medicine

Take AIM

Just before Christmas, I spent a weekend down in Bristol at Take AIM, a conference aimed at junior trainees who have an interest in acute medicine.

The second year of core medical training is notable for a sharp uptick in the number of times per week a person is asked if they’ve had any thoughts as to the specialty training they might consider. I tell them that I’m applying to ST3 in Acute Medicine, and they’re startled — either by my questionable life choices or my level of decisiveness, I’m never quite sure.

“Oh, and — really?” asked my most recent clinical supervisor. “Do you think I could get you to change your mind?”

I should be clear, my choice of medical speciality is hardly the first time I’ve had a questioning eyebrow raised at my life choices. My life choices have, after all, led to me sitting on the M74 on my day off looking for exit signs to Lesmahagow with my only provisions being a boot full of wedding paraphernalia, and being in the back of a Jeep reversing backwards around the corner of the shelf of the Ngorogoro Crater while the part of my brain not occupied with screaming asked if this was really how it was all going to end, and nearly getting arrested in the middle of Tianenmen Square. And those things all turned out brilliantly. So.

The raised eyebrows can be flattering, in their way, if their purpose is to persuade me out of my specialty and into theirs, which is sometimes.

But — unspeakably frustrating in another way.

At this point in CT2, some people haven’t made up their minds, which is fine: that’s why staff grade posts and taking time off from training are good things to do. I have, though. I had my time off from training, remember, and I needed an Archimedean epiphany fuelled by sleep deprivation and adrenaline, but I’m done. I’m sure. I’m not a foundation trainee who ought to be prudently murmuring about keeping her options open. I’m in, and with my eyes wide open. If my mind wasn’t changed by perpetual backshifts in a hospital that was literally closing down around me and where we occasionally had to see patients in the cupboard for lack of bed space, it is unlikely to be changed by the prospect of thirty years as an oncologist.

I know when I was ten that I thought that a doctor was a doctor and it was all basically the same thing, but it’s not like that’s actually true.

Yes, isn’t it nice that we don’t have to all be the same thing?, I want sometimes to say.

I’ll be honest, mind: I understand in my brain why my particular thing isn’t for everyone. In my heart, I don’t really understand why anyone would ever do anything else.

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Heart and Brain: TheAwkwardYeti.com

The frustration of being a core medical trainee is that it feels — and is — a terribly peripatetic existence. I don’t yet have my tribe, or whatever the collective noun for my specialty colleagues would be. An insanity of acute physicians, perhaps. I still don’t have that, five years in. My experience is that nor do most CMTs. You sort of have to go looking for it, and therefore my weekend in Bristol was precisely what I needed.

Take AIM was the initiative of registrars training in acute medicine and has the stated intent of promoting what is a still relatively new and rapidly expanding speciality to juniors. It gets funding from Health Education England and support from the Society of Acute Medicine, and it has consultant input, but it’s still principally led and run by senior trainees — which, as someone who isn’t yet but hopes soon to be in specialty training, is a helpful thing for me, to hear from people who are in a position to tell me what the next five years of my life are likely to look like and who are willing to do it in a warts and all kind of a way. My first real contact with them was in October 2015, when I joined in an hour-long discussion on a Sunday evening on Twitter and came away from it feeling that thing you feel when you have found your people and they get you.

Bristol was like that, too, but better.

It had a bit of careers advice in it, and a bit of debunking of the more commonly held myths of acute medicine. Personally, I’m considering getting the sentence No, I’m Not Just Going To Be The Med Reg Forever tattooed across my forehead. It was also very well populated with very lovely trainees who were keen to chat about training and careers between the main sessions.

A lot of the day was education on acute medical topics. The philosophy went something like: “We are going to expect you to engage in acute neurology teaching first thing on a Saturday morning, but we are going to make sure that you are very well caffeinated for it.” That’s basically what I mean when I call them my people.

