Happy Birthday, NHS, and Thank You

In July 2011, I was working in a hospital in Mwanza, a city in northern Tanzania — I was a fourth year medical student on a short elective placement, taking a period of time to experience healthcare in another country before my final year started and with it finals and job applications. In my brief time in Tanzania, I fell in love with it; with its land and people and culture; and in return it taught me a huge amount about a world wider than I’d known existed, and about my own privilege and the things I’d been taking for granted for the past two and a half decades.

On my last day, my supervising consultant asked me about how healthcare works in the UK. I explained it to him in, more or less, the words of the leaflet that was sent to all UK households in the lead up to July 5th 1948:

“It will provide you with all medical, dental, and nursing care. Everyone — rich or poor; man, woman or child — can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness.”

He asked a few questions about how it worked, about how the tax system worked, about what happened to the young and the retired and the sick and the unemployed. I tried to answer his questions. I quoted the principle that those of us who champion the National Health Service hold to be true: the principle of a system of universal healthcare, delivered free at the point of need.

He said with a kind of wonder: “But that’s a marvellous thing.”

*

It is a marvellous thing.

The NHS is a marvellous thing that until that point, that day, I had been absolutely sure of and had taken absolutely for granted, like the sun coming up.

And today it celebrates its seventieth birthday.

There’s been a cultural shift in the years since I returned home that summer, seven years ago. The shift of government to be meaner, less welcoming, more inward looking. The elevation of voices that are hostile to evidence and expertise, and the collateral silencing of experts and professionals. The consequences of austerity. There was a time in my adult life when I never thought I’d have to fight for the NHS. There are days now when that seems as if it was an awfully long time ago.

I have had reason to be grateful for the National Health Service for many years — among other things, I am the daughter who only ever had a father because of a kidney transplant performed by the NHS and the child who is alive because of maternal and neonatal services provided by the NHS. But my reality is also that as an adult, I have experienced the NHS almost entirely as a doctor who lives her life at the coalface of medicine.

That changed earlier this year.

There is a story to be told here. It is a story that has been told in waiting rooms and during difficult phone calls and alluded to piecemeal on social media. It is a story that I’ve been needing to tell in its fullness, and today seems the time to tell it.

This is the story of my mum’s death.

And it is also the story of how I ended up in the cafeteria of a strange hospital late at night, thanking God and Nye Bevan for the bold and miraculous hope of a system of healthcare for everyone, paid for by everyone, and delivered free at the point of need.

*

On January 31st, 2018, my mum celebrated her sixtieth birthday. It was a Wednesday. I was at work. I’d sent her a card and flowers. I checked my emails at lunchtime, and had one from her letting me know the five person dinner she had planned for that weekend had grown somewhat in the planning of it and that I should plan to make chicken curry for twenty people. I rolled my eyes and sent her a shopping list (“chicken breasts — enough for hungry people”). I arrived in Newcastle that Friday evening, and we had a nice evening and a nice Saturday together, watching television and fantasy house shopping on the Internet and preparing food. For once, we managed not to have a row about anything.

A few hours before her guests started to arrive, she started to feel breathless. She had had asthma for most of her adult life, and had had a bad winter of coughs, colds, and chest infections, but had been well for the last week or so, better than she’d felt in months. She was adamant that she didn’t need to see an out of hours GP or go to the emergency department — after all, people were coming. She would use her inhalers and have a lie down and be fine.

She wasn’t fine.

It eventually became clear even to her that her salbutamol inhaler wasn’t going to do the job this time, but by that time she had become so short of breath she wasn’t able to speak more than a few words and she wasn’t able to stand up on her own. And, of course, by that time, her living room was full of people. As I was dialling 999, she was still trying to find the breath to ask her sister if she was sure it was okay for her to go to hospital when there were all these people in the house expecting food and a party.

Paramedics from the North East Ambulance Service arrived with lights and sirens, and for a little while it seemed as if it all might settle down with a nebuliser and some oxygen. My memories of the next few minutes are incoherent and are in flashes: from her oxygen levels starting to climb, to her being on the floor with her head between my knees so I could help manage her airway until extra hands arrived, to another four paramedics thundering up the stairs, to us being kicked out of the room, to the moment when I heard someone say that they had lost cardiac output.

And that was when I was unwillingly thrust into a role that I’d never prepared for: being someone whose role in the massive machinery that makes up the NHS was to be not the doctor. The last time I had been at work, which at this point seemed like a lifetime ago but was in reality only two days earlier, I had been the cardiac arrest team leader. Now, I was the relative. I was the person panicking on the other side of a wall, waiting, waiting, waiting, with my aunt and my stepsister and my mum’s husband, and I was listening to someone else run my mum’s cardiac arrest in the next room. I had sent a text message to my family back in Glasgow when I’d left the room, which meant I had a timestamp, and, let me tell you, when you’re a healthcare professional who’s listening to someone else do CPR on someone you love, a timestamp is the worst imaginable thing to have. Because I knew when it had been twenty minutes, and when it had been thirty minutes, and when it had been forty minutes. And I can’t turn off the part of my brain that knows what it means when someone hasn’t had a cardiac output for forty minutes, even if they have had the best possible quality CPR anyone could ever have had. There were nine paramedics and a doctor in the house by that time, not counting me. I couldn’t turn that part of my brain off even when that someone was my mum.

