The English Surgeon

This interview was broadcast on KCRW's The Treatment on September 2, 2009. Audio is provided courtesy of KCRW.

Announcer: From KCRW in Santa Monica, this is The Treatment.

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Elvis Mitchell: Welcome to The Treatment. I'm Elvis Mitchell, you can also hear this show at kcrw.com. At the Hot Docs documentary show last year in Toronto, I had the pleasure of seeing an astonishing film, The English Surgeon, which I think is a really breathtaking piece of filmmaking and uses all the resources of the medium to tell the story. We're with director Geoffrey Smith. First of all Geoffrey, thanks so much for doing this.

Geoffrey Smith: Thank you.

Mitchell: Tell us about the movie.

Smith: The thing that we all love about documentary is that you really are watching the director's relationship with the subject. And if that's a great relationship, if it's one built on love and trust, then that chemical feeling transmits to the audience. And in a film like this where the surgeon, Henry Marsh, takes us into some sensitive, intimate situations, you've got to feel safe. You've got to feel, as an audience, that it's alright to be there; because it is reality, this is not made up. So that relationship was in place for five years before we made this film.

Mitchell: You were completely immersed in his life.

Smith: Yeah, I mean, we met in 2003 over some vodka. On the first night we discovered that we both had this love/hate relationship with Ukraine. And it was like a marriage that had to happen. I mean, we couldn't believe that there was another person with our sort of ten-year fascination with this forsaken, strange, fascinating, surreal place. And after we did the first piece together, which was a film for the BBC, both of us went out to the Ukraine. I went with Henry on one of his trips, and literally, within half an hour of arriving in that hospital, I knew I had my film, especially knowing Henry as I did by then, as a sort of soul mate and best friend. Unlike many people, and certainly unlike many surgeons, he's prepared to be vulnerable, he's prepared to let you in to the sort of agonizing dilemmas that afflict him every day and he's a deeply moral and artistic person who happens to be a brain surgeon. So he brings a great deal of reflection on philosophy and morality to what he does. People are most surprised when I tell them he's only 57. Looking at him, he does appear to be a great deal older, and the reason why is he does carry the worries and concerns of treating or striving or trying to save people.

Mitchell: Not only that but also his own kind of personal traumas are carried in his life as well, aren't they?

Smith: Bizarrely, we never got into the film, we had it in and we ended up taking it out. But when Henry's own child, when his eldest son was 18 months old, he had a brain tumor, the young boy. And Henry, at that stage, wasn't a neurosurgeon, he was a general surgeon. And like anybody in that situation, he was just a father, he says, wandering the streets of London, wanting to know, desperate to know whether his son was going to make it. And that experience -- dare I say, his son is now a very healthy 28-year-old -- that experience coupled with the incredible challenge of neurosurgery is what inspired him to take it up. And by challenge, he describes it as riding a bike down a steep hill with no brakes, that's his description of neurosurgery. He says he's a risk seeker, though. See, these are people that seek out that type of thrill or that type of challenge. But they carry these enormous consequences with them. I mean, in the same hands, really, he has the power to save life and the power to take it away. And he puts it beautifully, he says that, "I'm operating on your thoughts and feelings, I'm not operating on your knees or your arms. And if something goes wrong in my operation," he says, "I can change you irredeemably. I can destroy your personality, I can take away your intellect, you can become somebody your own family doesn't know." So that enormous moral responsibility is what he wrestles with. At the same time, he gives life, he saves people. So he, of course, moves forward. He's a pragmatist; and surgeons are, they're very much in the real world getting things done. I responded to that because a lot of these deep things, a lot of this business of the doctor-patient relationship, a lot of the questions of who we are, I love those sort of things. I'm very attached to deep dilemmas, ethical decision-making. And here in this man, I found the perfect vehicle, in a place, also, that's full of contrast, contradictions, difficulty.

Mitchell: It's The Treatment, I'm talking about the documentary The English Surgeon with its director, Geoffrey Smith. You talked about him as an artist but he also seems to be the doctor as philosopher, and that time he spent in the Ukraine really gave him a whole other take on the world as compared to where he's from and where he did his medical training.