I would not dare to speak for everyone on this, as training experiences vary across the UK and everyone’s experience of their own training is different anyway, but the topics covered are ones that in my experience are covered badly, not enough, or not at all. To take an example from one of the earlier national conferences, in 2015, a session on “The Pregnant Patient on AMU”. It is not a thing that I’ve ever been taught and yet is a patient demographic that I happen upon all the time. It is incredibly exciting to me to spend a day being taught useful things by people who understand what happens at the front door of the hospital and want to help make it happen better, and that was what that day felt like. The presentations from the Bristol conference are all available online for those of an acute medical inclination, and a Storify, which includes video of a hundred people doing the dermatome dance, still first thing on a Saturday morning, has been put together of the day as told via social media.

It didn’t convince me that I want to be an acute physician; I knew that already. I think it reinforced for me that I’ve made the right decision.

I apply for a job in a month. For those of you who have been on this particualr merry-go-round with me for the last five years: Yes. Again. It’s a bit scary, this time. I remember when I was an FY1 that I definitely thought the registrars were the Proper Grown Ups. If you need me, I’ll be taking deep breaths with my head between my knees.

Have We All Survived Changeover?

*clears throat*

Doctors.

How are you all doing?

It’s just about a month now since changeover. I hope that’s time enough for you to have figured out where the toilets are, and how to get hold of psych on call in the middle of the night, and which of your seventeen computer passwords is the correct one to make a CT scan happen. It’s not quite enough time yet to have unlearned the learned response for the way to do things in your old hospital, though; your hospital, where you knew everyone’s name and you knew the protocol for prescribing vancomycin without asking a pharmacist, two nurses, and an FY1. It’s not quite enough time for your new hospital to feel quite like your hospital yet, or for you to not still feel just a little bit at sea.

FY1s, have you stopped needing to suppress giggles yet when you tell people that you’re a doctor? Are your seniors being reasonable and helpful? Are you getting to teaching? Are you remembering to eat and drink? Are you okay? If you are not okay, have you found someone to talk to about that?

I am sort of aware, FY1s, that it would be comforting if I let you believe that the confusion and weirdness of August changeover is inversely proportional to seniority and that it gets less weird and confusing after you’ve done it a couple of times, but, for many many reasons, that would be a lie.

In August, there are new medical registrars who have never had to be the med reg before. FY2s have just completed their first month of being the SHO, and that’s a big step up. All over the NHS, junior doctors have started new training programmes and been given new responsibilities and some are doing it in new Trusts or Deaneries that are entirely foreign to them and where their support networks are not. August is scary as hell. This is why we all walk around the whole month looking like Sputnik just landed on our heads. And for the record, I’ve been working in my Trust for four years and I’ve been working mostly at an SHO-equivalent level for those same four years, and August is still scary as hell. I’m a quarter of the way through this rotation, and I still have not learned everyone’s names or the intricacies of my very specialty-specific and very new-to-me computer system or how a kidney, you know, works.

FY1s, let your comfort if you need it be that every year from now until the end of time we are all in this particular period of weirdness together.

So, therefore, how are the rest of you doing? Are your seniors being reasonable and supportive? Have you found your educational supervisor yet? Have you worked out who exactly it is that you’re on call for? Are you even as we speak lost in the rabbit warren of interventional radiology in a hospital whose layout you still do not quite understand and need one of us to come let you out? (Is that one just me?) Do you need a hug?

Welcome. Pull up a patch of floor. We’ve got cookies and coffee and mutual terror and spare copies of Cheese and Onion.

A Requiem for PACES, and Alleluia

In my third year of medical school, I volunteered to help with the running of the PACES exam at one of the big Glasgow teaching hospitals. It was an opportunity to spend all day dinging a bell, to eat an heroic quantity of Quality Street, and to, between circuits, be shown some clinical findings more complex than those we were usually given in our medical school OSCEs.

In June, I sat PACES.

You may recall that the last time I wrote, I had put myself into some kind of fugue state refreshing the results website.

I passed.

And, you know, saying that, it still doesn’t feel quite real, even two weeks later.

I passed.

And — well, let me explain this, a little bit.

In the UK, one of the criterion for progressing in a medical career is to complete the necessary postgraduate qualifications to become a member of the relevant specialist “College”. There is a Royal College of Surgeons, and a Royal College of Emergency Medicine, and a Royal College of General Practitioners, and so on. The membership qualifications for the Royal College of Physicians come in three parts, of which PACES is the final part. In all, they have taken three years, untold hours, and a significant amount of actual money spent on exam fees, revision materials, and all the caffeine in Glasgow. I also have less hair than when I started.