When they got her back. When they carried her down the stairs of the house I grew up in. When we all breathed again, for a few minutes. The thing I remember about it was that the first paramedic came back, to make sure that all their mess had been cleared up and that we wouldn’t come home to find syringes or Guedels on the floor. And when I tried to thank her, she said to me, “It isn’t over yet.”

My mum had exemplary care after she left her house that night. She was taken to the resuscitation room in the emergency department, and then almost immediately to the intensive care unit. My family and I were told exactly what was happening. I don’t think any of us slept when we left the hospital, but I don’t think any of us doubted that she was being left in safe hands and given world-class healthcare.

The days that followed that night were some of the longest of all our lives, but we never had reason to doubt that.

The life of an ICU visitor is a strange one; it exists in its own part of the time-space continuum. I had never spent any significant time in a high dependency area of a hospital in a context that didn’t involve me carrying three bleeps and a jobs list the length of my arm. It turns out that for other people, time in those parts of a hospital is about waiting, and watching, and wondering. It was about all my family — my family of origin, the ones who had already been there, and my other family, the ones who’d dropped everything to drive to me from Scotland when they got that first text message — camped out in a corner of the waiting room, telling stories and drinking too much hospital coffee and waiting for news. It was about sitting on my hands so that I would stop trying to react every time something bleeped, and getting to know all of the nurses, and trying not to think too hard about what I thought I already knew.

We waited for four days.

Do you have any idea how much an intensive care bed costs for four days?

At the end of the fourth day, we were given the results of the investigations she had had to determine how much of her brain function had survived when she had had an out of hospital cardiac arrest on her bedroom floor.

The answer was: not much, not enough to be taken off a ventilator, not enough for her to ever have anything like a meaningful recovery.

It’s like I said. I hadn’t been able to turn off the part of my brain that knew what it meant when someone hadn’t had a cardiac output for forty minutes. Not even when that someone was my mum. Maybe especially because that someone was my mum.

In the next 24 hours, she had some of the highest quality palliative care I’ve ever had the privilege of witnessing. She had time for everyone who loved her to come and see her, to say the things they needed to say. I spent part of that time telling her that I wasn’t sorry about the times we had argued; just because she was dying didn’t mean she hadn’t been wrong all those times. She would have expected nothing less of me. As a family we asked to explore the possibility of organ donation; something that ultimately wasn’t possible but that the transplant coordinators did their best to facilitate for us and for her. She was comfortable and looked after, and there was nothing that was too much trouble for the nursing or medical staff. In the dark hours before dawn, I remember being brought a cup of coffee by Sister and her apologising that it was too strong. “Don’t you dare apologise, it’s 5am, it’s fantastic,” I said.

My mum died a little after lunchtime on Friday 9th February, peacefully, with dignity, surrounded by the people she had loved.

*

I have a lot of memories of the week before she died. I’ve written here about only some of them.

One of the things I remember most clearly is from just 24 hours after she was admitted to hospital. I was sitting in the hospital canteen. I was alone for a few minutes. My memory is in some ways the answer to that question about knowing how much an intensive care bed costs for four days, because the answer is that I don’t know, and that I still don’t know.

My mum had the best possible chance at life and the best possible death, and all the way through she had access to the best healthcare in the world.

It was free at the point of her need, just as it had been for her whole life. We have been charged no money for the care she had. We will never be sent a bill or expected to write a cheque.

That moment in the canteen of the Royal Victoria Infirmary was when I thanked God and Nye Bevan for the bold and miraculous reality of the NHS.

*

On July 5th 1948, the Secretary of State for Health visited what is now Trafford General Hospital and met the first patient of the National Health Service, a thirteen-year-old girl called Sylvia Diggory. Later, she said, “Mr Bevan asked me if I understood the significance of the occasion and told me that it was a milestone in history — the most civilised step any country had ever taken.”

It isn’t perfect. There are things that we can do better. There are always things we can do better. There are things that go wrong, and those things should be taken seriously. There are days when working in it the whole enterprise feels as if it’s held together with a piece of string, the power of cake, and the goodwill of its one and a half million employees.

In spite of that, I still believe that it can be everything that Attlee and Bevan wanted it to be; that it is an aspirational thing that at its best represents the best of us.

And it is worth me saying this:

That my mother and I agreed on nothing, politically, but this, this we agreed on.

I work for the NHS. I will always work to make it better, to make it into the best possible version of itself, and I will always work against the unscrupulous and uncaring whose only goals are devaluation and privatisation.

But today the National Health Service celebrates its seventieth birthday, and all I am today is grateful for everything it stands for and for that week when it was a very real light in the most terrible darkness.

It is a marvellous thing.

It is a miracle.

And it can and should be the very best of us.

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Reflection for Good Friday

Who would be there for you on the worst night of your life?

The events of the Thursday and Friday of Holy Week always take me by surprise. Always.

There’s always something about starting on that road to Jerusalem — the celebrations, the dinner with friends, the joy and laughter, on a bright sunny day when the streets of Glasgow are become the streets of Jerusalem, when you can’t even begin to imagine what is coming next.

Two months ago tonight, I was driving to England. It had been a bright, sunny day — the kind of day that comes in late January, when you start to believe that spring is a thing that might happen someday. “It is sunny, and I have had hot coffee, and I am spending my day in good teaching. Life is quite excellent,” I’d said on Twitter. That evening, I had got in my car and set off on the journey to Newcastle to celebrate my mum’s sixtieth birthday with her and her loved ones.

