Doctor's jacket and Adam Kay reading
Photo: Getty and Adam Kay

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Secret diaries of a junior doctor

As a junior doctor, you’re a one-man, mobile, essentially untrained A&E department, getting drenched in bodily fluids (not even the fun kind), says Adam Kay, author of This Is Going To Hurt

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By Adam Kay on

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The decision to work in medicine is basically a version of the email you get in early October asking you to choose your menu options for the work Christmas party. No doubt you’ll choose the chicken, to be on the safe side, and it’s more than likely everything will be all right. But what if someone shares a ghastly factory farming video on Facebook the day before and you inadvertently witness a mass debeaking? What if Morrissey dies in November and, out of respect for him, you turn your back on a lifestyle thus far devoted almost exclusively to consuming meat? What if you develop a life-threatening allergy to escalopes? Ultimately, no one knows what they’ll fancy for dinner in sixty dinners’ time.

Every doctor makes their career choice aged sixteen, two years before they’re legally allowed to text a photo of their own genitals. When you sit down and pick your A levels, you’re set off on a trajectory that continues until you either retire or die and, unlike your work Christmas party, Janet from procurement won’t swap your chicken for her halloumi skewers – you’re stuck with it.

At sixteen, your reasons for wanting to pursue a career in medicine are generally along the lines of ‘My mum/dad’s a doctor’, ‘I quite like Holby City’ or ‘I want to cure cancer’. Reasons one and two are ludicrous, and reason three would be perfectly fine – if a little earnest – were it not for the fact that’s what research scientists do, not doctors. Besides, holding anyone to their word at that age seems a bit unfair, on a par with declaring the ‘I want to be an astronaut’ painting you did aged five a legally binding document.

Personally, I don’t remember medicine ever being an active career decision, more just the default setting for my life – the marimba ringtone, the stock photo of a mountain range as your computer background. I grew up in a Jewish family (although they were mostly in it for the food); went to the kind of school that’s essentially a sausage factory designed to churn out medics, lawyers and cabinet members; and my dad was a doctor. It was written on the walls.

Because medical schools are oversubscribed ten-fold, all candidates must be interviewed, with only those who perform best under a grilling being awarded a place. It’s assumed all applicants are on course for straight As at A level, so universities base their decisions on non- academic criteria. This, of course, makes sense: a doctor must be psychologically fit for the job – able to make decisions under a terrifying amount of pressure, able to break bad news to anguished relatives, able to deal with death on a daily basis. They must have something that cannot be memorized and graded: a great doctor must have a huge heart and a distended aorta through which pumps a vast lake of compassion and human kindness. At least, that’s what you’d think. In reality, medical schools don’t give the shiniest shit about any of that. They don’t even check you’re OK with the sight of blood. Instead, they fixate on extracurricular activities. Their ideal student is captain of two sports teams, the county swimming champion, leader of the youth orchestra and editor of the school newspaper. It’s basically a Miss Congeniality contest without the sash. Look at the Wikipedia entry for any famous doctor, and you’ll see: ‘He proved himself an accomplished rugby player in youth leagues. He excelled as a distance runner and in his final year at school was vice-captain of the athletics team.’ This particular description is of a certain Dr H. Shipman, so perhaps it’s not a rock-solid system.

Imperial College in London were satisfied that my distinctions in grade eight piano and saxophone, alongside some half-arsed theatre reviews for the school magazine, qualified me perfectly for life on the wards, and so in 1998 I packed my bags and embarked upon the treacherous six-mile journey from Dulwich to South Kensington.

 A great doctor must have a huge heart and a distended aorta through which pumps a vast lake of compassion and human kindness. At least, that’s what you’d think. In reality, medical schools don’t give the shiniest shit about any of that

As you might imagine, learning every single aspect of the human body’s anatomy and physiology, plus each possible way it can malfunction, is a fairly gargantuan undertaking. But the buzz of knowing I was going to become a doctor one day – such a big deal you get to literally change your name, like a superhero or an international criminal – propelled me towards my goal through those six long years.

Then there I was, a junior doctor. By the way, ‘junior doctor’ refers to anyone who isn’t a consultant. It’s a bit confusing as a lot of these ‘junior doctors’ are actually pretty senior – some have been working for fifteen years, picking up PhDs and various other postgraduate qualifications. It’s a bit like calling everyone in Westminster apart from the prime minister a ‘junior politician’. I could have gone on Mastermind with the specialist subject ‘the human body’. Everyone at home would be yelling at their TVs that the subject I’d chosen was too vast and wide-ranging, that I should have gone for something like ‘atherosclerosis’ or ‘bunions’, but they’d have been wrong. I’d have nailed it.

