Review of "This is going to hurt"

REVIEW OF "This is going to hurt"

Six years after Adam Kay quitted medicine, he wrote a series of diary entries about his life in medicine. This forms the book “This is going to hurt”. As someone who worked previously as a Senior House Officer in the National Health Service (NHS) in Britain many years ago, many of the issues he mentioned really resonates with me, even though I was in a totally different discipline. I’ll say that this book is a MUST read.

Adam talked about how he worked as a doctor from the day he joined the NHS as a House Officer to the days when he worked as a Registrar (a more senior trainee) and then as a senior registrar, in Obstetrics and Gynecology.

HOUSE OFFICER YEAR

The house officer year is equivalent to the medical internship year that American doctors have to go through. This is how Adam described the house officer job, and I love the second person viewpoint:

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.

For the non-medical readers: ECG refers to Electrocardiogram. MRI refers to magnetic resonance imaging.

Doctors are expected to gain experience so that they can manage patients on their own, by sacrificing sleep to fill forms. How can it be safe for patients, when sleep-deprived medical interns, the least experienced of physicians in the hospital, are the ones writing prescriptions and making decisions to correct electrolytes, etc, for most hours of the day? (There are 15 hours from 5 p.m. to 8 a.m., where regular team doctors are not present in the hospital wards).

A LIFE DEVOID OF BASIC NECESSITIES

Adam compared the life of an NHS doctor to that of a Shaolin grandmaster: train for a decade or more in a remote temple, waking up at 5 a.m. and only stopping at midnight, submitting themselves to a life of celibacy, devoid of material possessions.

Now, I personally did not do my houseman year in Britain, but I remembered that two thirds into the year, I still didn't have time to find out about the on-call rooms in the hospital. I remembered balancing my self between two couches at 5-6 a.m. just to catch an hour or so of sleep, over a thirty-two hour shift. I remembered filling discharge summaries at lunch time, and between periods of consciousness, my pen had drifted from one end of a page to another. And that was reasonably efficient because I didn't have to navigate computerised menus in those days. See below for Adam's experience with health IT.

When Adam completed his houseman year, he opted for Obstetrics and Gynaecology and became a senior house officer (SHO). The shock. NHS moves doctors every six or twelve months, making it necessary to frequently change addresses. The home insurance people asked a standard question about the number of nights the property is left empty. I realized that if I lived alone, the policy would be invalid as it would technically be considered an ‘unoccupied property’.

In one hospital, there was no car park, because they wanted to encourage use of public transport. This would mean a two-hour twenty-minute commute each way. Instead, Adam opted to drive seven-minutes and leaving the car at the visitors’ car park, paying three pounds an hour.

Hospitals are constantly implementing new 'performance indicators'. The problem is that the whole ecosystem can be disrupted simply by changing regulations in one unit of the hospital. Adam provided an example in his book. It is not easy for the Accident and Emergency (A&E) department to be able to admit (or discharge) all their patients within four hours. This is because lots of patients need to be observed for a while before certain diagnoses can be excluded. Also, the bed situation in many departments is critical (before and during the COVID pandemic), and so there may not always be a bed available, after the decision to admit a patient from the A&E.

Because hospitals aren’t under quite enough pressure, the government has decided that all patients in the A&E need to be admitted or discharged within four hours, whether they’ve had a stroke or stubbed their toe. If more than 5 per cent of these patients breach the target, the hospitals gets fined and the management unleash a heap of hell on the A&E staff.

EVILS OF COMPUTERISATION

Computerisation in hospitals has caused a lot of difficulty for health operations. For example, Adam noted that access to gmail was removed in one hospital. Interestingly, gmail is blocked on all the computers in my medical campus for cyber security reasons. The problem is, frequent updates of computer systems and medical record systems have thus far not resulted in more efficient patient consults. It is the view of Samuel Shem, who wrote Man's Fourth Best Hospital' that the main utility of electronic medical records are for easier billing. Currently, most hospitals still charge patients or the payer based on episodes of care, rather than complexity of care, so the diagnostic based billing has not come to the forefront except in major surgical procedures. Electronic medical records are useful for healthcare of the future, because only by pooling sufficient amounts of medical information can insight be gained through artificial intelligence and machine learning systems.

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. It certainly looks much whizzier (and less like an MS-DOS program from school), but they’ve not actually fixed any of the massive clunking problems with the software, they’ve just slapped an interface on top of it…This glossy interface uses so much of the exhausted system’s resources that it’s now slowed to a nearly unusable crawl…

The blood tests now all live in a dropdown menu, and to order one involves scrolling down an alphabetical list of every test any doctor has ever ordered in the history of humanity. To get down to ‘Vitamin B12’ takes 3 minutes 17 seconds.

In gynae clinic, I go online to look up some management guidelines for a patient. The trust’s IT department has blocked the Royal College of Obstetrics and Gynaecology website and classified it as ‘pornography’.

SURVIVAL OF THE SELFISH

There is a sense that many players in the NHS are just keeping their head above the water. There isn't enough spare capacity to cope with the usual disruptions of a normal life like staff sickness, marriage, compassionate leave, etc.

There seems to be a general lack of empathy among colleagues when it comes to covering duties for one another. When Adam was down for food poisoning he was asked to ‘phone around and find someone who’s on leave to cover you.’