I didn’t know what was coming next.

The next day, I drove her to have a haircut for her party, and frantically ordered same-day delivery flowers because the hat I was meant to be knitting for her was as yet tragically unknitted, and I stirred the huge pot of curry she always asked for whenever I’d be cooking, and I still didn’t know. And when her family and friends flooded into the house to begin the celebrations — cake, presents, fizz — none of us knew what was coming next.

The celebration descended into hours of chaos and terror, as sudden illness took hold and blue lights lit up the sky and the bottom dropped out of all our worlds. It brought us to a long watch in an emergency department and in an intensive care unit, as evening gave way to night and night broke into the thin grey light of a winter morning. A few days later, when it had become clear that nothing more could be done, in a room with people she loved, came death and the beginnings of an ununderstandable grief.

This story of the things that happened in Jerusalem two thousand years ago is all a little bit real, this year.

The story of the Passion is about a lot of things.

It’s about a man who wanted to make the world a better place. It’s about the choices we make, and the lives we choose to lead. It’s about learning what bravery looks like, and that the right thing is not the same as the easy thing. It’s about enemies reconciled, friends forgiven, and strangers made welcome. It’s about that there are indeed worse things in the world than no longer being alive.

I’ve often thought about those things when I’ve come to the cross on Good Friday.

But this year, the story of the Passion for me has been about that one question:

Who would be there for you on the worst night of your life?

On the nights when you wrestle with questions about life and death, and you don’t have any of the answers. On the nights when everything that has happened in the last 28 hours — and has it really only been 28 hours? — is right there every time you close your eyes but also doesn’t make any sense. On the nights when you haven’t slept, and you can’t stand up straight anymore, and your only prayer is a howl into a vast wilderness.

I was sitting at the back of church last night, after our gorgeous and joyous festival had descended into chaos and terror, and I was thinking about that question.

Because the story of the Passion is the story of the people who are there on those nights.

It’s about people who get in their cars and drive through the night without asking, and without hesitating. It’s about people who will take on the task of making food, and making tea, and making sure that everyone is looked after, and who are surprised when you try to thank them.

It’s about nine paramedics, and a resuscitation team, and the staff of an intensive care unit. I’ve seen the face of one of them over and over again in my mind’s eye these last two days. Her kindness and her ferocity. I’ll never know what her name was.

It’s about the people who prop you up when you might fall down — even when they have to do it from the other side of a border buried under snow.

And the people who are there to hold your hand, right until the very end.

And the ones you come home to when it’s all over.

Those people were in Jerusalem, too.

They were there in Simon, and in Veronica, and in Joseph, and the ones who stayed, right there at the foot of the cross, right until the very end.

This is the story of the that week in Jerusalem, and of our lives right here and right now.

It’s a story of the family that we choose for ourselves.

And a story of the kindness of strangers whose names we don’t know but whose faces we won’t forget, who stepped in and became part of our story, and, even in our grief, made it better.

There are stories worth telling. There are truths worth living.

This is one of them.

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Photo: Kelvin Holdsworth

Response to the Primates’ Meeting

With a tiny sigh, I foresee that the coming hours and days will be filled with headlines about the Anglican Communion being “fractured” and the Scottish Episcopal Church being “punished”.

Indeed, first thing this morning, my phone pinged with an email alert:

“Scottish Anglicans face harsh punishment for gay weddings.”

All deeply wrong.

Let’s start by putting things in their proper historical context. The Scottish Episcopal Church can trace its roots back to the arrival of Columba on Iona in the sixth century AD. We have existed in our modern form since 1689. We have been forged over the past four centuries by scarier things than Primates’ Meetings, for goodness’ sake; just Google “Jacobites”.

That headline came before anyone in the Primates’ Meeting had even said anything. And has been proven to be untrue once they did. You’ll forgive me if I didn’t start quaking in my shoes.

So, let’s try to unpack a little what has actually been happening in Canterbury this week.

There is a meeting of the Anglican Primates, which began yesterday and which will run until Thursday. It is a meeting that happens occasionally, and is an opportunity for the leaders of all of the Anglican provinces around the world to talk and listen to each other. The agenda this year is broad-ranging, including issues of evangelism, social inequality, and climate change. There has also been a conversation about the Scottish Episcopal Church, around the decision made at our General Synod earlier this year to change our Canon Law to allow for marriage equality within our Province. That happened today. This conversation has not come as a surprise to us — a similar one took place at a Primates’ Meeting shortly after a similar decision was made by the Episcopal Church in the United States of America, with the result that various “sanctions” were applied to ECUSA. That happened in 2016 and our brethren in America remain very much part of the Communion — the service of Evensong held at the Primates’ Meeting yesterday was led by their Presiding Bishop Michael Curry. It has never been in question that the Scottish Episcopal Church would remain part of the Anglican Communion, no matter what was said or done in Lambeth this week.

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Photo: Ruth Richards-Hill, used with the permission of Rosemary Hannah and Sophie Agrell.

The outcome of the Primates’ conversations around the Scottish Episcopal Church has been the application of very minimal sanctions. We are excluded from doctrinal debates, and we may not chair committees within the Communion. These are broadly similar sanctions as those that were applied to ECUSA in January 2016.

