Guest post: what we signed up for

I am so pleased to be able to publish this guest blog by River, writer of Hanging Round the Inkwell. She’s a doctor who’s had her fair share of bends in the medical career road, and talking to her is a solace to me. Her reflection is a pithy insight into something every doctor has either thought or been told after a tough day, and bears truths about the realities of being a doctor that the government still steadily refuses to acknowledge.

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“It’s what we signed up for.”

How often do you hear doctors say this? They describe some of the negative aspects of their job and then say ‘but I don’t mind because it’s what I signed up for’. I stayed late again, I missed my best friend’s wedding, I haven’t had a chance to pee in 12 hours, I’m exhausted after working 12 days in a row, I haven’t seen my family in ages… but it’s what I signed up for.

But is it though? Working as a doctor implies certain things. You will, at least at some point, have to be part of providing a 24/7 service which means you may work Christmas day and you will have to work some nights. You will have to deal with sick and dying people. You will have to have difficult conversations. You will have to take on responsibility.

Being a doctor, in and of itself, does NOT mean: having to work 12 days in a row, having to work 13 hour shifts, having to work without a break, having to cope with a workload that would be better suited to three or more people, having to stay late for non urgent reasons (usually on the whim of a senior colleague), having to explain to patients and relatives decisions and management plans made by other people, having to miss significant amounts of family time for a sustained period, having to miss events that are important to you and that you have given rota coordinators notice of. It does not mean having things dumped on you because other people can’t be bothered to deal with them.

So much and so many of the stresses of the job are, we are told, inevitable, part and parcel of being a doctor. We are told that they are what we signed up for. The fact is, for the vast majority of us this just isn’t true. We signed up to help people, to provide healthcare, to do applied human biology. For various reasons, and because of various interests and driving factors. We didn’t ‘sign up’ to be overstretched, to plug ever increasing gaps in an overstretched service, to work unsafe hours.

It would be possible to practice medicine in less relentless ways, and it would still be medicine, and we would still be doctors. Exhaustion and burnout aren’t what we signed up for and they shouldn’t be inevitable.

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Striking Doctors and Healthcare Innovations

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I can hardly believe it’s happened. Yesterday, for the first time in 40 years, doctors went on strike. I went out to the picket line at Guy’s and St Thomas’ hospital today to speak to and support the doctors out there. It was incredible how dignified this whole campaign has been. They know they have the moral high ground, because ultimately what they’re fighting for is the future of the NHS.

I have to say, it’s really weird not being one of them anymore. Weakening my bond to Medicine under normal circumstances would be difficult, but with all this unprecedented action going on, I feel like I’ve abandoned my colleagues and my profession when they most need support.

However, it is liberating not to be threatened with legal action and GMC hearings, as unfortunately some doctors have been lately. I feel I can truly speak my mind without having to worry about my career.

With this in mind, I said yes when my friend and mentor Gyles Morrison asked me if I’d spend the strike day with a small private healthcare company that provides advice and treatment over the phone or email. I know there’s a lot of controversy, even within the medical profession, as to how much private and public healthcare should be mixed, and with certain branches of the media so desperately keen for sensations at the moment, a training doctor couldn’t really be seen as being connected with a private company. Even though I’ve left, I have to confess feeling some trepidation as I made my way over to their office in Waterloo today. I could almost see the papers now… ‘Doctor spends strike day at private healthcare company.’ Well, at least she writes her own derogatory headlines…

One of the things this company were doing today was taking calls for free in support of the strike. I spoke with the CEO of the company. He told me that, while working in the city, he found it difficult to get GP appointments without taking time off work.

While I agree with reducing time-wasters for GPs, I know there are many who would say this kind of private initiative undermines the NHS. It’s a tricky one. When I met the founders of Doctify last year, Dr Stephanie Eltz explained how the idea for the online specialist database came from her own personal struggle to find someone who could treat her. She explained:

If you try to innovate within the NHS, you’ll be waiting forever. There simply aren’t enough resources. If you want to develop something new for the NHS, you have to do it outside of the system, and then take it back to the NHS once it becomes successful.

