Adam Kay’s book really made me think. Among the gags and orifice-centred humour, examples of disdain for patients coexist with expressions of deep caring. I wasn’t sure who the real Kay was. But then I realised, he is probably all of us. In our fatigue we have all simultaneously despised patients who (we perceive) are wasting our time or contributing directly to our distress, while at the same time feeling deeply for the plight of the vulnerable and blameless. Doctors are human, and make judgments. Any once or future patient reading Kay’s book will soon realize this.
At 3AM, when nature dictates that we should be asleep, it is hard not to feel angry when called down to diagnose a worried patient with having ‘taste-buds’ [p48]. How can one not feel toxic towards a patient when bleeped twice after 1AM to countersign their passport application [p77]? All this while contending with the disruptive domestic and financial pressures [p86-90] that, uniquely among the ‘professions’, destabilise the lives of young doctors (e.g. self-funding mandatory courses and exams, being unable to take leave to get married [p159] or be ill [p71], not knowing where you will be working [p61]). There are a lot of important ‘life-style’ insights this book, and for that reason I’m glad that thousands of people have read it.
I am not glad that those thousands might come away with the impression that doctors have little respect for their patients. In the book Kay refers to them several times as ‘f***ers’ [p26], and talks about ‘everyday patient idiocy’ [p74]. And don’t mention Jehovah’s Witnesses [p42] – ouch. Doctors trained to respect all views and all levels of understanding might find this quite hard to read. A practising, GMC registered doctor could not, surely, have got away with it.
It was with this in mind that I talked about the book with a patient recently. She said it was awful, what we had gone through in our training, and I replied, ‘Yes, it’s hard. But not everybody reacts like that. If they did, there would be no doctors.’ By which I meant, no doctors to deal with the next placental abruption, or the next difficult open-heart procedure, or the next dying child. She left the clinic room with a new perspective on the diaries, and I left the clinic feeling bad that I had dismissed the author as some sort of snowflake. Or, as unrepresentative – for by leaving the profession, he had, one could argue, lost some validity.
Which brings us to the word of the month – resilience. What was it about the job that Kay could not ‘hack’? In the end, it was a complication – a previously unrecognised placental abruption [p254] that bled catastrophically during a caesarean section. The baby died, the mother lost 5L of blood. It was the last straw, but followed a trail of tragedies, near misses and bad outcomes that are probably not unique to obstetrics and gynaecology. Each one brought with it stress, fear, a sense of personal accountability.
The cumulative psychological injury caused by these events (see my post ‘2nd victims’ for more) was in the end unsupportable. Interesting to me though, is the impression gained in the first half of the book that this doctor, more than most doctors, would be capable of withstanding these injuries due to the impersonal and dismissive descriptions of patients that he put in his diary. Superficially, there is an absence of caring. Yet, between these entries (which are humorous), he slips in the fact that for 3 months has been visiting the neonatal unit on his way home to check on the progress of a preterm baby, Baby L [p45]. Outside the hospital, he supports a near-suicidal friend [p73]. When invited to patient’s funeral, he goes [p84]. There is evidence of deep caring. There is dissonance. A natural tendency to care, diluted, polluted perhaps, by the endless demands placed upon a doctor in training.
So did Kay care too much? Is that the diagnosis? Or did he fail to develop the essential skill of caring enough to provide treatment in a sincere manner, while understanding that bad things happen, complications and error are inevitable (even as we continually do our best to minimise them), and by learning from them we become more expert.
Diaries lend themselves to psychological analysis by people who do not have genuine knowledge of the writer. The entries were written shortly after the experiences that they describe, and are bound to be emotionally raw. The humour, coming at the expense of nameless patients, reflects accurately the conversations that go on in hospitals. The sadness is sincere – and the book would not have such value or profundity without it. Samuel Shem’s classic ‘House of God’ has a similar mixture, as does the unforgettable Jed Mercurio TV series ‘Cardiac Arrest’. Perhaps these two responses to life in hospital could not co-exist forever in one mind.
But enough analysis! It is sufficient to recognise that this honest account sheds light on the stress-distress that trainee doctors commonly experience, and I am pleased that non-medics have read it. More importantly it explores the emotional fluidity, call it mercurialism, that many doctors develop to survive.