They are what we expected. No more. No worse.

We are given to understand from things that have been said to the conservative Christian press that demands were made by some primates for Scotland to be given more punitive sanctions. Justin Welby should be praised for holding a firm line against those demands, but at the same time it’s difficult to see that there was any other pragmatic option.

We take the Primates’ Meeting seriously — as seriously as it needs to be taken, which is somewhat less seriously and with a little more context than the press do.

For one thing, it would have been ludicrous to suggest that the Scottish Episcopal Church embarked on the process of introducing marriage equality in the Church with anything less than a full and keen knowledge of the consequences that we might bring down upon our own head. The story of the long campaign to make same-sex marriage possible in the Church is well documented within these pages and elsewhere. Those of us who have been at the sharp end of that campaign have never hung back from talking about what this might mean within the Anglican Communion, and at the same time we have been perfectly clear about what it cannot mean. For it would also be ludicrous to suggest that the Scottish Episcopal Church has not been fully aware of the considerable limitations of the Primates.

The Anglican Communion is not an autocracy lashed together by rules and regulations, with cross-provincial laws to be followed and punishments to be handed out to transgressors . The Anglican Communion is a fellowship, held together by bonds of affection and a shared history and an understanding that even the best of friends do not always agree with one another.

On this occasion, we in Scotland have come to a decision — a decision that was taken after conversation, after consultation, after much thought and prayer.

That decision has been one that not everyone in the Anglican Communion has agreed with. It has been one that not everyone in the Scottish Episcopal Church has agreed with. And we knew going in that that would be the case, which was why we worked so hard to ensure that respect for religious freedom and religious conscience were enshrined within our laws.

If only the same respect for religious freedom and religious conscience existed everywhere.

I am disappointed in the Primates’ Meeting, but I am not surprised. I am disappointed and saddened that a Province that has taken a decisive step forward in equality and justice for all God’s people is deemed deserving of sanctions and a place on the naughty step, while Provinces are allowed to go unsanctioned and unchecked when their leadership supports and defends the state-sanctioned murder of LGBTQ+ people in their countries. And though I praise him for his doubtless moderating influence today, I still believe that Justin Welby could learn a thing or two from Scotland about speaking truth to power and being prepared to live with the consequences.

Mark Strange, the Primus of the Scottish Episcopal Church, said to the Primates’ Meeting today: “We will continue to play our part in the Anglican Communion we helped establish and I will do all I can to re-build relationships, but that will be done from the position our Church has now reached in accordance with its synodical processes and in the belief that Love means Love.” His full statement is available on the SEC website.

We are very proud of Bishop Mark here. Do not think for a minute that any decisions taken in Lambeth today make the Scottish Episcopal Church any less the Anglican Communion.

And nor should we make the mistake that the Archbishop of Canterbury did this week in GQ magazine of believing that the differences between Western Anglicans and Anglicans in the global South are a black and white issue.

In my speech to General Synod in June, I reminded Scottish Episcopalians that there are people beyond our borders who have cheered us on, who have prayed for us to shine a light into the places on Earth where our LGBTQ+ brethren and their allies live and too often die under the darkness of systems that oppress and persecute. I told them that we do a disservice to our sisters and brothers around the Communion when we presume that they are of one mind any more than we are of one mind, and that we do them a disservice when we believed that if we kept our mouths shut we would be keeping them safe. I called on them to do better, and do better they did.

In the next few days as I read the stories that a scandal-hungry media will produce about the gloomy portents and doomsday scenarios for the Anglican Communion, stories that will no doubt be fed into by some clergy who ought to know better, I’ll think of the Anglican Communion that I know and that it’s convenient for them to be blind to. I’ll think of the baptisms that took place in my cathedral this weekend, Scottish babies and African babies together. I’ll think of the marriages that have taken place before our altar and in the sight of God. I’ll remember the great group of the Nigerian community, many of them first generation immigrants, who have become part of our community, and who gathered together joyfully on Sunday with their families on that same altar for a blessing from their gay, fabulous, Scottish priest.

We are the Communion. We are the people of God and the living, loving, world-changing body of Christ. As we have been called in our task to the Church here we will still be, tomorrow and tomorrow and unto the ages of ages.

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Photo: Beth Routledge

Angels

There is a story about a great holy war. There was a battle between the angels and a dragon, and the dragon was slain.

It is a glorious thing always when St Michael and all his angels come down to Great Western Road.

Today, we gathered people from all corners of the Anglican Communion, even Edinburgh, around one table. We welcomed three brand new small people into our community. We celebrated Nigerian Independence Day. Amid a great cloud of smoke and a blast of music, we ordained a young and faithful soul into the diaconate. There was a real live dragon too.

But the dragon was slain.

And when all the noise and joy and razzmatazz had died down, we looked back through the darkened church and there she still was.

A reminder that good is stronger than evil.

That love is more powerful than hate.

That light can never be defeated by darkness.

And that so long as there are people who have the courage to fight by their side, the angels will always win.

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On An Anniversary, A Letter To My Love

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One day in the middle of September 2007, I woke up at half past four in the morning and set off from my parents house to catch the rail replacement bus service to Scotland.