It’s difficult as a doctor to think commercially sometimes. We automatically reject any talk of monetary value, because our priority is our patients of course, and the thought of having to decide how money is spent on them is honestly a bit repulsive. When you choose to be a doctor, the financial side of things just doesn’t come into it.

Instead we let non-medics dominate the world of clinical commissioning and health policy. I met Dr Harpreet Sood, a Senior Fellow for NHS England, and he completely shocked me when he told me that when he arrived, there wasn’t a single clinician at the top level of NHS England. Until it became desperate, everyone accepted this situation. Now, however, we’re left wondering where the hell the £130 million NHS budget goes, and why NHS services are being out-sourced to private companies. The few medics that do exist in that ‘world’ have often turned out to be the rotten eggs – money-grabbing sell-outs who crossed over to the ‘dark side.’

Could the solution be these innovative start-ups, hatched and grown in the private sector until they’re ready to tackle the NHS? I really don’t know. This is a world I am new too and O just don’t understand it yet.

So… what do you do?

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December is the prime time for this question, or versions thereof. With everyone getting together for Christmas and New Year, I knew I would be catching up with friends and relatives and meeting new people, so small talk would be abundant for a good two or three weeks. I have to admit, I was dreading it. I was afraid of their judgement and remarks. I suppose I was also afraid of how I would react to their reactions. I could hardly justify my situation to myself, so how could I justify it to others?

I have always taken it for granted that I could give people a satisfactory progress report. “I’m in year 13” turned into “I’m in year X at medical school,” which turned into “I’m working at such-and-such hospital.” The only variation to contend with was the inevitable follow up question: “Have you chosen your speciality yet?”

Traditionally, the responses I have given to these queries have depended largely on how I feel about the person asking them. With kindred spirits – the people I feel will really listen and might understand my point of view – I am honest, but mostly I’ve just been busy hiding my true feelings about it all these years, even from the people closest to me.

As Christmas loomed, everything seemed so complicated. What was I supposed to say when people asked me what I was doing now?

“I had a quarter-life crisis and quit my job with no plan B, so I’m now officially unemployed and relying on my savings and my fiancé to get by. I have no current certainty or prospects, and not much of an idea about what to do, except a vague plan to write a novel that I’m unjustifiably optimistic about.”

It sounded terrible. I almost wanted to avoid the festive parties altogether to save myself from this humiliating admission. I also felt bad for my parents – when people asked them how I was getting on, they would be having exactly the same problem.

Then, two things happened to me.

The first was deciding to locum after my little visit to the job centre. That gave me something solidly medical to say, and was a relief. “I’m locuming at the moment” is a brilliant answer for those you don’t really want to talk to, and who are just asking you for the sake of saying something. It’s satisfying for both parties and the perfect precursor for a swift exit line.

The other was this: at the start of December, in between dancing for joy and plunging into the depths of despair, I started job hunting on the Guardian website. I found an ad I was interested in for a managerial role in a charity, but being inexperienced with this sort of thing, I was doubtful. I worried that I didn’t meet the criteria in many of the job specifications, because a lot of them stated the necessity for formal qualifications or specific experience. But, as my fiancé told me, job specs are not hard and fast rules. They represent the ‘ideal’, and most companies would rather hire the closest match than wait for the perfect candidate. My career coach has also been helping me to realise the value of the skills and experiences I already have.

So I shot off my CV, not really believing anything would come of it. Then two weeks later, I got a call. The charity had said my application was certainly unusual, but they had loved it. They offered me a telephone interview, and after that, they offered me a formal interview. I’m going in for it next week. Whether or not I get the job in the end, it’s been such a boost for me just getting to interview.

