Rise of Medical Memoirs: Humanizing the Medical Staff

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Introduction

From 2010 onwards in the United Kingdom and the United States, there was a notable surge in the number of new medical memoirs being commissioned and published. The medical memoir rose to generic prominence across this period through a range of key titles including Kalanithi’s “When Breath Becomes Air” and Kay’s “This Is Going To Hurt”. Whilst medical memoirs offer necessarily individual and personal narratives, they each also draw upon and help to underline a wider sense of shared experience and solidarity amongst doctors. Certain medical memoirs are most notable for their graphic detail about the contemporary national health services, and for their use of dark humour when tackling matters of life and death. They discuss the effects of critical clinical decisions made in a very short time, doctors not getting enough sleep, and staff shortages in hospitals.

Impact of Medical Memoirs

Medical memoirs offer an insider perspective on what happens in the absorbing and relentless jobs in the health sector. They also demonstrate the impact of medical professions on the identity of doctors. They give a human voice to individuals working in an increasingly depersonalised system of care. The authors of medical memoirs offer radical reflective writings and declare their own identity by choosing to portray their often unheard experiences. Across medical memoirs, authors detail numerous instances of denied sick leave, enforced overtime and, resultantly, a fundamentally damaged personal life. Readers are encouraged to empathise with medical staff and consider them as fallible and human individuals.

While “When Breath Becomes Air” is written in a formal manner and a serious tone, “This Is Going To Hurt” is written using informal language and humour. The former is a memoir exploring life and death. It is also about the inadequacies of language to find a meaning to the absurdity of the human condition. Kalanithi immerses himself in literature in order to find a vocabulary to make sense of his death. He relies on literature for this purpose as well as to allow him to face the monolithic uncertainty that illness brings. He writes, “I need words to go forward”. It is eventually Samuel Beckett’s seven-word antiphon that provides him with the words he needs: “I can’t go on. I’ll go on”.

While Kalanithi’s memoir is his last contribution before his death. Adam Kay’s memoir is his last contribution as a doctor. He uses it to denounce the National Health Service, and as a means of depicting the lives of doctors; he shows the obstacles they have to overcome as well as the enormous pressure exerted on them. Kay also hopes to change the way the general public views doctors. Written initially as a diary, Kay decided to turn his writings into a book following the junior doctors’ strike in 2016 as well as the wider growth of the medical memoirs in the publishing marketplace.

Like many other texts in its genre, Kay’s medical memoir exposes a clear tension between public demands for medical staff to “be more human”, as set against a medical system that treats the same staff inhumanely. Kay details the uncomfortable reality of working as a doctor in the NHS. Both memoirs explore the issue of ethical dilemmas in medicine and medical organizations, and in order to do so, both authors include common themes in their books, such as the pressure on doctors, the long working hours, the nature and demands of being a doctor, the hierarchy in medical organizations, the shortcomings of the health system, the ethical decisions made, the responsibilities held and the guilt felt by doctors, the fragility of human bodies, and finally, the impact of the profession on both the authors’ personal lives.

Challenging Conditions in the Medical Profession

It is essential to consider the impact the long working hours have had on the way both authors describes their lives as doctors. Kalanithi worked fourteen-hour days and had to take self-medication in order to survive the arduous hours. Kay also worked ninety-seven hour weeks. The former describes the life of a neurosurgeon as a life full of emergency duties and constant workload. He writes, “People often ask if it is a calling, and my answer is always yes. You can't see it as a job, because if it’s a job, it’s one of the worst jobs there is.” He explains that not many people would want to have such a job, given its demand of time and strain on personal life. Thus, in order for one to be able to work as a doctor, they have to see the positive side of their job and view it as a calling. Similarly, Adam Kay writes, “the hours are terrible, the pays is terrible, the conditions are terrible; you’re underappreciated, unsupported, disrespected and frequently physically endangered”.

