Adversarial Book Review: This is Going To Hurt, by Adam Kay
I
“Tuesday, 5 July 2005. Trying to work out a seventy-year-old lady’s alcohol consumption to record in the notes. I’ve established that wine is her poison. Me: ‘And how much wine do you drink per day, would you say?’ Patient: ‘About three bottles on a good day.’ Me: ‘OK . . . And on a bad day?’ Patient: ‘On a bad day I only manage one.”
A: The first faces I ever saw in this world were three sweaty, anxious obstetricians, and one of them was holding the rest of me. My father had been the senior surgeon on the Caesarean section. The patient on the table was my mother, who is also a gynaecologist. He was assisted by my paternal grandfather, who is also a gynaecologist. My maternal grandmother, who is also a gynaecologist, was outside in the corridor doing crowd control, partly because of her people skills and mostly because the operating theatre had run out of space for elbows. I was extracted from the uterus, given the customary slap on the rump, performed the customary screaming, and resolved on the spot, somewhere below the level of conscious memory, to give the speciality a hard pass. The first impression had been bad.
I am, today, a psychiatry resident in the UK’s National Health service (NHS). I came to this through a sequence of choices that involved, at various points, an Indian medical internship, the discovery that I am fond of sleep and a predictable evening meal, and a gynaecology rotation that confirmed every prejudice the Caesarean had instilled. My family is very slightly disappointed. They are quite possibly correct.
I tell you this not to establish my credentials as such, but because Adam Kay's This Is Going To Hurt is a book about obstetrics and gynaecology, alongside an unusually clearly documented decline in mental health, and reviewing it without naming where I'm reading it from would be a small dishonesty. The speciality is in my blood, more or less literally. The system Kay is describing is the one I currently work inside. The condition he is describing in himself, although he doesn't quite name it, is one I have seen up close in colleagues and, on at least one bad stretch, in myself.
I will let my older, wiser, and possibly more handsome colleague take over:
B: That is one impressive set of credentials for reviewing this book. Thanks for the introduction, I suspect I am only one of those things. While my birth was not nearly as salubrious, and while I’ve never worked in the NHS, I’m a doctor who is more or less an exact contemporary of Kay (so I’m a senior doctor now), and winced along in recognition over a lot of what he says here (although, as we’ll get into, I have a dimmer view of him than you do).
I think we need to set the scene for the book we’re talking about. At base, this is a medical memoir, from the ‘junior doctor’ subgenre. The junior doctor experience is common in popular culture, mostly via television: ER, Scrubs, Grey's Anatomy and, most recently, The Pitt. But there’s also a long tradition of medical memoir or semi-autobiographical novels about these years. The ur-text of British medical anecdote delivery is Richard Gordon’s Doctor in the House series from the 1950s, with the famed House of God the canonical text from the medical system in the US. The latter owes an obvious debt to Catch 22 with its mix of absurdity and bitterness, substituting hospital medicine for war (House of God is at its best when it can convince you that one is much like the other). This is Going to Hurt slots nicely into this tradition: it’s ostensibly a set of diary entries rather than a novel, but it covers much of the same ground as those earlier works, has the same mix of medical anecdotes, cynicism and burnout. House of God ended with its protagonist going into psychiatry training; without spoiling too much, it’s safe to say that this wasn’t the outcome for Kay.
A: The book has been read in two dominant ways since it came out in 2017. The first is the heroic reading: a comedic exposé of NHS dysfunction, a love letter to overworked junior doctors, the kind of book you press into the hands of a relative who has just complained about waiting times. The second is the hostile reading, of which Tanya Gold's essay probably counts as the ur-example: a self-indulgent memoir whose author offloads his exhaustion onto the bodies of female patients, dressed up in jokes that are funnier to him than to the women they reference. Both readings have things going for them. Both miss what I think the book actually does, and by a country mile.
This Is Going To Hurt is, read with a clinical eye, a textbook case study of moral injury and post-traumatic stress in a competent doctor, narrated by the patient himself, with the diagnosis hidden in plain sight. Kay is both author and index case. The book is his presenting complaint. The institution that produced him then declined to treat him, and the book is the receipt for that decline. Once you see the book this way, several things follow. Kay's defenders are right about more than they realise; his critics are wrong about more than they think; and the system that broke him in 2010 is, in 2026, still producing more of him, faster.
B: I agree something went very wrong with Kay, and we’ll get into all the contributors to this process, culminating in the horrific event that ended his medical career. But while I work in a similar system, I (and the readers) don’t have a good handle on the NHS so, if you would, a brief primer on the UK’s health service for the uninitiated?
A: Of course. The National Health Service was founded in 1948 by a Welsh ex-miner turned Health Minister named Aneurin Bevan, who spent the previous decade campaigning for the proposition that nobody in a wealthy country should have to choose between treating their child's pneumonia and paying the rent. The system he built rests on three principles that have remained nominally intact for nearly eighty years: care is comprehensive, universal, and free at the point of delivery. You walk into a hospital. They fix you. Nobody asks for a credit card. For Americans and others only accustomed to for-profit care encountering this for the first time, the experience can feel vertiginous, like you've stepped into a film about the Soviet Union, except the doctors speak English and the building has running water. I do suspect there's less phage therapy and more tea involved.
The doctors did not all want this. The British Medical Association in 1948 was, in the main, a polite gentlemen's club of independent practitioners who saw nationalisation as the first step toward becoming salaried clerks. Bevan, who had a sharper sense of professional psychology than the BMA gave him credit for, executed one of the great political manoeuvres of the twentieth century. In his own words, he "stuffed their mouths with gold." The compromise was this: surrender your private practice and submit to a state monopsony, and in exchange you'll receive lifetime employment security, generous final-salary pensions, the social prestige of belonging to a respected profession, the right to do private work on the side once you reached the consultant grade, and the moral satisfaction of a job whose nature could not be reduced to a balance sheet. The grueling apprenticeship of the junior years was framed semi-explicitly as a temporary hazing on the way to a comfortable consultancy. Both sides honoured the bargain, with strain, for about half a century.
The bargain started failing somewhere around the late 2000s, and it has been failing in ways that compound. Pay erosion against 2008 levels currently sits at roughly 21% in real terms for resident doctors (if we use the British Medical Association’s calculations). The pension reforms of the early 2010s clawed back a substantial chunk of what was supposed to be the back-loaded reward. The consultants' tax-and-pension regime got rewritten in ways that actively penalised them for taking on extra clinical sessions. Adding on the remarkably regressive nature of Britain's taxes, which offer many convenient cliffs to drive your modest sedan off, the predictable result was that the most experienced clinicians started reducing their NHS hours. Hospital estates went unmaintained for so long that some of them are now propped up with literal scaffolding because the post-war concrete is structurally unsound. The wait list for elective procedures in England reached 7.7 million cases at its peak; it has come down to roughly 7.29 million, a figure the government trumpets as a success in the same way one might celebrate surviving a car crash.