My application to the University of Glasgow had been on the flimsy grounds that Scotland was one of the few places to have not yet turned me down, and I had accepted their offer on something not much more than a whim. I arrived in the city in the still early hours of that Sunday morning to an already autumnal chill and a sense of not quite knowing what I’d got myself into.

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That was ten years ago today.

In New Zealand, the Maori people have a word, “turangawaewae”. Its literal translation is “a place to stand”, but there isn’t really a word for it in English. It means our places of being. The places where we feel connected to and the places we are empowered by. It is about how we choose to define ourselves. It means belonging and tribe. It means home.

So, here’s to you, Glasgow.

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My dear green place.

To your streets and bridges and waterways.

To the place where I found out who I am, and where I’ve learned to be who I want to be.

To strangers who became friends. To friends who became family. To the people who have made it worth it.

To tears and laughter and memories.

To the mountains and the air. To the spires on Great Western Road. To fish and chips on the beach in Largs. To the sun that shines on Loch Lomond. To the burning orange sky setting over the Clyde and rising from a hospital window.

To battles fought and won. To battles still to fight. To a world changed.

To the city that people make, from one who was taken in and made one of its own.

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My heart belongs to you.

Review: This Is Going To Hurt

Last month, I got my hands on a pre-release copy of This Is Going to Hurt, the medical memoirs of Adam Kay which were published this week.

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It had landed on my doormat when I arrived home on a Monday morning after my first set of nights as the medical registrar, which was also the first weekend after August changeover and therefore my second shift working in a hospital so unfamiliar that on leaving induction two days earlier I had driven nearly as far as the ferry terminal to Troon before I realised that this probably wasn’t the road back to Glasgow. I left the book on the kitchen table, changed my shoes, and went in search of breakfast.

The next day, my day off for catching up on life admin and grocery shopping and for getting my body clock turned the right way up, I sat down and read the whole thing in one sitting.

Adam Kay is a writer and script editor of comedy. In a previous life, he was an obs and gyn registrar and is known to medical students all over the country as one half of Amateur Transplants. This Is Going To Hurt is taken from the diaries kept in his years of junior doctoring.

Now, the memoirs of doctors are ten a penny these days. We are required by our training boards and the GMC to reflect on our practice, and I suppose some of us think we may as well publish it. It would be disingenuous of me to say otherwise; you are after all reading my blog. I’ve read some of the ones that made it into book form, the oldest of which was published in 1992. (I have never read House of God.) I’ve liked some more than I’ve liked others. (This is unsurprising. I like some of my colleagues more than I like others.) This is the first one I’ve read that has made me want to invite it over to Sunday lunch with my four best loved doctors, and that is among the highest compliments of which I am capable.

My affinity with it exists on a number of levels.

It knows the value of a good footnote.

It’s written by someone who plainly loved his job and was good at it. (I realise that you might then ask why he left. That isn’t my story to tell.)

It’s funny and friendly. It reads as easily as a colleague telling me stories about their week, which I suppose is what it is. It contains at least a dozen anecodotes that sent me into a tailspin of, “oh, remember that time…”, which is the hallmark of good medic chat. Fair warning, one of those anecdotes contains a vagina, a railway spike, and Newtonian inevitabilities.

And it would be disingenuous of me to not admit that at least part of my affinity with this book comes from having read it just exactly when I did. Adam writes about what it’s like to be on nights, “sailing the ship alone: a ship that’s enormous, and on fire, and that no one has really taught you how to sail.” He writes about how as House Officers we all think that our registrars are geniuses, “like God maybe, or Google”, and the horrifying moment when, “before you know it, the registrar is you.” He writes about how as the senior on call he couldn’t sit down, but would “prowl anxiously around labour ward, flitting from room to room asking ‘is everything ok?’” It is a strange and immersive experience to read a book like this immediately after a weekend like the one I’d had. I kept thinking, “YES THIS ALL OF IT ALL WEEKEND,” and then looking up to say it out loud, only remembering after I already had that no one was actually in the room. The job I do is nothing like being an obstetrics registrar, apart for in all the ways that it’s exactly the same.

The existence of the book owes itself at least partly to the Secretary of State for Health. In his epilogue, Adam writes about the Conservative government waging war on doctors and his own realisation that everyone who works or has ever worked in healthcare needs to shout about the reality of the work that we do. His acknowledgements include no thanks whatsoever to Jeremy Hunt.

It isn’t a book about politics, except in the sense that we live these days in a time and a place when to tell the truth about being a doctor is a political act. For those of us who believe in what Nye Bevan believed, there is no option to be apolitical about healthcare. And there is no such thing as “just politics”, for, please, if the next generation learns anything from ours let it be the inconvenient truth that “just politics” was always a lie.

This Is Going To Hurt is written by Adam Kay and published by PanMacmillan. It is available now.

Sitrep, One Month In

It’s been just about a month since I started this job.

That’s four weeks since the night I drove to work reciting ALS algorithms in my head, and four weeks since I read a management plan that had been written by a nurse practitioner and got to the part that said “medical registrar aware” and got the giggles when I realised that they meant me. This weekend, I managed for the first time to tell someone I was the med reg without automatically putting a question mark at the end of it. It was only because I was trying to persuade them that I wasn’t the nightshift coordinator. I was neither of those things. I was trying really hard to go home.

The rest of you are all all right? FY1s, I’m mostly looking at you.