Both books show the same paradox: doctors offer one of the most vital services and yet they operate in some of the hardest conditions. Another issue discussed by Adam Kay is the recognition of doctors. This is shown when the author says “it’s the first time I’ve had anything approaching a compliment since I qualified.” The author attempts to show the irony lived by doctors; in most jobs, recognition is common as it motivates employees, however in the health sector, it is not.

Adam Kay points out that the choice of a career is made at the age of sixteen, when students are picking their A level subjects, thus implying that potential medical students do not know what kind of lifestyle they are going to have to adopt later on. Similarly, Kalanithi describes his struggles in choosing a career. While Kalanithi states that he was initially certain he would never become a doctor, Kay recalls that a career in medicine was “the default setting for [his] life”.

It is also essential to consider the fact both authors had relatives that were doctors, thus possibly influencing their career choices. Kalanithi says he “knew medicine only by its absence”; he describes the impact of his father’s profession (a doctor) on him and his family, his father “went to work before dawn” and had to eat “reheated dinner”. His profession is what forced Kalanithi’s family to move as he was “drawn [...] by the opportunity to establish a regional cardiology practice”. Kalanithi believed the “price of medicine [...] was simply too high.” However, Kalanithi’s choice of career was based on the fundamental question “What makes human life meaningful?” This is why he was highly connected to his role as a neurosurgeon and he saw his occupation less as a job and more as a sacred calling. He also talks about becoming invalid because his sickness obliged him to lose his ability to practice neurosurgery which has been part of his identity for some time, to the point where he has almost forgotten who he is without his job. Having been so occupied with it, Kalanithi did not have time to think about things that are important to him and that he values.

Moreover, both authors show that in order for doctors to manage the incredible pressure, they have to make it through without any food, drink or rest between emergencies. Through his diaries, Kay describes the responsibilities of doctors on night shifts: only one doctor is responsible for every patient in the entire hospital. He uses a simile in order to describe the anxiety felt by doctors when they have a responsibility as such. He writes, “you’re up on the wards, sailing the ship alone. A ship that’s enormous, and on fire, and that no one has really taught you how to sail.” In this simile, the author appeals to the reader’s emotion and illustrate his feeling of loss, especially because he feels as though he was not adequately prepared for such situations.

Adam Kay’s memoir aims to show the unfair treatment received by doctors from their mentors as well as their patients. Kay denounces the fact patients expect doctors to always be available and to treat every patient with equal care, compassion, and expertise, and they are also expected to never make mistakes. One patient once told Kay that patients “don’t think of doctors getting ill”; Kay believes that “it’s part of something bigger: patients don’t actually think of doctors as being human.”

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Doctor-Patient Relationships in Kalanithi's Memoir

In their memoirs, both authors also discuss the difficulties of doctor-patient relationships. For Kalanithi, these discussions were in the form of reflections following his switch from doctor to patient. The gist of his reflections was that doctors are so busy and overwhelmed in their lives with so many patients that they hardly can afford to build a ‘human’ relationship with the patients, trying to understand their perspectives, their concerns and listening to whatever they have to say. In addition to being a reflection on coming face-to-face with one's own mortality, Kalanithi’s memoir is also a commentary on the responsibility doctors have to help their patients and their families through that same reflection, whether it happens with some warning or suddenly.

Later on, when Paul became a patient himself, he understood that doctors play a much more important role in patient’s life, than the doctors realize: “how little do doctors understand the hells through which we put our patients”. According to both memoirs, doctors are in a constant rush to get as much work done as possible. And, this compels them to start seeing their patients as ‘problems that need to be solved’. While Kalanithi reflects on the fact doctors do not see their patients as human beings, Kay reflects upon the fact patients do not see their doctors as human beings.