It was finally time to step out onto the ward armed with all this exhaustive knowledge and turn theory into practice. My spring couldn’t have been coiled any tighter. So it came as quite the blow to discover that I’d spent a quarter of my life at medical school and it hadn’t remotely prepared me for the Jekyll and Hyde existence of a house officer.

During the day, the job was manageable, if mind-numbing and insanely time-consuming. You turn up every morning for the ‘ward round’, where your whole team of doctors pootles past each of their patients. You trail behind like a hypnotized duckling, your head cocked to one side in a caring manner, noting down every pronouncement from your seniors – book an MRI, refer to rheumatology, arrange an ECG. Then you spend the rest of your working day (plus generally a further unpaid four hours) completing these dozens, sometimes hundreds of tasks – filling in forms, making phone calls. Essentially, you’re a glorified PA. Not really what I’d trained so hard for, but whatever.

The night shifts, on the other hand, made Dante look like Disney – an unrelenting nightmare that made me regret ever thinking my education was being under-utilized. At night, the house officer is given a little paging device affectionately called a bleep and responsibility for every patient in the hospital. The fucking lot of them. The night-time SHO and registrar will be down in A&E reviewing and admitting patients while you’re up on the wards, sailing the ship alone. A ship that’s enormous, and on fire, and that no one has really taught you how to sail. You’ve been trained how to examine a patient’s cardiovascular system, you know the physiology of the coronary vasculature, but even when you can recognize every sign and symptom of a heart attack, it’s very different to actually managing one for the first time.

You’re bleeped by ward after ward, nurse after nurse with emergency after emergency – it never stops, all night long. Your senior colleagues are seeing patients in A&E with a specific problem, like pneumonia or a broken leg. Your patients are having similar emergencies, but they’re hospital inpatients, meaning they already had something significantly wrong with them in the first place. It’s a ‘build your own burger’ of symptoms layered on conditions layered on diseases: you see a patient with pneumonia who was admitted with liver failure, or a patient who’s broken their leg falling out of bed after another epileptic fit. You’re a one-man, mobile, essentially untrained A&E department, getting drenched in bodily fluids (not even the fun kind), reviewing 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 sink or swim, and you have to learn how to swim because otherwise a ton of patients sink with you. I actually found it all perversely exhilarating. Sure it was hard work, sure the hours were bordering on inhumane and sure I saw things that scarred my retinas to this day, but I was finally a doctor.

***

This is Going to Hurt is my collection of diaries from the six years I more or less lived on the wards as a junior doctor. I specialized in Obs and Gynae (or ‘brats and twats’ as it was known) working on various labour wards. It’s an amazing specialty – you end up with twice the number of patients you start with, a pretty impressive batting average – and it was an incredible privilege to be able to play such an important role in the lives of the countless hundreds of families whose babies I delivered. There were the ridiculous moments too: a pregnant patient presenting in the middle of the night complaining of a huge number of painless spots on tongue (diagnosis: taste buds), patients naming their children Sayton and LeSanya, festive vaginal burns from a patient stuffing a string of lights inside and turning them on (bringing new meaning to the phrase ‘I put the Christmas lights up myself’). There was the huge toll the job took on my personal life – routinely staying hours late at work because of emergencies on labour ward and no slack in the system, the 97 hour weeks where I saw the Costa barista more than my partner, missing friends’ weddings, cancelling my own holidays, waking up the next morning in the hospital car park where I’d fallen asleep in my car after my shift the previous evening.

Promise me this: next time the government takes its pickaxe to the NHS, don’t just accept what the politicians try to feed you

And of course there was the sad stuff too. And it was a tragic day on labour ward that ultimately led me to leave medicine (sorry for the spoiler – but you watched Titanic knowing how that was going to play out) – unfortunately the price you pay for the height of the highs in that specialty is the depths of the lows.  

***

After it happened, everyone at the hospital was very kind to me and said all the right things; they told me it wasn’t my fault, said I couldn’t have done anything differently, and sent me home for the rest of the shift. And yet, at the same time, it felt a bit like I’d sprained my ankle. A flurry of people asking me ‘Are you OK?’, but also the definite expectation that I’d still come into work the next day, the reset button firmly pressed. That’s not to say they were heartless or unthinking – it’s a problem that’s baked into the profession. You can’t wear a black armband every time something goes wrong, you can’t take a month’s compassionate leave – it happens too often.

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’d seen babies die before. I’d dealt with mothers on the brink of death before. But this was different. It was the first time I was the most senior person on the ward when something terrible happened, when I was the person everyone was relying on to sort it all out. It was on me, and I had failed.

Officially, I hadn’t been negligent and nobody suggested otherwise. The GMC will always judge medical negligence by asking the question ‘Would your peers have done anything differently in that situation?’ All my peers would have done exactly the same things and had exactly the same outcome. But this wasn’t good enough for me. I knew that if I’d been better – super-diligent, super-observant, super-something – 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.