Smith: Like Igor, his Ukrainian colleague, actually, they're both just mavericks, they have no truck, no place, no store with bureaucracy. They hate paperwork. They hate being tied down having to fill forms out, because they have a very raw and direct relationship with wanting to help people. It sounds sweetly, sickly saintly and too good to be true, but this is the magic and the sort of very special reward that comes from being a doctor. And Igor puts it this way in the film, he says, "Look, I could have become a medical bureaucrat, I could have become a professor. I could be earning a lot of money, abroad, basically. But I just choose to be a doctor, a good doctor who listens to his patients." And when you're in that room with him and you see the humanity in all its forms, in the best and the worst and the most tragic, that is a very rewarding experience. Henry's reward comes from dealing and wrestling with the stuff of life.

Mitchell: But Marsh really is an outcast and that seems to me to be the theme that you found so attractive about him as a subject is that he's made a place for himself in the Ukraine because he really didn't fit anywhere else.

Smith: Yes, he, like in the great British tradition, he thought here's an underdog, here's someone who's being persecuted, when he found Igor, in that wonderful English/British tradition of going for the underdog, saving the person who's being kicked. And Henry refused to give in to the easy way out, which was maybe to send him a few things and then forget about it. He literally chose to take it on himself to go out there for 17 years now, twice, if not more, each year, massive amount of consultation on the telephone, because of a very deep friendship as well. And he has a huge commitment to Igor, but he has simply, as he says, a commitment to those people, and he can't let them down. And it begins to sound a bit -- as I say, in this day and age of ours, which is ruthless and cynical, it begins to sound a bit too good to be true.

Mitchell: That must have been what attracted you to it, that it was so good you had to make a movie about it.

Smith: Yes, and when he walks in to the operating theater, and I've seen him many times in that situation, he's supercharged, he's like working at a sort of ultra-fast speed. And I said, "Look, tell me about that because I want people to know that you also get a big thrill out of what you do." And he says, "Look, surgeons love operating. It's the fierce joy of operating, it's the thrill of riding that bike down a steep hill. It's a risk seeking activity." So there's altruism, yes, but there's also an incredible amount of deep fulfilling satisfaction that comes from wrestling with a tumor whilst the patient's awake.

Mitchell: That's the thing that's so fascinating about the film is that it gives a sense of physicality to the way he practices medicine. And as a movie maker, as a director, that must have been incredibly alluring to you to find a way to get something about the way that medicine is practiced that we don't see in documentaries.

Smith: Let's take Marion, who's the patient in the film, he's the one we as an audience will emote with, and then to have this man awake through a procedure where an old Bosche drill is being put into his head with no anesthetic except the local into his scalp so he doesn't feel any pain, but the sort of Frankenstein, B-movie side of it is very funny and it's surreal, that situation, but it all happened in front of three cameras in Kyiv two years ago.

Mitchell: It's a theatrical experience and you talked about the drill, and I don't want to give too much away about the way you use the sound of tools in the movie, but you took it upon yourself to say, "This is a theatrical film, it's not something I've done for television. I'm going to use my experience in making films for TV, which is really just about getting the information across. I want this to feel like a much bigger kind of thing." And that had to be part of your calculation in putting the film together.

Smith: Absolutely. From day one, the drama inherent in what he does is top level stuff. And I thought, I'm going to structure it, shoot it, score it, cut it, conceive of it as a drama, right from the beginning. And you can do that with a small shoot time. You can have multiple cameras that don't move around. You don't have cutaways because you've actually got reaction shots all the time. The idea that it's got an overarching moral theme to it, that it's not just a piece of information, this is one man's struggle to do go things, everything in the film, all the pictures, particularly the soundtrack, is trying to push you into thinking about those things. It's a very, very deliberate, structured event. Everything happens as it did, there's no contrivance, there's no things made up because they move so fast, those two. We were literally hanging on their coattails.

