This Is Going to Hurt: Secret Diaries of a Young Doctor

by Adam Kay

I should still give you a very quick primer about our health-care system; unlike an intern’s first day on the wards, I won’t drop you in the deep end, breeze off, and expect you to know exactly what’s going on. The NHS was founded on the principle that it’s free at the point of delivery and you’re treated according to clinical need, not ability to pay—whether you live in Windsor Castle or on a bench outside Windsor Station. Other systems around the world might be more efficient, but I’d drag myself out of a coma to argue that none of them is fairer.

Reading back over it, I was reminded of the brutal hours and the colossal impact being a junior doctor had on my life. It now seemed extreme and unreasonable in terms of what was expected of me, but at the time, I’d just accepted it as part of the job. The extra mile was the normal distance. I wouldn’t have flinched if an entry read swam to Iceland for prenatal clinic or had to eat a helicopter today.

my personal life became a hobby I never had time for,

Personally, I don’t remember medicine ever being an active career decision; it was 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 doctors, lawyers, and politicians; and my dad was a doctor. It was written on the wall.

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 if you’re okay 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.

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 personal assistant. Not really what I’d trained so hard for, but whatever.

The night shifts, however, made Dante look like Disney—an unrelenting nightmare that made me regret ever thinking my education was being underutilized. At night, the house officer is given a little paging device affectionately called a bleeper and responsibility for every patient in the hospital. The fucking lot of them.

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 inhuman; and sure, I saw things that have scarred my retinas to this day, but I was a doctor now.

By the time the tube was inserted, he’d stopped bleeding. Bleeding always stops eventually, and this was for the saddest reason.

All junior doctors at the hospital have been asked to sign a document opting out of the European Working Time Directive* because our contracts are noncompliant with it. This week I have seen H for under two hours and worked for a grand total of ninety-seven. Noncompliant doesn’t quite seem to cover it. My contract has taken the directive, dragged it screaming from its bed in the dead of night, and waterboarded it.

About to take a ten-year-old straight from the ER to the operating theater for a ruptured appendix. Colin, a charming registrar, has been conducting a master class in dealing with a worried mum—explaining everything that’s going on in her son’s tummy, what we’re going to do to fix it, how long it’ll take, when he’ll be allowed to go home. I try to absorb his method. It’s about telling her just the right amount—keeping her informed but not overwhelmed—and delivering everything at the right level; not too much jargon but never patronizing. Above all, it’s about being professional and kind.

I told a patient that his MRI wouldn’t be until next week and he threatened to break both my legs. My first thought was Well, it’ll be a couple of weeks off work. I was this close to offering to find him a baseball bat.

(Orthopedics is basically reserved for the med school’s football team—it’s barely more than sawing and nailing, and I suspect they don’t “sign up” for it so much as dip their hands in ink and provide a palm print.)

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 cut through human skin for the first time, open up a uterus for the first time, and deliver a baby abdominally for the first time. I’d like to say it was an amazing experience, but I was concentrating far too hard on every step to actually take any of it in.

it’s a free country, so we respect everyone’s (fucking stupid) values and wishes.

numerous Jehovah’s Witnesses have died because they declined blood products. She signs, though she admits part of the reason she’s refusing is that her family would never speak to her again if she received blood. (Even more of an incentive to have a transfusion, if you ask me.)

I, too, will very likely be in a hospital for every single one of my birthdays until I’m too weak to blow out the candles,

the quality of the transcription would suggest the back end of the system involves two tin cans, a length of string, and a lemur who’s been trained to type.

For me, the true miracle of childbirth is that smart, rational people with jobs and the ability to vote look at these half-melted fleshy blobs, their heads misshapen from being squeezed through a pelvis, covered in five types of horrendous gunk, looking like they’ve spent a good two hours rolling around on top of a deep-pan pizza, and honestly believe they look beautiful. It’s Darwinism in action, an irrational love for your progeny. The same hardwired desire to keep the species going that sees a woman come back to the labor ward for round two eighteen months after the irreparable destruction of her perineum.