Personal Sacrifices of the Doctors

An interesting instance in the book is when Lucy Kalanithi remarks that “doctors do a worse job prognosticating for patients they’re personally invested in”. She thus implies that hope plays a very significant role in doctors’ lives; doctors subconsciously hope that the patient will get better, will live longer, or will be completely cured. Thus, doctor-patient relationships may impact a doctor’s judgement. This is also confirmed by Adam Kay in his memoir, when he writes, “we’re constantly reminded […] not to be doctors to friends and family”. This underlines the role played by hope in doctor-patient relationships.

However, although doctors are told not to offer medical advice to friends or family, several of them do so anyway as they feel as though it is the only thing they can offer. When Ron, Kay’s friend, asks him for medical advice about his father’s symptoms, Kay is unable to tell him the real prognosis: “I desperately wanted it to be OK - for Ron and for his dad, who I’ve known since I was eleven - so I lied.” Adam kay depicts the ways in which emotion may affect a doctor’s judgment. Another important aspect of doctor-patient relationships is honesty with patients. Nonetheless, honesty may be affected by judgment. Kay argues it is unethical to “lie to your patients to give them false hope,” however he feels obliged to lie to his friend due to their close relationship.

On the other hand, to avoid giving patients false hope, some doctors tend to prefer to not talk about prognosis altogether. This is the case with Kalanithi’s oncologist, who might have been trying to balance honesty and hope. Although both Paul and Lucy Kalanithi could not initially understand the reason for which Kalanithi’s oncologist refused to talk about prognosis, they soon understood that “it is irresponsible to be more precise than you can be accurate”. This thus implies that Kalanithi thought talking about prognosis in terms of a likely range is beneficial for the patient as it allows them to decide what decisions they will make, for instance Kalanithi believed the variable distinguishing between whether he would write a book or continue practicing neurosurgery is an estimate of how much time he had left before his eventual death. Similarly, when Kay talks about the communication between a doctor and their patient; he writes, “it’s about telling [them] the right amount -- keeping [them] informed but not overwhelmed….it’s about being professional and kind.”

Additionally, the impact of being a doctor on one’s emotional health is discussed in both memoirs. For instance, in Kalanithi’s memoir, he discusses the pain of failure that he felt when he was unable to help his patients or offer them what they would like. He also writes about Jeff, his friend, who committed suicide, following a surgical complication, who cost him his patient’s life. Kalanithi makes an allusion to the Bible, “Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel,” thus comparing a doctor trying to help a patient fight death to Jacob wrestling with the angel. This accentuates the fact doctors care about their patients and their health and Kalanithi implies that they do everything in their power in order to help the patients. Several cases of clinical burnout are due to the overwhelming guilt felt by doctors, when they are unable to help their patients.

Clinical burnout is discussed in both memoirs, as both authors have experienced it and consider it to be a cause of deficit in the number of doctors, Kay writes “Chip away at the ingrained notion that healthcare professionals shouldn’t talk about these things – because that same ingrained notion is partly responsible for the huge rise in people leaving the NHS [...] Care for the carer.” The author uses repetition in this sentence in order to underline the importance of clinical burnout and how it can be avoided.

Both medical memoirs contain many instances in which doctors have to make important decisions which may have grave consequences on their patients. Doctors are described as busy individuals with significant decisions to make about their patients’ lives. They take on consequential responsibilities while treating patients. For instance, they have to make judgement calls about life and death. Kalanithi writes, “How could I ever learn to make such judgment calls? [...] would knowledge alone be enough, with life and death hanging in the balance?” This metaphor is used by the author to demonstrate the immense amount of responsibility held by doctors. It is due to this responsibility that Kay ended his career as a doctor; following a complication during labour, Kay had to deliver a dead baby, and the mother lost a lot of blood and died. The guilt and trauma felt by Kay during this experience has led him to clinical burnout.

