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The surface narrative of this story is the week-by-week account of a local General Medical Council process taking a month to examine a junior doctor's fitness to practise after a life-threatening surgical complication reported to them by the anaesthetist.
Woven into this is the story of the protagonist's somewhat traumatised childhood and how that led to her life choices. It raises questions about motivation in medicine, specialty choice, coping styles and senior support. It covers a number of topics that are rarely dealt with in novels: surgical ethics, hospital politics and professional self-regulation in medicine.
Weston has a flair for describing tangible sensory moments conjuring scenes to life. This was notable in her first book Direct Red and remains her style.1 Setting the book around four meetings works well giving a neat feeling of a stage set which contains the plot allowing the mental meanderings to stray—but not too far.
Looking at reviews elsewhere makes me focus on Weston's choice of protagonist. Readers do not like Nancy. She is a young woman who is not charming and engaging, who is ambitious and ‘unfeminine’. Many novels invite easy identifications and projections from the reader onto the hero or even the anti-hero, giving these figures some foibles or monologues that catch the reader. Books that do not do this, particularly when well written, invite distaste and a desire to push away the whole book. They do not seduce one, and for this they are not easy reading. I think this device is used in this book to force the reader into the position of some antipathy towards her, a feeling of irritation with her detachment and her interest in what the bosses think with an almost complete lack of awareness of what she wants and believes. Self-reflection is almost absent and thus she drifts, terrified of losing her key identifier ‘being a doctor’ through these weeks and this judiciary process. She goes over her personal narrative but that remains superficial only seeming to emphasise her inability to develop a meta-discourse about what underpins her choices. The areas she dwells on seem to be turning points where if she reflected on her motives and choices she might find a way to help herself in her predicament. But she seems absent from these points and this leads to a moment of enacted dissociation in her practice that nearly kills a patient. This leads up to the core of the book, an inner monologue about the problems and practicalities of being an abortionist. Interestingly, having dwelt on the unsaid within the narrative, the author here encourages one not to read this. What is it to perform abortions? How does it sound and feel? What do you see? But if you cannot speak of it where can you retreat to? In what silences is it accepted, signed up for, performed? It is a powerful unflinching spotlight on this procedure and those involved in it.
The dysfunctional coping style of the protagonist is rendered beautifully and the writing forces you to follow and identify this structure. As we are told of her inner thoughts, we respond to her frightening lack of intimacy with her own self. Even before ‘dissociative’ gets used in the book, it was tangible in her blocking out of inputs and not attending to what is said in the hearing. As a psychological study this is good, it examines the personal cost of never being honest to oneself, maintaining a childhood choice of defence that makes her so brittle later.
The psychiatrist in the story has a position that is both in the wrong but broadly speaking supportive of Nancy. As readers we know more about formative events than the psychiatrist does, he has been fed a censored version of events. Despite this obstacle, he seems to formulate a ‘good’ diagnosis—framing her case as a form of post-traumatic stress disorder experienced by people who perpetrate acts normally thought of morally reprehensible even if they do so under circumstances when they are permitted or even expected. This narrative strand might well be used to discuss how ‘taking a history’ is affected by the patient and the circumstances. The role of the psychiatrist in judicial situations is fraught with a different relation to truth because of what is at stake for the ‘patient’. Here the protagonist wishes to ensure that a certain picture of herself is secure, in other situations there are other stakes and outcomes.
This book would be an interesting way to talk about reflection with colleagues and students who are sceptical as to the value of reflective practice. It shows concretely the impact of its lack, both in one's practice of medicine and in life in general.
It is obvious that it would provide good material to look into questions surrounding fertility and abortion ethics and for junior medical students. However within Dirty Work there are several other questions about medicine. What is supervision about? Who does it? Where is the senior support when things go wrong? And similarly, how and why are roles in medicine accorded status? Is abortion ‘dirty work’? are neurologists brainy? And orthopaedic surgeons strong but dim? Who and what do these stereotypes serve, and do we as professionals wish to support them?
This is a complex book, the primary narrative of which would be of great interest to those teaching medical humanities; however, there is far more to it than just a discussion of abortion.
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Competing interests None.
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Provenance and peer review Commissioned; internally peer reviewed.