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Nothing thrills me more than the human body. But, until my mid-20s, it didn’t cross my mind that someone like me could become a doctor. There were no medics in my family. I was slow at maths and science, and gave them up before the age of 16. After school, I decided on an English degree, because it was what I found easiest.
Then, in my final year, something important happened. A few of us were hanging out at a friend’s house one evening when his dad, a surgeon from London, arrived to stay for the weekend. Over dinner, we all sat enthralled as he told us stories of his hospital life. He fetched a surgical textbook from his bag, full of photos of some of his favourite operations, and I remember sitting at the kitchen table late into the night, poring over these luminous images, skin peeled back to reveal muscle and bone, tumours and blood vessels. It was my first glimpse of real anatomy, and I was astounded by its beauty.
After graduation, unhappily employed as a clerical assistant in a publishing house, I heard about a new course being pioneered at one of the big London medical schools. A professor there had a hunch. Maybe the usual stock of candidates with perfect science scores weren’t the only ones who could make good doctors. What if there was a hidden population of arts students out there, overlooked because they didn’t have the right qualifications, who could be trained to do the job just as well?
Before I knew it I had quit my job and was joining nine other unlikely would-be doctors to become the second cohort of the Foundation Course in Natural Sciences, my single biology O-level making me, in that professor’s words, the least-qualified medical student in the country. The deal he was offering was tough but miraculous. We would join first-year students of maths, physics, chemistry and biology for their lectures and exams. Anyone able to pass all four subjects at the end of the summer term would get a place at medical school.
The years that followed were some of the happiest of my life. It wasn’t until years into my training, by which time I was trying to combine a career in surgery with new responsibilities as a mother, that I started to feel some of the constraints as well as the joys of my profession. The more clinical medicine I learned, the less it made sense to me to regard the body as a purely mechanical entity. All too frequently, I saw surgeons disregarding the feelings of their patients. Standing next to my consultant one day while he yanked out staples from a woman’s abdomen, showing little consideration for her distress, I found myself thinking back to that radical anatomy professor. Surely, when he was dreaming up a way to bring an arty bunch of kids into the conventional world of medicine, he had something more in mind than simple camouflage? He must have hoped we had something fresh to offer, that we might doctor differently than our more traditional peers?
I began writing with a simple desire, to honour the opportunity that professor gave me, to set out on an exploration of anatomy, which – by blurring the boundaries that usually separate science from art, rational from emotional, objective from subjective experience – might help me arrive at a deeper and more complete understanding of what we’re made of.
But then serious medical events in my own life changed everything. At precisely the point I might have expected to become intimately in touch with my physical self, I found myself disoriented. Just when I thought being a doctor would be most useful, I felt powerless. When I was finally able to return to writing, I knew that I needed to find a way to convey something of the messy and frightening experience I now had of living inside a human body, one which had suddenly become a text for other doctors to read.
September 1995
We are first-year medical students and testing our new stethoscopes. My boyfriend’s is bright red and stands out like an artery against his immaculate white coat. We’re by the window in his flat, sun flashing on the river, and when I lean in, though it’s his heart I’m supposed to be listening to, it’s really mine I’m aware of, racing and skipping the way it sometimes does, especially when I get this close to him. When it’s his turn, he listens for ages. And his face is so rapt when he looks up that, for one foolish moment, I expect romance. Instead, he says: “I can hear a murmur. There’s something wrong with your heart.”
From: GWeston
Subject: patient/dr with new symptoms
Date: Sunday 31 October 2023
Dear Adult Congenital Heart Disease Team,
I am a longstanding patient of Prof. A, having been diagnosed with mitral valve prolapse as a medical student more than 20 years ago. I’ve been under routine review since, with no worsening of my heart condition in that time. Over the last week, I’ve developed recurrent and prolonged palpitations, unlike anything I’ve had before. I’m thinking of phoning for advice first thing tomorrow. Please let me know if I should be taking more urgent action.