The bargain is, in any meaningful sense, moribund. The state retained the monopsony. It stopped paying out the gold.
This is the system Kay's diary is set inside, captured at roughly the inflection point. The book covers 2004 to 2010. It reads now, with hindsight, as a dispatch from the moment the goodwill ran out.
B: The NHS is an enormous part of the post-war British psyche and of the British economy, not least because it employs more people than Amazon, over 1.3 million (not counting general/family practitioners whose money also comes from Government coffers). And like most health systems this big, it works like any large organisation: there are a woefully inadequate amount of frontline workers, while behind them sit an increasing number of medical administrators whose job it is to fill rosters and keep the hospital running.
I remember reading about the NHS discourse around the time the book came out (I suspect it predated your arrival in the UK). In 2015, the UK’s then health minister, Jeremy Hunt, proposed to make it a seven days a week system. People get sick every day of the week, but outside usual Monday-Friday working hours, hospitals (outside the Emergency Department) run on a rostered skeleton staff of on-call clinicians. They do this because it’s hard to staff things any other way - when Hunt decided on this expansion without a plan to recruit any more doctors, strikes followed. More importantly for our purposes, a small trend for junior doctor memoirs emerged, talking about how hard the system was to work in as-is. Around the time Kay was publishing his book, ex-journalist and current palliative care physician Rachel Clarke’s Your Life in My Hands took a similar look at a stuttering NHS, although Kay’s version outsold hers handily because his featured a woman putting a Kinder Surprise in her vagina.
II
“Dear drug-dealing scrote,
Over the last few nights, we've had to admit three young men and women — all dry as a husk, basically collapsed through hypotension, and with their electrolytes up the fuck. The only connection between these individuals is their recent use of cocaine. For all its heart-attacking, septum-shrinking risks, cocaine does not cause this to happen to people. What I'm pretty confident is going on here — and I want a Nobel Prize or at the very least a Pride of Britain Award if I'm right — is that you've been bulking out your supply with your nan's frusemide.
Aside from the fact you're wasting my evenings and my unit's beds, it feels like fairly terrible business practice to be hospitalizing your customers. Kindly use chalk like everyone else.
Yours faithfully, Dr Adam Kay”
A: Adam Kay went to medical school at Imperial College London and qualified in 2004. He did his House Officer year (corresponding to intern in US parlance), his Senior House Officer rotations, then specialised into obstetrics and gynaecology and worked his way up to Senior Registrar (resident to senior resident), the grade immediately below consultant (attending). In December 2010, after a clinical incident I'll come back to, he resigned from medicine. He spent the following years as a comedy writer and stand-up. In 2017, Picador published his diaries from those six years as This Is Going To Hurt. The book sold a million copies in the UK alone. It produced a sequel, a stage tour, and a seven-part BBC adaptation starring Ben Whishaw which aired in 2022.
B: Don’t forget the seminal work he did writing for Mrs Brown’s Boys.
A: Never heard of them, but I'm sure they're good lads. But I wish to dawdle, dwelling longer than is conventional on why the book is good, because most reviews of it skip this step on the way to making whatever ideological point they are paid to make, and Kay is funny enough to deserve having his actual craft acknowledged. He is, at a minimum, the best comic writer about hospital medicine working in English, and that makes him an idol for me. The book is good for at least three reasons that are worth pulling apart.
The first is the diary as form. Most medical memoirs are retrospective. They have the shape of someone explaining their career from the safety of having survived it: the structure imposed late, the meaning extracted with the benefit of hindsight, the messy bits sanded down because they don't fit the arc the author has decided to write. Kay's diary is far rawer. The entries were written close to the moment they describe. The book preserves the timeline. You see a doctor who doesn't yet know how the story ends, who is processing in real time, whose jokes are dated to a Tuesday in May. The reader watches the cumulative damage accumulate, without the editorial smoothing that hindsight provides. This Is Going To Hurt is a child of a love-hate relationship that emerges, almost against the author's intentions, from the accumulation of one-day entries. The structure is the argument. The reader is doing some of the work the writer does in conventional memoir, which makes it harder for the writer to lie.
B: I’m not sure if I buy this. The ‘diary entry’ set up for a book is a convenient one as an anecdote delivery system - it frees you from the need to construct a plot, develop characters or even write to a deliberate theme. Kay’s conceit is that these entries were written contemporaneously as self-reflection exercises and simply published later, but that seems unlikely to me. They might have been written at the time, and I gather the NHS does ‘encourage’ these sorts of diaries, but self-reflection is not one of Kay’s strong suits (as I’ll get into) and I’m not sure any NHS authorities would have been interested in Kay’s thoughts on Les Miserables or his Valentine’s Day dinner in which he ate a candle. These are the notebooks of someone who is working on material for his standup and indeed, he’s toured this material ever since.
A lot of this is forgiven if the anecdotes are funny, and many of them are. Every doctor has their collection of body horror/body comedy stories that they like to wheel out to rapidly diminishing crowds at parties, and Kay’s ones don’t disappoint: the ‘bizarre foreign object in an orifice’ is a classic, and as well as the aforementioned Kinder Surprise, there’s this one:
“Most of these patients suffer from Eiffel Syndrome — 'I fell, doctor! I fell!' — and the tales of how things get where can be skyscraper tall (come to think of it, it's only a matter of time before someone tries to sit on the Gherkin), but today is the first time I've actually believed the patient's story. It's a credible and painful sounding incident with a sofa and a remote control that at the very least had me furrowing my brow and thinking, 'Well, I suppose it could happen.' Upon removal of the remote control in theatre, however, we notice it has a condom on it, so maybe it wasn't a complete accident.”
A: Don’t forget the footnotes. Kay annotates his own diary for the lay reader. A medical term gets a footnote. A piece of NHS jargon gets a footnote. A drug name gets a footnote. The footnotes are at first purely functional. Then they start having jokes in them. Then they start having jokes that are funnier than the entry above. By the second half of the book, the footnotes have become a parallel narrative track, a place where Kay says the things the entry above is too tired or too defended to say. This is genuinely innovative for the medical-memoir genre, solving a problem we've historically struggled with: how to write for both the medical and the civilian reader without boring the first or losing the second. Kay's solution is to give the civilian a translator who is also funnier than the main text. That translator is himself, albeit older, funnier and more bitter.
Here's one of them, attached to a Christmas Day cardiac arrest:
“If your heart stops, you're probably going to die. God is fairly strict on that matter. If you collapse on the street and a bystander starts CPR then your chance of survival is around 8 per cent. In hospital, with trained personnel, drugs and defibrillators, it's only about twice that. People don't realize quite how horrific resuscitation is — undignified, brutal and with a fairly woeful success rate. When discussing Do Not Resuscitate orders, relatives often want 'everything to be done' without really knowing what that means. Really, the form should say, 'If your mother's heart stops, would you like us to break all her ribs and electrocute her?”
