Your debut novel The Registrar was shortlisted for the Victorian Premier's Unpublished Manuscript Award last year. Can you tell me about your writing journey with this book, and particularly, what drew you to writing fiction?

I've always read fiction. It's my preferred genre, broadly speaking. I think the reason I like it is because it gives us a very detailed insight into how people live and how people think. Memoir really concentrates on the person who’s writing it, and there's such a singular subject, whereas with fiction, you can shift that focus around. This book itself, as a story, I've been thinking about since I was a registrar, and that's going back more than ten years. When I was stuck in hospitals at nighttime, I'd sit around waiting for theatre and I imagined stories just to pass the time. Then, about four years ago, I heard the news that one of my colleagues had died of suicide. She was someone that I had worked quite closely with soon after I finished my registrar training and she was at about the same level of seniority as me. We swapped lots of stories about what it had been like: the great stories, the awful stories, the wins, the losses, everything. She had died six months after I had last worked with her, and it struck me that they were all of these stories, particularly women's stories, that just had never been told. I sat down the night that I found out about her death, and I wrote the first three chapters.

I came to write the book in part because I know that people love that ‘behind the scenes’ look at the medical world, but also because I thought many of these stories had value. It took probably two years, but it was really only about six months’ worth of writing, because I got very heavily involved in refugee and asylum seeker work and advocacy, and I almost didn't look at it for eighteen months. Interestingly, what I found is that because some of the themes of the novel are a little bit personal and a little bit traumatic, when I went back to write it, it was actually doing all of that high pressure, high risk advocacy work that put me back in the right mindset to revisit these themes and finish it off.

In the novel, we follow Emma Swann’s first gruelling year as a surgical registrar at The Mount, a prestigious teaching hospital. Emma herself is gutsy, intelligent, hardworking and empathetic. Where did the character and voice of Emma come from?

I think Emma is emblematic of a lot of registrars. By the time you’re a registrar, you've had to have that grit and determination to get a very good mark in high school, then you've done somewhere between four and six years of medical school and quite possibly some other years of university courses before then. You've then worked in hospitals for a few years and gone through another process to be selected into these specialist training programs. Fundamentally, everyone is very good, very motivated and passionate about what they have decided to do. One of the things that I find interesting is how the system almost thinks that you have to have that broken out of you in order to progress to the next step. So Emma's voice, to an extent, is probably my own (even though it's not my story), but I think I could relate a lot to her in terms of that early, young enthusiasm she brings to this new role and then how that role affects her as the book goes on.

Your book certainly explores the immense pressure registrars are put under during their medical training and takes aim at the system. Can you speak to some of the those pressures and why these traditions exist in the medical world?

Medical education is still evolving, and it's based largely on old principles of learning on the job, and often learning through humiliation. I've sat in a meeting where a senior surgeon has said, “if we don't give our trainees a hard time, how will they have the gumption to deal with a crisis?” People genuinely believe that you've got to have the softness beaten out of you. Otherwise, when a patient is dying, you won't have the wherewithal to stand up for yourself and do what needs to be done. In actual fact, what we now know is that being bullied and harassed clearly deteriorates performance, and actually isn't very good for people. If you want to teach people how to respond to a medical emergency, you need to train them to respond to a medical emergency. Bullying isn't going to translate into that.

As Emma discovers, being a woman in this male-dominated space comes with specific challenges. What are some of the issues that female surgeons and healthcare workers face?

I actually had an epiphany in the last few days, which was when we say “male dominated,” we mean that it's dominated by a particular kind of man and a particular kind of culture. It is a very alpha male, patriarchal culture. In the same way that this realisation came to me quite late, I think Emma walks into an environment where she doesn't appreciate what she's being asked to assimilate into. It's a very brutish culture, it's a very arrogant culture, it's a very “you just have to get on and do it” culture. You know, there's a point where her mentor David says to her, “I learned to operate with a textbook open in the corner of the room,” and even though Emma wants to provide really high quality care, she doesn't want to operate on someone and not get it right. She's being asked to compromise those values all the way along. And that in itself causes moral injury, it causes trauma and it causes her distress, all of which ultimately lead to burnout - which we can see with her brother Andy as well. So, that's the overall issue with the culture. But then there are very specific issues such as the discrimination that she faces, the assumption that she can't do the job as well because she's a woman, her inability to find mentors and allies within the profession because she doesn't neatly fit into a culture that doesn't really talk about issues that are not exclusive to women at all but tend to be made so, like childbearing and having a family. Then she is also subjected to unwanted male attention as well.

Emma often finds solidarity with other female staff, and makes an effort to see her patients as people. We follow one patient in particular throughout the book: Jacqui Miller, a young mother from the country diagnosed with cancer. In some ways, she acts as a foil to Emma. Why does Emma feel such a connection to Jacqui and her story?

In hospitals, there are not always many patients whose stories stick with you, and it's hard to know in advance who those patients will be. There are also often not a lot of patients who need a long episode of care. Particularly with cancer patients and patients with ongoing diagnoses, there is a lot of involvement. I wanted to demonstrate that there are those patients that capture our heart, and that we put a lot of effort into treating. I didn't want the book to be just about health care workers, because the health system is about patients as well.