The first two parts are multiple choice. The first part is six hours long (with a break in the middle), and I have previously described it as being not unlike spending six hours having one’s brains kicked in by a rugby team. I took it four times. The last time was in the Newcastle United football stadium, one of the stranger places I’ve ever been in the name of my medical education. The second part is nine hours long, and I sat that only once but in a room that contained no air during the hottest two days there have ever been in the west of Scotland. After 27 hours worth of multiple choice exam, I had lost the will to live but had grown very comfortable with colouring in boxes in 2B pencil.

The third part is not like that.

I think the thing that will perhaps best describe PACES is for me to say that even while in the middle of actually taking it, I was aware that I was muttering frantic karmic apologies to every single doctor at whom I had dinged that bell back when I was a third year medical student.

“You will be fine,” my consultants had been saying to me in the week leading up to it. “You’re a good doctor.” This was kind of them, but I kept reminding them that being competent at my job and appearing competent in this exam were two very different kinds of competent.

You wake up too early in the morning. You try to eat breakfast. You travel to a hospital that is not your own, and may not be exactly in the back of beyond but certainly feels like it. I went off to the conference suite of a hotel that is attached to the national specialist cardiology centre — a place that I have spent a lot of time on the phone to, but, despite nine years of living in Scotland, had never seen for myself. “This is Dalmuir, where this train will terminate,” said the Scotrail tannoy, which felt ominous. You sit in a room where time stops, making nervous small talk with the other four people who are taking the exam with you, filling in your name and candidate number on sixteen separate pieces of paper and flicking frantically through Cases for PACES as you try to remember the indications for liver transplant.

The next two hours pass at warp speed.

The basic structure is the same for everyone: assessments of communication skills and ethics, examinations in the four major body systems, and a final station two-case grab-bag of can-be-absolutely-anything. The patients are sometimes actors, but are mostly real patients who have been recruited in for the day. In my version of the exam, I was asked to take a history from a woman who I promptly blanked on half of her presenting complaint, I was asked to counsel a young man who was angry with my boss, I struggled to find anything at all wrong with the patient whose abdomen I was examining, and trying to listen for heart sounds I briefly wondered if my stethoscope had turned itself off. In the middle of telling me about his syncope, one patient, who had also mentioned that he was on a blood-thinning medication, said that he had hit his head on the ground when he had fainted. “I haven’t really,” he said when I started trying to look for a head injury. “I’m allowed to tell you that I haven’t really.” The whole time, there were two examiners, watching, scribbling things on those pieces of paper that I had painstakingly filled in back in the room-where-time-stopped.

As each of my examinations was completed, I turned to them, tried for a winning smile, and began, “Mr Jones is a fifty seven year old gentleman. He is comfortable at rest…”

In this exam, stage fright is a real thing.

A week earlier, in Edinburgh, I had sat down after making a speech to the great and the good of the Scottish Episcopal Church and said that if failing my exam was the price I had to pay for being there, it would have been worth it. (I could, after all, have sat it again in the autumn, which would have been a pain but hardly the end of the world.) Now, on the other side of it, it’s not that I’d necessarily recommend spending three days at General Synod as a revision strategy for PACES, but the experience does throw a person’s whole idea of what counts as an intimidating room into rather harsh perspective.

They go on to ask questions. I said things like, “I would want to get an abdominal ultrasound,” and, “I would expect the left hemidiaphragm to be raised on chest x-ray,” and, “Oh, hell, I’m sorry, I totally forgot to ask him about that,” and, at one point, “Well, on a SPECT scan you’d normally see, uh — ” and, screwing my nose up as I tried and failed to articulate it, drew a picture of what you’d normally see on a SPECT scan with my fingers in the air.

And then that bloody bell dings and you get the hell out of there while shouting through the door, “I’d do an ESR and a CRP, too!”

Forget having your brains kicked in by a rugby team.

“I think I’ve been smacked in the face with a baseball bat,” I said, collapsing in the car.

It wouldn’t have been the end of the world, of course, to take it again, but am I ever glad that I haven’t got to.

Is That Even A Word?