These footnotes pay for the pedicure. They start as a clinical correction (the public massively overestimates resuscitation success rates), pivot through a piece of useful patient-facing information (what "everything to be done" actually means), and land on a joke whose comedic structure accidentally teaches medical ethics better than most textbooks. A lay reader finishes that footnote knowing something they didn't know, having been entertained while they learned it, and slightly more equipped to have a difficult conversation with a relative's clinician. It's a good footnote. The book has a hundred of them.
B: I did like the footnotes. But you said there were three reasons the book was good, and I only count two.
A: The third is the range of registers he uses. Kay can be very funny in at least four distinct modes, and the book moves between them with control that is easy to miss because it never draws attention to itself. There is the absurdist register, where the situation is so improbable that comedy is just a matter of accurate description; this is the register most often quoted in reviews (we’ve done it already with the foreign object stories) because it is the most extractable.
There is the observational register, where Kay catches the small humiliating details of the job that nobody else has bothered to write down: the bleep that won't stop, the consultant who can't be reached, the Christmas rota nobody told you about, the friendship that atrophies to dust because you keep cancelling. Six years in, an old school friend tries to dump him:
“Ron tried to dump me as a friend today — a proper, sombre, grown-up discussion. He doesn't know why he bothers trying to keep in touch with me when it's clear our lives have drifted apart massively since school.
I should at least vary up the excuses I give him. Do I really expect him to believe I couldn't come to his engagement party or his stag do because of work? That I couldn't make the wedding ceremony because of work, and almost missed the reception as well? That I missed his dad's funeral and his daughter's christening because of work? He knows my job's full-on, but how hard can it be to swap shifts if it's something you really want to do?
I put my hand on my heart and swear to Ron that I love him, he's one of my best friends and I wouldn't lie to him. I know I've been useless, but I've seen a lot more of him than almost anyone else I know — the job is just unimaginably busy. Non-medics can never appreciate quite how tough it is to be a doctor and the impact it has on real life. I totally lied about the christening, though — fuck that shit.”
Look at the move that last sentence makes. Three paragraphs of cumulative damage, an earnest reassurance to a friend who has, on the evidence, every right to be furious, and then a single deflecting joke that lets Kay walk away from the emotional weight without quite addressing it. This is how doctors actually talk about this stuff. The joke isn't a coping mechanism in the abstract; it's what allows the entry to end without Kay having to wrestle with what he's just admitted. The book is, on a sentence-by-sentence level, a record of how this maneuver works.
B: This is the lack of self-reflection I mentioned earlier. He sidles up to taking responsibility for things like the erosion of friendship and his relationship, but there’s always the punchline to undercut things. The closest he comes is an extended section about how he decides to work on his beside manner after a complaint against him, a justification about how being nice to patients and offering them choices is counterproductive, and a punchline in which he gets a rude response to a ‘good morning’ and decides to return to his baseline dourness. It’s the mark of a comedian rather than a doctor.
A: I protest that being a doctor and being a clown are not mutually incompatible. God knows that I've relied on humour to prop up my bedside manner. Still, Kay saves the most savage register for entries that are deployed against consultants, administrators, and the institution. Kay is extraordinarily generous to his patients across the book; the contempt is reserved almost exclusively for management and for senior colleagues who fail in their educational and supervisional duties. On the absence of any meaningful positive feedback in NHS training:
“All medics get to grips with the lack of promotion and financial incentives, but it's harder to accept the fact that it's rare to get a 'well done'. 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. It didn't strike me for years, until the fifth or sixth time I'd had my knuckles rapped for some trivial fuck-up when a degree of human error had kicked in, that none of my consultants had ever taken me aside to say I was doing a good job. Or that I'd made a smart management decision, saved a life, cleverly thought on my feet or stayed at work late for the thirtieth consecutive shift without complaining. Nobody joins the NHS looking for plaudits or expecting a gold star or a biscuit every time they do a good job, but you'd think it might be basic psychology (and common sense) to occasionally acknowledge, if not reward, good behaviour to get the most out of your staff.”
And there is the tender register, which is rarer and harder to spot but is what elevates the book above a string of anecdotes. I'll save the strongest example of this for later in the review, where it makes for the best argument.
What the four registers add up to is a doctor with a real comedic ear and a real moral compass, both of them partially submerged under the operational requirements of staying functional through the shift. Kay is funny in the way many overworked doctors are funny: as a survival mechanism that has been polished, by sheer repetition, into something close to art. Psych textbooks love to blabber on about various kinds of defense mechanisms, and humour ranks high on the list.
I consider the book an actual achievement, not just a representative document. I find it worth articulating this before the rest of the review begins to complicate things.
B: No, let’s start complicating it now. Kay will use that undercutting punchline against anyone, patients included, if it gets him off the hook and tends to be generous only when there isn’t a good joke in it.
I agree he focuses most of his ire on the institution: NHS doctors are cruelly used, forced to work long hours, and shafted when it comes to being able to take holidays. Kay recounts several instances of this - being asked to return to work the middle weekend of two weeks of holidays overseas, a best man at a wedding finishing his speech and then going to work the night shift, and so on. Poor rostering practices and staff shortages make this a system that runs on goodwill and the willingness to chuck in pre-existing plans to work a few more hours (sometimes paid, sometimes not).
But as you read further and Kay becomes more senior you begin to notice some odd things. Amidst all the complaining about excessive hours, he voluntarily stays several hours after his shift to tend to particular patients. He drives an hour to the hospital on a Saturday to review a patient he’s operated on despite one of his colleagues having seen the patient less than an hour earlier. He picks up several locum (casual) shifts a week at a private hospital in addition to his usual workload.
And then you notice that after his account of his initial year (where he is, as most of us were, pathetically reliant on his registrar to make the important decisions), there are no accounts of him asking any of his registrar colleagues for help. None are even mentioned fondly or their competence praised. He works with a department full of midwives but he praises only one, and only to compare her to another one he hates (both are called Tracey, so he calls one “reassuring Trace” and one “non-reassuring Trace.” This is a joke about fetal monitoring traces. They can’t all be winners). The consultants are distant, brief presences who float in and out of the narrative but whom Kay never calls for help until the very end - to be fair to him, this is something some of his bosses actively discouraged.
Worse, he begins to refer to patients in increasingly disparaging terms as the book goes on, at one point gleefully discharging them for being “bed-blocking fuckers” in the context of anticipated casualties from the 7/7 London terrorist attacks being admitted to his hospital.
Some of the caustic tone is deliberate - the stories about entitled and stupid patients are funnier than heartwarming stories about good outcomes. But, like you’ve already highlighted, something else is going on here as well. We are coming, slowly and by degrees, to the trauma that ended Kay’s career, but things were going wrong before that. On one level, this is textbook burnout. The gradual telescoping of life into work. The feeling of being alone amongst colleagues, with each fresh request for your time creating a yawning pit of involuntary despair and anger. The contempt for your job and everything involved with it.