One of the things that was really interesting in my writing and editing journey is that one of my children was diagnosed with a chronic disease in the midst of the whole process. All of a sudden, I was the mother of a patient on the receiving end of healthcare and having to deal with those challenges of navigating the system - which was actually relatively easy for me, because I know how the system works. But it's really hard without that inside knowledge. So, I wanted a character that readers could empathise with and who could demonstrate the challenges that patients face in the healthcare system.

The body is central to medicine and the scenes of surgery are so visceral and detailed - particularly the hindquarter amputation, which is something I’ve never read before in fiction. How did you approach writing these scenes?

It's funny, they were actually the easiest things to write. It's what I do every day. I guess because I'm accustomed to talking to people about the details of surgery, I found them quite easy to write. It was my husband who suggested that that was a good thing to put in. As we were discussing it, he was saying, you know, these novels that capture your imagination are the ones that actually give you an insight into something that you would otherwise have no exposure to whatsoever. In TV, that's one of the things they can't really show because you can't show live surgery and pretend surgery isn't the same.

There’s humour in the book too, even if it is dark or double edged - like when Emma drops a bone during surgery, or the staff have to participate in a meditation session featuring whale sounds. Why was it important for you to imbue humour into this story?

I think what we do is mad sometimes. I couldn't ever do comedy. I don't think I'm a naturally funny or comedic person, and I thought about writing it with more black humor, but I found that I just didn't have it in me. So, I guess those moments of levity are not quite accidental. I guess when you're writing any scene, you're always thinking: right, this is happening, and what's the next thing that could happen? What's the next thing that could happen? What's the worst thing that could happen? And that’s where moments like Emma dropping the bone come from.

Emma's relationship with her husband Shamsi brings moments of comfort and levity as well, but they also go through a very difficult period caused by Emma’s overwork and a lack of communication between them. What does this relationship bring to Emma?

I think the thing about these hard jobs, and particularly medical training, is that you can't do it alone. I know that people really rely upon their partners, their parents, their siblings, their friends, whoever it is that is close to them. But I also know, having been that person, that we're not very good at maintaining those relationships, because there's just no emotional capacity or time to give them the value that they deserve. Even if you understand the statistics, even if you've heard the stories, living through something that is difficult is very different to hearing about it. It's hard for people to know what their responses to that challenge are going to be. It's the impact of these statistics that I wanted to explore with that relationship. In some ways, you finish your medical training, and it's almost like coming up for air. You've got to take a deep breath, and you've got to mend all of the things that are broken around you and resurrect friendships with people you haven't seen or spoken to properly in years. You've got to fix your relationship with your spouse, and sometimes your children. I wanted to portray that complexity as they go into it with a sense of naivety, where they don't necessarily have the skills or the tools to address what's happening. But as things go on, they come to realise what their new reality is, and that they need to have tools to try and deal with that. Because at the end of the book, she's still got four years to go.

In the end, Emma says to Professor Bones: “you could be nicer to everyone… you could see people for what they have to offer, not what you think they do wrong. You could listen to our anger for a change and make things better.” Do you think Emma, and doctors like her, are a force for systemic change?

Absolutely, a hunderd percent. The big thing that I have seen change over the last ten or fifteen years is there are a lot of younger, outspoken forces that are doing their best to change the culture. Changing culture is really difficult and you do need a critical mass to do it. You need a lot of people to work fairly hard at it. But I think we're at that point where people are putting in that work. Our academic understanding of what needs to change, how it needs to change and why is also a lot more developed than it has been in the past. In part, that drive has come from the healthcare profession itself but it also comes from patients who have demanded that doctors know their name, and treat them as humans rather than as diagnoses. So as patients press us to be better, it makes it easier for those within the profession who have always known that we should be doing things better to actually be able to push for that change as well.

What were some of your literary inspirations for this novel, and what kind of books do you like to read?

Even though medical dramas are really popular in TV and film, there's not a lot of literature about the hospital world. There's no shortage of doctors who are writers - even in Melbourne, we've got Leah Kaminsky, Melanie Cheng and Grace Chan - but to find a book like this you have to go all the way back to the late 1960s with House of God. Even a lot of memoir has been written by men. Yumiko Kadota’s Emotional Female and Adam Kay’s This is Going to Hurt talk about similar themes and issues. That said, I didn't read either of those books until I was several drafts into mine. More broadly speaking, I read a combination of commercial and literary fiction. My tastes, if I'm honest, swing more towards the commercial because I'm often very tired - give me a murder mystery any day. I do read the literary stuff because I should and it's important, and I liked Jessie Tu’s book A Lonely Girl is a Dangerous Thing because there's something about it that's just a bit different. I think there are some similarities with my book, because it gives this insight into an industry and a world that most of us aren't particularly familiar with. Another one was Burnt Sugar by Avni Doshi in which she explored the idea of a mother's developing dementia. It made me think a lot as I was writing because it shows the impact of an illness on a family and how it makes people behave.

Interview with Neela Janakiramanan

Aniko Press

Interview with Neela Janakiramanan

Emerging Writers Series: Grace Chan

Emerging Writers Series: Lauren John Joseph

Aniko Press