You know something is not quite right in the NHS when the head of the General Medical Council likens modern medicine to war in Helmand Province.40 In 2016, after an internal inquiry revealed that twenty-eight doctors had committed suicide while being investigated for professional misconduct by the GMC, the doctors’ regulator announced new plans for would-be doctors to have to demonstrate their ‘emotional resilience’ before being allowed to practise.

The GMC chair, Professor Terence Stephenson, stated that medics needed to learn from the armed forces, being formally trained, just like servicemen and women, in coping strategies for handling the pressures of practice. He told the Telegraph,

At the time, being intimately acquainted with a member of the military myself, I turned to my long-suffering husband and asked him, ‘When you went through officer training, did they teach you how to be resilient?’ Dave’s snort of laughter was telling.

‘Are you kidding? We got taught how not to get bollocked by the drill sergeants whose main purpose in life was to whip us into shape and toughen us up the hard way. We got taught how to drag ourselves out of bed at five a.m. and be screamed at for a speck of dust on a windowsill without breaking down and crying in front of our mates. So, no, we did not get taught resilience. But we learned it pretty quickly, or we left.’

Perhaps, in these times of austerity, the most efficient way for the NHS to deal with its haemorrhaging staff would indeed be, first, to weed out the weaklings through compulsory boot camp, ensuring only the toughest were permitted to take on employment in the NHS; but one senses the GMC had something else in mind. In fact, since my husband’s officertraining days, UK Armed Forces does now run courses on resilience and has even built a Stress and Resilience Training Centre at its defence academy in Shrivenham. But the NHS is not a battlefield, doctors are not soldiers and caring is not armed combat. Moreover, implicit in the GMC’s approach to doctor burnout and suicide is the assumption that the fault lies within the individual doctor, whose psychological inadequacies have somehow rendered them incapable of coping with the stresses and strains of medicine.

What if, instead of individuals’ emotional failings, it is warped conditions of work within the NHS that are driving doctors and nurses to the edge? The debilitating pressures of constantly operating in an environment that denies you the resources to do your job safely? A little like facing Helmand with peashooters, to borrow the military analogy of which NHS leaders can be so fond. Under those circumstances, an online course in tick-box ‘resilience’, while welcome, may be doomed to failure, ignoring as it does the fundamental factors eroding doctors’ and nurses’ capacity to bounce back.

‘Resus’ is where patients are sent when doctors worry they might die. We were waiting around this particular empty resuscitation bed like predators poised to pounce. Emergency attempts to save a life are often brutal, and resuscitation, when the team first descend, can horrify any next of kin who witnesses it. None of us spoke. The paramedics had called in the trauma to A&E with sufficient warning for a full team to be assembled, our roles pre-assigned and displayed on the cardboard signs we now wore pinned to our scrubs. Our team leader, a seasoned trauma consultant, had the kind of battle-weary composure that inspires total calm. It was, as so often, a road-traffic collision. All we had been told was that the victim was young and unconscious. She had been hit by a lorry while walking through town. A mobile phone was rumoured to have been involved. No one knew anything for certain. But we were ready to launch into coordinated action the moment she swept through the swing doors.

I was ‘Doctor 2’, the most junior doctor in the team. I felt awkward in the bulky lead apron I wore to shield me from radiation, should bedside scans be required. This was my first time in a trauma team and I was desperate to do a good job, staying calm and focused no matter how bloody the unfolding events proved to be.

As the paramedics rushed the patient into resus, we descended en masse, as one. Seamlessly, one nurse attacked clothing with scissors to expose bare flesh, while another applied electrodes and oxygen. The anaesthetist assessed the girl’s level of consciousness, deciding whether or not she required urgent assistance with breathing. Several policemen hovered in the background. I shoved a cannula in the largest vein I could find, then stabbed the main artery in the wrist to provide a sample of arterial blood. In under a minute, a fifteen-year-old girl – her name was Chloe – lay naked but for her knickers, the plastic collar protecting her C-spine and a tangle of plastic tubes and wires. There was no blood, no bruising, no mangled limbs, nothing to suggest her recent impact with a twelve-tonne truck. She was, in a word, perfect. Her body was flawless – it had the kind of litheness and beauty possessed only by the very young – save for one devastating detail. From her nostrils trickled a trace of clear fluid. You might barely have noticed, had you not set out to find it. Cerebrospinal fluid – the liquid that surrounds and cushions the brain and spinal cord – was leaking out of her skull through her nose. Beneath its immaculate exterior, her head had suffered a blow of such force it had fractured the skull into pieces, allowing the telltale seepage of fluid. Who knew the state of the brain beneath? She began to groan and flail at the hands that accosted her. Probably, she was cerebrally irritated – blood was inflaming the meninges, the protective layers in which the brain is wrapped.