You know, there are the days when I ask for specialist advice, and I nod and I ask at least vaguely intelligent follow ups and I write down all the investigations that they want me to arrange and I say thank you and I hang up the phone.

There are days when that comes with a side of nerding that’s based in never having seen That Really Cool Thing before in real life.

And then there are days when I ask for specialist advice and they know things that are so weird that I nod and I ask follow ups about spelling and I write down all the investigations that they want me to arrange and I say thank you and then the conversation is over.

And then I say, “Soooooo, just for my own education. WTF?”

Entirely Bonkers (But All The Best People Are)

It was quarter to eleven on a Sunday evening, a year or so ago. I had spent the weekend in one of the busiest of the old hospitals in Glasgow, and a half hour earlier had finally handed over the medical receiving bleep to my nightshift colleague. I talked to one of the nursing staff, checking on the management plan for a patient who hadn’t yet come over from the emergency department with their notes.

I’d come back to my department to document a few things that existed in my head but not yet on paper. I looked over a few blood results. My post-work plans were to attend with all due urgency to the food that was waiting a mile down the road for me and my FY1 before seeking horizontalness.

And standing at the nurses’ station at the end of the thirteenth hour of my Sunday, I blinked.

“I could do this forever,” I thought. And then: I can do this for a job!

And then: “I’ve gone mad.”

I was mentally and physically exhausted, bursting with joie de vivre and exultation at the sense of a job done to the best of one’s ability. I was flying high and obviously preparing to crash. It was clearly not the moment to make life-altering decisions about my career path, and so I fetched my coat and went off to my pizza and my bed.

But over the next few weeks that thought kept coming back to me and I kept poking at it, like a bruise that won’t go away.

The remit of acute medicine is (and here I’ll paraphrase from the JRCPTB website) that it concerns the first 72 hours of assessment, diagnosis, and management of adults who are admitted to hospital with a medical illness — the definition of “medical illness” being a very broad church but essentially meaning anything that couldn’t, in theory, be fixed with a scalpel. The idea of being a person who is trained in acute medicine with a view to that being the thing they have expertise in and then does it as their whole job is a very new one. Indeed, it wouldn’t have been possible when I started medical school in 2007. In the autumn of that year, I was given a tour of the recently opened acute medical unit in one of the local DGHs and the fact that that existed was considered hugely innovative. It didn’t become a specialty in its own right until the mid-2009.

I did an acute medical job in FY1, and loved it. I did an acute medical job in FY2, and loved it. In the year I took out of training last year, I spent 80% of my working hours in a really lovely job that I honestly enjoyed and for the rest of the time did locum shifts in my old receiving unit where I bounced around like the Energiser Bunny on steroids before ending up in my car at midnight marvelling that people were actually paying me to do something that I loved so much. All the career options that I’d mulled over and not been able to settle on during FY1 and FY2 had one thing in common: the part where I’d kept saying, out loud, even, that my priority was to be able to keep doing acute medicine. My favourite thing in the world (other than chocolate, maybe) is the part of my job where I start with a completely white piece of paper. And then from various sources there’s a whole muddle of information that doesn’t make sense, may not all be relevant, and more often than I’d like contradicts itself, and I get to try to organise it into a coherent narrative and work out what to do next and, on the very best days, actually fix it. And to a certain extent all of medicine is about that, but acute medicine is about that.

And a part of the reason that that was my priority was that I couldn’t choose an organ. My internal narrative went along the lines of: “I like the idea of endocrinology but haematology is still super interesting and the lungs and heart are kind of important and do things that I’d like to know more about but the liver is cool too and the kidneys work by magic which is amazing.” My personality is best described as Definitely An Adult Physician, But Eternally Indecisive About What Kind Because The Medical Specialties Are All Brilliant.

I like getting to start at the beginning. I like unpredictability. I like that even the things that are about pattern recognition aren’t the same, because people aren’t the same. I like listening to peoples’ stories. I like talking to patients and their families, and trying to demystify things for them. I like doing simple things that make big differences. I like doing practical things. I like being busy and useful. I like lists of problems and complicated things that I can start to unravel. I like teaching. I am fond of the occasional shot of adrenaline in my coffee.

