Dirty Work describes the “Fitness to Practice” investigation into the work of Nancy, a registrar in obstetrics and gynaecology. The investigation is triggered by an operation which goes wrong, and Nancy’s inability to deal with the situation.
The author, Gabriel Weston, is an ENT surgeon, and so is possessed of some insight into how these things work. She also has a remarkable talent for describing aspects of medical life in ways that are both accurate and poetic.

A good doctor needs to know how to spin a yarn. That’s what they teach you at medical school, though no one ever says in in so many words. They prefer to give it a safe sort of name, the powers that be. The call it history-taking, this supposedly natural process in which a patient and doctor collaborate to weave a shape out of what’s gone wrong. They make its sound straightforward. And to the patient it probably feels that way. In reality, though, the competent clinical inquisitor is all the while asserting their own semantic frame, encouraging the patient to dwell on key symptoms, ignoring the white noise of emotion, veering away from anything that has no pathological meaning, doing what is necessary to help a diagnosis emerge. The doctor is rewriting the patient’s story while seeming only to bear witness to it.

If there’s part of that which sounds a little uncaring, perhaps a little too direct, fear not. An epiphany is coming…

I began to see that the words a patient uttered were not always what counted most; that there might be a more important meaning beyond what was being said, a contrary melody, if only I could train my ear to hear it.

This short novel has more characterisation than plot, which feels right for the story it is discussing. It also has a good deal of tension, uncertainty, and occasional confusion.

The work which most affects the protagonist, and the operation in which she makes her mistake, is the provision of surgical abortions. I think this is a shame. There is little in the content of the book that is specific to abortion-related work, and I think it would almost have been more interesting to explore the pressure on Nancy if she were the provider of any other kind of surgery. The subject of abortion – for better or worse – carries a lot of baggage. Weston doesn’t moralise, but the occasional graphic descriptions of the work Nancy carries out weigh, I think, unduly heavily on the mind of the reader. This becomes a novel about the psychological impact of abortion provision, and the myriad other pressures on Nancy are comparatively minimised.

This minimisation feels a bit unfortunate because it removes the focus from Weston’s talent for describing the universal fears and pressures weighing on all doctors, which are less frequently discussed and so possibly more interesting than the specifics of the pressures of an individual line of work:

How on earth will I manage if I am erased, removed, struck off the medical register? I will lose my entire frame of reference. And what would I have to replace it? What is a doctor, if not a doctor? That that title away and there may be very little left over.

I would have liked to have seen these ideas explored further, without the baggage of abortion. Weston’s descriptions and language speak to me.

I have seen that other reviewers have felt that the book fails to emotionally involve the reader with the protagonist, but I couldn’t disagree more strongly. I felt deeply involved with Nancy’s story, and worked through this book in no time.
However, given that I’ve praised the book for its true to life descriptions, I should also caveat by saying that this isn’t consistently true. There are strange lines here and there which ring utterly false. There is a scene in which Nancy – reputedly a registrar – described a consultant “decoding” very common terms like ERPC, D&C, and ToP for her. This is patent nonsense. The terms aren’t even explained to the reader, so there isn’t a clear explanation for why the line exists. These aberrations, while frustrating, are mercifully few.

As a whole, I very much enjoyed this novel. It wasn’t perfect, but there were parts that came remarkably close to perfect. There were some distinctly wrong notes, but they were few and far between. I found the novel made me reflect on my own life and medical practice, and made me reconsider issues I haven’t though about for some years. I found it moving, and somewhat thrilling. I wouldn’t hesitate to recommend it.

Dirty Work is available now from amazon.co.uk in hardback and on Kindle. Many thanks to Bantam Press for supplying a free copy for the purpose of this review.