Mitchell: We're talking about the film The English Surgeon with its director Geoffrey Smith. It's The Treatment. You start the film in a really deliberate fashion. It takes on that speed and the momentum builds, but literally, in the first segments of the movie, you're setting all this stuff up and you walk us into it; we hear it before we see it.

Smith: Well the tools, as we say, audio is such a big part of a big screen experience.

Mitchell: It is.

Smith: Probably more than 50%.

Mitchell: And it's fascinating how rarely it's used to its full effect in documentary. And in doing the stuff you've done for the BBC where you didn't have time to craft the sound that way, you must have been thinking for a long time, "When I make a theatrical film, I'm going to make it feel like a theatrical experience."

Smith: Absolutely, I mean, the rawness of his fascination with tools, the sort of sound of that KGB hospital, it's full of weird buzzing funny lights that aren't working and pieces of instrumentation and you've got crisp snow outside. You've just got a whole world. My cameraman was looking through the lens one day when we were in the back of the ambulance and he said, "This is Blair Witch Project meets Tchaikovsky." And that sort of sums it up.

Mitchell: I was going to say Blair Witch meets Dr. Zhivago, but that works too.

Smith: It gets under your skin. And a lot of people say, "Oh, look at how horrible and grimy and nasty it is," but to me, I'm in love with that style. So audio and soundscape is a huge part of it and to make all that come together with a great sort of icing on the cake, I grew up in Melbourne and I knew Nick Cave for a while through a mutual friend, I said to myself, I knew Nick would like this character, Henry. He's full of the sort of struggles and the sense of redemption and pain.

Mitchell: And obsession.

Smith: And obsession that Nick's so in love with with characters and what he writes about. And sure enough, he really liked the paper proposal. I came back from the Ukraine, I got him and Warren to come over.

Mitchell: Warren Ellis.

Smith: Warren Ellis, his cohort, who really is the soundtrack genius. And they simply fell in love with the Russians and said, "Okay, we're in, we want to help." The difficult thing was scheduling them to literally be together in a studio in London. They are manic, they're workaholics. And yet, the other thing that's the most important here to stress is that I don't know anyone in my business who watches more films than they do.

Mitchell: Really?

Smith: No. They are incredibly cine-literate and they devour everything from schlock horror down to the best stuff. So their ideas about how you convey emotion are crystal clear, because we did that whole soundtrack -- although Warren had brought some loops in, as he says -- we did the whole thing in about three and a half days in London.

Mitchell: I'm talking to Geoffrey Smith, the director of the astonishing documentary, The English Surgeon, which you can start with, the title just pulls you in. Just the way you play with The English Patient, you can't help but be amused by that and I wondered -- we were talking about sound before the break, but I just quickly wanted to discuss the title a little bit because it's such a great title and because of those words, English and surgeon, it's kind of deceptive, isn't it?

Smith: We played around with titles so much. Anyone who's a filmmaker will know the sort of agony that you can go through.

Mitchell: Did you have a lot of titles that you were playing with?

Smith: Well, the working title for a long, long time was "Henry Goes East." And Americans loved it but Nick Cave and John Hilcutt, my friend who's a fiction director said, "Look, the film is much bigger than that." And in a way, it also, there's a sort of -- there's books in England, Biggles Goes North, or these wartime hero books, which I wouldn't want it to be associated with that. So we had to ditch Henry Goes East. And one night, Henry's out with his wife, who's a very, very, very funny and talented woman, she's an author, and she just said, "The English Surgeon, there's a formality about it. There's this beautiful, understated British crispness about this title." It may or may not translate as well, I don't know but I've never had any complaints about it. But the moment we fitted it in to the opening scene, everything locked together, because you see those words before you see him open his tool cupboard up. And there's this one little richness going on already, "What is a surgeon doing with a chisel? And what is he doing with a drill? And who is this man?" And so just by putting the three right words together, you can create in the audience's mind a whole universe of connotations.

Mitchell: It does so much work because it tells you who the film is about and it doesn't give anything away. I'm wondering, because you said the title came at that point, how much it informed the way you were shaping the film?