In such circumstances, it isn't surprising that doctors are not prone to give encouragement to each other. The butlers at Buckingham Palace, under orders to float out of rooms backwards and never to make eye contact with the Queen, probably get more recognition.

POOR WORK LIFE BALANCE, POOR PERSONNEL SUPPORT

The term "Work-life balance" wasn't as well known in those days before the COVID-19 pandemic. It is clear that Adam's journey highlighted the poor administration and support available for medical staff in NHS.

Once I became a registrar, I noticed the interesting paradox that while you become an expert in prioritizing at work, you generally become even worse at prioritizing in real life.

When Adam and his partner wanted to spend a fortnight in Mauritius to celebrate their five years together, he was told he needed to work the middle weekend. They refuse to organize a locum—their best suggestion is that I pop back to England for a bit.

The system is so faulty that a guy accepted a shift from the locum agency as an obstetric registrar and no one there or at the hospital bothered to ask whether he’d ever worked on a labour ward before. Apparently he’d never done a Caesarian section. I send him home and call the consultant to ask what to do, knowing full well the answer involves me working another twelve hours for free.

Because they’re down by one registrar in the antenatal clinic one day, Adam finished the morning clinic at 3 p.m. All the patients were pissed…I strongly suspect if I was a pilot and my co-pilot didn’t turn up, the airline might find a better solution than ‘plough ahead and see what happens’.

MENTAL HEALTH AND STRESS IN THE PROFESSION

In such conditions, the physician's relationships, mental and physical health inevitably pay a price.

A 2015 study by the Medical Protection Society showed that 85% of doctors have experienced mental health issues and 13 per cent admitted to suicidal feelings. A 2009 paper in the British Journal of Psychiatry showed that young female doctors in the UK are two and a half times more likely than other women to kill themselves.

…most doctors’ relationships crumbled after a year or so—the cracks that they all develop would appear far too early, like some bizarre premature ageing disorder…The system runs on skeleton staff and, on all but the quietest shifts, relies on the charity of doctors to get things done…which means you stay late after almost every shift…Our weekends were usually spent at work…either you fail to tune out the bad stuff from work and become permanently distracted and haunted at home or you develop a hardened emotional exoskeleton, which apparently isn’t considered an ideal quality in a partner.

…recurrent theme, doctor after doctor, is how everyone remembers the sad stuff, the bad stuff, so vividly…presses record in HD. They can tell you the number of the room it happened in, one labour ward they last saw a decade ago…Senior consultants’ voices shake when they talk about their disasters—six foot tall former prop forwards on the verge of tears.

POOR PHYSICAL HEALTH

The job definitely got to Adam. When he developed a blood pressure of 182/108 mmHg, she (the practice nurse at the GP) wouldn’t accept my explanation that I was just off a night shift with two locums, still tightly wound from twelve hours on the wards, my mind jittering with a dozen medical equivalents of ‘Did I turn the gas off?’ Did the patient have that CT scan?

A patient said, “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.

POOR COMPENSATION

I remembered that during my houseman year, some of my colleagues performed a calculation and found our per hour salary to be lower than of the hospital janitor. Times have improved slightly since.

When Adam got promoted to senior registrar, his salary was noted to be equivalent to 'bank cashier' or 'reasonably experienced milkman'. But this increase was not proportional to the increase in responsibility. The senior registrar was the highest-ranking person in the department out-of-hours. He would have to deal with every problem that the SHO and registrar failed to resolve. 

During his SHO years, Adam had to be innovative to save money. In lieu of an incentive scheme at work, I’ve invented my own perks: I take scrubs home for pyjamas and steal the odd patient meal at night.

It’s not a profession you go into to satisfy the dollar signs behind your eyes, whatever the occasional dead-mouthed politician may say. Besides, even if you’re unhappy with your salary, there’s sod you all can do about it. It’s all determined centrally, and rolled out across the entire profession.

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.

In his open letter to the secretary of State for Health, Adam said,

you...should have to work some shifts alongside junior doctors. Not the thing you already do, where a chief executive shows you round a brand-new ward that's gleaming like a space station. No: palliate a cancer patient; watch a trauma victim have their leg amputated; deliver a dead baby. Because I defy any human being, even you, to know waht the job really entails and question a single doctor's motivation. If you knew, you would be applauding them, you'd be proud of them, you'd be humbled by them, and you'd be eternally grateful for everything they do.

The way you treat junior doctors demonstrably doesn't work. I strongly suggest you seek a second opinion.

DEPARTURE FROM THE SYSTEM

In Adam's case, there was a strong sense of regret getting into the medical career.

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…

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

Adam found out that many doctors in the NHS have left for Canada, Australia, or pharmaceutical companies. I personally know doctors in my system who have left clinical care. One has even become a world renowned scientist. We are definitely selecting a very narrow kind of doctors in our system, the kind of soldiers that may become disillusioned at some point down the line. We have to ask ourselves some hard questions. If we cannot have empathy towards our own successors, how can we be caring for patients?

PS. If you're interested in reading my review of "The Big Free," a medical fiction novel, please click here.

Adam's book, though about a serious topic, is humorous and is an easy read. Hey, I urge you to get a copy and enjoy. 

Do you agree with these viewpoints? Please comment below.