An urgent CT scan of her head confirmed everyone’s worst fears. Chloe’s skull was shattered in five separate places, her brain swollen and clouded with blood. Though her body lay unblemished, we had no way of knowing if the person she had been was preserved. I was not there when her parents burst into resus, but I heard their screams, reverberating all the way to the other side of the department. The father, one of the nurses told me afterwards, had collapsed to his knees at his daughter’s bedside.

In an NHS Emergency Department, the queues of patients never end and there is no time to dwell upon any of them. You move on, do your job, refuse to indulge your own feelings, because your next patient deserves better than an emotion-addled doctor. But that night, and for several more afterwards, Chloe’s image – this pale, perfect girl on the cusp of adulthood – floated into my dreams. We would be crowded round her bed again, fighting to save her, while knowing she was slipping away. I held my children extra tightly that week and chose not to follow her progress on neuro-intensive care, preferring instead to believe in those uplifting patients who once in a while defy their doctors’ pessimism.

It was by no means the bloodiest or ugliest of my early medical experiences, yet for a while Chloe continued to haunt me. I imagined the banality of her chitchat with a schoolfriend, giggles and gossip about last Saturday night; then, from nowhere, never glimpsed, twelve tonnes of truck bearing down, a mobile phone bouncing off the pavement, a body lying still in the road. The mother in me recoiled. No quantity of parental love, hope, fear or grief ever protects against the casual indifference of whom A&E decides to summon to its bays.

It is this, in one sense, that the GMC was latching onto – and rightly so. As Terence Stephenson put it,

Stephenson is partially right. When you are a doctor, a bad day at the office might mean, ‘She has catastrophic brain damage’; ‘He won’t walk again’; ‘We lost the baby’; ‘We did everything we could, but we couldn’t save him.’ A bad day is disability, death or grief of an order that cuts through the routine hospital backdrop of recurring loss and pain. A bad day makes you want to tell the world to please go to hell because only cursing, or maybe alcohol, makes you feel better. If you cannot face raw human suffering, medicine is not for you. But, equally, when your job is not killing but healing, the notion that good doctors must be clad in ‘emotional armour’ risks the unintended harms of numbed and battle-scarred clinicians, all too evident in the drivers of the scandal of Mid Staffs.

In my experience as a junior doctor, what makes me resilient – able to function with the mental elasticity to absorb the stresses of the job I chose, weaving them positively into my working life – is, above all, other people. My colleagues, my mentors, my team. I am nothing without the doctors and nurses with whom I work every day. Break down the human relationships that sustain and nurture a medical workforce, and you risk creating doctors who first lose their compassion, and then become too brittle to remain in work. Patients are best served by neither.

‘What the hell is going on with our patients?’ asked Sally, my fellow junior doctor, as we worked our way through a bottle of wine. ‘You do realise more of them have died this month than lived?’

It was our first month on haematology, the speciality that, more than any other, is accused by other doctors of inappropriately poisoning its patients, refusing to pull out and permit dignified deaths. Sometimes, this boils down to misunderstanding. Blood cancers such as leukaemia are not like other malignancies, where cure rests on cutting out a tumour. In leukaemia, where the cancer is spread throughout the blood from the outset, it is often only the ‘poison’ – aggressive, even life-threatening chemotherapy – that gives the patient a shot at a long-term survival. But the stakes are high. Chemotherapy attacks not only the leukaemia cells but also the healthy bone marrow where all the other, noncancerous blood cells are made. If a patient’s bone marrow begins to fail, this puts them at risk of potentially fatal bleeding or infection.

I had never seen such a collection of desperately unwell patients as in my first few weeks on a haematology ward. Most of my patients were there for bone-marrow transplants, where someone is subjected to chemotherapy so devastating their entire bone marrow is wiped out, including – or so we hope – every trace of leukaemia. Marrow from a donor, perhaps a sibling or another closely matched relative, is then transplanted into the patient, replacing what we have destroyed. If the marrow successfully ‘takes’, and if the patient does not die from bleeding, infection or the powerful immunosuppressants they will now have to take for the rest of their life, then maybe, just maybe, they will be cured. Poison, I had to admit, was rife here, and with the poison came the deaths.

First, a mother to three young children succumbed, in increasing pain and fear, to the ravages of what can be one of the most brutal blood cancers, multiple myeloma. Next, in swift succession, several of our patients with bone-marrow transplants died. But the most searing experience, for me, in this relentless month of deaths, was a night spent looking after an unusually young patient admitted earlier that day onto our ward. At eighteen, Azra had never really known life without leukaemia. Diagnosed while still a small girl, she had spent years in and out of hospitals receiving chemotherapy, radiotherapy and transplants. Now, she had arrived with her father, gasping for air and clutching a small, scruffy bunny, a much-loved comforter since birth. Her leukaemia may have been at bay, but her lungs were overwhelmed with infection. In someone with a normal immune system, the bug in question, cytomegalovirus, is rarely even noticed, but, in the lungs of an immunosuppressed patient, it can wreak absolute havoc.

