‘For all our days that tear the heart
Leave us nowhere
For all the years we left untold
Hurt, we couldn’t hold much longer’
Jessie Buckley and Bernard Butler
I don’t know if it’s because of my ever greying hair or simply the result of wishful thinking on the part of those who are posing the question, but currently a day hardly seems to go by without one of my patients asking me how long I think I’ll remain a GP. Admittedly the idea of retirement is one that is increasingly appealing given how recently, just when you thought the job couldn’t get any busier, it went and got a whole lot busier!
When I think, though, about how many times in my career I have considered giving up medicine, it is in some ways remarkable that I have lasted as long as I have! The first time was about a month into my A Levels. Back then I was hating Physics so much that I decided to give up sciences and study History and Economics with a view to following my big brother into the bank. Thankfully, after a few wise words from my Dad, I dropped Physics and took Biology in its place. After which things got better.
And so I clambered aboard the conveyor belt of medical education and got a place at Bristol. After a wobbly first couple of terms during which I again considered ending my medical career before it had begun and I was also briefly prescribed ‘prothiaden’ which, back then, was a fancy new antidepressant, I eventually settled into university life. But after failing to enjoy the third year and my first experience of clinical medicine, I intercalated, unconventionally late, in Psychology with the specific intention of leaving university with a degree that would offer me the possibility of a job outside of medicine. For a while I flirted with the idea of accepting the offer I was made to do a PhD but chose instead to return instead to Medicine and eventually graduated in 1991.
My year as a houseman wasn’t a happy one and my wife will tell you how low I was during what was also, purely coincidentally you understand, our first year of marriage. She sometimes had to literally feed me breakfast in the morning, and put my shoes on to get me ready to leave for work. So convinced was I that I would not remain a doctor for long, I even temporarily opted out of the NHS pension scheme. But in time things got better again and I somehow survived my first year as a doctor.
GP training was also an initially miserable time, so much so that, before completing my training, I lined up a job in Psychiatry thinking I might follow this as an alternative career path. Six months of that though was enough and so, with my MRCGP now under my belt, I became a GP locum. One practice I spent three months at asked me to apply for the partnership that they were advertising and, having done so, I was fortunate enough to get the post. And so, in January 1997, I began what thus far have been 26 largely happy years at the practice at which I still work. Initially I hated it though. Not only was I genuinely convinced I was useless, I also was totally convinced that everybody regretted taking me on a partner. But then things got better once again proving that, at least on occasions, things can and do improve over time.
That said though, I’m not sure that medicine is getting better. On the contrary, I am concerned that the world of medicine has lost it’s way. I’ve been writing about this for well over a decade now but the situation only seems to be getting worse with every passing year. With the medicalisation of normal life and the overemphasis on clinical parameters rather than the individual to whom those parameters refer, modern medicine has diminished what it is to be human and diminished too what it is to be a doctor. What’s more medicine has for too long arrogantly acted as if it had the power to bring about eternal life and never ending happiness. It spends far to long trying to do what it can’t and too many of those charged with that Sisyphean task have killed themselves and made themselves unhappy in the attempt.
And, perhaps as a consequence, whereas once doctors were their patients advocate, it seems that patients now are too often perceived as the enemy, made up of those who have to be managed rather than those who need to be cared for. And as doctors are driven further away from their patients, as they become more remote from them, so I believe they will find themselves caring for patients less – even as their patients care less about them.
It also seems to me that medicine has priced itself out of the market. With all that medicine can potentially do, it is now simply too expensive, not only in terms of the burden it imposes on the tax payer but also in terms of the personal cost paid by those who work in healthcare. The toll is too high and something really does need to be done about it.
I’ve been writing now for a little over four years. I find it helpful – so much so that this website is far too cluttered with posts. In his essay ‘Why I write’, George Orwell gave four reasons, suggesting that, to a greater or lesser extent, each one is present as motivating factors in all those who put pen to paper.
The first reason he gave, was SHEER EGOISM. I don’t deny it. I enjoy writing for writing’s sake but if occasionally someone likes what I write, if perhaps I manage to raise a smile or somebody finds something I’ve written helpful, I find that that brings with it a little extra satisfaction.
Next came AESTHETIC ENTHUSIASM. And once again I put my hand up to that one. I enjoy writing because I enjoy writing, even when no one else enjoys reading what I write! I like playing with words, finding an arrangement of sounds that rolls off the tongue and which is pleasing to at least my ear.
Thirdly on Orwell’s list, was HISTORICAL IMPULSE – the simple desire to write about how things are, to record for others what the truth is. Again mea culpa! I feel it’s important to write about the state of the world, or at least the medical world that I inhabit. And writing helps me think about what is going on around me, it helps me understand the realm in which I operate.