It’s also nice to sing my own praises. It’s not something I got to do much in medicine – it was more about people assessing me. ARCPs are tick-boxing exercises and applying for clinical jobs requires more form-filling and exam-taking than knowledge of your true strengths, skills and weaknesses. It’s just the nature of the medical profession that everybody is presumed to have all the necessary skills for their level. As a result, the thought of doing a non-medical interview is scary. No longer can I rest on my laurels; I actually have to prove myself. It’s made me sit down and think about what I’m really good at, what suits me and what I really want – perhaps for the first time in my entire life.

As the Yuletide approached, I started to see my situation is a different light. Yes, there are things in my current situation that I don’t like, but there is also plenty of potential. This is a really exciting time for me, and I really need to give myself a break. It sounds cliché to ‘have faith in yourself’ and to ‘stay positive’ but these little things can be incredibly difficult to do. I still struggle sometimes, but I’m working my way towards another cliché where I see my glass as half full.

So now, when people ask ‘what are you doing now?’ I have an answer I’m proud of:

“Well, I’m planning to locum while transitioning into a new career. I’ve got an interview with a charity soon for a management role. In the meantime, I’m volunteering for Medic Footprints to help other doctors in their careers – a role that I got because the directors were impressed by an article about their conference on my personal blog. I’m also researching the British colonization of Asia to give historical accuracy to the novel I am currently writing.”

There. Sounds much better doesn’t it? And the best things are: it’s all true, and I can say it to everyone.

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Image from Malla.

Malla is a small business coach and expert at answering this question!

The Dangers of Ego: how medicine became my self-esteem

ohne arbeit

The other day, I was on my way to the Royal London Hospital to discuss my resignation with the Dean of my Foundation School, when a man going past on a bicycle stopped next to me.

“Are you lost?” he asked, with an accent that I recognised to be Sri Lankan. I turned away from the map and looked at him, and his features confirmed our common heritage.

I explained I was looking for the hospital, and he pointed me in the right direction, but before I could get very far, he began to tell me all about the amazing pastor at his church, who apparently had died, visited hell and heaven, had a chat with Jesus, and come back to earth again. I suppressed a smile as he asked me if I had time to chat, and said I was in a hurry. He then asked me why I was going to the hospital. I obviously didn’t go into my real reasons, but the moment I said the words ‘I’m a doctor’, he looked at me with such awe, as if I were the one taking return journeys in and out of the afterlife.

It’s not an uncommon reaction. Although the medical profession is much less revered now than it was twenty years ago, people are generally still impressed when you tell them you’re a doctor. “Wow! That’s incredible! You must be clever,” they say, or “I couldn’t do what you do.” As for my Asian relatives, particularly the older generations, I represent the ultimate achievement.

When I think about how hard I’m finding it to leave medicine, I can’t help but admit that part of it is losing that massive ego boost. The moment you qualify, you are seen almost universally as intelligent, selfless, noble, caring and respectable. Another bonus is the fact that people have a basic understanding of what it is you actually do – as opposed to the non-vocational folk like my fiancé, whose job description of ‘business consultant in macroeconomics and econometrics’ is vague at best, and downright confusing at worst. I don’t have to justify myself as a good person because my occupation automatically confirms that. I save lives. I help people. I took an oath to devote my life to healing the sick. What kind of person breaks that promise?

The “Bristol Promise”

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When I think of how amazing and necessary the work of a doctor really is, it’s hard to validate my existence without it. If I am ever one day shipwrecked on a desert island, I’d have gone from being someone you’d definitely want to keep alive to someone who can be eaten without any great consequence.

The funny thing is, when I step back and look at it objectively, I can see quite clearly that Medicine is not the only ‘noble’ thing to do in the world. Our intricately connected society relies on the collective effort of many, and we all can influence the world around us for the better in our own way. The problem is, these things are not always recognised in the same way that being a doctor is. In this world where money and fame is more celebrated than anything else, medicine is still holding on to respect and value by the tips of its fingers, whilst the actions of good teachers, parents, farmers, legal aid lawyers, emergency service personnel and countless others fall by the wayside.