You’re okay? You’re eating and sleeping and going home? You know where to get help when you need it? (If you aren’t. If you don’t. If you just need to unspool for a little bit. My comments and contact inbox are open.)

For me, life at present can be summarised like so:

1) I haven’t been so consistently and thoroughly exhausted since the beginning of my FY1 year.

2) I’m buzzing. I have my tribe. I chose well.

3) I am really really glad I had a renal job in CMT.

Glasgow Pride 2017: Changing The World

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Photo: Beth Routledge. Badges: Kelvin Holdsworth.

One ordinary Thursday in June, my friends and I went to Edinburgh and we changed the world.

I’ve spent a great deal of time these last two months thinking about that day when the General Synod voted for marriage equality in the Scottish Episcopal Church.

This weekend, I’m going to be part of a great and glorious delegation of Scottish Episcopalians marching in the Gay Pride parade through the centre of Glasgow. I’ll be marching with clergy and laity. I’ll be marching with my LGBTQ brethren, and with the many allies who turn out to support us. I’ll be marching with people from around the Diocese of Glasgow and Galloway, and from across the Province, and from the General Synod Office. I’ve been sent with messages of support from the congregation that I represent, as well as friends around Scotland, friends from other provinces, and ecumenical and interfaith friends. This year as I march, I will remember particularly that we march with the personal blessing of the Primus and of each and every Bishop in the Scottish Episcopal Church.

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Photo: Gordon Smith

The world has changed so much since the first time I went to Pride.

It is not quite a decade since I met up with four other Scottish Episcopalians on a damp Edinburgh afternoon to march at Pride Scotia, our first one. It was just the four of us, and a couple of umbrellas that were losing the battle, and a vague notion that the Scottish Government might be persuaded to introduce legislation for what we then called gay marriage.

A few months earlier, I had got myself involved with the petition for that legislation. A group of people from St Mary’s Cathedral had taken clipboards and gone up to the University and told people that we were campaigning for equal marriage rights for same-sex couples, and we had been a little taken aback when everyone wanted to sign up. A friend and I had said to each other, “It won’t ever happen, but we have to try anyway.”

In 2008, there weren’t a lot of countries that had even thought about what we now call equal marriage. I have this idea that one day when I’m old and grey I’ll tell this story to people who aren’t born yet who simply won’t comprehend that, but it is the truth. It simply wasn’t a thing.

But as the law went through the process of being debated and voted on in the Scottish Parliament, the idea started to take hold on an international level. My involvement in this campaign in Scotland and the Scottish Episcopal Church has spanned a time that saw the New Zealand parliament singing a Maori love song, and all of Ireland going home to vote, and the interns delivering the news on the steps of the US Supreme Court, and the day it was made the law of the land in Westminster in the country I was born in. It was a time that felt as if the beacon of equality and justice was lighting up the world. It was also a time when we started to notice that Pride seemed to be getting bigger. We were still a ragtag group, but a larger one, and now we had our own banners. The first year we had banners, I made them with felt tip pen and sticky tape on my floor on the Friday night.

And it was during that time, while it was still being debated in Holyrood, that the time seemed right to start making some noise in the Scottish Episcopal Church.

We still didn’t believe it would happen in the Scottish Parliament, mind you, but the Church was being asked to give its opinion and we thought that if we were giving opinions then we might as well be honest about it. If marriage equality were to become the law of the land in Scotland, there were members of the Church who would want it to be possible in church. That was our truth. And so it began.

Said the same friend and I to each other, “This won’t happen, either. But we have to try anyway.”

I still believed that in June. I still believed it in the coffee break between the vote and the result on that ordinary Thursday, and I still believed it as the votes were announced and I did frantic maths. I believed that this day would never come.

Why am I telling this story on the evening before Glasgow Pride? Why am I dwelling on a time when I thought we were going to lose?

I’ll march at Pride this weekend, and I’ll be proud of who we are, and proud of what we did, and proud to stand behind a banner that proclaims to all the world that the Scottish Episcopal Church Welcomes You, and proud that I can say, and mean it, “Yes. Yes. You.

But the thing I will be proudest of all is that we thought we were going to lose, and we did it anyway.

It is a thought worth holding onto, in these days.

Because nothing that means anything comes without risk.

Because the victories worth having are never in the sure things.

Because the losing battles are the ones that need fighting most.

And because changing the world is not in the winning, but in the knowing you might not and then trying anyway.

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Photo: Beth Routledge. Artwork: Audrey O’Brien Stewart.

#tipsfornewmedregs, please

On Thursday, I said goodbye to the staff in my current medical receiving unit. I’ve worked with a lot of them for four years, on and off. I’m certain I’ll be back again, someday. I pop onto the ward at the beginning of next week for a couple of days, and then on Wednesday it’s all change.

New commute. New colleagues. New corridors to get lost in. New job.

The first Wednesday in August — as it was in the beginning, is now and shall be forever, world without end.

My final weekend before changeover will be spent doing an online induction module, building furniture, and taking deep breaths.

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This is what the inside of my brain looks like right now.

I’m pretty sure the new FY1s think they are the only ones who are nervous.

I am thirty-two years old and have a hip that aches if I sit cross-legged for too long, and yet every summer I still get ready for my first day at new school and worry if the other kids will like me.

So.

If anyone has any #tipsfornewmedregs, this would be the time.

