Writers Read 7: “This Is Going to Hurt: Secret Diaries of a Young Doctor” by Adam Kay

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Finished reading date: January 28th, 2023

My rating (out of 5): ⭐️ ⭐️ ⭐️ ⭐️

Genre(s): Nonfiction, medicine, humor, memoir

Summary

Any medical system will have its benefits and disadvantages. The people who know this viscerally are those that work from within it. Adam Kay interweaves personal stories that he journaled down during his time as a doctor with passages of reflection. Sharing a view of the full spectrum of humanity from his front-row seat, with both beautiful and heartbreakingly tragic moments, the book highlights the moral and bureaucratic maze that is becoming a doctor in the UK and the sacrifices of staying one.

Analysis Rant

Memoirs are one of those types of books that are more difficult to analyze. After all, how do you rate a life? What right do we have to do that? None, really. But while this is Adam Kay’s real-life story, his presentation of it can be addressed and analyzed, as well as whether his stylistic choices added or took away from his story.

While it seems to be my habit of pulling apart books and leaving only criticism in my wake, I feel like it truly is necessary to lean into the positives of this book. Mostly because this is an important book, and I don’t necessarily want my brutal analysis to keep people from reading it. The most impressive thing about the book, in my eyes, is also the thing that is most difficult to do. This is leaning into the humor that is the awkwardness of human life and particularly the awkward and odd situations that doctors have to deal with. All the facets of life that we might be more likely to keep to ourselves (bowel movements, sex life, life and death, mental health, etc.) are often on full display for doctors, whether they asked for it or not. Just by simply being a doctor, it’s as if there is some gate that lifts to reveal a sign that says, “Ask me anything.” And people do. Even when it’s not your specialty. The expertise of the “doctor,” and I would add nurses and other caregivers, seems to create this belief that they are all-knowing and that anything is okay to ask. I have often thought that having boundaries as a doctor must be extremely difficult. Having read this book, I think they are almost impossible in certain areas with the way that the medical field is run right now.

And with all the “gross” bits of life on full display, there is so much room for humor and vulnerability. And Kay finds it and fully milks it. Where he does his best work in this is simply when he tells the story. The story itself is funny, and he doesn’t ruin it by adding too much commentary. He simply allows the humor of the situation to speak for itself. So many weird and wonderful and fascinating and heartbreaking things can happen in hospitals, so he doesn’t have to force the humor or the emotion. It’s just there. And he, for the most part, allows himself to just be the vehicle of the story.

Another thing he does well is blending together the humor with the heartbreak. When something is heartbreaking, he (more often than not) honors it. When something is humorous, he leans into it. When something is ironically funny, he finds its pulse. And a lot of the time, he doesn’t have to define it one way or another, the story tells itself, and he doesn’t usually tell you what you should think or feel about it. “This is funny. Laugh.” “This is sad. Cry.” Not really any of this. You just feel it. It’s not black and white. It’s so messy sometimes. And that’s very human. More times than not, it would be too difficult to even describe what you are feeling by reading the story, as it’s always a mixture, and it’s likely that it would have been even more difficult to describe if we had been the ones actually there.

With that being said, there are a couple of times when he does jab with his own commentary about things that he doesn’t necessarily believe in and he sees it as ridiculous, and it reads as disrespectful, particularly in regard to religion. It’s as if he puts religion in the “okay to mock” category. This isn’t always the case, but it did happen a few times for Christian and Muslim patients, and it didn’t sit well with me. This is largely because he added his own jabs and commentary to the story in order to “add spice” and “humor” to it. The story itself may have been fine and presented as an interesting situation, but oftentimes, it was like his cynicism toward religion creeps in and he just lets it out with a mutter. Perhaps it’s an honest take on the frustration he feels as a doctor when patients will not receive treatment that could save them, and I get that, but it was a bit disappointing, especially considering how often he was really generous toward the nuances of things like obesity, abortion, and miscarriage, etc. It’s like, he decided what was and was not within the patient’s capacity to choose (such as miscarriage and obesity often not being our own choice, but rather, something that is due to genetics or other biological reasons), without realizing that if something is against our religion, it is equally not always of our choice. Or rather, it may be our choice, but there is also a larger framework involved. And perhaps that’s where the disconnect is, because, to a nonbeliever, it feels like it should be. I get that, and to be honest, I’m not critiquing him as a doctor or as a person. But in terms of writing, it becomes more complicated, and in my preference, I would have preferred if he would have allowed the story to have spoken for itself rather than his personal “humorous” jabs that just felt like overkill. With that being said, though, it’s difficult too, because this is a memoir. It’s his story too, so I can imagine it’s difficult to find the balance between telling the story and telling his part of the story.