Smith: The front of any film is the most difficult. And in the documentary -- I won't use that word, nonfiction film, real live drama, anything but documentary. We have to get away from that word because it doesn't bring people to the screen.

Mitchell: It also communicates an expectation of experience which you were out to contradict with this.

Smith: I describe my film as a sort of moral fable. Craft is an integral part of telling the story. It's not some extra that is thrown on the top with some sort of slick editing or a few nice shots or something. It is literally how you think about communicating what it is you're trying to say. A simple shot of Marion walking into a Russian church in the film, it's just the sound of the singing, the women singing going on underneath it, the old people in that church, you don't have to say very much. And that's the realm of filmmaking, you're trying to present images, obviously, but saturated somehow with the theme and with a sort of intent. So there's a vision here, there's a deliberate idea behind what that is doing.

Mitchell: And a move away from narration, which I thought that was your way too of saying, "All these things I want to do in the films I've been making but didn't get a chance just because that form is so rigid, in terms of television, all these things I wanted to do, I'm going to do them now in this." It's almost like you've built up an entire career of don'ts that you were going to step away from.

Smith: I mean, narration is a curse, really. People treat audiences so badly across the world. They think they don't know, they think they don't understand. Well, they do. They go to films. They're very capable of reading pictures and the beauty of having a character where you can enter into his world and his universe for 90 minutes and he constructs his own narrative for you, he's the one we hear. So we're inside his head and we're inside his struggles. That's a beautiful experience. We all want to be voyeurs, we all want to go places where we can't. And that's the point of doing it that way, not some third person voice of God type of thing, which crashes the spell. Every time someone comes in with a voiceover like that, it breaks the spell and I've just spent vast sums of time and money trying to create that spell for my audience, so I don't want it broken by some imposition.

Mitchell: Geoffrey Smith is talking about his new film, the documentary The English Surgeon. It's The Treatment, which can also be heard on KCRW.com. Getting back to what we were talking about before the break: It's one of the things that Nick Cave and Warren Ellis responded to is that all those general kinds of ornamentations built on to sort of tell you what you are seeing as you're seeing it, which has been the curse of especially intelligent documentary, because the presumption is that people really aren't paying attention. Because when you're watching TV, you can read or you can go online or you're on the phone, so you do that kind of stuff and that's kind of bled into feature or theatrical documentary and betting that Nick Cave and Warren Ellis, that they're responding to the meat of this.

Smith: Yes. And the thing that we all sat down and agreed on, and Nick, like me, he hates sentiment, instead of violins coming out at any point in the film, instead of there being this need to underscore what's there on the screen -- because if you're having to do that with a violin, then really your story's not there. And the bottom line is your character's not rich enough or the story's not there. A lot of what we did with this music is counterpoint the emotion. So the music goes seemingly in a different direction to what's happening on the screen, and that dissonance really, that resonance at the same time, is what allows the viewer so much more space to fill things in. I'm not manipulating them with music, it's about counterpointing some very rarified deep ethical emotion.

Mitchell: Because it's so rare that a score composed for a documentary isn't just saying in italics what we've already said.

Smith: Yes. There was a point in the film, about 12 minutes in when I said to everybody, "Look, what's going on here is a man in England who's sitting in a lovely house in South London is reaching out to this incredibly poor dying 26-year-old in a sort of forsaken village in western Ukraine to save his life. They don't know each other, they've never met each other. And Marion, on his part, is putting such faith into a man he's never met. He's prepared to put his life in his hands. So how do you say that?" So we have just simple visuals of Henry riding his bike from left to right and Marion walking against a cemetery, of course, which is the shadow of death he's living under, coming from right to left. And I said to Nick and Warren, "The music has got to bring in our audience's mind that there is now this special connection between these two people." It's just done with those two pictures and that beautiful piece of music. And that's when the film -- you can hear it in the audience, people just go unbelievably quiet because they begin to get the depth of connection between these two characters in the film.

Mitchell: It plays beautifully and I wonder what it was like for you seeing it in a theater with an audience for the first time, because in all the years that you've been working, it's a new experience for you.