As the night wore on, Azra’s temperature soared and her breathing became more ragged. Her father’s face wore the drawn expression of someone who confronts the abyss. In spite of giving powerful antiviral medications through a drip and the most concentrated oxygen we could administer, Azra’s oxygen saturations continued to fall. I could see the fear in her eyes every time I came towards her, doctors at her bedside invariably meaning limbs stabbed with needles or worse. She clutched her threadbare bunny to her side, as if a talisman against the pain I might inflict. She did not know it, but my pleas to allow me to take a sample of her arterial blood – a procedure that is invariably painful, sometimes exquisitely so – had her best interests, her life, at heart. Without an accurate recording of her oxygen levels, Intensive Care would never agree to giving Azra a bed. Even when finally armed with the dire oxygen readings, I faced an ICU registrar who bristled with hostility.

‘The trouble with you haematologists is, you just can’t stop poisoning your patients, can you?’ he glowered.

My own registrar was managing another equally unwell patient, the ICU registrar didn’t want to know, and Azra, I feared, was going to die on the ward without the invasive therapy only ICU could provide. I felt alone before a father’s beseeching stares and his daughter’s naked fear. Finally, mercifully, the daytime haematology registrar arrived, took one look at me and asked what was wrong.

‘It’s Azra,’ I told him. ‘I think she’s going to die if we can’t get her to ICU. Please, please try to get her there.’

We exchanged a look. In that instant, I knew he knew what the night had been, the desperate scrabbling to hold onto a life that you fear might be slipping through your hands. Of course he knew. Like every seasoned registrar, he had been there a hundred times before.

‘OK. Just go home, Rach. Get some rest. I’ll sort this out.’

My gratitude, exaggerated by sleep deprivation, left me close to tears. I knew Azra was now in safe hands. Returning to the ward that evening for the next of my night shifts, I found she had been sent to ICU shortly after I had left, where she now lay attached to a ventilator machine that mechanically inflated her ravaged lungs. She never managed to breathe again by herself and died, still ventilated, several days later. You could argue that ICU had been perfectly correct in their original assessment not to admit her, whereas my judgement had been clouded by sentiment. When ICU beds are like gold dust, only those patients with a genuine chance of survival earn the right of occupation.

Back in the pub, as I discussed with Sally the trials and tribulations of haematology, even Azra’s death lost its sting. No explanations were needed. We had already shared so many deaths, bad deaths, the ones where you cannot shake the feeling that your years of toil and study have failed you, failed, above all, your patient. Our camaraderie was forged in each other’s worst moments – the angry, exhausted, bitter, hollow times – and the solace this afforded, more than anything else, was what kept us cheerfully going on. Nothing helps resilience quite like knowing you are in it with your comrades-in-arms. Before long, we were laughing. Black humour, certainly. Jokes you could never repeat to a non-medic. The slightly twisted take on dying that brings you back to the wards, renewed, heartened and ready for more.

Sometimes, on returning home after a long shift on call, the first thing I need to do is wash it away under a scalding shower. Then, an obligatory large glass of wine to take away the hard edges. Talking to my family is not an option. A husband neither wants nor needs to know that today you were called to a crash call where the patient was vomiting up blood so profusely his circulation crashed and he suffered a cardiac arrest; that security guards scrambled to clear the public from the route between the ward and the operating theatre; that, as the crash team ran with the bed down the corridor, you knelt atop its blood-soaked sheets, pumping the patient’s chest with such force you feared you might lose your balance and topple to the floor below; that in theatre, despite the surgeons cracking the chest, wrenching the ribcage apart and manually compressing the heart, it never regained a rhythm; that later, long after the time of death had been called, when you stripped off your sodden clothes, you found even your underwear was bloody. Why would he want to hear this? Why, frankly, would anyone? They say nothing is thicker than blood. But even genealogical ties do not bind as tightly as those blood ties to my other family, the one with whom I share the daily sorrows and trauma of life inside a hospital.