Just before Christmas, I was involved in a Twitter conversation organised by the Society of Acute Medicine. A consultant who evidently has more poetry in his soul than the JRCPTB described the specialty as, “It feels like you’re standing in the hospital’s engine room every day.”

That’s it. That’s what I want.

As someone who is not yet in specialist training, the most frustrating thing about it is the number of people who look at you as if you’re having a psychotic break when you tell them that it’s what you want to do. I get why it isn’t for everyone, I do, but it’s for me, I think. In retrospect, the most surprising thing about my epiphany at the nurses’ station on that Sunday evening was only that it had taken me so long to have it. And if I am a little bit mad, I think that’s okay. As the Cat said to Alice, we’re all mad here.

Like A Lady Doc

I’ve got a story to tell you about my Sunday.

As a doctor working in a National Health Service whose doors (no matter what the Health Secretary might have you believe) are open twenty-four hours a day and seven days a week, I work my fair share of Sundays.

This Sunday, I went to a 9am meeting and took a handover from the female medical SHO who had been on overnight. The female medical consultant, who had been there since 8am, continued reviewing the overnight admissions, I headed off to the medical wards to start seeing overnight admissions. A member of the nursing staff on the first ward that I arrived on had a message for me, to say that the female gynaecology SHO would be up that morning with her female registrar to review a patient I’d spoken briefly with them about the previous night. I spent a little time on that ward, reviewing blood results, refining treatments, and arranging to get two patients discharged home. As I left, the female haematology consultant arrived to review her patients. The rest of my morning was reasonably uneventful, reviewing patients on the wards that I’m responsible for. A female FY1 was doing some bloods when I went into my usual ward shortly before lunchtime. I raided our coffee stash, reviewed several patients, and tried to review another one but was told by the nursing staff that there was no need as a female respiratory consultant had already seen her. I stopped in briefly to the receiving unit to see how my colleagues were getting on, and was then bleeped to go see a patient in resus who it was thought might need to be admitted to the coronary care unit. I was met there by the female consultant in emergency medicine who had seen the patient initially and thanked me for coming. It quickly became clear that there was more going on than we had first thought. I spent quite a bit of time getting them stable and making a plan, and calling the female medical consultant, who was in the receiving unit having by that time started her second ward round of the day, for a bit of advice. She came down to the department to see if there was anything else that needed to be done — after all, she was also going to be the one who would be phoned at any time overnight if anything had been missed. The patient was transferred and I left the department after saying hello to a few of the female emergency medicine registrars and SHOs who were congregating for their afternoon handover meeting. In the corridor, I met the female orthopaedic SHO who let me know that a patient I’d reviewed on her ward on Saturday was doing much better. I went back to the wards and continued on with my planned reviews. In the coronary care unit, the nursing staff made me a cup of tea and fed me a sandwich when they realised that I hadn’t yet eaten lunch. I was bleeped by one of the surgical wards asking for some medical advice, and I went across there to see the patient they were asking about. As I wrote in the notes, I chatted briefly to the female neurosurgical trainee who I’d first met the previous evening with her female anaesthetic colleague when we had attended a periarrest call. And then, finally, five minutes late as usual, I ran down to the evening handover meeting where I handed over to the female medical SHO and the female FY1.

I did work with men this weekend, of course. I just haven’t mentioned them here. I am careful about what I say on the Internet, for many good reasons. This story has been judiciously and deliberately edited to not mention identifiable information about patients, or the exact nature of the curse that I uttered in a public corridor when I realised that I’d spent so long in ED that the sandwich place had closed, or the existence of my male colleagues.

This is because I got home from work to discover that while I had been working my thirteen hour Sunday, the Times had published a column by Dominic Lawson claiming that female doctors are pushing the NHS to the precipice of disaster by refusing to work antisocial hours. It’s better in the airline industry, for example, because there aren’t a lot of female airline pilots and that’s a good thing, he said, as Amelia Earhart rolled over in her grave and the 1950s called, outraged, to ask for its glass ceiling back.