A: And now we're really disagreeing, instead of mostly pretending to disagree for comic effect.
I can confirm that the NHS has serious problems with “bed blockers”, putting aside the pejorative terminology. It is difficult to get a patient into a hospital, somewhat harder to nurse them back to good health, and an utter ballache to convince many of them to leave afterwards.
B: Point taken. But in the ‘bed-blocking fuckers’ episode he discharges everyone then, when the anticipated casualties failed to materialise, twiddled his thumbs for a week.
A: You also can’t mention burnout without addressing the most under-appreciated aspect of This Is Going To Hurt: what grade Kay was at by the time the book ends. He was a Senior Registrar in obstetrics and gynaecology, the rung immediately below consultant. In British medical hierarchy, this means: not the boss, but the most senior doctor physically on the wards at three in the morning. The consultant is at home. The SHO is calling Kay. The midwives are calling Kay. Five things are happening at once. A decision that will be reviewed in a coroner's court two years later is being made by a sleep-deprived doctor whose nominal supervisor is asleep across the city.
That grade is designed to produce moments where a single person carries clinical, legal, and moral weight that nobody at any level of the hierarchy openly acknowledges they are carrying. The British registrar role is an awkward one. It combines the responsibility of a consultant, the supervisory presence of a junior, and pay somewhere in between despite the workload of both at once. Kay's worst entries are not the long-hours-bad-pay ones, which are bad enough. They're the ones where you can hear him realising that he is the last line and there is nothing behind him.
A scene from August 2008. Kay is the registrar on labour ward and the patient under his care is a private patient of a consultant called Mr Dolohov:
“Out of the room I call her consultant, Mr Dolohov, a traditional courtesy with a private patient. He isn't very courteous in response. He says he's only a minute away and coming straight over: under no circumstances am I to deliver 'his' patient. I go back into the room and prepare everything for his arrival — forceps, delivery pack, suture set. And then I decide this is ridiculous; the baby is clearly unwell and will deteriorate every moment I don't deliver it. What if he's only a minute away like every minicab is 'only a minute away'? If the baby comes out compromised because of my inaction, that's my GMC number up the fuck. And worse, it's a damaged baby. If this Mr Dolohov wants to complain about me, the worst that can happen is I never work again in a hospital I now have no desire to work in.
I deliver the baby — it takes a moment to breathe but soon perks up, and cord gases confirm I was right not to wait.”
Scrutinize the structure of that decision. Kay is being given an explicit, unambiguous instruction by a consultant. The instruction is wrong. Following it would harm the baby. Disregarding it carries a non-trivial risk to his career. He has, at most, a few minutes to make the call. He is alone in the room. He overrides the consultant, delivers the baby, is vindicated by the cord gases, and writes the entry. What does not appear in the entry, because Kay is too restrained a writer to spell it out, is the additive effect of being asked to make decisions like this, repeatedly, alone, with no real backup, for years on end. Each individual override is the right call. The system that requires the override is broken.
B: Note the order of the consequences he worries about. It’s his career “up the fuck” first; while the damaged baby is worse, it’s second. In burnout, each complication is a fresh affront to you, personally. We’ve all been there at some point, having unworthy thoughts - I’m just not sure Kay even realises he’s tipping his hand here.
A: It feels slightly unfair to argue that you're reading too much into that excerpt, or at least I feel hypocritical saying so. Still.
I'm not complaining about the existence of seniority gradients. Some of this is unavoidable in any medical system; you can't the consultant in the building twenty-four hours a day. Even from the perspective of someone quite junior: assuming our careers go as planned, the majority of our working lives will be spent as a consultant, and we all hope to eat dinner at home and spend time with our kids once we're in our late thirties.
What I’m actually over kvetching about is that the British registrar carries this load with markedly less institutional backup than the equivalent grade in other systems. The American senior resident has an attending who is at least theoretically reachable and accountable. The German Oberarzt sits inside a tighter chain of supervision. The British senior registrar has a consultant who, if reached, will sometimes give telephone advice but will much more rarely come in. The expectation is that you will cope. The promotion to consultant, once attained, is at least partly a reward for having coped without complaining, and the reward includes the right to not come in at three in the morning yourself.
The buck stops with you, and you carry it alone, and when something goes wrong, the institution won't absorb the blast wave for you. It locates the registrar. Consider the case of Hadiza Bawa-Garba, a paediatric trainee at Leicester Royal Infirmary.
In 2011, working in a severely understaffed unit, covering the work of three doctors, with the hospital's electronic systems down so that crucial blood test results were delayed by hours, she was the doctor on whose watch a six-year-old boy named Jack Adcock died of sepsis. The system had failed at every conceivable level. The chosen response of the state was to charge the trainee with gross negligence manslaughter, secure a criminal conviction, and have the General Medical Council strike her from the medical register. She was eventually restored after a successful appeal and a long campaign by her colleagues. The institutional message had already been delivered: the registrar carries the moral and legal weight of system failures, alone, after the fact, in court.
Kay's exit from medicine is a milder version of the same logic. The institution did not need to charge him with anything. It just needed to let him understand, in the silence after the placenta praevia case, that nobody was coming. He understood. He left.
I will allow myself a brief personal note here, because it would be dishonest not to: I have been on call as the senior decision-maker on a ward, and felt the floor of the hospital tilt toward me. The stakes weren't quite as high as anything Kay experienced (and thank fucking God for that), but like the hypomanic contemplating mania, I can better imagine the fit of his shoes. The book is the only place I have seen it described accurately.
B: I take your point about the load he was under. It’s broken people before him and will break people after him. But how do you square this with the extra shifts? The unasked-for checking in on colleagues? The sniping about how few of his colleagues can spell ‘caesarean’ (maybe they were a bit tired from the long hours as well)?
No, what we have here is a classic martyr complex, the inevitable result of feeling like you’re the only competent person in the hospital. Every department has one. The person who takes on extra shifts because of job shortages at the cost of letting everyone know about it (other staff generally put up with this as the price of doing business; which is worse, hearing ten minutes of whinging from the martyr or doing ten extra hours of work yourself?). The person whose narcissism renders them the most vulnerable to that classic HR trick of assuring you you’re the only one who can pick up the shift or do the extra clinic. The martyr is the roster-makers best friend and the martyr’s own worst enemy. Being a junior doctor can drive anyone into the ground, but it takes a martyr to step on the accelerator.
In an enormous, unfeeling public health system, one person is eminently replaceable and also, in the grand scheme of things, unimportant. When I finally retire from my hospital job I, judging by my experience of my colleagues’ leaving dos, will end up getting a small morning tea with people popping in and out in between seeing patients, along with a few platitudes from a manager who’s been with the service for a far shorter time than I have and with whom I’ve barely interacted. If you are well-liked, the department springs for the A3 card and the whip-around gets you the nice chocolates.