Memoirs are also difficult because it’s difficult to say what their purpose is and whether there truly is a purpose. I don’t necessarily know that every piece of literature has to have a particular intention behind it, but I think as human beings we are designed to look for it and try and find it even if it didn’t necessarily exist for its author. After all, literature has the ability to bring a different purpose and meaning to each person who reads it. By the end of the book, it wasn’t like I was confused by its purpose, but rather, it just felt like an account of a life. It felt like the account of a relationship and the reflection upon that relationship after its conclusion: its ups and downs, its positives and negatives, its happy moments and sad, the beginning and the end. I think people could pull different things from the book. I think my main thought at the end was, “Medicine is hard. It is necessary. Some people may not be made for it. But also, the system is broken, so you almost have to be a little broken yourself in order to be made for it. And sometimes, breaking yourself to that degree is not worth it. And that’s okay. But for those that it is still worth it, we have to do better to support them and try and to bring awareness and fix the situation as best we can.” I don’t think he is necessarily pushing people to become doctors or pushing people not to become doctors. I think he was just showing his reality, which is the reality of many. And I think there are things to learn from this, but at the same time, I don’t think Adam was the one teaching us most of the time. He was just telling us the stories. And sharing his perspective. We are the ones to have to pull from it what this means for us. And I think that does really make a good memoir.

There are also a lot of footnotes in it, though. Some of them are funny, some of them are really informative, and some of them feel unnecessary. In the end, there are just a lot of them, and sometimes that pulled away from the experience of the story. This is a difficult one as well, I feel, because there are going to be many different people who come to this book. Some of them are going to want to know all the details of what everything means, and some of them are likely not going to care. Some of them are likely going to be coming from a medical background, and some of them might just know the right dosage of Advil they need to take for their headache (no shame). I was somewhere in between. And for me, it was a little bit much. But there was a lot that I did appreciate. And actually, there were a few times when I felt like he made some uncomfortable jokes, but then he did a counter-joke within the footnotes that made it a little bit better (emphasis on “little bit”).

I really appreciated the structure of the book as well. The chapters themselves are fairly long, but they are more like sections than actual chapters. Each chapter is marked as a new year in his medical career, with new benefits and pressures attached to it. He does a little reflective piece at the beginning, adding a bit of context, and then fills in the chapter with the diary entries that he had written during that year. I would be very interested to know how much editing actually went into the journal entries themselves and whether the story order was rearranged or if he stayed true to the actual dates. If they were not rearranged, that would amaze me due to their consistency. But really, day-to-day real life is far more consistent than when creating a fictitious word, and he really is just sharing with us his “regular” life. It’s likely far easier to write a coherent piece when it really happened and it’s not just up to your own brain to create consistency. Human beings are far more consistent than we readers try to make them, I think, likely just due to the fact of wanting to create drama or because of laziness and not knowing where to go next. Normal lives are often just that: normal. But each normal life is also unique, and therein lies the story. The journal entries were typically quite short, so it created a fairly nice pace for reading.

Also, I could feel that there was quite a bit of respect that was put into this. Respect for the people in his life who had to suffer the consequences of his job, respect for the profession and the people involved, respect for midwives and nurses, and respect for the field itself. He is quick to make a joke, but more times than not, it doesn’t fall on the side of irreverence (except in the places I already mentioned). Often it fell to the side of frustration and irony, but there was very little that felt like whining, even when whining would have been a very understandable response. For sure, he doesn’t present himself as a fully invulnerable human being without needs, but rather than really complaining or whining about it in the book, once again, he just let the story speak for itself, facts first, and kinda allows the reader to feel it along with him. And we feel it. We feel the injustice of a lot of it. A lot of the time, I wanted to whine for him, as well as for his friends and girlfriend. There were a lot of things that were going on that made you feel pity for him, and maybe he even felt pitiable himself, but he very rarely forces it upon you or asks you to commiserate with him. Truly, I felt like this was really a good writing choice and helped us to like him as our narrator (even though he wasn’t without issues… but so is no human).