People Make Bad Choices If They’re Mad Or Scared Or Stressed

All over the UK, newly graduated medical students are starting to look ahead to the first Wednesday in August and their first day as Actual Proper Doctors.

If they are anything like I was, they’ll be having increasingly terrifying nightmares about holding the cardiac arrest bleep on their first night. And getting lost. And they’re the only one on the arrest team. And they can’t remember how to do CPR. And there’s a dragon in the corridor. No? Just me? OK.

A couple of years ago, I wrote a long piece that contained practical advice for new doctors. If you are a new doctor and you are looking for bullet points on where to get help, how to ePortfolio, the unsettling but central role that half-coloured in ticky boxes will come to play in your life, and other things, that piece is here and still contains the best advice I have to give. Over on Twitter, search the #tipsfornewdocs hashtag, and remember that we all remember this and that almost none of us bite.

Today, I want to talk about something a little bit different. I want to take a bit of time to think about resilience and self care.

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The idea of ‘resilience’ is a psychological one that has to do with the capacity of the collective and of the individual for what I’ll call ‘coping’. It was defined by Andrea Ovans in the Harvard Business Review as “the ability to recover from setbacks, adapt well to change, and keep going in the face of adversity”. In the last few years, it’s developed into a buzzword in the language used to talk about and to public sector workers. The first time I became aware of it as a thing that was being said to doctors was during the junior doctor contract negotiations in 2015.

Now, the first thing to say is that I’ve never met a junior doctor who didn’t possess resilience. It is a requirement of the job. It is a requirement of getting the job. So, the second thing to say is that when the government talks about junior doctors not having resilience, they are lying.

But if what they mean is that junior doctors have proven increasingly unwilling to be actual martyrs — well, yes, that might be true, and that might also not be a bad thing.

As a teenager, I wanted to be John Carter from ER. I wanted to live all the hours in the day for my job. There is a picture of a recruitment poster for Emergency Medicine going around at the moment that invites applicants to “choose surviving on coffee and adrenaline”. It is a terrible message to send, but half my life ago it was absolutely what I wanted for myself. And even as a slightly more elderly medical SHO, there are days when that kind of thinking still has its seductive qualities. On the seventh day in a row of thirteen hour days, I can enter a mental state that is some sort of meld of beautifully Zen and utterly psychotic. I know all my patients inside out and back to front, and half the patients of the other teams, too, and I am completely on it and, look, I just live here now and I’m pretty sure that’s actually fine. (I have a bad-coffee-and-sleep-deprivation-fuelled memory of this precise thought process going through my brain, about eighteen months ago, and also I think I was skipping down a corridor at the time.)

It is perfectly possible to live like this for short periods of time. I clearly do and so do lots of other people, not all of whom are doctors. It is not sustainable. A period of work like that has to be punctuated by a period of rest and rejuvenation, or else the whole thing falls apart. I love my job, but my capacity to do it for thirteen hours a day without a day off is not infinite. I believe that that is true of any human in any job, no matter how much they might love it.

It is partly because no one has an infinite mental or physical capacity. In this job, that part of it is a patient safety issue as much as it’s anything.

It is also partly because you do eventually go home from your job, and it is at that point that you remember there is no food in the fridge and that you have no clean pants.

And that’s the part we don’t hear about enough when we hear about resilience. We don’t hear about self care: about how to keep ourselves alive and fed and sane and happy. In fact, we too often hear the opposite of that: that to do the things we need to do to take care of ourselves is selfish or lazy or uncommitted or in some way not being a team player. That is a perception that I want to challenge.

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First, put on your own oxygen mask.

Maslow's Hierarchy of Needs

Maslow’s Hierarchy of Needs. (Wikimedia Commons)

There are lots of ways to look after yourself well, and I can only talk about what works for me and what hasn’t worked for me. This is the part that is non-negotiable. You need to eat. You need to drink. You need to sleep. You need to put on your own oxygen mask first. You need to remember to go to the toilet.

I am pretty sure that if anyone had said any of that to me in the week before I started FY1, I would have rolled my eyes too. I was worried I might accidentally kill someone, not that I might forget to pee. Trust me, you will forget to pee.

The need to eat and drink and sleep is about more than keeping yourself alive. It is about that, too, of course, but it’s also because everything seems so much worse when you haven’t.

This is a crap job, sometimes — for all sorts of reasons. A tip of the hat to @DrTonyGilbert on Twitter who aptly described this as “those nights where you’ve been punched and your shoes are full of ascites and you think, ‘I could’ve worked in a bank'”. The world will be much more manageable on the other side of a good meal and eight solid hours of sleep. I’m not saying those things will fix everything, but they will make most things look a lot less dire.

