Neela Janakiramanan on writing what really happens to our doctors

Dr Neela Janakiramanan is a reconstructive plastic surgeon and advocate, and with the 2022  publication of The Registrar she adds novelist to her list of achievements.

Neela was also one of the medical leads in the Kids off Nauru campaign and in bringing together the Australian medical community and operationalising the Australian Medevac legislation to facilitate medical care for refugees in offshore detention.

Neela is a regular contributor to Women's Agenda, and has also written for The Age/Sydney Morning Herald andThe Saturday Paper, and often appears on ABC's The Drum.

You may also be interested in our recent interview with literary agent Melanie Ostell, who is mentioned in this interview.

Neela Janakiramanan on writing what really happens to our doctors


ASTRID: Welcome to The Garret, Neela.

NEELA: Oh, thank you, Astrid

ASTRID: Neela, I confess we are friends, and I am a little bit in awe of you. Not only are you a surgeon, you have now written and published your debut novel which... Look, I get sent a lot of debut novels and this one is really, really very good, Neela.

NEELA: Oh, thank you.

ASTRID: And I want to ask you how and why you did it.

NEELA: Astrid, I've always written. When I say always, I used to write a long time ago and then I wrote textbooks for 20 years, and then I started writing again because someone told me I had told a funny story and someone said, ‘Just write that down’. So, I did. It turned into a hobby that got out of control, I suppose, but this particular work, there were a few catalysts for it.

The first was I had finished my medical training. I'd been a specialist for a few years, and I was really frustrated about the lack of women's stories in medicine. There had been fiction written by men. There had been memoir written by men. This was before Yumiko Kadota's Emotional Female was even a conception. It was before her blog post that went viral and spawned that book, and the only stories that medical women had written really were about their experiences as a patient, not as healthcare workers, and I thought, ‘We've been more than 50 per cent of the workforce since the late 1980s. Why aren't women telling women's stories?’

So, that was broadly the first catalyst, but then I was having a conversation one night with some friends, and someone mentioned someone who I had once worked with and said, ‘When so and so died’, and I didn't know that so and so had died. I'd worked with her very closely for a while, and then I'd moved onto a different hospital, and it just stuck me into guts because she had died of suicide six months after I last worked with her, and I hadn't known the issues, I hadn't seen the signs, I hadn't looked for them. I had no framework with which to deal with that, and this was on the background of having lost other friends and colleagues in the past. And so, I thought back to a lot of our conversations that we had had about what it was like to be a woman in medicine, and I thought, ‘I'm going to write her story’, and that's how this started.

ASTRID: And that is the letter to Josephine that opens…


ASTRID: Josephine, the real woman and your former colleague, and that opens the novel. It opens The Registrar.

NEELA: That's only in the proof copies.

ASTRID: Oh, well, I read the proof copy.

NEELA: Yes, that is not in the published version.

ASTRID: Okay. Can you tell me why?

NEELA: It was mostly a decision by my publisher, Jane Palfreyman. I mean, this is all new to me and maybe all of your listeners will know all of this, but there's always this back-and-forth process with the publisher about what the cover's going to look like, and what's going to happen with the proof copies, and who's going to get them, and all this sort of stuff, and publicity. I talked about Josie's story in some of the publicity stuff, and Jane called me up and she said, ‘I really want to put this in the proof copies to the book sellers, to reviewers so that they know why you wrote the story’. We never really talked about it making the final printed manuscript, and I'm not sure I would have been comfortable if that had been the case because even though I'm happy to talk about Josie and she was a friend, but her story's not really mine to tell, and I'm happy to talk about it in podcasts and in things like that. But I don't know, it kind of strikes me as perhaps a bit disrespectful or intrusive for that to be the headline of the whole thing.

ASTRID: Thank you for sharing that, and letting me ask you about it on The Garret. I'm glad we got to talk about it because I actually had a question which was given I read your letter that mentioned Josephine at the beginning, and then obviously read the review copy, it actually changed my reading of the novel, and I wanted to ask if you and your editor and publisher had had a conversation because I feel like it kind of gives away a storyline that I don't know if you want to give away.

NEELA: I mean, I guess, I assume everyone who listens to The Garret is used to spoilers.

ASTRID: Totally.

NEELA: And so, that's fine, and maybe it does. I mean, we didn't have that explicit conversation. I think ultimately my hesitation to including it in the final copy I think would've been about respect, but I do think that it does give away the storyline of how what happens in our workplaces can drive us to suicide, and as was my experience with Josephine, it creeps up on the people around you. You don't see the signs. You don't see it coming. And so, that's what I was trying to capture in the novel is you can see the cracks, you can see all of the struggles, but they're normalised, and so everyone's just putting up with it, putting up with it, putting up with it, and no one sees what is actually altogether too common.