I used to dream about working as a doctor in Africa or Asia with Médecins Sans Frontières, providing healthcare for the poorest and most vulnerable. When I started to become unhappy in Medicine, this dream was the only thing that kept me going, but I realise now that my desire to be of service had become tainted with selfishness. I wanted to make a point, to show that I am a good person, but there’s something paradoxical in the truth about this: if you do something you hate for the sake of being good, resentment will poison any happiness you gain until you can’t do it any more. But if you use something you love to do something good, the happiness you gain will motivate you to keep doing it, and the good you do will be tenfold. The line between selfishness and selflessness suddenly doesn’t seem so clear.

These next few months are not going to be easy, I know. I have already experienced the sneers and sometimes just plain disbelief that I would ever dream of giving up Medicine, and I’ve barely told anyone in my family about it yet. I dread my next trip to Sri Lanka, as there the judgement will be even more severe.

However, I am coming round the idea that my self worth isn’t quite so dependent on Medicine as previously thought. As my best friend once said, “I don’t love you because you’re a doctor – I love you because you’re loyal and kind, and always there for me.”

I am still determined to help people, but perhaps being obsessed with the goal is actually more of a hindrance than a help. After all, my literary inspiration, Jane Austen, didn’t write her books with a view to helping me, but she has. Her books have been my joy and comfort in many a dark moment – one of many unexpected echoes of her quiet, modest life that she will never know. I’m sure if she were alive today, she would tell me to chill out and take myself less seriously, albeit n more Austen-y language!

Perhaps she’d tell even me to listen to Bertrand Russell, who I believe once said:

“One of the symptoms of an approaching nervous breakdown is the belief that one’s work is terribly important.”

The New Junior Doctor Contract

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A great deal has already been said about the junior doctor contracts row, so I will keep this short.

As the years have passed, working as a doctor in the NHS has become more and more about service provision and meeting targets than about good patient care. As training overhauls like MTAS, eportfolios and the degradation of the firm structure have come to pass, training itself has become more of a tick box exercise. You are no longer rewarded for actually being a great doctor, and can easily work your way up the system by simply looking good on paper. For doctors who care, and who chose the profession as a vocation, this is incredibly demoralising.

The current political storm has revealed the extent of this disillusionment: many doctors are already at the end of their tether. Little things like having night-time resting facilities, access to a locker, or being allowed to park on hospital grounds for late shifts, magnify the more fundamental issues of adequate break times, poor management and punishing rotas. Meanwhile, external opportunities for doctors are increasing, whether it be working abroad, in locum agencies or changing career altogether, the pull to leave the NHS is getting ever stronger. 

In other words: if junior doctors had any doubts about staying in medicine, the imposition of the new contracts will be more than enough to erase them.

Why don’t you just finish…? Life on a conveyor belt.

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From youtube.com

You’re 15 years old. It’s careers days at school and various people are giving you talks, presentations and hand-outs about their jobs, and your careers advisor is telling you which GCSEs you’ll need to do. You’re suddenly faced with the enormity of the decision: what do I do with my life?

Medicine was always the path mapped out for me: my father is a brilliant doctor who loves his job, my uncles and aunts are doctors and dentists, and I come from an immigrant Sri Lankan community in which it often feels the only respectable vocational fields are medicine, dentistry or law. Well, sometimes accountancy and engineering are ok, but only if you didn’t get into Medicine or Law – I am only half joking here.

When you see how deeply this idea is engrained into Asian culture, you can understand why it’s so hard for me to tell my family that I’m leaving (a job which I have yet to do…), but I don’t think it’s just an Asian thing. Everybody knows that medicine is a noble profession, and when you tell people you’re a doctor, many of them still look at you with a sense of awe and respect, and in today’s society, achieving your ambitions no matter the consequences is seen as a good thing. I suppose I fell in love with the idea of being doctor, of being like my dad: a life saver, a game changer, an inspiration.