I don’t know what the rotas of those women I was working with on Sunday look like. I don’t know if they work full time or part time. I don’t necessarily know that about the men I was working with, either, because it’s not only women who have responsibilities outside of their primary paid employment or find it important to have a work/life balance. I know that a lot of them will work full time, as I do myself. I don’t know if the ones who don’t are working an eighty percent job or a fifty percent jobshare or not on Wednesdays or forty hours a week — which is part time, in this job. I don’t know if they’re part time because of family responsibility or for medical reasons or because they split their time between clinical duties and teaching or research commitments. It is truly none of my business, and none of Dominic Lawson’s, either. The only thing I know for sure is that on Sunday they were all at work with me.

I feel sad for Dominic that his life so clearly doesn’t include any women who happen to be doctors.

I know doctors who are brilliant, smart, competent, compassionate, passionate, driven, committed women who work ferociously hard and who inspire me to be a better doctor. I know doctors who are all of those things and who are my family. I know doctors who are all of those things and are also raising children, and they are legends.

You will forgive me if this response is a little less than timely, Dominic. I worked 88 hours last week and then I went into work on Monday morning to keep going for five more days, and lives have needed saving and antisocial hours have needed worked and the laundry has at some point needed done so you will understand that you are not at the very top of my priority list. The kingdom of God will surely have arrived on Earth when I do not live in a society in which it continues to be relevant for me to incessantly link people to a post that I was compelled to write three years ago about why I am not a woman doctor. I’ve seen a lot of patients in the last week and a half, Dominic. My vagina — a bleeding one, at that — has at no point been an impediment to my making clinical decisions, or doing difficult procedures, or running up six flights of stairs, or breaking bad news (or good news), or crushing peoples’ ribs as I’ve tried to restart their hearts. I have intermittently been mistaken for a nurse, which happens, too often, yes, but people don’t look upon me as if they’ve just met a unicorn when I correct them and I still live in hope that the day will come that I don’t have to.

In the course of my working day, I turn up at a lot of beds and I say the words, “Hello, my name is Beth and I’m one of the doctors.” The reply has not once, not ever, been, “Oh, it’s lovely to meet you, dear, but I’d really rather see a doctor with a penis.”

All About The Glamour

If you ever find yourself thinking about going into medicine for the cars (with lights and sirens) and the booze (rx: diazepam and Pabrinex) and the women (competent women in scrubs are attractive in real life, too), remind yourself of this:

It will happen from time to time that you are eating lunch and doing paperwork, when one of the nursing staff will appear, and, via eyebrow semaphore and a series of deeply apologetic hand gestures and the fact that with the other hand they are carrying a distinctive shape covered in an array of paper towels, communicate something that, eventually, leads to you saying,

“Oh, God, do you want me to look at it?”

Not Safe, Not Fair

For the last few weeks I have been giving daily thanks for the combination of fate, circumstance, and medical school admissions committee that led to me moving to and falling in love with Glasgow eight years ago.

Because I live in Scotland, I have not been forced into seriously thinking about taking industrial action as the only viable way to save my profession. Because I live in Scotland, I do not wake up every morning feeling sick at the prospect of not being able to pay my rent come next August. Because I live in Scotland, I have dodged the bullet of the imposition of the new junior doctor contract by the Health Secretary in Westminster.

In England, my colleagues have had an exhausting couple of months. They have been devalued and demoralised. They have been accused of lacking professionalism and vocation. They have been threatened and lied to and bullied and abused. They have fought back against their bullies. And they have done it while routinely working more than twelve hours a day and working twelve days in a row, and at a time of year when most of them have been rotated into new jobs in unfamiliar hospitals in areas that will not have been entirely of their choosing.

Last night in London there was a peaceful protest by thousands of junior doctors marching on Whitehall. It was the biggest march by junior doctors in history.

They were protesting the imposition of a contract that will result in the following:

  • A pay cut to all doctors below consultant grade of anywhere between 10 and 40%.
  • An end to the safeguards in place to prevent Trusts from forcing their doctors to work what are considered unsafe hours.
  • An increase (from 60 hours to 90 hours) in the hours worked that are considered “social”, so that in effect working at 9pm on a Saturday would be the same as working at 2pm on a Tuesday.
  • A financial penalty to people who have children (thus increasing gender pay disparity), to people who change specialities, to people who choose to take time out of programme to do research, to teach, or to further their own medical education, to people who change specialties.

