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(Linear accelerators) are triumphs of physical science and high-tech engineering, which have taken decades and thousands of scientists and engineers to create. A magnetron - just as in your microwave oven-generates radio frequency waves (streams of photons). An electrongun (usually a heated tungsten filament) fires electrons down 'the wave-guide' - a long tube which lies within the radiofrequency waves. The electrons, steered by surrounding magnets, surf the waves, and are accelerated close to the speed of light to slam into a tungsten target. The target spits out photons as the high-speed electrons react with the tungsten atoms. The photons are then filtered and focused and shaped into a narrow beam, like the light from a torch, and fired into the cancer (and whatever else surrounds it.) By firing the photon beam in a rotating arc, and modulating its intensity, as well as its shape, a high dose of X-rays is delivered to the tumour and a relatively low dose to the surrounding body.

Children and language

The brain is sculpted by experience, cutting away connections that are not being used. Until the age of two, for instance, children in all cultures can discriminate between all the basic sounds of all languages, but from then on, they can only recognise the phonemes of their mother tongue.

Compassion

After I had been diagnosed with advanced prostate cancer and became a patient myself, I was surprised to keep on remembering more and more patients whom I had completely forgotten - some were cases going back more than thirty years. Now that I was so anxious and unhappy, feeling abandoned, I realised how anxious and unhappy so many of my patients must have been, and yet how I had chosen to turn a blind eye to this. My former patients became reproachful ghosts who came to punish me....I thought of how I would be a much better doctor if I could start all over again. How I would be full of the compassion and understanding that I lacked when I was younger. But would this then leave me unable to enter the operating theatre, pull on my gloves, and cut into my patients' heads? I simply don't know, although I do know that the arthritis I am starting to suffer from in my hands makes it all a nonsense anyway.....

As a doctor, you could not do the work if you were truly empathetic..... Empathy, like exercise, is hard work, and it is normal and natural to avoid it. You have to practise instead a limited form of compassion, without losing your humanity in the process. While I was still working, I thought that I had achieved it, but now, looking back, and as a patient myself, I was full of doubt."

Mistakes

He mentions the time he operated on the problem of a trapped nerve, but he operated on the wrong side of the man's neck. The man was incredibly understanding and said he understood, he installed kitchens for people and said he knew how easy it was to make a mistake. Marsh ends by saying that nowadays the pressure on him to lie would have been far greater, as if the mistake had happened today he would probably have been dismissed. (He also says that this happened in the time before the introduction of checklists, although in this instance that probably wouldn't have helped.)

Surgeons and experience

Marsh stresses that the question we need to find out about surgeons doing our operations is how experienced they are in doing these types of procedures.

The Private Finance Initiative

"The building was built under the private finance initiative (PFI), and it was owned by a private, highly profitable company that rented the building to the NHS. PFI was supposed to be a cheaper and more efficient way of building hospitals and schools than direct government funding, but as many warned at the time, the opposite was true. PFI was a con, little short of an economic crime, for which nobody has been held to account."

The pleasures of working in a small hospital

He writes about the pleasure he had working in a small hospital - Atkinson Morley's Hospital in Wimbledon. "It had tall ceilings and high windows, the emphasis being on fresh air and light. It was built before hospitals became machines for healing, and when Wimbledon was still surrounded by fields and gardens. The hospital had its own stables, and laundry and staff residences. When I worked there it was only three stories high, and it had a staff of fewer than 200. It was built on a human scale. I knew all the staff - not just the other doctors, but the nurses, the physios, the porters and the cleaners. I think all of us, at all levels, had a real sense of belonging and personal responsibility for what happened to our patients. The hospital was famously efficient - I would get through three or four major surgical cases a day, something unimaginable now.

We are tribal animals - we are happiest in relatively small groups."


FreeWill

Given that nerve cells act over space and time, perhaps we should not be surprised that scientific experiments show some strange effects. Some of the earliest, and most famous, were Benjamin Libet's experiments in America in the 1980s. These showed (and have been confirmed subsequently many times) that the conscious decision to move your hand comes a few milliseconds after electrical activation of the brain's hand area, as revealed by electrodes placed over the scalp. Libet's experiments have inevitably added to the already excessive literature about 'freewill'.....
Studies have shown that a remarkably high proportion of violent offenders in prison have a history of previous head injury, or an abusive childhood, or both. In my work I often saw patients with physical brain damage, typically to the frontal lobes from accidental trauma. This often causes personality change, almost invariably for the worse. They were almost always unaware of this themselves, but it could be quite terrible for their families. Such experiences make it very hard indeed to believe that thought and feeling, and consciousness itself, are not generated by physical processes in our brains. Free will might be a legal necessity for an ordered society, but it is an illusion. Our decisions are determined by our past..... But that doesn't mean that pain isn't painful, or that difficult decisions are not difficult. It just means we don't understand how our brains work.

AI
I am not worried about super-intelligent AI in some way replacing us in the foreseeable future, although it may well render large numbers of people unemployed. (Most economists argue that this does not usually happen with the introduction of new labour-saving technology, and instead new jobs are created.) But I am deeply worried about the way AI will be used in a malign way by my fellow human beings, and especially by despotic governments. The loss of anonymity, for instance, that comes with omnipresent CCTV and facial-recognition software puts enormous power in the hands of a few people.

Establishing trust with your patients

You should always be seated.
You should never appear to be in a hurry.

The curse of good medicine

Although scientific medicine has brought great and wonderful blessings, it has also brought a curse - dying, for many of us, has become a prolonged experience, even if severe pain is now only rarely a problem.