Kind regards,
(Dr) Gabriel Weston
Heart
If you make a fist with your left hand and press knuckles against the reassuring solidity of your breastbone, you delineate the approximate size and position of your heart. It doesn’t make sense to imagine this organ still, when its defining feature is the heartbeat, a phenomenal physiological event which occurs 100,000 times a day, delivering 5,000 gallons of oxygen-rich blood to every fibre of our bodies. The heart is no inert lump of flesh, but the hub of a vast network of 60,000 miles of arteries and veins, two distinct but interconnected circuits held together in one snug embrace.
The right side of the heart is in charge of the pulmonary circulation. Veins laden with oxygen-depleted blood from around the body all converge and empty into the right atrium. This is also home to the sinoatrial node, which generates the heart’s electrical power. Contracting when full, the right atrium pushes blood through a little door called the tricuspid valve – so named because of its three leaflets – into the right ventricle. Then, the right ventricle squeezes blood out of the heart and towards the lungs, and the tricuspid valve closes, preventing backflow into the atrium.
The systemic circulation is managed by the left heart. Oxygenated blood from the lungs pours into the left atrium until it’s at capacity, sending its contents through the mitral valve, into the left ventricle. As the left ventricle starts to pump newly minted blood out and around the rest of the body, a healthy mitral valve will slam shut, preventing blood leaking back into the left atrium. But in someone with a floppy valve like mine, one or both leaflets overshoot, like the swinging doors in a saloon bar after a cowboy has made his showy entrance, allowing blood to regurgitate into the left atrium.
For a cardiac patient, conceiving of the heart as an electrically charged pump doesn’t require a leap of faith. I regularly have a series of investigations, to see whether the abnormal backflow of blood through my heart is bad enough to warrant surgery to correct my mitral valve. Once a year, an envelope containing a Holter monitor lands on my doormat, and I stand in front of the mirror fastening electrodes to my chest, clipping the recording device to my waistband, happy to think of thousands of my heartbeats being traced while I go about my business. Every six months, I lie down in a shadowy hospital room, while an echocardiographer applies jelly and a probe to my chest, and maps the incremental progression of my disease, the usual quiet lub-dub amplified to a Niagara-like roar, my errant mitral valve flapping around on the grainy screen like a loose piece of washing on a line.
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Brain
Did I think being a doctor would protect me? Did I imagine something going wrong with my own body was the worst thing that could happen? How can I describe this, the crease around which my life is folded?
A headache is all there is at first. My son says it is manageable mostly, but sometimes really painful. Like on standing: one, two, three bang. Or on sitting up from lying down. It’s 10 days or so before I begin to worry. And even then, it takes a change to wake me up. First day of the school holidays and it’s cut-glass perfect outside. And yet my teenage son is still in bed at lunchtime, room ablaze with sunshine, skateboard accusing him from the carpet, no phone in hand. Get out of bed, I think. Get up or there’s something really wrong.
If you hold a brain in your hands, it looks solid and inscrutable, but it’s really the organ of ultimate flux, information shooting like stars from one hemisphere to the other, between lobes, from one gyrus to the next and across trillions of synapses too tiny for even the microscope to see. All of this is made possible by a rich blood supply. Internal carotid arteries bring blood to the front of the brain. The basilar artery supplies the back of the brain, and the two systems form a circuit that goes round and round. Venous blood collects in deep grooves called sinuses and these all drain to the internal jugular veins, and down to the heart.
The operational unit of the brain is the neuron. Thinner than a human hair, each of these consists of a cell body, dendrites and an axon. Dendrites branch out, like fronds of seaweed, and receive electrical messages from hundreds of other neurons. These travel to the cell body, which contains genetic material in its nucleus, where a decision is made about whether a signal should travel onwards. Outgoing electrical messages are conducted down the axon to its tip, where little sacs open and empty neurotransmitters into the synapse, the space between one neuron and another. These chemicals are taken up by receptors on the dendrites of the receiving neuron. And so the process continues.
Dexamethasone for swelling. Blue light across town to where the sick kids go. Wheelchair down corridors, up lift and home to a ward with a cuddly name and no stinting on Christmas decorations. Straight to bed, legs curled up, too tall for the colourful cot. A welcome tour: our very own fridge, the coffee room and shower, a quick lesson in how to fold the armchair down to make a bed. But don’t sit just yet. Come now and meet him. Serene neurosurgeon, sleeves rolled up against infinite work. The room is tight with no good news. Won’t see his next birthday, whisper the walls. The monitor flickers. I’ll get out what I can, he says. But first I need more scans.