In July, the British Medical Association left talks about the proposed contract after it was made clear to them that they were not allowed to negotiate unless they accepted certain preconditions of it including that pay cut of an unspecified amount. We are now nearly three months away from that and still NHS Employers in England have refused to withdraw their preconditions for negotiation, have been unable or unwilling to put a number on what people can expect their salary to be in August, and today cancelled with five hours notice a series of meetings that were being held for junior doctors to ask questions about this contract after it became clear to them that junior doctors were going to protest and were going to ask questions — questions, one can only assume, that will be awkward and embarrassing to these agents of our anti-NHS government.

I am now into my fourth year of postgraduate working and my third year of postgraduate training. I spent last year employed not in a training programme. I spent a year being a doctor in the job for which I was contracted and then in my evenings and weekends running around various hospitals in the west of Scotland being a locum to plug rota gaps, keep up my acute medical experience, and make up for the fact that I would not have been able to pay my bills on my basic salary. I got a lot of experience last year. I took that year because of a commitment to both my specialty and my region, a commitment for which under the proposed new contract I would have been penalised.

I am still considered a junior doctor and still will be for at least another eight years,  providing I don’t extend my training to do anything like teaching, researching, or having children, all things which under the new contract are considered mere frivolities of no value.

My current rota has had me working one in two weekends since I started this job in August, which is legal because I’m not on the rota to do more than twelve days in a row. I finish a run of night shifts at 9.30am and am expected back at work at 9am the following day, which is legal because I’m getting the mandatory eleven hours of rest between shifts. I have been working a 59 hour week on average, although often running straight into another week without any days off, which is legal because I get a few weeks now where I’m not on call at all and so over the course of sixteen weeks it will (presumably, although I haven’t actually done the maths) average out to 48 hours. My colleagues and I come in early and stay late and, no, despite the hilarious conversation I had with the rota monitoring department last week, never go to lunch, on the days when that actually happens, without taking our pagers, and wouldn’t want to. Any reading or exam studying or teaching preparation has to be done in my own time. I am paid a £32,000 basic salary for this (before tax, pension contributions, National Insurance, or student loan repayment) and then an additional 50% banding supplement (on which I pay National Insurance, tax, and student loan repayments, but not pension contributions) for the extra 10 hours per week (the basic salary is for a 38 hour week) and the fact that a percentage of my hours are worked at night and at weekends (these are “antisocial”, partly because they are antisocial and partly because work intensity is higher at those times).

All this under the current contract. My rota is within legal limits and probably not even the worst I’ve ever had and I am renumerated well for my work. I am not looking to work less. I am not looking for a pay rise. I tell you this all to illustrate why my colleagues in England are fighting so hard against a contract that will make it worse, for less pay, and with no repercussions for any of the safeguards being violated anyway.

It is insulting and demoralising, yes, but it is also not safe. It is not safe for doctors, but it will not be safe for the patients either.

To read some of the papers and even to read some of the documents from NHS Employers themselves, you’d be forgiven for thinking that people who aren’t consultants are just playing at it. No. I remember primary school, and playing was never this exhausting and never with this much riding on it. No, no junior doctor is playing at it, and the majority of us aren’t fresh-faced dew-eyed just-finished-medical-school 23 year olds with not a care in the world either. The few who are don’t stay that way for long. You don’t, not after you’ve run an overnight surgical take by yourself in an inner city hospital or been part of a team that was unable to resuscitate someone or been the person to give another person the worst news they will ever have. This is a difficult and demanding job, and we do it proudly and we do it well and we do not stand quietly by while our work is devalued and our patients’ care is compromised by making them be cared for by doctors who are being forced to work unsafely.

I know — oh, believe me, I know — that we have not yet returned to the bad old days of hundred hour weeks and thirty-six hour shifts, but remember, if that’s going to be your argument, just remember that doctors campaigned to get that changed. It was done then, and it can be done again. I have never known the medical world be so united — senior colleagues, the BMA, the Royal Colleges, all of them standing up and agreeing with us that this contract will be bad for doctors and bad for patients, and if enough of us keep talking then eventually someone will have to listen.

Yes, junior doctors in Scotland and in Wales too have got a lot to be relieved about right now, but from our safe havens we have a responsibility to stand up for our colleagues in England and we will do so.