And the last reason Orwell gave for why writers write was POLITICAL PURPOSE, by which he meant a desire to influence others, to move others to think in ways that the writer thinks themself. And I suppose that’s true of me too, at least to some extent. Indeed I suspect it would be a bit odd if it were not the case.
But there is, I think a fifth reason for why I write, one which is at least slightly different to those given by Orwell. And it’s this. The NEED TO BE HEARD.
There are some things that are so important to us, that we need them to be important to others. And for that to happen our concerns have to be heard, and felt, by others.
In an indifferent world it’s important that we listen to those we care about, to make a real effort to hear what they are saying. We may not be able to do much about what is spoken about, not in any practical sense at least, but caring enough to recognise it matters to the one who is saying it is, at least, a start. Because to share a little in the experience of others, perhaps even shedding a tear ourselves as others express their sadness, draws us a little closer to the one who suffers, and makes a connection with the one who grieves, a connection that, too often in this frequently contactless world, we fail to make.
And so I write about the things that matter to me most.
I write about cricket – is there anything more important than the domestic cricket season and the violence being done to it by the introduction of franchise cricket? I doubt it, but even so, now is not the time for me to get on that particular soap box again.
I write about medicine – of how the NHS is broken and breaking the people who work within it. I write of how it bothers me immensely that patients aren’t getting the treatment they need, not, at least, in a timely fashion. And I write about how it bothers me immensely that people who I care about, people with whom I work, are too often close to tears because of what the job now demands of them.
And, though not explicitly, I write in general terms about personal concerns that trouble me because, despite what I said earlier about things getting better over time, sometimes things seem to only get worse. Outside of work too, I spend a lot of time trying to do what I can’t, to raise a smile in one who is sad or say something that might be of help to another. And when I can’t, it helps me to express some of the sadness I am sometimes prone to feel in the things I write.
And I write too about my faith – because if it’s everlasting life and infinite joy we want, I believe we will need to look for it somewhere other than medicine. Without the faith which sustains me in difficult times, without the sure and certain hope of a better tomorrow, I really don’t know how I’d be able to cope with all that life sometimes entails. Like the psalmist I believe that, though weeping may tarry for the nighttime, joy comes with the morning – and this I hold to be true irrespective of how long and dark the night may be, or how far off the day still seems.
So as working in the NHS becomes evermore difficult, will my recurrent thoughts of wanting to leave medicine finally be realised? Will I retire a year or two earlier than 59 which is, I believe, the average age that GPs now hang up their stethoscopes? I don’t know. But if I do it won’t be for the reason that I have considered giving up so many times in the past. Back then my thoughts of quitting were largely linked to my feelings of inadequacy, of not being good enough as a doctor. Now, however, though still inadequate to meet the needs of all that is demanded of me, I have become resigned to my inadequacy. In his 2014 Reith Lectures, American surgeon Atul Gawande spoke of our ‘necessary fallibility’ – that now we all inevitably make mistakes because it is simply not possible for us to know all that there is to know or be able to do all that we are asked to do.
So then, if I do leave early, the reason will be, not just because there is something else I’d rather do, but also because of what medicine has become, an often arrogant and frequently cruel taskmaster, one that I have lost faith in. I don’t want to work in an environment which forces us to be more concerned for our own welfare than the welfare of others. There’s a lot of talk these days about how we need to be kind, generally accompanied with the caveat that our kindness should extend to ourselves. There is undoubtedly much truth in such talk but it remains the case that if we’re to be kind to those we interact with, it is inevitably going to mean that sometimes we will need to be unkind to ourselves, to sometimes make sacrifices for the sake of others. But here’s the thing – when we do, I believe that, rather than suffering, we are enriched by our actions. Sometimes real success comes as a result of our losing everything. There is, I believe, historical precedent for such a view.
Some years ago, on my day off, a parent phoned the practice regarding their 8 year old son who had been experiencing diarrhoea and vomiting. He was given wholly appropriate advice for home management and advised to call again in the event of any deterioration. The next day the father did indeed call back but proceeded to inform me that all his son’s symptoms were improving. But there was something about the fathers tone of voice that unsettled me and so, at around 6.30 that evening, I called him back and learnt how the child had subsequently significantly deteriorated. Though I was not on call, I offered to do a home visit, an offer that was gladly accepted. When I eventually arrived, the lad had the most obvious meningism I have ever encountered and I duly gave him a stat dose of iv benzyl penicillin and called for an ambulance which, as they did in those days, duly arrived and whisked him off to hospital in good time.
Now as it happened, that evening I had been invited to a party of a friend who was celebrating her 80th birthday. Inevitably I was very late. When I arrived, several guests expressed their concern for me, imagining, given my tardiness, that I must have had a bad day. I hadn’t though. Though entailing an interruption to my plans, being where I was genuinely needed was hugely rewarding, it was a joy to have been able to help that evening. And today the lad is a young man, one who is still my patient, and always thanks me every time he sees me, foolishly imagining that it was me who saved his life rather than the clever souls at the hospital who did all the hard work.