The neurosurgeon comes to find me on the ward. We go into the corridor and sit by the computer. For comparison, he shows me yesterday’s CT. I angle my face to the screen but blur my eyes. I don’t want to see it any more. Then he clicks on the MRI. I prepare myself to hear that my son’s spine is as full of tumour as his brain.
The surgeon flicks through images, axial and coronal sections. He credits me with more medical knowhow than I am capable of. This ventricle, that lobe, this vessel, all the details collapse before my eyes. But then he stops on one picture and something inside me wakes up. The mass appears different here. It’s clean-looking, cartoon-bright. He has to repeat himself several times, before I hear what he’s explaining to me. Cancer doesn’t have this appearance on an MRI. This isn’t a tumour, it’s blood.
They say we’re safe to go home. We bring the Christmas tree in from the garden where we left it, still in its corset of netting. The hospital leaflets lie next to the box of fairy lights. Cavernomas are abnormal clusters of blood vessels, one tells me. I put the tinsel on. They occur in the brains of one in 600 in the population, but only cause symptoms in one in 400,000 a year. I hang the papier-mache decorations the kids made when they were small. Seizures and brain haemorrhage are the two most serious consequences. These cavernomas present surgeons with a perilous dilemma: is it riskier to take them out or leave them alone?
A month later I stand at the top of the driveway and watch him getting smaller. In the quiet morning, the only sound is the roar of wheels on asphalt. He’s thinner than he was a month ago, and I am too. He’s a bit shaky on his skateboard, as I feel shaky in my heart. His hood is up, concealing what lies underneath, a soft white dressing and below that a narrow shaved strip and five-inch wound, black with blood and stitches. As for me? I am changed in every cell of my body. I think of all that I’ve learned from books about the brain and the things I’ve seen in the past few weeks that I never thought I’d see. And I bring my scattered mind to stillness on one point, which is the brain’s limitless capacity for fresh knowledge, for repair, for life. In the distance, he attempts the tiniest of jumps, feet barely breaking contact with the board. And for the first time, I dare to imagine he’ll soon be up to his old tricks again.
I am not the same person I was and my body isn’t the same body. So, what has this time – in which I’ve added becoming a patient and the parent of a patient to my medical credentials – revealed about how we practise medicine? We proceed on the basis that our facts are right, though it only takes a glance at medical history to realise they may soon be out of date. Our western healthcare systems persist in an outdated, post-industrial assumption that the body is a mechanical apparatus, when there is abundant medical evidence that our physical and emotional selves shouldn’t be separated. If we’re serious about improving our NHS, we have to take pause. We should teach medical students that any anatomy that doesn’t take account of the person is false anatomy. We need to persuade managers who force doctors and nurses to work like machines that human bodies aren’t automata, that individual stories matter. We must provide doctors and patients with enough time to talk. For at no point are we more ourselves, or more adrift from ourselves, than when we are ill.
That said, it’s taken becoming a patient to show me there are limits to how much we should expect even the best doctors to truly know us. I can say not a day goes by when I’m not grateful for the brain surgery that saved my son’s life. I can tell you I’ve made peace with the long wait for heart surgery, with my cardiologist’s view that – though my mitral valve inevitably will need to be repaired at some point – the right time for that is not now.
But that’s not the sum of it. There remains an essential contradiction in medicine. To care for a patient, you have to step away from them. Knowledge and being can’t be fully reconciled. Is this why my desire to fathom the human body remains as fierce as on that first day at medical school, why moments of revelation don’t tend to come when, as a patient, I’m flooded with the primary experience of my own failing body – nor when, as a surgeon, I step up to the operating table, tense with information – but somewhere in between, standing in a colleagues’ theatre, or at some other momentous medical event, when all that’s required of me is still observation, heartfelt attentiveness, a kind of quiet bearing witness?
This is an edited extract from Alive: An Alternative Anatomy by Gabriel Weston, published by Jonathan Cape on 6 March.