Writer’s Takeaway

  • Allow the story to speak for itself on most occasions. You are the medium for the story; leave as little of yourself as behind as possible for full immersion. If the reader feels like they are being preached to by the author or feels like they are being told what to feel, the full experience may get lost.
  • Don’t tell a reader what to feel. Make them feel it.
  • Real life is more interesting than you think. Medicine certainly is. More consistent, too. Don’t force drama for the sake of drama. Lean into reality.
  • Be respectful. If you feel like you have to force in a joke to make it humorous, don’t make the joke. If you feel like you have to disrespect someone for the sake of a joke, don’t make the joke. Most things are funny just as they are. Not everything needs a commentary.
  • Think about your structure and pace. The audience WILL have a different experience depending on how long or short the chapters are and whether that fits with the pace of the story.
  • Not everything needs purpose immediately. Readers will create their own purpose. Just write. But try and be aware of what might be drawn from it and whether that is or isn’t a message you would like to spread (or like to be attached to). Don’t be overly concerned about it while you write, though, to the point of creating writer’s block. That is what editors and test readers are for.

Annotated Passages

However a health-care system might be set up or funded, the experience of being a doctor is utterly universal. The same heartbreak, the same hilarity, the same damaging work schedule, and, of course, the same baffling array of objects getting constantly inserted into orifices.

→ The experience of a doctor is universal because humans experience much of life very similarly (although always with different nuances).

You’re a one-man, mobile, essentially untrained ER, getting drenched in bodily fluids (not even the fun kind), seeing an endless stream of worryingly sick patients who, twelve hours earlier, had an entire team of doctors caring for them. You suddenly long for the sixteen-hour admin sessions. (Or, ideally, some kind of compromise job that’s neither massively beyond nor beneath your abilities.)

→ It’s fascinating that that is often what is asked in professional fields: either be more than you are (or can physically possibly be) or less than you are.

The device goes off. I say, “Oh my God,” and reflexively jump to my feet. It’s not that I’m particularly excited about my Fiorentina; it’s just that the fucking thing has the exact same pitch and timbre as my hospital bleeper. H takes my pulse—it’s 95. Work has pretty much given me PTSD.

→ One of the things that is most sickening to me about the medical system is that those who are in the role of helping us often get the least amount of help. Those in the role of keeping us healthy are usually placed in positions of significant lack of health.

In my confusion, I accidentally sign off with “Love you, bye.” It’s partly exhaustion, partly my brain misfiring because H is normally the only person who says nice things to me, and partly because, in that moment, I genuinely loved her for saying that.

→ For everyone (including myself) that has said “I love you” to someone random…

In the event, it took me months to actually make up my mind, commit, and apply. I think the reason I hesitated was that I hadn’t made any significant life decisions since I chose which medical school to go to as a teenager—and even that was mostly because I was impressed with the curly fries in the Student Union Hall. Age twenty-five was the first point I actually got to make an active decision in the Choose Your Own Adventure book of my life. I not only had to learn how to make a decision, but also ensure I made the right one.

Our computer system has been upgraded and, as happens eleven times out of ten when the hospital tries to make life easier, they’ve made everything much more complicated.

→ Why is this? Why is this so true? Once again, I’m often amazed at our skewed priorities within society and the things we actually spend money on. Also, why is the beeper still a thing in medicine? Medicine is a world of contradictions.

We talk about boring, practical things, rational concerns, irrational concerns, and I can see from her eyes it’s helping her. It suddenly strikes me that I’m almost certainly the first person she’s opened up to about all this, the only one she’s been totally honest with. It’s a strange privilege, an honor I didn’t ask for. The other thing I realize is that none of her many, many concerns are about herself; it’s all about the kids, her husband, her sister, her friends. Maybe that’s the definition of a good person. The undiluted selflessness of someone fully aware of what her absence will do to those she leaves behind.

→ I loved much of this. How often it is the case that when are the sickest, what we miss the most is just “normalcy”…

→ The power of presence is a real thing.

→ To die may be a scary thing, but to live and to live on without someone can feel far more devastating, I feel. To die may come with complications, but there is always an end. And the very end is always simple, always just one option (although the quality of that option may be different). The pain finishes for them. To live, though… is never simple. And to live without them may extend and extend and extend the pain until death claims us as well. To be aware of this is both beautiful and so hard.

I’ve spent two hours in this room, the longest I’ve ever spent with a patient who wasn’t under anesthesia. On the way home I phone my mum to tell her I love her.

→ There is a certain level of awareness of the finiteness of life that comes with being so close to death every day.

He must realize we have the same chat every time, but it clearly doesn’t matter—he just wants to know there’s someone out there who cares. And actually, that’s a very large part of what being a doctor

→ I have many conflicting thoughts about this.

