‘This Is Going to Hurt’: A Grossly Funny Memoir of a Burned Out Doctor

• This Is Going to Hurt: The Secret Diaries of a Junior Physician
• Adam Kay
• Picador Books (2017)

This is a very sad, very funny book. It’s not yet available in print in North America (I downloaded my copy on Kindle). I wish it were required reading in every medical school around the world, though it might encourage the dropout rate. Those who stayed would at least know what they’re getting into.

It also ought to be required reading for politicians and policy wonks, because it dramatizes a truly serious problem we have foisted off on healthcare workers, not to mention all the others who clean up our messes, like soldiers, cops, and first responders: we turn the cleanup crew into part of the mess.

Adam Kay grew up, he tells us, in a British medical family. Once out of med school he became a “junior doctor” in the UK’s National Health Service, and found 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” — that is, the most junior of junior doctors in British hospitals.

“The night shifts,” Kay writes, “… made Dante look like Disney — an unrelenting nightmare… At night the house officer is given a little paging device called a bleep and responsibility for every patient in the hospital. The fucking lot of them. The night-time SHO [special house officer] and registrar [senior doctor] 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.”

That strikes the theme of the book: the impossibly stressful workload of a frontline healthcare worker. From 2004 to 2010, Kay worked in British hospitals, chiefly in obstetrics and gynaecology, on schedules that left him exhausted, cost him his partner, and paid him, he estimated, something less per hour than a hospital parking meter. During that time he kept his “secret diaries” to record and reflect on his experiences, and to learn from them.

Kay’s first patient death taught him the virtues of black humour: “I didn’t panic when the patient I was reviewing unexpectedly started hosing enormous quantities of blood out of his mouth and onto my shirt… I asked the nearest nurse to get Hugo, my registrar, and meanwhile I put in a Venflon [cannula for administering fluids intravenously] and ran some fluids… I was completely out of ideas by that point. Start looking for the patient’s stopcock? Shove loads of kitchen roll down his throat? Float some basil in it and declare it gazpacho?”

That kind of gross hilarity is clearly a defence mechanism, and Kay had repeated need of it during the six years of his medical career. I suspect it’s how most healthcare workers cope, though it probably doesn’t work much better for them than it did for Kay. Eventually he witnessed one death too many and quit. He now deals with his own PTSD by working as a standup comedian, reading from his book to packed houses.

A macho medical culture

Kay was working in the NHS before its current stresses, which have become a major political issue in pre-Brexit Britain. His book is actually full of praise for the NHS and those who serve in it, who do incredible work despite a chronic lack of people, resources, and money. But it is also an indictment of the macho culture of underfunded healthcare, where doctors, nurses, and staff are expected to keep calm and carry on, and on.

Last year, a Royal College of Physicians report on junior doctors warned that the NHS is “underfunded, underdoctored, and overstretched.” This means intense overwork: “Junior doctors commonly go through seven shifts per month without drinking enough water, and four shifts per month without eating a meal.”

As a result, “Four in five junior doctors regularly experience excessive stress because of their job. One in four junior doctors report that their role has had a serious impact on their mental health.”

Canadian and American healthcare systems are unindicted co-conspirators, exploiting their workers in the name of serving patients at a politically affordable price. Search the website of the New England Journal of Medicine for the term “physician burnout” and you’ll get 72 hits. The problem starts in medical school and takes many forms thereafter, from stigma to scheduling to sexual harassment and violence. It means physicians and other healthcare workers must deal with their own depression, emotional exhaustion, and suicidal thoughts while also trying to care for their patients.

Chief cause of death for young physicians: suicide

OMA Insurance, a program run by the Ontario Medical Association, says Canadian physicians face problems as serious as their American and British colleagues:

“The overall physician suicide rate cited by most studies is two to four times higher than the general population. In the United States, this translates to an equivalent of one to two average-sized medical school graduating classes needed every year just to replace the number of physicians who commit suicide… Moreover, studies have also concluded that suicide is the most common cause of death for young physicians (26% of deaths). Male physicians commit suicide at a rate about 1.4 times greater than the general population, whereas female physicians have suicide rates about 3 times higher than the general population. Unlike the general population, where males complete suicide four times more often than females, male and female physicians have approximately equal suicide rates.”

Ironically, the Canadian Medical Association Journal says Ontario doctors who seek counselling through OMA insurance may receive only $350 for counselling, and get nothing for counselling or medication if they have a pre-existing condition of mental health concerns.

A recent article in CMAJ, the journal of the Canadian Medical Association, sums up the North American problem: “One in four Canadian physicians reports high levels of burnout and one in three screens positive for depression. South of the border, more than half of physicians in the United States have symptoms of burnout. One in five is thinking about reducing their hours and 1 in 50 is considering early retirement, despite mounting physician shortages. Meanwhile, some 400 physicians and 100 medical students die by suicide each year.”

Changing the culture

Cultures are stubborn. They endure for generations, through any number of technological and political revolutions. Transforming modern medical culture could be tougher than establishing Pasteur’s germ theory of disease, when generations of doctors just knew “miasmas” (tainted air) were the cause of illness.

No doubt we patients stupidly harm our doctors’ mental health by failing to vaccinate our kids or persisting in harmful lifestyles. But it’s clearly in our own interest to ensure that the doctor who sees us is calm, rested, undistracted by administrative chores, and in control of his or her schedule. Such a doctor can give patients the careful attention they need.

Equally important, such a doctor should be able to call on his or her colleagues for support when needed, and expect the same caring response a patient would receive.

Changing political culture is as tough as changing the doctors: politicians get re-elected by making someone else “do more with less,” and praising the doctors who pay the price their bosses won’t.

That praise doesn’t go far when a healthcare worker has endured too many stresses, and it doesn’t help patients get better. When it’s one of your loved ones who’s bleeding out in emergency, it’s not funny at all.