ASTRID: So, The Registrar makes explicit the deliberate torture, if I can put words into the podcast, that the medical profession puts on trainee doctors at all different levels, to the point of extreme mental, emotional, psychological distress, and in The Registrar, you then explore how not only that affects the individuals who will become our lead doctors, but also their friends, their family, and their patients. It's the laziest question in the world to ask how much of you is in this novel, but I kind of want to... I feel like you're almost daring interviewers to ask this because you are a surgeon. I mean, it's even marketed as you're a surgeon who's writing about the medical profession in this amazing page-turning novel. Are you as a doctor, putting your surgeon hat on, how exposed do you feel to your peers and colleagues in the medical community?

NEELA: It's really funny, Astrid. I've had cause to call up a whole bunch of colleagues around the state and interstate in the last couple of weeks over completely separate issues. These are people I haven't spoken to sometimes in years, and the first thing they've all said to me is, ‘Congratulations on your book. Am I in it?’ And so, it's interesting. I think my colleagues feel more exposed than I do. I don't feel exposed at all. I mean, obviously, we all draw from our own personal experiences to write stories, and I can tell you, I really did make a tray of ice cream cone cupcakes for a child's birthday and drop them all on the floor. So, that definitely did happen. Most of the scenes that I chose, I chose because there was a universality to them because obviously I have to be really careful about telling patient stories as well. And so, the patient stories are by and large clinical cases that are common and some of the details are completely made up. I've never dropped anything in a park.

ASTRID: Look, I'm very glad to hear that, knowing what the character drops in the park.

NEELA: That's good. But yeah, so I think there is a bit of a universality, and it came from speaking to lots and lots of colleagues about their experiences as well.

ASTRID: So, you just mentioned patient stories. I am often a patient, and I receive very good care in a hospital, and I found myself squirming sometimes when I was reading this really engaging story about doctors who are without sleep and traumatised and kind of close to breakdowns, and often the whole team is close to their own very separate, very real breakdown, and yet they're still trying to help the patient, and in one way that's so honourable because they are there helping the patient, but I'm also that patient and nobody seems to be functioning very highly.

NEELA: Yes. Yeah.

ASTRID: And there's an analogy in the novel where this wouldn't be allowed for a pilot. A pilot has 300 or so people's lives in their hands at any one time, and there are rules and regulations and a system in place to make sure that pilot is highly functioning, and there are not those same rules in place for doctors and surgeons and specialists and everything else that you find in a hospital. What conversations are you trying to start, and is that with patients? I mean, patients aren't really in a position to rebel, but I feel like I want to.

NEELA: Look, I do think that patients have a role to play in this conversation because patients have an enormous capacity to advocate, and we know that slow medicine is better than fast, rapid turnover medicine. We know that having adequate staffing is important, having good quality staffing is important. There's actually a study that shows that making your nursing staff happy is actually the best thing you can do for patient care because the patient experience is driven more by the nursing care they receive than the medical care that they receive sometimes.

And so, I think that in the Australian context where Medicare rates haven't risen for almost a decade, where health systems are strained, where the expectation is that doctors and nurses, they really destroy themselves to provide this level of care, I think there is a role for patients to say, ‘Hang on, we want something better’. And look, I think that that is a little bit problematic because patients can be in vulnerable positions to do that, but if we bear in mind that we are all patients at one point or another, then we all have the ability in times of wellness to consider what governments we want to elect and what we want to demand from our politicians and bureaucrats.

ASTRID: Neela, you've just given me the perfect segue into some of your advocacy work. You in your capacity as a medical professional and advocate, you were involved in Kids off Nauru, and a lot of the inactioning of the medevac legislation. The Registrar is fiction. The Registrar is a great read, but it is also clearly dealing with clear and present dangers in our medical system. It affects patients and doctors. It is in a way, and I hope I'm not putting words into your mouth, but it's kind of advocacy. So, where do you put this entirely new career that you've started in context with the more traditional and hardcore advocacy that you do?

