Author: Rachel Clarke
Written with intense feeling, this book offers an insight into the direct impact of political decisions on the work and lives of doctors, and the patients they care for. It is a very passionate account of the author’s medical practice and political activism as a junior doctor in the British National Health Service. The author describes the book as ‘the untold story of the challenges of trying to stay kind while practicing in an overstretched NHS front line’ (page xxiii). As she fervently advocates for her concept of good medical practice, she also stridently criticises the politicians who she blames for the chronic underfunding of the NHS. Her unambiguous message is that doctors are obliged to ‘speak out, uncowed’ whenever there are threats to patient safety (page 224).
The key theme of the book is the immense pressures under which junior doctors in the NHS perform their very critical work. The author accurately depicted how doctors struggle to uphold patient safety and be compassionate under extreme time limitations and resource restrictions. She also paints a clear picture of an NHS which is threadbare, scrappy, and perilously understaffed, and which is ‘barely held together’ by staff who are ‘routinely scrabbling against impossible odds merely to keep their patients safe’ (pages xvii and 16). She was particularly concerned that the intense work pressure, by eroding the compassion of doctors, is turning them into hardened machines; she illustrated this with her personal experience of struggling to find the appropriate time and compassion for her patients, ‘enslaved‘ as she was to her ‘incessant pager’ (pages xxi and 8).
The author’s love and devotion to clinical work shines through on every page. For example, she describes ‘the sheer exultation‘ of saving lives, the satisfaction of diagnosing rare diseases, and cherishing ‘the quiet moments of connection with patients’ (pages 34-37, 194-195, and 43-44). Indeed, her prose was at its sublime best when she portrayed her encounters with patients. An example is when she entered the room of a dying patient who was ‘as exhausted by the effort of staying alive as it is possible to be while still living’, and, in the presence of his family, she felt ‘more like an intruder than a healer, invading collective grief as thick as blood’ (page 8). She was also fond of teaching medical students, describing the gratification of demonstrating conditions such as situs inversus (pages 189-204). She however decried the time pressures that threaten the ‘fragile, extraordinary ecosystem of kinship, affection, respect, and goodwill that inspires individual doctors to teach and train each other’ (page 205).
Perhaps the most important theme of the book is the transforming power of kindness in health care. The author emphasised the value of the ‘ordinary, everyday humanity‘ of offering kind words, extending caring gestures, and simply reaching out to patients, arguing that ‘even when medicine is exhausted’ there is ‘our touch or voice or smile‘ (pages 38-68 and 271). In contrast, she graphically illustrated the consequences of lack of kindness with the example of her grandfather, whose death she argued was the result of a system that was ‘pushing all of us away from kindness and further towards callousness‘ (pages 91 and 239-241). Indeed her commitment to kindness eventually influenced her decision to train in palliative care, a specialty where ‘life, as much as death was everywhere’, and ‘is often filled with more of what matters in life’ (pages 255-256).
A significant part of the book is dedicated to the author’s ardent political activism, a passion she expressed in the press, on social media, and eventually on the picket line as a central player in the UK’s first ever doctors’ strike. She gave valuable insights into the drivers and the consequences of this episode, describing it as ‘an act of desperation borne out of our lived experience of the NHS front line’ (page xx). She proffered several justifications for the strike, such as how doctors had been made to feel ‘demoralised, insulted and cheap‘. But she also admitted ‘profound discomfort at striking’, acknowledging that her patients were the ultimate victims; she reflected this unresolved moral ambivalence of strikes when she described the sense of ‘shame mingled with relief and pride‘ for ‘standing up for what we believed in’ (pages 29 and 172-177). It was however not clear if the author thought the strike achieved its objective, as she said the dispute ‘swiftly degenerated into the unedifying spectacle of doctor turning on doctor’ (page183).
Sprinkled throughout the book are pearls of wisdom on good patient care, and perhaps the most relevant lessons relate to how doctors should serve as the best advocates for their patients. In this regard, she emphasised the importance of values such as ‘tenacity, doggedness, and a stubborn refusal to take no for an answer’, arguing that getting results sometimes required ‘deliberately circumventing arcane systems that often seem designed to waste our time and thwart good patient care’ (page 39). She particularly highlighted the imperative of assertiveness in emergencies, pointing out that, in these situations, ‘reticence has the potential to cost patients their lives’ (pages xiv-xvi). Her lessons covered a wide range of related subjects including gender disparity in health care, burnout, resilience, physician suicide, whistleblowing, and learning from error (pages 147, 153-157, 165-167, and 220-232).
This book brings home the true impact of resource and time limitations on healthcare systems. It explores the political intrigues and impenetrable administrative structures that perpetuate the crisis in the NHS, pointing out the heavy toll this takes on staff and patients alike. The author attempted to justify strike action by doctors, but her moral ambivalence to this extreme measure was evident; this very contentious issue perhaps has no clearcut answers. Beyond this, the book is replete with clinical and human lessons for doctors, and it is a masterclass in understanding the politics of healthcare, and the activism that is often required to protect it.
This book paints a clear picture of the consequences of an under-resourced health service, and it highlights the responsibility of doctors to engage in the politics of healthcare. The author illustrated the varied forms of advocacy this may take, although the moral justification of some measures in not clear. The need to address the situation is however inescapable because inaction has deleterious consequences. The book is an eye-opener and I recommend it to all doctors.
- Publisher, Place, Year: Metro Books, London, 2017
- Number of chapters: 16
- Number of pages: 296
- ISBN: 978-1-78606-865-1
- Star rating: 5
- Price: £5.74