I’m not sure though that modern general practice is conducive to that sort of doctor-patient relationship anymore. Not only is this a great shame, it also makes losers of us all, both doctors and patients alike. Sadly the way General Practice used to be is over and those who work in primary care can no longer be expected to work in the way they once did. For whilst there is much that is rewarding about going the extra mile for patients, constantly being required to give more than you have to give is simply unsustainable. And whilst I would like to think we could abandon medicine by rote and return to a simpler and more thoughtful way of working, I fear that now there is no going back. The horse has bolted and the stable door has been left flapping in the wind.
And so at 56, assuming the colorectal screening that I’ve just had the dubious pleasure of undertaking doesn’t result in a spanner being thrown in the works, I am of an age when I may yet be able to give 10 years to something else. As such I am open to moving on in a way that I’ve never been before. I would of course miss my patients but I already feel less connected to them than I once did. And I would of course miss my colleagues who really are some of my very best friends.
Even so, whilst recognising that I am nothing special and that in times past I could easily have been replaced, the fact is that recruiting GPs is currently almost impossible. As such, were I to retire prematurely, I would struggle if my leaving destabilised the practice which has been such a large part of my life, the practice that provides care for the many patients of whom I have become so very fond, and the practice which, as I’ve already said, is made up of colleagues who are also my friends.
So what am I saying? How long do I think I’ll remain a GP.? Well if there were half a dozen excellent doctor’s hammering on the doors of the practice, each one of them desperate to join the partnership, I think that, in the event of some alternative opportunity being presented to me, I would almost certainly consider moving on. But as thing’s stand, I really don’t know. Just now though it’d be hard to leave.
Time will tell if things will one day get better again. I for one am sure they will, in ways better than we can possibly imagine, when every tear will have been wiped away, death will be no more and doctors simply won’t be required.
And then we can all retire. Personally I can’t wait!
‘For all our days that tear the heart
Leading us somewhere
Somewhere else to start’
Before an option to read a whole load more words, for those who would rather hear them sung beautifully instead, here is a link to the title track of Jessie Buckley and Bernard Butler recently released album. My advice though is to listen to the whole album – it really is superb.
To read ‘An Audience for Grief’, click here
To read ‘On Not Remotely Caring’, click here
To read ‘Contactless’, click here
To read ‘Vaccinating to remain susceptible’, click here
To read ‘On Approaching One’s Sell By Date’, click here
To read ‘Eleanor Rigby is not at all fine’, click here
To read ‘The Abolition of General Practice’, click here
To read ‘General Practice – still a sweet sorrow’, click here
To read ‘On being overwhelmed’, click here
To read ‘General Practice – is time running out?’, click here
To read ‘Blaming it on the Boogie’, click here
To read ‘Health – it’ll be the death of us. Is there institutional arrogance in the NHS?’, click here
And now three blogs which, in my mind at least, make up a trilogy on the subject of burnout:
To read ‘Somewhere over the Rainbow’, click here
To read ‘When the Jokes on You’, click here
To read ‘With great power…’, click here
And one blog on the dangers of perfectionism:
To read ‘Professor Ian Aird’ – A Time to Die?’, click here
Some unlikely GP tales:
To read ‘Mr Benn – the GP’, click here
To read ‘A GP called Paddington’, click here
To read ‘Scooby Doo and the Deserted Medical Centre’, click here
To read ‘Paddington and the Ailing Elderly Relative’ click here
To read Dr Jonathan Harker and the post evening surgery home visit’ click here
To read ‘Bagpuss and the NHS’, click here
To read ‘the day LITTLE RED RIDING HOOD got sick’, click here
To read ‘A Dream of an Antiques Roadshow’, click here
To read ‘The NHS Emporium’, click here
To read ‘Jeepy Leepy and the NHS’, click here
To read ‘The Three Little GPs and the Big Bad Secretary of State for Health’, click here
To read ‘The Happy Practice – A Cautionary Tale’, click here
To read ‘The State of Disrepair Shop’, click here
A selection of cricket related posts:
To read ‘Scooby Doo and the Mystery of the Deseted Cricket Ground’, click here
To read ‘Brian and Stumpy visit The Repair Shop’, click here
To read ‘A Tale of Two Tons’, click here
And finally, on an explicitly Christian theme:
To read ‘Hope comes from believing the promises of God’, click here
To read ‘T.S, Eliot, Jesus and the Paradox of the Christian Life’, click here
To read ‘Luther and the Global Pandemic – on becoming a theologian of the cross’, click here
To read ‘Why do bad things happen t9 good people? – a tentative suggestion’, click here
To read ‘Suffering – a personal view’, click here
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