So:

  • FY1s cannot live on coffee and Mars bars alone.
  • Eat breakfast. You don’t know when you’ll next get a chance to eat.
  • But do eat lunch. There are really very few things that can’t wait until you’ve eaten a sandwich and had a drink.
  • If you can get off the ward for a break to eat lunch, do that. The days when you eat with a sandwich in one hand while writing a discharge letter with the other hand will come, but they should be the exception rather than the rule.
  • Drink. If your patients’ kidneys need fluid, so do yours. The correct response to, “Doctor, Mrs Jones has only passed 30 mls of urine in the last 3 hours,” should not be, “Well, that’s more than I have.” Get a reusable water bottle and use it.
  • Meal plan. If you can make food with leftovers, you can come home from an on call shift and have a home-cooked meal in the time it takes to transfer a plate from the fridge to the microwave. This is a wonderful thing. It also means that you’re less likely to collapse on your bed and fall asleep without eating.
  • The existence of supermarkets that will provide you with ready-prepared food and people who will bring delivery food to your house is evidence of the kingdom of heaven on Earth. It isn’t sensible to live off them, perhaps, but they have their uses.
  • Comfy shoes. Get some.
  • Take care of your physical health. Register with a GP. If you are a doctor with a chronic illness or a physical disability, take the time you need to take care of that. A friend of mine, Dr Beth (no, we are not the same person), wrote a blog post recently about this which was aimed particularly at doctors who have diabetes but which I think is worth reading for everyone.

Learn how to say no.

Take your days off. Take your annual leave. If your work emails are connected to your phone, learn how to unsync them.

There will always be situations where someone needs a shift to be covered on short notice. People get sick. People have family emergencies. Rota coordinators fail to take into account the fact that the staff grade’s contract was only for six months and ended last week. You will end up being the person who covers these shifts some of the time. You do not have to be the person who covers these shifts all of the time.

At some point, you will be asked to participate in rota monitoring, where you fill in a form for a couple of weeks with your rota hours compared with your actual hours. Your Trust is supposed to use this to ensure that your rota is legal, that your department is staffed appropriately, and that you are being paid correctly. If you are asked to work differently to your usual practice or you are asked to lie about your hours, say no to this too. (However, do not expect the person from the rota monitoring department to understand your job. I gave up fighting that battle on the day one of them tried to insist that I should be leaving the cardiac arrest bleep behind when I went to eat lunch.)

Likewise, there will always be work that needs to be done outside of normal work time. This will sometimes be valuable, and sometimes not. Like the online induction module that even as I type I am side-eyeing in my learnPro account, which will take time that I could instead have spent learning something about cardiology before I commence my six month cardiology rotation. The point is, there are exams, and ePortfolio, and quality improvement projects, and things to read and learn. This isn’t entirely a bad thing. It is part of what being a professional is. But develop some sort of system to deal with it so that it doesn’t end up taking over your whole life, because it absolutely will if you allow it to.

Don’t forget to look after your mental health, too.

There are lots and lots of doctors who have mental illness. It is not a shameful thing. It is not an unusual thing. Don’t ever let anyone tell you otherwise. You will not be the only doctor who takes medication to maintain your mental health, or sees a counsellor or a psychiatrist or goes to therapy. Do what you need to do to keep well, just the way you do for your physical health.

If the above does not apply to you, don’t presume it never could and don’t ever be ashamed to ask for help.

My sanity has been saved — so many times and in so many ways — by having brilliant friends.

If you are struggling, please talk to someone.

If you think you aren’t struggling, please talk to someone anyway.

Your most readily available resource is your colleagues. You may not have met your fellow new FY1s, yet, but you will become each others’ most reliable support. (The thing about getting off the ward for lunch if you can? It’s even better if you can get lunch together.) There is no one who understands this weird job like the people who are going through it with you. Use your seniors. Your educational supervisor is there to support you, not just to tick boxes on your ePortfolio. If they aren’t supportive or you think they’d be difficult to talk to, there are other consultants. If that seems too intimidating, your regs and SHOs did this not too long ago and I promise most of us are nice. The administrative staff, too. In my FY1 year, it was known that our postgraduate administrator’s office door was always open for a cup of tea and a biscuit and a bit of a cry and I think we all took her up on that at least once.

You won’t be the first person to have cried in a sluice; that’s what sluices are there for. If you cry in the sluice every day, that’s not okay and please talk to someone.

It is okay to not be okay, but people won’t know you need help unless you tell them.

Do the things that make you happy.

I suppose there is a professional bit to this, about finding your niche and finding your people and not worrying when you don’t like every single rotation you do as an FY1 or even FY2. I’m pretty sure that I grew up thinking it was all “being a doctor” and I know that I have friends and family who pretty much still think it’s all “being a doctor”, but one of the brilliant things about medicine is that it’s all so very different. I think that’s all true, and you’ll do that.

But what I really wanted to say was, remember that you’re still a person as well as a doctor.

I can’t tell you what it is that makes you happy.

The things that make me happy include but are not limited to:

  • Real books
  • Sunday dinner with people I love
  • Running around the parks of Glasgow or along the Clyde with music or a podcast and the sound of my feet on the tarmac
  • The work I do in “my” cathedral
  • Taking the extra five minutes in the morning to make real coffee
  • Cats who like to give me Eskimo kisses
  • A knotty bit of Beethoven and the adrenaline rush from singing it on stage
  • Netflix and Yarn

Your list will not look like that. You will have your own list. But remember to find the time and space to do the things that make you happy.

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Listen, I am not good at all of this and some weeks I am not good at any of it.

You are about to do a thing that is real and hard and that you can never be properly prepared for, not really. For the first few months, you will be more tired than you have ever been in your life. You are going to do a job that is brilliant and terrible, and that will give you unsurpassable highs and will also completely break your heart. You owe it to yourself to look after yourself while you are doing it.

And for when absolutely everything else fails, I always keep emergency ice cream in the freezer. It’s a start.