Somebody once told me that becoming a doctor is a high price to pay for being good at science. I was good at science at school, but then I was good at everything – a straight A student – which meant I never learned the connection between being passionate about what you do and being good at it. Passion breeds genius, and I couldn’t see my genius: in science I was fine, but I was outstanding when it came to languages.

Picture from www.intherooms.com
Picture from http://www.intherooms.com

I remember so clearly the day I tentatively told my parents that I wanted to read modern foreign languages at university. They were worried that there were no job options for language graduates unless you wanted to be a teacher. I guess it was just a lack of knowledge on their part about how the job market works, having only ever been exposed to a very limited variety of professions, but I was only 17 at the time so I believed them. My own ignorance about the working world frightened me, and I thought it best to follow the advice of my elders. They actually recommended dentistry at first, but I was not taken with the idea of looking into people’s mouths (I admire my dentist uncle for being able to stomach it!)

So medicine it was. I applied enthusiastically, and a few months later, got offers from Bristol Medical School and Leeds Medical School. Cambridge turned me down, to everyone’s dismay but mine. I had secretly sabotaged my Cambridge application by opting for one of the colleges with the fewest places available for medicine in the hope that I wouldn’t get in. I didn’t want to go to Cambridge – I had only applied to Cambridge in the first place because my teachers thought I should, such was my need for approval.

I have to state here that I do not blame my parents or teachers for advising me as they did. The told me what they knew and helped me to the best of their ability. It was just unfortunate that it didn’t work out.

The first two years at Bristol were what we knew as ‘Pre-clinical’, as they were devoted to pure science. There was a small amount of clinical teaching thrown in, but it was mostly hard core lectures on Anatomy, Biochemistry, Physiology, Epidemiology, Embryology and other subjects I slept through.

As time went by, I began to miss feeling academically brilliant. When you go to medical school, you make the unpleasant transition from the top of your class at school, to feeling like a very small fish in an incredibly intelligent pond. Oh yes, I had been good at science at school, but here were people with eidetic memories, with natural mathematical flair, with research skills I could only dream of. I felt very mediocre. I never failed an exam, but I always got a ‘Pass’, and never a ‘Distinction’ like the brightest students in my year. I worked very hard, and envied those lucky few who seemed to go out clubbing every other night and still did better than me! I began to doubt my intelligence.

I had a very difficult patch in second year, when I felt so unhappy that I went back home to my parents, determined to give my studies up altogether. I am actually very glad they turned me round and sent me back again, because at this point it was the stress of exams that was getting to me, rather than a desire to change careers. Going back and getting the pass mark helped me to appreciate how resilient I was.

I was also reassured by the people around who said ‘you don’t need to be academically brilliant to be a great doctor.’ My dad was always telling me medicine was more of an art than a science, and he is right in many ways.

“It’s all very well being a bookworm, but when it comes to patients, you need people skills, compassion, detective work, communication.”

I still believe this to be absolutely true, but I miss being an academic geek.

‘Just get through pre-clinical,’ he said. ‘The clinical years will be better because you’ll actually be on the wards.’

I took a year out, as many medical students do, to do a BSc in Medical Imaging at Leeds University. I’m still a little vague on my reasons for doing this – I think I was stalling, trying to run away. I hated it. The complex mathematics and physics involved baffled me, and I came out of it with a disappointing 2:2. I felt some success when I presented my dissertation at a national conference, but the mind-numbing boredom I went through to collect the data for that project made it seem hardly worth the effort.

Then it was back to Bristol, to complete the long awaited clinical years. People were right – they were better than pre-clinical. I got to be in a hospital and see how things worked, and I got to speak to patients and their families which I genuinely enjoyed. While following the doctors around, I felt (as most medical students do) that I was getting in their way a lot of the time, but I was glad to get the chance to see what medicine was all about.