Doctor's Lives Beyond the Hospital

Furthermore, both authors argue that being a doctor has a significant impact on their lives and relationships outside of work. It is suggest by both memoirs that doctors cannot have lives outside of the hospital. The arduous hours not only have an effect on their own emotional health but they also have a detrimental effect on their relationships: Kay writes, “This week I have seen H for under two hours and worked for a grand total of ninety-seven.” Additionally, he describes many occasions he is obliged to miss due to his work, for instance, he cannot attend his friend’s wedding, he is unable to celebrate his birthday and Christmas with his loved ones. Thus, Kay had to provide care for his patients, even if that is to the detriment of his own relationships. This is why it is very difficult for Kay when he is sued by a patient. On top of the usual strain of being responsible for life-or-death decisions, he now has added stress and guilt; he has to spend long hours preparing for a tribunal, even though he does not have the time. He also discusses the fact junior doctors constantly have to change hospitals, thus resulting in many cancelled holidays and the inability to buy a house. Likewise, Kalanithi recognizes how his speciality affected his relationship with his wife: “Neurosurgical training [...] had surely put a strain on our marriage”.

In addition to the fragility of personal relationships, both authors also use the fragility of human bodies as another motif in their medical memoirs. Kalanithi is taken aback by the glaring unpredictability, transience, and fragility of life – it’s ability to suddenly, simply, snap and end. Through the author’s mortality, the reader realizes their own mortality. Kalanithi not only discuss the fragility of his own body, but he also mentions the fragility of his patients. For example, he tells the story of a boy complaining of headaches that finds out he has brain tumour. He then talks about certain children needing more attention, time, energy, money than others. Certain ill children do not get the same childhood experience as others, this is especially true in cases in which children have a terminal disease and die at a very young age. In contrast, Adam Kay describes mortality in a glib way. The death of his patients is sometimes briefly commented upon then overshadowed by something crude and vulgar. He also talks about patients in vulnerable, frightening, humiliating positions. GALLOWS HUMOUR. Gallows humour is a form of irony used when the person finds themselves in a hopeless situation, thus Kay’s use of gallows humour demonstrate the hopelessness of the National Health Services as he views it.

The working conditions of doctors would spark an outcry in any other profession. Adam Kay criticizes the National Health Service and describes it as a busy, understaffed and time poor organization. He takes particular interest in discussing the hierarchical behaviour in medical organizations. For instance, he talks about the consultant on-call who does not want to be called, and the private doctor who does not let him touch a patient. Through his memoir, Kay explores the different personalities that make up a large organisation and their different styles of working.

Moreover, in Kay’s memoir, there is an evident criticism of the salaries. Adam Kay gives a sobering picture of the British National Health Service at a time when its funding is stealthily being reduced by the government, and the Health secretary seems to ignore what a doctor’s work actually consists of. He even points out that the hospital parking meter earns more than him. When he compares himself to his friends, he realizes he earns less than them. However, it is also necessary to take into account that Kay recognizes that higher positions in the “medical hierarchy” earns higher salaries. Thus, short term pain leads to long term success.

In conclusion, both memoirs discuss medical ethics in very different ways. While Adam Kay uses humour, sarcasm and compassion, Paul Kalanithi writes in a humble and thoughtful manner. Both authors approach themes of existence, meaning, intimacy and identity. In Kalanithi’s memoir, ‘identity’ and its relation to ‘time’ are crucial points of interrogation. Kalanithi tries to conceptualize one’s identity knowing that the time he has left is limited. However, it is Kay’s book which is more likely to evoke sympathy and create more empathy for doctors. Through his memoir, he is able to lead to a change in the perception and treatment of doctors.

Conclusion

However, it is worth noting that both authors still loved being doctors and their professions were very important to them. Adam Kay writes, “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.” And, Paul Kalanithi notes that providing care for his patients allowed him to find what truly makes life meaningful; he writes, “Being with patients [...] certainly had its emotional cost, but it also had its rewards. I don’t think I ever spent a minute of any day wondering why I did this work, or whether it was worth it. The call to protect life — and not merely life but another’s identity; it is perhaps not too much to say another’s soul — was obvious in its sacredness.” 

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