NEELA: You're very famous for asking probing questions. I think that the intersections of medicine and writing and broader advocacy, I think that there is a lot more overlap than people necessarily give each of those things credit for. There's a real myth that doctors shouldn't be advocates, but I advocate every single day, and it might be for the one patient who needs access to an operating theatre, and it might be for health system reform, but it's all advocacy. And if we look at the system as a whole, if there are individuals that the system is willing to throw aside, to ignore, to not provide adequate healthcare for, then I think that we are all at risk of finding ourselves in that same position at any moment in time. So, I think it is important that doctors advocate, and ultimately, I hope that this book is fun and interesting, but it is also unashamedly a degree of advocacy to create awareness of what it's like for healthcare workers and for patients so that we can all, I guess, work together to address these issues.

ASTRID: Neela, this is a really engaging read, and I guess I jumped straight into the kind of harder, darker things with my questions, but your manuscript was highly commended in the Victorian Premier's Literary Awards. Nobody gets that recommendation if it's not incredibly well written and with a heart and with a soul. So, my question is, firstly, that's a really quick turnaround. We are only just in mid-2022. So, in terms of your writing Process, and then the editing process, the publishing process, and this is the first time you've done it all in terms of a novel, how much did the manuscript change and what's it like working with Melanie Ostell who I've also just recently interviewed on The Garret?

NEELA: Oh, I love Melanie. We can get to that in sec. The manuscript changed a lot. My first draught, which another publisher had a look at and then told me to go off and redraft it, so that I started in 2018 and then had sort of an 18-month break to do the refugee advocacy work, and then finished that sort of towards the end of... Or early 2020. That had a lot more of the stuff that some of my colleagues might be worried about. That was a bit more raw and had a bit more me in it, and I think that it was really important to write that in retrospect because I then got it all out of my system, all of that anger and revenge and those emotions that you feel when you've had a really difficult time.

And so, then I redrafted it, and it was the second draught that I sent to the VPLA, and that was quite a surprise, but then once that shortlisting was announced, things kind of changed. I had lots of requests from various publishers, lots of requests from various agents. I actually hunted down Melanie because of A Lonely Girl is a Dangerous Thing actually. I had read that book in lockdown and I thought, ‘There's something different about this novel that makes it kind of a bit unique in the Australian landscape’, and I couldn't quite put my finger on what exactly it was, but it was, whether you like the story or not, it had great structure, it held together tightly, didn't have any narrative holes, and ultimately, when I went into my writing process, this is what I was most worried about. I appreciate that every work of writing is ultimately a failure that we have finally abandoned, and I do believe that because you can just keep working on things and try to make them better and better and better, but at some point, you have to stop.

I always read the acknowledgements of all books that I read, and I thought, ‘I don't know what it is about this team, but this book really hangs together well’. And I looked up Melanie and I approached her, and she was happy enough to have a read, and I may have told her that I had drafted it four times when I asked her to read it and just crossed my fingers that hopefully because the VPLA judges had thought it was okay that that would be enough.

And then after Melanie took me on, we redrafted it again completely, and that's sort of what Melanie does. She does a lot of editorial work prior to submission to publishers, and we had a couple of phone conversations where she just told me everything that was wrong with it. Not everything that was wrong with it, but she just picked up all of the this is what needs to be improved, this character doesn't quite work, this one is good but you need to clarify that. She suggested in that conversation a few potential scenes that might add to the whole novel. So, my original draught was very much set in the hospital. There wasn't a lot happening outside of the hospital. So, for example, the chapter where Emma and her friend Daphne drive to the forest, that was built on a suggestion that Melanie had made about maybe contrasting real nature with the pot plants in the hospital.

And so, then that took us through to about May. So, we started talking about it, redrafting in January. So, I redid a full draught. That was done by May, and then we sent it off publishers and got picked up in June, and then I got editorial notes back in September, and they were back in by sort of the end of the year. And so, we're up for a July publication.

ASTRID: Melanie has a reputation of being an incredibly good agent and also a person who gives full and frank feedback. What was that like, given that this is your first novel in an industry that you haven't been working in for 20 years?

NEELA: What I said to both Melanie as my agent and Jane as my publisher was that they could not say anything to me that a surgeon had not said. It was just, no amount of blunt feedback that they could give me that would hurt me. But I also appreciate that my experience leading up to this is perhaps a bit different to other authors who might find themselves in that, position. And leaving that aside, leaving aside that surgeons could be jerks, I think the thing that I came into this with was the knowledge that writing was not something that I had expertise in, that there were structures and conventions that needed to be learned, and in the same way that I had never held a scalpel before and learned how to operate, writing was also a learned skill.

So, my goal was really to surround myself with expertise so that those people could help me make this as good as it could be, but likewise, you are putting yourself in a vulnerable position doing that because people will tell you where they don't think you've done a very good job, and you can take or leave it. There was certainly some comments that I left because I didn't think that they were necessarily relevant to the text. So, by no means saying you should do everything that other people tell you, but particularly given it was my first major piece of work, I have to confess that I accepted more criticisms than I rejected by a good long way.

