[This is one of the finalists in the 2026 book review contest, written by an ACX reader who will remain anonymous until after voting is done. I’ll be posting about one of these a week for several months. When you’ve read them all, I’ll ask you to vote for a favorite, so remember which ones you liked]
(An adversarial book review)
“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 reach 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.
“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…