Smith: Absolutely, I mean, TV you get vast numbers of people watching, but you never meet them. The cinema experience, and I've been through it a lot now, is a collective experience with people in a room. And the film is very funny, dare I say as well, so there's a huge range of emotion. There's fear, there's people cowering as a matter of fact. We've actually had 15 people faint in the screenings I've attended. So I have to make some sort of announcement about that in the beginning. "Will you be number 16?" That's basically what I say. Because it's not the gore, it's more the conceptual fuse-blowing that happens. I had a woman say, "Look, I'm watching Henry Marsh talk to me, so his brain's talking to my brain. In the back of the shot, there's an open brain. That belongs to a patient who's also talking to Henry," and then she went, "Bzzzzt," and she just sort of blew a fuse, philosophically she just couldn't get her head around so many brains connected together. We had someone come up, this woman was in tears saying now she understood her father for the first time. He was a neurosurgeon. She said she never had any idea of what he did, not what in the mechanical sense but in the moral and the sort of philosophical sense.

Mitchell: We're talking about the film The English Surgeon with its director, Geoffrey Smith. This is The Treatment. Even in medical documentaries, there's so much that's about "We're going to fix this," and then they fix it and then we move on. And I would say, strictly speaking, the film doesn't really end. Just because doctors have worked on a case doesn't mean that they've detached from the person. And just that sense of carrying something away gives it a real novelistic feel. And I wondered if literature was as much a part of the way you put this together as filmmaking was.

Smith: A little bit. I think more perhaps the end was sort of vodka-filled conversations I've had with Henry really because he's very, very well-read and understands -- he did Soviet studies at university -- and I'd been traveling in that part of the world for a long time, so I'm just steeped in a different way in that type of sentiment. But it's expressions like "the nobility of failure" which Henry uses, which is a beautiful way of -- I mean, there is no resolution to that. He's going to keep trying but he's also going to keep failing on occasions. He's also going to run into the impotent point at which he can't do anything, which is why certain scenes in the film, where we render them as men, they're not gods anymore. Despite what you and I want from our surgeons, we want them to be supermen and shamans and magicians--

Mitchell: But you set him up as a man, just the way he's using his hands and that obsession with the tools. And at first we think, is he going to go off and work on his MG or something?

Smith: That's right, it's a beautiful, beautiful aid, because he's is most relaxed, actually, he's most sweet and relaxed when he's making these things with his wood; more so because, you know, he doesn't run the risk of damaging anybody when he's making furniture. [LAUGHTER] But he does say, very funnily, he says, "Human joints are much easier to fix than furniture, because if you don't get the joints right with furniture, it's not going to grow into itself."

Mitchell: But there's also that love of how precisely the human body has been constructed and that drive to want to get in and see what makes it work, why it works. That's why I say novelistic because it's almost that thing about why does this thing work. And he almost basically admits, "I don't quite understand it myself."

Smith: No, I mean, look, he describes brain surgery as some giant bulldozer trying to push a pin down a sort of alleyway. The scale, the crudity of what they do -- well, it's unknown to the public. People think it's precise and it's all laser precision stuff. He says, "Crap," he says, "it's not like that at all. You're using a vacuum cleaner to try and extract a tumor where you do not know where the border between brain and tumor is. There's no 'Cut here' signs anymore." There's nothing like that patently saying, "Do this, do that." He's got to feel -- and he says, "Normal brain is like cream cheese" -- he's got to feel when the cream cheese isn't cream cheese. But that's your memories he's playing with. That's literally 1968 coming out of your head maybe. And that's why you can see there's so much black humor in it, because you've got to somehow diffuse that responsibility and surgeons are famous for their black humor, and certainly neurosurgeons are. So the ingeniousness of having somebody awake is all about saving them. It's all about them being the last sort of safety valve before destroying a part of the brain that is obviously going to change the way you think, feel or act.

Mitchell: We're out of time. Geoffrey, thank you so much. It's such a great film and I'm so glad to finally get a chance to have you sit down and talk about it with me. Thank you again.