The trick as a doctor is to be able to believe in your unimportance (so you can draw appropriate boundaries, prioritise your work-life balance by not doing more than you need to, relying on your colleagues to share the load) while simultaneously recognising that a large proportion of what you do is literally life and death. In fact, recognising the latter is what makes you so rigid in your boundaries around the former; you’re no good to anyone tired and burnt out. Unfortunately, it’s a lesson many doctors (like Kay) learn far too late.
A: I am much more sympathetic to Kay, and not just because of professional solidarity. The NHS and its training pathways strongly select for would-be martyrs. This is not entirely unjust; every country desires soldiers who will go to war while willing to take a bullet, so does the NHS of its foot-soldiers.
More generally, medicine strongly rewards a Type A personality, something I sadly lack. Surgical specialties, in particular, select for strivers, perfectionists, the anankastic and those with a martyr-complex. Less charitably, a God Complex.
Someone with something to prove, who is willing to go above and beyond without prompting? That looks perfect from inside the system, especially a system that (as you've well articulated) relies a great deal on the goodwill of its staff. The same factors that made Kay an above-average registrar also made him a prime candidate for burnout.
And the extra locum shifts? Can we really blame Kay for that, when he's described the financial precarity of his situation? London isn't cheap. The extra pay supplement provided for doctors living there is laughably inadequate.
B: Is that common though? Are all the London doctors picking up extra locum shifts? Genuine question, I’d be interested in what our readers (if any of them have made it this far) know about this topic. In the meantime, let’s move on. What was that you were saying about misogyny?
III
A: A small industry of writing has emerged arguing that This Is Going To Hurt is a misogynistic book. The one that's closest to a Steel(wo)man of the case is, as I’ve already mentioned, in this essay which I'll take seriously because Gold is a careful reader and her examples are real ones. The urogynaecology passage with the "bunch of nans". The sex worker with the Fireman Sam sponge. A pattern in which Kay's revulsion seems, on casual scrutiny, to track patient gender.
I think this reading is not only uncharitable, but outright wrong, and I'll explain why I'm dying on that hill.
Kay is a doctor in a speciality that, by definition, sees only female patients. If his cynicism and his moments of revulsion are gendered, that's because his entire patient population is gendered. The relevant comparison is not "does Kay write more cruelly about women than men", because there are no men in his ward to compare them to. Instead, we should ask: does Kay write more cruelly about his female patients than a urologist writes about men with foreign objects in their rectums, than a paediatric trainee writes about parents, than a forensic psychiatrist writes about defendants, than an emergency physician writes about drunks? The answer, in my reading experience across these specialties, is no. He is, if anything, on the gentler end of the distribution. Burned-out doctors in any speciality mock the patient population available to them. The mockery is a symptom of the burnout, not of an underlying ideology about the patients' demographic group. Read House of God if you want a properly contemptuous medical memoir.
The strongest single piece of evidence against Gold's reading is also the most unbearable passage in the book, and the one I held back earlier so it could better serve me (and Kay) here. June 2008. A couple Kay has been seeing through their pregnancy come in for a stillbirth induction:
“She and her husband seem oddly pleased to see me — a familiar face, someone who doesn't need an explanation and is already tuned in to what's happening, can be of some comfort on such an awful, scary day.
What the hell can you say? It feels like a woeful gap in our training that no one's ever told us about talking to grieving couples. Will I make it better or worse if I talk positively about 'next time'? I want to give them hope, but feel like I shouldn't say it. It's an extreme version of 'there are plenty more fish in the sea' after a break-up, as if babies are totally interchangeable, just so long as you have one. Do I say how sad I feel for them? Is that making it all about me, giving them yet another person's feelings to consider? They'll have plenty of their own family members throwing themselves at their feet in misery; they certainly don't need this from me. How about a hug? Too much? Not enough?
Stick to what you know. I just talk practically about what will happen over the next few hours. They have a thousand questions, which I answer as best I can. This is clearly their way of coping for now, medicalizing it.
I pop back every hour or so to see how they're doing. It goes past 8 p.m., and I decide to stay on labour ward until they've delivered. H is expecting me back home any minute but I lie in a text that there's been an emergency and I need to stay. I don't know why I can't just tell the truth. I lie to the patient too when she asks why I'm still here gone 11 p.m. 'I'm covering for someone,' I say. It does feel like my presence, if not my conversational skills, are helping them a bit.
Delivery happens shortly after midnight, and I take blood samples from mum and talk through all the possible tests we can do to find a cause for the stillbirth. They opt for everything, which is understandable, but this means I have to take skin and muscle samples from baby, the worst thing for me in this whole job. It used to upset me so much when I first started that I'd practically have to look away while I did the necessary. Now, slightly more desensitized to a thing you can never quite believe you'll ever become desensitized to, I can look. I just find it heartbreakingly sad cutting into a dead baby. We expect them to look beautiful, perfect, unspoiled; often they don't. He's been dead a couple of weeks, looking at him — he's macerated, skin peeling, head softened, almost burnt-looking. 'I'm sorry,' I say to him as I take the samples I need. 'There we go, all done now.'
I dress him again, look up to a God I don't believe in and say, 'Look after him.'”
Hold that up against the misogyny charge. A registrar stays four hours past the end of his shift, unpaid, to be present for a couple losing a baby. He lies to his own partner about why he can't come home. He lies to the patient about why he is still there, because he doesn't want her to know that the truth is that he wanted to be there, that the act of staying matters to him in a way he can't articulate. He apologises to a dead baby while taking the post-mortem samples nobody else wanted to take. He addresses a God he doesn't believe in on the baby's behalf. The entire passage is a doctor being kind, at cost to himself, in a situation where nobody would have noticed if he hadn't been. If this is the work of a man who hates women, then we should hate him for it. If this is what it means to hate, then I'd rather be hated than loved.
There is a third point, one I find harder to make without sounding defensive on his behalf. Kay's speciality is one in which female patients are, for intractable reasons, sometimes presenting with conditions that are simultaneously medically serious and socially embarrassing. Discussing such cases with honesty requires writing about embarrassment, including one's own. The alternative, in which the doctor pretends the embarrassment is not there because acknowledging it would be impolite, is a worse book and arguably worse medicine, because it sustains the social conditions that produce the embarrassment in the first place.
The case Gold makes is not utterly tenuous. There are individual passages where Kay's wit attains a sharper edge than some would like. I don't mind, I am willing to tolerate bitterness and acerbity in a man who is a better doctor than I am, and probably a better writer. But the book is not the misogynistic artefact she presents it as, and the cumulative effect of treating it as one is to obscure what the book actually is.
B: I don’t have much to add to this. I didn’t get misogyny from Kay, I got gender non-specific burnout and contempt.
I want to change the subject now, if it’s okay with you. Should Kay have been a doctor at all?