Yes, I came back to work the next day. I was in the same skin, but I was a different doctor – I couldn’t risk anything bad ever happening again. If a baby’s heart rate dropped by one beat per minute, I would perform a caesarean. And it would be me doing it, no one junior to me. I knew women were having unnecessary caesareans and I knew colleagues were missing opportunities to improve their surgical skills, but if it meant everyone got out of there alive it was worth it. I’d mocked consultants for being over-cautious 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.

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 counselling – 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.

No matter how vigilant I was, another tragedy would have happened eventually. It has to – you can’t prevent the unpreventable. One brilliant consultant tells her trainees that by the time they retire there’ll be a bus full of dead kids and kids with cerebral palsy, and that bus is going to have their name on the side. A huge number of ‘adverse outcomes’, as they say in hospitalese, will occur on their watch. She tells them if they can’t deal with that, they’re in the wrong profession. Maybe if someone had said that to me a bit earlier I’d have thought twice. Ideally, back when I was choosing my A levels and getting myself into this mess.

I asked if I could go part-time (‘not unless you’re pregnant’) and investigated switching to general practice. But first I’d have to drop right down to SHO grade for a couple of years to work in A&E, paediatrics and psychiatry. I didn’t want to take a long journey backwards in order to start moving forwards again, only to find I didn’t like that either.

I paused my training with the deanery and did some half-hearted research and lazy locum shifts on private units, but after a few months I hung up my stethoscope. I was done.

Promise me this: next time the government takes its pickaxe to the NHS, don’t just accept what the politicians try to feed you

I didn’t tell anyone the reason why I left. Maybe I should have; maybe they’d have understood. My parents reacted like I’d told them I was being tried for arson. At first I couldn’t talk about it, then it became something I just didn’t talk about. When cornered, I would reach for my red nose and clown horn, and bring out my anecdotes about objects in anuses and patients ‘saying the funniest things’. Some of my closest friends will read this book and hear that story for the first time.

These days, the only doctoring I do is other people’s words – I write and script-edit comedy for television. A bad day at work now is if my laptop crashes or a terrible sitcom gets terrible ratings – stuff that literally doesn’t matter in the scheme of things. I don’t miss the doctor’s version of a bad day, but I do miss the good days. I miss my colleagues and I miss helping people. I miss that feeling on the drive home that you’ve done something worthwhile. And I feel guilty the country spent so much money training me up for me just to walk away.

I still have a very strong affinity with the profession – you never totally stop being a doctor. You still run to the injured cyclist sprawled across the road, you still reply to the text messages from friends of friends cadging fertility advice. So in 2016, when the government started waging war on doctors – forcing them to work harder than ever for less money than ever – I felt huge solidarity with them. And when the government repeatedly lied that doctors were simply being greedy, that they do medicine for the money – for anything other than the best interests of the patient – I was livid. Because I knew it wasn’t true.

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 healthcare professional – every single doctor, nurse, midwife, pharmacist, physio 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 of the NHS because, when it came down to it, I certainly couldn’t.

Putting my book together, six years after quitting medicine, I met up with dozens of former colleagues. Their dispatches from labour ward tell of an NHS on its knees. Every one of them spoke of an exodus from medicine. When I left, I was a glitch in the matrix, an aberration. Now every rota bears the scars of doctors who’ve activated their Plan B – working in Canada or Australia, in pharmaceutical companies or in the City. Most of my old colleagues were themselves desperately groping for a ripcord to parachute out of the profession – brilliant, passionate doctors who’ve had their reasons to stay bullied out of them by politicians. Once upon a time, these people were rescheduling their own weddings for this job.

The other recurrent theme, doctor after doctor, is how everyone remembers the sad stuff, the bad stuff, so vividly. Your brain presses record in HD. They can tell you the number of the room it happened in, on a labour ward they last saw a decade ago. The shoes the patient’s husband was wearing, the song playing on the radio. Senior consultants’ voices shake when they talk about their disasters – six-foot-tall former prop forwards on the verge of tears. A friend told me about a perimortem caesarean he performed: a mum dropped dead in front of him and he cut the baby out on the floor. It survived. ‘You saved the wrong one! You saved the wrong one!’ was all the dad could cry.

I’m not the right person to talk about dealing with grief though – that’s not what my book is about. It’s simply one doctor’s experiences, some degree of insight on an individual level into what the job really entails.

But promise me this: next time the government takes its pickaxe to the NHS, don’t just accept what the politicians try to feed you. Think about the toll the job takes on every healthcare professional, at home and at work. Remember they do an absolutely impossible job, to the very best of their abilities. Your time in hospital may well hurt them a lot more than it hurts you.

@amateuradam

This Is Going To Hurt, published by Picador, is out now

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