I knew however, in my heart of hearts, that I didn’t really belong in this world. There was something about it that I just couldn’t get on with, but it was difficult to express that to my tutors. ‘Just finish the clinical years,’ they said. ‘It’ll be better once you’re working.’

The clinical years went by. I was lucky enough to be at Bristol Medical School at a time when they ran an Erasmus exchange for medical students, and got to spend six months at the Université Pierre et Marie Curie in Paris. My professors warned me that my exam marks would most likely drop when I got back due to the fact that I was going to a different country, with a different language, different medical school, different curriculum and completely different way of doing things – but I didn’t care. I just wanted to speak French. That should have been a massive warning sign right there, but I didn’t see it.

‘Just do your Finals,” I told myself in the mirror, “Then at least you’ll be qualified.’

I still held onto the hope that actually being a doctor would wash away all my doubts, that somehow things would be different, and I would be different. And with the recession biting, I was glad to have a secure job waiting for me at the other end of university.

I sat Finals. I qualified. I got my first choice of job in East London. I still didn’t feel complete.

‘Just finish FY1, at least then you’ll have a full registration.’

I started my FY2 year. Things were getting worse. I was becoming deeply unhappy. I wanted to leave.

‘No don’t leave now,” said my supervisor, “Just get into a specialty training programme. Do your exams, finish your training and become a GP. It’s only three years. Then you’ll be a completely qualified GP and stand in much better stead.’

Three years of misery would stand me in better stead for what exactly?

I know my family, friends, tutors and colleagues have meant well with their ‘just finish’ advice. They want me to be in a good position and credibility in life, and I do too. The ‘Just Finish’ mantra has come as much from my own voice as it has from others, and I have learned much from my experiences. I wish I hadn’t done a BSc that was so wildly at odds with my entire personality, but I am glad I finished my medical degree. It was tough, but it was an achievement, and a great degree to have.

However, there comes a point when it has to stop. I have jumped through hoop after hoop, hoping there will be something good on the other side, convincing myself it will be worth it, but each time all I can see are more hoops and more exams, and each time I become more exhausted and disheartened. It is easy to stay on the conveyor belt in medicine – to keep going for the sake of keeping going, to do the next thing simply because it’s the next thing to do, and not because you really want to. I don’t want to look back one day and wonder how I got there, having been so obsessed with the destination that I forgot to enjoy the journey. I don’t want to ask myself one day why I spent my youth doing something for everyone else but me.

I was planning to finish my FY2, but then I got sick, very sick. As I was lying in hospital contemplating my attitude towards the future, I realised I had subconsciously assumed that I would have plenty of time to do the things I wanted to do, and that the people around me had reinforced that idea in my head by saying things like, ‘you can study your languages when you’re pregnant and have nothing else to do’ or ‘you can write your novel when you’re retired.’

My illness made me face the idea that I may not have a tomorrow. It sounds melodramatic, but it’s true. I began to think about the things I wished I’d done, and finishing my novel was one of the things that stuck out so strongly in my mind. Was I going to slip out of this world with that story untold, those precious words unspoken? Time was suddenly precious, and unbearably limited.

I am aware that finishing my FY2 would make it easier for me if I come to regret my decision to leave, and eventually come back to medicine. My supervisors are going to say that when I come crawling back to medicine, my current deviance will make it harder to find a training post, look bad on my CV, maybe even prevent me from practising again without some sort of retraining. They will berate me for having no plan B. Is this bravery or madness? Who knows.

It’s also going to be really hard to tell my parents.

Once upon a time, these arguments scared me, but not now. Frankly, I do not believe I will ever come back. Medicine is a wonderful and noble career, but it’s not for me. I’ll be scribbling stories, dabbling in poetry, brushing up on German grammar, grappling with Sinhalese vocabulary and maybe discovering Spanish, Italian and Hindi.

And one day I will be back in Paris, gloriously unfinished, and speaking French.

My best friend and I in Paris.
My best friend and I in Paris.