The Sun Is Coming Up

You find me on a late summer evening, slumped at my dining table, in sock feet and an old race shirt and ancient leggings. My hair has long since given up on its plait. I have no idea what timezone I’m in. The only decision I am competent to make tonight is what kind of food I would like the delivery people to fetch me. I’ve either just flown halfway round the world, or else I spent my weekend going from dayshift to nightshift and back again by Tuesday morning.

Internet, let me let you into one of my dirtier secrets:

I really like working nights.

This is born out of my romantic notions about them, notions of which three years of, you know, doing it, have entirely failed to disabuse me.

Look, I know it’s a bit weird. If you say it out loud to people, they tilt their heads and say, “but nights are awful”, like I’m trying to be a brave little soldier, which couldn’t be less true, or like I’m a bit mad, which… well, I also have romantic notions about marathons, New York, the nature of democracy, empty cathedrals, London, and the NHS, so you go on and decide for yourself how mad I am.

Oh, they have their unpleasant bits. This past weekend there was a night when I went from actually sitting still for a bit to running up five flights of stairs and I promptly lost both my lunch and my dignity down the sluice. I have on one occasion been so tired that my four o’clock in the morning brain forgot how to use a tampon. And the sheer dragging-myself-through-treacle effort of transitioning back from nights to days, which really is awful.

But that would be like saying that New York is awful because of the jet lag on the way back, or that because of David Cameron we should all give up on the nature of democracy and move to North Korea.

In one of the last episodes of The West Wing, on a night that has lasted whole lifetimes and has seen friends and co-workers through unimaginable highs and unthinkable lows, when newly President-elect Santos makes his victory speech, he says this: “You know, if you haven’t left this room in a while, the sun is coming up!” And everyone applauds. And that’s how I feel when I see a nightshift sunrise; every time. At the end of a night when a great deal of work has been accomplished, for better or for worse, and I’ve spent it wide awake and being allowed to do my acute medic thing for twelve hours and wandering the dark corridors of a world that is very peculiarly mine, I think of that, and I think too of the dawn prayer: “we thank you for bringing us out of the shadow of night into the light of morning.”

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Early on Monday morning, I crossed the ambulance bay in the crisp early light of half past six in September in Scotland. I was as content in that sunrise, heading back to AMU for my microwaved porridge, as I was huddled over a mug of coffee the morning I watched the sun come up over the Serengeti.

This was originally going to be a nightshift survival guide for junior doctors, but it got away from me a bit in the writing of it. At some point perhaps I’ll do that properly, and, look, yes, I’m very lucky, it’s not heroic to like working nights if you can sleep anywhere and at any time and have a stomach that can mostly tolerate whatever and whenever you feed it. But the most important piece of advice I can give is to stop listening too much to people who tell you that they’re something to be endured and start trying to enjoy them a bit.

For All Doctors: New and Old, Starting and Starting Over and Starting Again

Go placidly amid the noise and haste, and remember what peace there may be in silence.
As far as possible without surrender be on good terms with all persons.
Speak your truth quietly and clearly; and listen to others, even the dull and ignorant; they too have their story.
Avoid loud and aggressive persons, they are vexations to the spirit.
If you compare yourself with others, you may become vain and bitter;
for always there will be greater and lesser persons than yourself.

Enjoy your achievements as well as your plans.
Keep interested in your career, however humble; it is a real possession in the changing fortunes of time.
Exercise caution in your business affairs; for the world is full of trickery.
But let this not blind you to what virtue there is; many persons strive for high ideals;
and everywhere life is full of heroism.

Be yourself.
Especially, do not feign affection.
Neither be critical about love; for in the face of all aridity and disenchantment it is as perennial as the grass.

Take kindly the counsel of the years, gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune. But do not distress yourself with imaginings.
Many fears are born of fatigue and loneliness. Beyond a wholesome discipline, be gentle with yourself.

You are a child of the universe, no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you, no doubt the universe is unfolding as it should.

Therefore be at peace with God, whatever you conceive Him to be,
and whatever your labors and aspirations, in the noisy confusion of life keep peace with your soul.
With all its sham, drudgery and broken dreams, it is still a beautiful world. Be careful. Strive to be happy.

Max Ehrmann, Desiderata