And now I’m sitting with a woman who’s asking me if she should have her ashes scattered on the Scilly Isles. It’s her favorite spot, but she doesn’t want it to be a sad place for her family once she’s gone. The undiluted selflessness of someone fully aware of what her absence will do to those she leaves behind.

Sometime during my early years as an SHO, I remember watching a documentary about Shaolin kung fu masters. They train for a decade or more in a remote temple, waking up at five a.m. and only stopping at midnight, submitting themselves to a life of celibacy, devoid of material possessions. I couldn’t help but feel it didn’t sound that bad—at least they didn’t have to uproot their lives every year and go to a completely different temple.

So while all my friends in sensible careers were getting mortgages and puppies, H and I were taking on yearlong rental contracts and living somewhere mutually inconvenient roughly halfway between our two workplaces. It was yet another item on the list of ways my job was inflicting collateral damage on H—medical widow, post-shift counselor, and now nomad.

I suspect he can get better help from someone who didn’t have to panic-google What to say to someone who’s suicidal. But it seems I’m better than nothing—at the very least, he’s still alive.

Aside from the fact that I know what less than half of these words mean (and most of the ones I do know are prepositions), I can’t help wondering how it’s relevant to my baby-delivering abilities. But if it’s what my insane demonic overlords want me to know, who am I to argue?

Doctors tend not to complain about the money, though. It’s not a profession you go into to satisfy the dollar signs behind your eyes, whatever the occasional dead-mouthed politician may claim. Besides, even if you’re unhappy with your salary, there’s sod all you can do about it. It’s all determined centrally and rolled out across the entire profession. Perhaps it’s unhelpful to describe it as a salary; the NHS should call what they pay doctors a “stipend,” acknowledging it’s below the prevailing rate but that physicians are in the job because it’s their calling rather than for any financial imperative.

There’s no opportunity for a bonus—the closest that exists is “ash cash,” where juniors get forty pounds a pop for signing a form for funeral directors confirming the patient about to be cremated doesn’t have a pacemaker. (Pacemakers explode during the process, taking with them entire crematoria and congregations, as one family presumably found out during a particularly stressful funeral.)

Patients tended to get it, though. When one of them said thank you, you knew they meant it—even if it felt like it wasn’t for anything special, just one of the smaller horrors thrown at you that day. I’ve kept every single card a patient has given me. Birthday and Christmas cards from family and friends would always get thrown away, but these guys survived every house move, escaping even my cathartic clear-out of medical paperwork once it was all over. They were little fist bumps that kept me going, rays of thoughtfulness from my patients that hit the spot when bosses couldn’t, or wouldn’t, oblige.

I realized that most of my colleagues weren’t so lucky, especially when it came to their home lives. Mine was largely held together by superhuman levels of tolerance and understanding; most doctors’ relationships crumbled after a year or so. The cracks that they all develop would appear far too early, like some bizarre premature-aging disorder.

I know colleagues who’ve had to cut honeymoons short and miss family funerals, so the odds were never great for them bending my schedule for a holiday.

In the UK we see the skyscraper-high bills in America as the Ghost of Christmas Future unless we fight to stop the NHS getting privatized. Politicians may act dumb, but they’re not, and we’ll be lured very stealthily into this particular gingerbread house. We’ll be promised it’s only little corners of the NHS that are changing, but there’ll be no trail of bread crumbs to help us find our way back through the forest. One day you’ll blink and the NHS will have completely evaporated—and if that blink turns out to be a stroke, you’re totally screwed.

I could always see myself doing the odd bit of private work as a consultant, one evening a week in clinic, maybe, the occasional hysteroscopy if I thought I deserved a Mercedes, perhaps a cesarean a month if I thought my Mercedes deserved a chauffeur.

There may well be a light at the end of the tunnel, but the tunnel is eighty-five miles long, crammed full of impacted feces, and I have to eat my way out of it.

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.

Percy and Marietta’s wedding today felt like a huge triumph against the odds. Not one but two doctors able to get their big day off work. And the whole day too, not like my former colleague Amelia, who could only wangle the afternoon of her wedding day off and ended up conducting her morning clinic in full bridal hair and makeup to make the timing work. The main miracle is they’ve managed to last this long together despite a system seemingly designed to ruin their relationship.

