, of the less than edifying transactions that sometimes occur between doctors and patients. She examines these with an honesty that is both brave and uncomfortable. We are told about the stoic woman with exquisitely painful strangulated piles whom Weston patches up and sends home in order to escape derision from consultants determined to reduce admissions. A patient with recurrent oral cancer is badgered into accepting radical surgery - not her only treatment option, but the one most appealing to those whose vocation is the scalpel. Elsewhere, Weston is mocked by a female colleague for honouring a request from a young woman facing a double mastectomy. The patient asked that a simple mole on her chest be preserved - a tiny gesture of control over the therapeutic mutilation to come, but somehow an affront to one unsentimental surgical mind.
The most affecting aspect of the book is the emotional journey Weston has travelled. At three o'clock one morning, she was called to the ward to see a distressed and alone 10-year-old boy, Ben, admitted for investigation of headaches. Uncomfortable with his tearfulness, exhausted by her lack of sleep, she did what every doctor will have done at some point: doubled his pain medication, patted him brusquely on his shoulder, told him things would get sorted in the morning and left. He died later that week, from a sudden complication of an unsuspected brain tumour. "I still feel ashamed of how I behaved ... what Ben needed from me that night was to give him whatever small amount of my heart's warmth I could afford. Without a parent nearby ... Ben sought the nearness of another person ... And he was unable to find this comfort in me."
Direct Red ends with Weston's decision to relinquish her ambitions to become a consultant, opting instead for a part-time staff-grade post. It was of lower status, but afforded the chance to become more of a parent to her own children, until then seen in snatched minutes at either end of long working days. She professes contentment, but admits occasional sadness at the "notional future I have given up". One finishes Direct Red with the conviction that the qualities that prompted this choice are the very ones that will be valued by her children and patients alike.
Druin Burch is also a practising doctor. His Taking the Medicine is an account of the stuttering application of scientific method to the field of therapeutics. For much of medical history, doctors have prescribed treatments that were either wholly ineffective or downright injurious. Not that they knew it at the time. Burch details the belief systems that underpinned practices such as bleeding and purging, and shows, somewhat laboriously, how scientific techniques gradually moved therapeutics on from these dark ages. The apogee is the randomised controlled trial (RCT), the tool by which novel medical interventions are now objectively evaluated. The closing decades of the 20th century saw the birth of evidence-based medicine (EBM), and the majority of treatments now on offer have been shown, at least on a statistical basis, to work. This is, arguably, modern medicine's greatest advance, and Burch quite rightly celebrates the pioneers such as Archie Cochrane, who set the revolution in train.
Burch is an evidence-based medicine enthusiast, and Taking the Medicine fails to consider the potential downsides. Evidence is expensive to obtain, so doctors' awareness is inevitably biased towards interventions promulgated by those with financial clout, principally the pharmaceutical companies. Then there is the process by which evidence is turned into myth. Consider statins: 15 years ago some solid research showed they saved modest numbers of lives in high-risk populations - those with established heart disease - within a certain age range. The finding spawned an urgent mythology, carefully tended by those with vested interests: if you don't want a heart attack, you'd better take a statin. The result has been ever-expanding prescription of the drugs, even to perfectly healthy people. The evidence-base, limping slowly along behind, has failed to justify much of the burgeoning use. There will be people reading this who are swallowing statins for no reason. Many others would be shocked if they were told quite how vanishingly unlikely any benefit might actually be.
By their nature, randomised controlled trials examine isolated interventions. Real-world patients and their complex clinical presentations defy reduction. Burch ends with a careful caveat: "Clinical trial(s) ... will not replace the rich complexity of an interaction between a patient and a doctor ... They add to your ability to make decisions. They do not wipe out the importance of making them."
What Burch states blandly is illustrated, powerfully and repeatedly, within the pages of Direct Red. Back in A&E, medical student Gabriel Weston's retired English professor abruptly crumpled, his playful exchanges with his wife cut short. He turned grey and sweaty. His pain had not been coming from a kidney stone; the largest artery in his body had been leaking, and leak had become flood. Weston collided with a chair in her rush to get help. Suddenly, people were everywhere. Mr Cooke's trolley was crashed into theatre, his wife left wordlessly behind. Weston watched, stunned, as the professor bellowed and struggled and thrashed, fighting the orderlies trying to strap him down so an anaesthetist could send him to sleep. Within minutes he was sliced open, his guts heaved to one side, and an hours-long attempt made to repair his ruptured aorta. It failed.
The evidence is clear: without surgery, imminent death was inevitable; with it, his chances were roughly 50/50. Yet, as Weston says, "In the process of acting in a patient's best surgical interests, we may sometimes make the final moments of their life more terrible than they would ever have been had we left them alone to say their farewells uninterfered with, more wholly and with more grace."
• Phil Whitaker is a doctor and writer. To order Direct Red for £15.99, or Taking the Medicine for £18, both with free UK p&p, call Guardian book service on 0330 333 6846 or go to theguardian.com/bookshop