“I’m sorry,” I say to him as I take the samples I need. “There we go, all done now.” I dress him again, look up to a God I don’t believe in, and say, “Look after him.”

→ Belief in something greater than ourselves helps us when the things that should never happen in this life do indeed happen.

Science may trump the supernatural, but once someone tells you an operative technique is bad luck, it’s probably better to be safe than sorry. No one wants to be bleeped in the middle of the night because a plateful of intestines has made a surprise appearance out the front of a patient’s abdomen.

→ It’s things like this that make me think that we all believe and have faith in something. Even atheists.

We’re constantly reminded by the GMC not to be doctor to friends or family, but I’ve always just ignored that and provided them an on-call private service. Because my job makes me such a useless friend in so many ways, I guess I feel like I have to offer something to justify my name on their Christmas-card lists. And this is basically why we’re taught not to.

→ The guilt, man…

Actually, that’s probably the wrong way of looking at it. You don’t cure depression, the same way you don’t cure asthma; you manage it. I’m the inhaler he’s decided to go with and I should be pleased he’s gone this long without an attack.

→ This is so good.

So I told them the truth: the hours are terrible, the pay is terrible, the conditions are terrible; you’re underappreciated, unsupported, disrespected, and frequently physically endangered. But there’s no better job in the world.

→ I believe the same thing can be said for teachers and teaching. But at the same time, we should be doing something about the awful situation around it.

One day I realized—as if blinking awake after a serious accident—that I was now in my thirties and still in a career I’d signed up for fourteen years earlier based on the very flimsiest of reasons.

→ Getting caught in the torrent of your own life, with your brain always on default, is an excellent way to end up waking up in your 40s (with a list of addictions and self-medications), feeling miserable, and wondering how you got here. It’s so important to be aware of what is actually going on inside your heart and head. If there is no time for that, maybe consider why and what might need to change.

“It’s funny—you don’t think of doctors getting ill.” It’s true, and I think it’s part of something bigger: patients don’t actually think of doctors as being human. It’s why they’re so quick to complain if we make a mistake or if we get cross. But it’s the flip side of not wanting your doctor to be fallible, capable of getting your diagnosis wrong. They don’t want to think of medicine as a subject that anyone on the planet can learn, a career choice their mouth-breathing cousins could have made.

→ Doctors live in a double bind.

It’s a system that barely has enough slack to allow for sick leave, let alone something as intangible as recovering from an awful day. And, in truth, doctors can’t acknowledge how devastating these moments really are. If you’re going to survive working in this profession, you have to convince yourself these horrors are just part of your job. You can’t pay any attention to the man behind the curtain—your own sanity relies on it.

→ I hate that this is the reality. The lack of compassion is brutal.

I might have gone into that room an hour earlier. I might have noticed some subtle changes on the CTG. I might have saved the baby’s life, saved the mother from permanent compromise. That “might have” was inescapable. I’d mocked consultants for being overcautious before, rolled my eyes the moment they turned their heads, but now I got it. They’d each had their own “might have” moment, and this is how you dealt with it.

→ This is an excellent example of trauma and how it messes with our brains, which messes with how we do everything.

Except I wasn’t really dealing with it, I was just getting on with it. I went six months without laughing; every smile was just an impression of one—I felt bereaved. I should have had counseling—in fact, my hospital should have arranged it. But there’s a mutual code of silence that keeps help from those who need it most.

→ Maybe one of the most heartbreaking lines in the book.

At first I couldn’t talk about it, then it became something I just didn’t talk about.

→ And this is how it is.

The junior doctors lost that particular battle, largely because the government’s booming, baleful voice drowned out their own reasonable, experienced quiet one. I realized that every health-care professional—every single doctor, nurse, midwife, pharmacist, physical therapist, and paramedic—needs to shout about the reality of their work so the next time the health secretary lies that doctors are in it for the money, the public will know just how ridiculous that is. Why would any sane person do that job for anything other than the right reasons? Because I wouldn’t wish it on anyone. I have so much respect for those who work on the front line because, when it came down to it, I certainly couldn’t.

But promise me this. Next time a government tries to denigrate doctors or take a pickax to the health-care system, don’t just accept what the politicians feed you. Think about the toll the job takes on every medical professional, at home and at work. Remember that all of them do an absolutely impossible job to the very best of their abilities. Your time in the hospital may well hurt them a lot more than it hurts you.

→ Aaaand, I’ll just leave this here as food for thought.

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