Eventually there comes a point where you have to decide what kind of doctor to be. Not the technical stuff, like whether you’re into urology or neurology, but the more important matter of your bedside manner. Your stage persona evolves throughout your training but you generally settle on a way of dealing with patients a couple of years in and carry it through into your consultant career. Are you smiley, charming, and positive? Quiet, contemplative, and scientific? I presume it’s the same decision police officers make when they decide if they’re good cops or bad cops (or racist cops).

According to their expert opinion, which seemed to have been honed from skim-reading a book called Law: Just Throw the Fucking Lot at Them and See Who Gets Back Up Again, the trust was negligent, I’d carried out the operation well below the standard reasonably expected

We chatted for an hour or so and I reminded him he could call me any time, day or night. But we’d had this chat so often in the last three years, and it’s miserable to think that we’re no further forward than when he posted that first cry for help. 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.

“Dr. Adam! You delivered my baby!” squeals the woman behind the cheese counter at Sainsbury’s. I have no recollection of her whatsoever, but her story seems to check out—that is, after all, my name and occupation.

We learn to recognize a limited set of specific problems from patterns we’ve seen before—a doctor is like a two-year-old who can point and say “Cat” and “Duck”

H and I were looking to upsize mildly and were going round a flat we liked with a real estate agent. The barely twenty-year-old weasel was doing the hard sell; it’s a great location, we were told—he bought his own place on the road behind. This made it all the more depressing; an embryo in shiny nylon could spare the cash to buy a flat somewhere we could barely afford. Was I in the wrong job? Or was a real estate agency like a thrift shop, where the staff got first dibs on everything that comes in?

By the time I was six years deep into medicine, the shine had definitely rubbed off the surface. On more than one occasion my finger had hovered over the metaphorical “Fuck it” button—days

there were two things keeping me there. First, I’d worked long and hard to get as far as I had. Second—and I realize this might sound a bit earnest—it’s a privilege to be allowed to play such an important role in people’s lives. You may be an hour late home, but you’re an hour late home because you stopped a mother bleeding to death. You may have had forty women in a prenatal clinic designed for twenty, but that’s forty women relying on you for the health of their babies. Even in the parts of the job you hate—for me it was urogynecology clinic, a bunch of grannies with pelvic floors like quicksand and their uteri stalagtiting into their thermals—each decision you make can immeasurably improve someone’s quality of life. And then a patient sneezes, you have to get a mop and bucket, and you wish you’d opted for a career in accounting.

You may curse the job and the hours, own voodoo effigies of the management, and even carry a vial of ricin on you at all times in case you ever meet a health minister, but on an individual basis, you really care for all the patients.

People at the Deloitte table were even handing out doughnuts, which felt a bit like cheating. What should I have brought to entice people into a career in medicine? Toy stethoscopes? Amniotic-fluid smoothies? Diaries with all your weekends, evenings, and Christmases handily crossed out?

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.

The careers on the other tables had their obvious draws—the principal one being a shit-ton of cash every month—but there’s no feeling like knowing you’ve saved a life. Not even that, half the time; just knowing you’ve made a difference is enough. You go home—however tired, late, and blood-spattered—with a spring in your step that’s hard to describe, feeling like you have a useful part to play in the world. I said this little speech about thirty times, and by the end of the morning I felt like I’d been through rigorous couples therapy—talking all the problems out, realizing the spark was still there after all.

A nice evening out with a few old med-school friends to persuade ourselves that our lives are fine, despite significant evidence to the contrary. It’s nice to catch up, even if it needed to be rearranged seven times.

Having gone to medical school, you might as well finish and become a house officer, then you might as well become an SHO, then you might as well become a registrar, then you might as well become a senior registrar, and by then you’re practically a consultant. There almost certainly don’t need to be so many different grades; I strongly suspect it’s designed so that the next step is always just round the corner. It’s the fifty-pound note you chase down the street, swept up by another gust of wind the millisecond before your hand makes contact. And it definitely works. 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.

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.