ASTRID: Changing tack slightly, Neela, let's talk about sex scenes.

NEELA: Ugh. Do we have to?

ASTRID: Yeah, we do. I don't normally specifically ask, but how do you know if it's good? How do you know if you're not going to make your reader cringe? What is the kind of process that you went through to write a sex scene?

NEELA: I showed it to a few people and said, ‘Oh my god, this terrible’. I should say at the outset that writing sex scenes is not something that comes naturally to me at all, and in fact, those sex scenes didn't make it in until a very, very late draught, and I agonised over the writing, and in fact, I was just like, ‘I don't know how to write a sex scene’. And so, we were cooking dinner one night, and my husband said, ‘I'll find you some sex scenes’. And so, he googled best sex scenes ever written, and I'm sitting there staring at soup and he's reading these sex scenes out. It was very unsexy, can I just say. It was just all cringe from my point of view, but I also realised that they served a narrative purpose in the text to demonstrate the arc of Emma and her husband Shamsi's relationship. And so, I just had to suck it up and write them, but ultimately, yes, I just, I showed a few people, and it went through a bit of a drafting process with my writer's group of friends. And so, hopefully, they're not too cringey.

ASTRID: Oh, they're not, they're not. I just felt a desperate need to ask you, Neela, because I could see how the sex scenes made Emma, the protagonist, more real, and they are essential to her story and her arc, but I can also see how you could have left them out, and I was just interested in that kind of authorial choice.

One other thing I noticed in the narrative is you really place a lot of emphasis on the buildings, the hospitals that Emma is currently working in, but also has worked in previously, and there's kind of, I found, or at least my interpretation was you bring in the history and the weight of the medical profession and how we've been training surgeons for literally centuries by the buildings, and who gets the bigger office, and where the admin people are, and how the hospital is laid out, and whether that was cost cutting, or back in the day because it's old and they did it better then. I just found there was quite a lot of respect for the profession that you spoke about through the buildings. And just a broad question, were you aware of that or have I totally misread this?

NEELA: No, no, I do think the hospital itself is almost a character in the novel, a relatively minor one, but the physical environment so deeply impacts on workflows and on how you feel. There's a lot of writing about hospital and healthcare architecture and design, and how that impacts on the patient experience. But likewise, it is also a luxury to be able to have good architecture and design because ultimately the healthcare funding pool is not unlimited, and so that is not something that is generally prioritised.

I've worked at a lot of hospitals in my training from modern hospitals, all the way through to ones that were built in the era that The Mount was. I've been stuck in lifts that you're just, you're pressing the phone button saying, ‘Can someone come and save me?’ You can see the history of the beds that have bashed into the walls of the hospital, and I have sat in hospitals at midnight thinking about the doctors, the nurses, the patients that have walked those corridors and had all kinds of experiences there. So, yes, no, describing the physical space and how it came to be was important to me.

ASTRID: Neela, my final question for you, why fiction? It may have just been an urge, but earlier, you mentioned there have been male surgeons who have written memoirs, male surgeons who have written novels, and apart from Yumiko's Emotional Female, there's not really a lot of female doctors writing about their own experiences. Why fiction for you?

NEELA: I like reading fiction. It is my preferred type of book to read. So, it made sense to write it. I don't love memoir as an art form which I know you and I have talked about in the past, and I can see that there is very, very good memoir out there, but in the way that we can't always pinpoint why we enjoy the things we do, memoir isn't up there for me, although I do enjoy good one. But ultimately, I wrote fiction for this particular story because I didn't want to tell my story, and I think the problem with telling a single person's story is that it's very easy to dismiss it as the kind of rantings of one cantankerous individual that didn't get what they wanted which is rarely what it is, but is exactly how it is dismissed, and so I just didn't want to do that.

NEELA: I do think that fiction has that ability to be a little bit universal. I mean, I chose a white protagonist which comes as a surprise to a lot of people, and I chose a white protagonist who comes from the medical establishment because I wanted to show that this isn't something that happens to a South Asian migrant doctor like me. This isn't something that happens to people who are marginalised in some sort of way. This happens to everyone, and it doesn't matter how much power you come into the system with, we can still wear you down, and fiction was the best way I could think of to make that point.

ASTRID: Neela, your novel is an extraordinary debut. Congratulations.

NEELA: Oh, thank you, Astrid.