IV
“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 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.”
B: When you apply to an undergraduate medical school, you might still be 17 years old. Nobody thinks this is an age when you know what you want, but medical schools have to discriminate somehow. Exam results are the obvious metric, but there are interview processes and perusal of CVs. Like admissions to competitive colleges in the US, extra-curricular activities are taken as evidence of a ‘well-rounded’ person who may score somewhere above the basal levels of extraversion (as Kay notes, this isn’t always the sign of a good outcome: Dr Harold Shipman had excellent extra-curriculars). Some medical schools run a ‘rat-race’ of scenarios where prospective students are shuffled between up to a dozen mock ethical dilemmas, one every ten minutes, and asked to say how they would manage. Then they take all of these metrics and intangibles, run sophisticated weightings and statistical tests, and select whichever candidate has a doctor for a parent.
This is only a small exaggeration. One study suggests that children of physicians are 14% more likely to get into medical school compared to their nepotism-challenged colleagues after controlling for ability, and another suggests the proportion of new doctors with one or both parents being medics has increased over the years up to nearly 25% - far more frequently than the progeny of lawyers heading to law school.
Why might this be? Basic genetics tells us that children of people who went through a course that selects for high academic achievement are more likely to clear that academic bar themselves - particularly when there’s a reasonable chance that both parents are doctors. But genetics doesn’t explain everything; the rest is probably just poor imagination, middle-class striving and nepotism.
Kay is, as you might have guessed, a son of a doctor (and of Polish immigrants, for added middle-class striving), and describes it as the “default option” at the end of high school. He joins Doctor In The House author Richard Gordon, whose protagonist’s “acceptance into St Swithan’s medical school came as no surprise to anyone, least of all him – after all, he had been to public [ie private] school, played first XV rugby, and his father was, let’s face it, ‘a St Swithan’s man’.” Kay himself recounts his medical school interview in which his clunky responses were passed over with a “Oh, you’re Stewart’s boy, aren’t you?”
It’s hard to know how medical school went for Kay, but it’s probable his heart wasn’t really in it. He certainly spent a lot of time on the quintessential medical school ‘comedy’ activity of writing medical-themed parody songs like this one, and even had a minor hit with London Underground, a parody of a song by UK band The Jam, although The Jam’s version didn’t feature any fantasies about murdering public transport workers.
Does a background in which you are the son of a doctor, lacked the imagination to do anything else and went through medical school rhyming “stated” with “externally rotated” prepare you to be a reasonable doctor? It can: full disclosure, this describes my medical school journey pretty closely. But I’m still a doctor and Kay is not. What happened?
A: In case anyone missed it, I too am the offspring of doctors. More of them than you can cram into theater. Medicine was the default outcome, the safe career choice. Psychiatry represents a break from tradition, or at least a concession to my real interests. I think that I'm mostly safe from accusations of nepotism, but reading the playbook while in the crib probably helped. I feel for him, and in all fairness, inheriting the profession of your parents was the norm for most of human history. Maybe even last Tuesday.
Why could Kay take no more of it? We've considered several reasons, but like any annoyingly multi-factorial condition, there's always other hypotheses to discuss. Maybe it’s the lack of pastoral care baked into the system. Take rotational training. UK postgraduate medical education is rotational by design: you spend four to six months at a hospital, then move. Sometimes hundreds of miles. For years. Kay's diary is full of new hospitals, new colleagues, new teams. There is no continuity to be had. There is no senior who has known you long enough to notice you're cracking. There is no friend group that survives intact across the move. You can't put down social roots because the next deanery letter is six months away. By the time you have worked out where the hospital canteen is and which consultants will actually answer their bleep, you're already packing.
Here is Kay's entire entry for his first day at a new hospital, August 2006:
“It's Black Wednesday and I have started at St Agatha's. It is an established fact that death rates go up on Black Wednesday. Knowing this really takes the pressure off, so I'm not trying very hard.”
The footnote underneath explains what he didn't need to say out loud, at least not while writing his diary:
“All junior doctors change hospitals on exactly the same day every six or twelve months, which is known as Black Wednesday. You might think it would be a terrible idea to exchange all your Scrabble tiles in one go and expect the hospital to run exactly as it did the day before, and you'd be quite right.”
I find this baffling, accustomed as I was to a very different system. Every single trainee in the country changes hospital on the same day. The institutional memory of a ward, on the morning of Black Wednesday, is reset to roughly zero below the consultant level. The death rates do measurably rise. The system has known this for decades and has done essentially nothing about it. The reason it has done essentially nothing is that fixing it would require giving some thought to where doctors live, and would increase the logistical burden. The system has decided, as a matter of structural principle, that this is not its problem.
B: I will note that googling St Agatha’s doesn’t come up with any hospitals in the UK, only one in Cologne. Unless the NHS’s rotational system is way worse than I thought, I suspect some pseudonymisation. Did Kay move much outside London?
A: Can't say, old pal. But it wouldn't surprise me, being tossed around is part of the package. This was already corrosive in Kay's era. I dare say it's meaningfully worse now. The geographic spread of training rotations has widened. The housing market has made it borderline impossible to buy property anywhere you might be sent, which means that doctors in their thirties are still renting near hospitals they will leave next August. The result is a workforce that is institutionally homeless. You cannot reform a hospital you do not live in. You cannot build a support network out of people you'll see for sixteen weeks. You cannot, in the deeper sense, belong anywhere, which means that burnout is the predictable terminal condition of a system that has decided, on grounds of training efficiency, that doctors should not be permitted to belong to any one place.
This may sound cynical, but I suspect that the purpose of the rotational system is more to force doctors to work in/at places they would much rather not. Rural district hospitals, the ones in cities that have a reputation (and not good ones). We don't have a choice. If we're told to jump, we jump, and pray we don't break anything on the landing. Other countries don't ask this of their residents or trainees, and nobody misses the additional “exposure”. Ah, the joys of a monopsony, don't you hate to see it?
B: In the country where I work, you do indeed get sent rurally for a term or two, and your cynical reading is openly acknowledged - you can’t staff these places without press-ganging people to go. This goes double for many specialty training schemes, most notably the surgeons - in their case, I can see the point of the system, where the increased responsibility and increased rate of registrar-led operations is a feature rather than a bug. You can be stuck in centre-of-excellence land where you don’t lay your hands on a scalpel for anything complicated until you’re nearly a consultant and they let you loose with no supervision.
A: Even so, a rarely-acknowledged cost of this is that the senior doctor who would have noticed Kay was struggling does not exist. There is no such person, because nobody has known Kay long enough. The person who would have intervened in a stable employment relationship is in a different hospital in a different city, watching some other registrar struggle whom they also do not know well enough to help. The system distributes its supervisory failure across enough relationships that nobody is responsible for any one trainee's collapse. This is what allows the institution to maintain plausible deniability about why so many of its young doctors leave. Many of them go to Australia, which represents an upgrade in terms of pay, climate and working hours.
B: And when they get here, they do indeed go on and on about the NHS like it was ‘Nam, bless them. So I guess Kay’s a representative example.
V
A: Read the diary as a clinician, and a different book emerges from underneath the comedic one. Kay does not quite seem to know he is writing, even if he is more self-aware than most.
The early entries are recognisable as adaptive humour: gallows wit as a survival mechanism, the standard medical-trainee toolkit. Any psych textbook will yap on about mature defense mechanisms, of which humor ranks highly. Every doctor I trained with had some version of this. You learn to make jokes about things that would otherwise destabilise you, and the jokes are protective in proportion to how dark they are. Kay's are very dark, and very good, and in the early sections of the book they are doing what they are supposed to do.
By the middle of the book, Kay asks more of his sense of humour than it can sustain. The cynicism has curdled into something that, in a patient sitting opposite me in clinic, would prompt a screening conversation about depression. The depersonalisation of patients has crossed the line from "tired doctor's coping" into something more concerning. He describes intrusive thoughts about cases. He describes avoidance. He describes flattening of affect, the loss of pleasure in things he used to enjoy, the slow strangulation of his relationship with his partner, who appears in earlier entries as a person and disappears, by the latter entries, into the background like a piece of furniture. Anhedonia. Withdrawal. Sleep disturbance that is not just situational. The diagnosis is forming on the page, and Kay does not *quite* have the framework to recognise it.
Then comes the climactic case, the laden straw that would give even the most long-suffering camel a prolapsed disc. December 2010. A patient with undiagnosed placenta praevia, a condition in which the placenta sits across the cervix and which is supposed to be picked up on antenatal scans. The scans had not picked it up; and this is clearly not Kay’s fault. Kay is the operator in theatre when the haemorrhage starts. The mother survives, after twelve litres of blood loss and an emergency hysterectomy. The baby does not. Kay carries no causal responsibility, but he absorbs the full psychological impact, because he was the doctor in the room. He holds the buck in his hand, hot as coal, and tries to douse it hotter tears. He orders his thumping heart to be still. He fails on both counts.
He describes, in the months after, what happened next. This is from the retrospective chapter that closes the book:
“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.”
A page later:
“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 SHOs or junior registrars. 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.”
And, finally:
“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.”
Read against the diagnostic criteria for PTSD as they're laid out in the DSM-5, the symptom inventory in those three paragraphs is essentially complete. Hypervigilance and altered risk-perception (the unnecessary caesareans, the refusal to let trainees operate). Anhedonia and flattening of affect (six months without laughing, every smile an impression of one). The grief response to a non-bereavement event ("I felt bereaved"). The recognition, retrospective, that he should have received care he didn't receive. He doesn't quite name what he had. He didn't have the framework. We do.
B: I’ve read Kay’s (far weaker) sequel to this book, Undoctored, and the avoidance persists: he plays it for laughs in a manner that suggests he still hasn’t learned anything, but he keeps accidentally getting more and more serious injuries that he exacerbates by pathologically avoiding hospital. There’s home suturing. It’s not pretty.
A: It's not. But let's just say I haven't been the best patient either, so I don't wish to judge.
What is conspicuously absent from the diary is any meaningful institutional response to what has happened to him. There is no debrief that does anything. There is no critical-incident process worth the name. There is no occupational health referral that produces care. There is no supervisor sitting him down in a room and asking the questions that demand asking. Re-examine the first of those three paragraphs again. Everyone said the right things. Everyone asked if he was OK. The expectation, simultaneously, was that he would be back the next day, carrying on with a stiff upper lip. The kindness might have been genuine, it was also procedural formality. It absorbed the institution's discomfort without addressing his. He simply stops showing up to work some months later, and eventually the medical career ends and the comedy career starts. This is a clinical scandal, and it was a moral failure.
B: I would love to hear a view from one of Kay’s colleagues from around this time. He’s already demonstrated he doesn’t listen to or trust them; this tendency predated the placenta praevia case, it’s just gotten worse since then. If you’re closed off to help, then you don’t even hear the offers. The people reaching out and asking whether you’re okay are the offers of help: this is how it works. I agree that the official institutional response could have been much better, but I can picture an alternative paragraph in Kay’s book where he’s sent to mandatory counselling, he denies having any problem, and gets in a few good punchlines at the expense of the hapless therapist. Maybe that’s unfair - maybe he was reaching out for help and everyone was unfeeling and terrible. I have my doubts.
A: The dominant reading frames Kay's exit as a sane person escaping a mad system. I endorse something closer to: a man with a treatable post-traumatic syndrome whose only available coping strategy was career exit, because the system that broke him had no apparatus for putting him back together. These are two very different stories. The difference matters more than it might initially seem. The first one is comforting. It says: of course the doctors leave, the system is impossible, what can you do, at least Kay had the comedy to fall back on. The second one indicts the system specifically. It says: this person could have been treated. This person could have continued in his career. He was a good doctor. He was a kind doctor. We should have fought tooth-and-nail to keep him where he belonged. The failure to offer that care is not an act of God or an inherent feature of medicine. It represents a flavor of organisational failure that other organisations have solved.
The first reading lets the institution off the hook. The second one names what the institution actually did. The book, as I see it, is an argument for the second reading, even if Kay never quite phrases it that way.
VI
A: I still think people should read it anyway. The diary form captures texture that no third-person account manages: the four-in-the-morning phone calls, the cancelled birthdays, the way patients become a strategy problem your shift has to dispose of rather than people you happen to be looking after. The footnotes are inspired. There are scenes that could not have been written by anyone who hadn't actually been there and done that, and there are jokes that could not have been written by anyone who hadn't survived it.
B: Oh, it’s true to life. This is one of the reasons it’s so popular amongst doctors - we all recognise ourselves in it. There’s a sense of “there but for the grace of God go I”. I developed the sinking gut feeling and tachycardia oh shit moment as he narrates the final case that broke him, even though the prose was uncharacteristically flat and joke-free (I very much doubt it was written at the time).
A: The single best entry in the book, for my money, is from November 2009. Kay visits Ron's father, who is dying of cancer:
“Visiting Ron's dad in hospital. He looks terrible, jaundiced skin stretched tight over jutting bone. A roadmap of blood vessels is visible across his face where his body has burnt away every single fat cell, throwing all its energy at fighting a cancer it has no chance against. 'I wish people didn't have to see me like this,' he says. 'We'll be spending a fortune on the undertakers making me look nice afterwards — can't you just wait a few more months?'
He's in hospital for an oesophageal stent insertion so he can continue to eat and drink, to make his final chapter as comfortable as possible. The retired engineer in him is fascinated by the mechanism of the stent, a self-expanding metallic mesh, strong enough to push back the tumour and open up his gullet. 'Wouldn't have been possible twenty years ago,' he says, and we talk about being lucky to live in this current blink of civilization's eye. 'Do you think they'll be able to cure cancer twenty years from now?' he asks. I can't work out whether saying yes or no would be more comforting. I deflect with, 'I only know about vaginas, pal,' and he laughs.
Next question. 'Why do we always say that people lost their battle with cancer, and never that cancer won its battle against them?' He keeps making jokes — to be fair, he's done it the entire time I've known him. I find it uncomfortable for the first few minutes of my visit, but I'm soon genuinely enjoying a morning I'd been dreading. It's a kind and clever move — it doesn't just make it easier for his friends and family when they visit, it also means we'll remember him as he always was, diminished physically maybe, but not in personality.”
There is so much going on in this entry. Notice that it is not a clinical vignette. Kay is off-duty, visiting a friend's father as a friend, not as a doctor. Notice that the dying man is the comedian; the jokes are his, not Kay's. Kay's contribution is to receive them, to recognise what they are doing, and to let himself be brought into a morning he had been dreading. The "I only know about vaginas, pal" line is a verbal hug, and it makes me want to hug Kay back. A question that has no comforting answer is deflected with a self-deprecating joke that gives the dying man the cue to laugh, which is what he needs from this interaction. Kay then closes the entry with an observation that is the reason the book deserves to exist. The dying man's jokes do not represent denial. It's an even more strongly distilled version of humour-as-a-defense-mechanism I've previously mentioned. He is putting on a brave face, he is working hard to manage how he will be remembered, and Kay sees this, and writes it down, and the writing-down is its own small act of care.
This is the book at its best. It is, I think, what Kay is when the comedy is not being asked to absorb damage on his behalf. Read this entry and the misogyny charge becomes harder to make in good faith. Read it and the case-study reading of the book becomes more poignant, not less, because you see what Kay was capable of when the system left him enough room to be it.
B: I also like this passage: Kay sounds like someone human here, rather than someone doing a bit. You’ve talked about your sense of him being a good doctor and a kind one. For my part, I think Kay was a better-than-average doctor who fell into the profession through poor imagination rather than vocation. He was a comedian first and a doctor second, hamstrung by his own cynicism and tendency to undercut things with humour. I talked about the martyr complex, and I think he may not have been the most pleasant person to be around during those years, if the complaint about his bedside manner and the way his friends dump him is anything to go by. The system can be a cruel one and it failed in its ability to recognise that something was wrong early on, but I also think that Kay is much better where he is now - maybe he can be gracious, the way he is in this passage, more consistently.
But I want to leave the last word to you. You’re the local. Did the book do anything for you or your colleagues? Did it make us as a society more understanding of the gauntlet we ask our young professionals to run?
VII
A: The book did not change the public conversation about the NHS in the way Kay seems to have hoped it would. It sold a million copies. It produced a hit BBC drama. It made Kay famous and, presumably, comfortable. The conditions inside the hospitals it describes have continued, on most measurable axes, to deteriorate. The book's political theory of itself, the idea that if the public only knew, things would change, turned out to be wrong. The public knew. Things did not change.
Why? Partly because the book is too good at its job. It works so well as comedy, as catharsis, as a thing you press into a relative's hands, that the reader is given an emotional outlet that does not require them to do anything. Reading This Is Going To Hurt lets you love the NHS, pity its doctors, feel personally educated about the conditions, and then close the book. The genre's function is therapeutic for the reader. It is not, by itself, mobilising. The book is a release valve, not a wrench, and a release valve is exactly the wrong tool for fixing the pressure problem it relieves.
I am not blaming Kay for this. That would make me an arsehole. He wrote a very good book. The British public's relationship with the NHS is what it is, and a single memoir was never going to change it.
I am writing this from inside the situation Kay describes, fifteen years and several governments later. As I type, NHS resident doctors have completed their fifteenth round of strike action since 2023. Pay erosion against 2008 levels remains in the high teens. The current Health Secretary is on the news citing one set of pay numbers; the BMA is citing a different set. Negotiations stall, resume, stall again. The strike days come and go. Activity catches back up. Nothing structural shifts.
The thing that has changed the most, since Kay wrote the book, is the public. In April 2020, during the first wave of the pandemic, the British public went out onto its doorsteps every Thursday at 8 pm and clapped. The doctors and nurses, working in PPE so inadequate that many of them died, were the heroes of a national emotional ritual. The British public is well-read, and takes seriously the adage that they should never meet their heroes, let alone pay them well.
Three years later, when the same doctors went on strike to ask for the restoration of wages they had lost since 2008, the same press that had run the hero coverage in 2020 was running editorials calling them militants. The public's affection for the NHS, the abstraction, turned out to be largely separable from any practical commitment to the people who staff it. It is possible to clap for someone in March and curse them in October without acknowledging any contradiction, and this capacity has been demonstrated at scale.
A small amount of what looks like good news. In late 2023, the BMA finally retired the term "junior doctor", which had the surreal effect of describing thirty-five-year-olds with two postgraduate degrees as if they were children, and replaced it with "resident doctor". Trainee wellbeing is a recognised topic in a way it simply wasn't when Kay was living the diary. NHS Practitioner Health, a confidential mental health service for doctors, has expanded substantially. Less-than-full-time training has become far more accessible. Schwartz Rounds and structured debriefs after critical incidents exist in a way they didn't in 2007. The system is heterogeneous, and there are trusts where supervision is taken seriously and the consultants do their educational job with care. Some things have legitimately improved.
The unfortunate caveat is that these improvements have been swamped by the deterioration of almost everything around them. Practitioner Health is a good service; using it requires a level of self-advocacy that is hardest to summon at exactly the moment you need it most. Schwartz Rounds work where the local culture supports them; in many places, attending one means doing it on your unpaid lunch break. The improvements are real and they are not enough. They are being asked to do reform work that they were never resourced to do.
This Is Going To Hurt remains a cult classic. It is not discussed in medical circles, because the cohort of British doctors does not need to. Most of us have experienced what it says firsthand.
The honest answer about the NHS is the one nobody campaigning for it wants to give. The system as currently configured is not sustainable. The routes back to sustainability all involve pain. Either austerity acute enough to cause real ischaemia, then amputation of what falls off, or eventual collapse, which will hurt more, and at a time of nobody's choosing. The third option, in which nobody gets hurt and the system continues much as it has, does not exist and has not existed for some years. This Is Going To Hurt is, in this sense, an accurately titled book about a country that has not yet accepted what its title is telling it.
Should you read it? Yes. Fuck yes. Read it as a memoir, by all means. Read it as comedy, if you can still laugh, and you should be able to, because Kay is good at his job and the book has earned its laughs. But read it also as a case file. The patient is the doctor. The doctor was the patient. The physician could not heal himself. The system has not yet decided who is responsible for treating whom, and until it does, the book will keep being relevant.
That is, in the end, the worst thing that can be said about it.