These days, when not calling for compulsory resilience, NHS leaders are invariably agonising over rock-bottom morale among NHS staff. And rightly so. Low morale is linked not only to sickness but also to lower standards of patient care. NHS England has estimated that sickness absence costs the NHS a staggering £2.4 billion a year. If that sickness absence were reduced by only one day per person per year, the NHS would manage to save £150 million, enough to pay for six thousand additional full-time staff.41 Put simply, there is an enormous financial incentive to cheering us up. In 2015, the chief executive of NHS England, Simon Stevens, summarised the economic argument for improving staff morale and wellbeing:

NHS staff have some of the most critical but demanding jobs in the country. When it comes to supporting the health of our own workforce, frankly the NHS needs to put its own house in order. At a time when arguably the biggest operational challenge facing hospitals is converting overspends on temporary agency staff into attractive flexible permanent posts, creating healthy and supportive workplaces is no longer a nice [thing] to have, it’s a must-do.42

But Stevens’s implicit accusation that the NHS is to blame for its own morale issues is somewhat rich, given the political and financial constraints under which every NHS institution is forced to operate, and over which the government and Treasury exercise control. While I would dearly love my hospital to treat me with a little more kindness, a little less indifference – and undoubtedly there is much work to do here – a Zumba class or two is never going to come close to addressing the corrosive impact on our daily working lives of navigating the gruelling workloads caused by insufficient numbers of frontline staff. And, in an era when hospitals are being expected to slash their expenditure under the guise of ‘efficiency savings’, the pressure is on them to shrink, not expand, the size of their wage bill.

Recently, a doctor writing anonymously in the Guardian encapsulated perfectly the conditions that can defeat the most resilient of doctors:

The stamina required to get through a shift like this – and every doctor has worked them – fills you with anticipatory dread. The chaos, the pitifully small number of on-call doctors to tackle the onslaught of patients, the potential risks of the lack of bed space, the fact that no one in the hospital wants to hear about any of it. Perhaps most souldestroying of all is that, too often, at the widest level – in the national conversation between politicians, journalists and commentators about the state of the NHS – it can sometimes feel as though no one is willing to confront head-on what is actually happening on the ground. This is precisely the sort of denial, a kind of wilful collective blindness, whose dangers Sir Robert Francis warned of, except that, in this case, it operates at a governmental rather than Trust board level. Morale is built on belief. But how can NHS staff maintain theirs in the institution they love and serve when its political masters appear to be turning a blind eye to its slow, inexorable demise? As the medical registrar in the Guardian put it,

In military circles, morale – or a unit’s ‘esprit de corps’ – is often defined as the capacity of a group’s members to maintain their belief in an institution or goal, particularly in the face of opposition or hardship. If a unit’s morale is depleted, they are at risk of cracking and surrendering. A Pulitzer prize-winning American military journalist, writing during the Second World War, gave a stirring definition of high morale as being when ‘a soldier thinks his army is the best in the world, his regiment the best in the army, his company the best in the regiment, his squad the best in the company, and that he himself is the best blankety-blank soldier man in the outfit’.44

How does that compare to the NHS? My army (my health service) is crumbling around me. Year on year, the government’s underfunding undermines the collective efforts of my colleagues and me to provide the public with exemplary care. Waiting lists balloon. My inpatients suffer the perils of rota gaps – arising where doctors have either fled the NHS or been signed off sick, leaving the remaining staff to carry their workloads. My regiment (my hospital) is in deficit. My squad (my fellow junior doctors) was recently reduced by sick leave from three to two. And me? I’m too tired to believe in much these days: it takes all my efforts to be safe and competent.

Recently, I witnessed a stark example of the caustic effects of understaffing on morale. My team and I were discussing our patients prior to setting off on our morning ward round when a house officer walked into the doctors’ mess looking so broken and stunned he was almost staggering. We stopped our conversation in alarm. ‘I know him,’ I said to my consultant. ‘I’ll have a chat and find out what’s wrong.’

Samir had just completed a night on call, attending to the emergency needs of a hundred or so medical inpatients. We sat side by side on a stinking sofa and I pressed a hot coffee into his hands. After a while, tears began to trickle down his cheeks and I could see how much he hated being seen to cry. At age twenty-four, he was two or three months into his career as a doctor.

‘I just couldn’t do it,’ he eventually muttered. ‘There was too much to do and I tried to ask the med reg for help but she was flat out in A&E and she couldn’t leave the sick patients.’

‘Did you have sickies?’ I asked him, this being the code for patients so unwell you fear their illness might end up being life-threatening. Silently, he nodded, the tears flowing.

‘I know it wasn’t her fault,’ he continued. ‘She wanted to help me but she had all the new admissions in A&E to sort out and they were sick too.’

I knew precisely what he had been through. The feeling of abandonment, through no fault of his senior doctor, who herself had spent a night fighting fire in an equally overrun part of the hospital. The fear – a deep-seated foreboding that someone that night was going to die on your watch.

‘I don’t know if I can do it any more,’ he told me. ‘I don’t even know if I want to.’

I assured him that it was not that he was slow or incompetent or feeble or useless, that he had been defeated all night by an impossible workload, that if I had worked his shift I’d be feeling just as he did, that the law of nights meant that after this shocker he’d earn at least one gentle shift before the week was out. I could see he did not believe a word of it, but he smiled half-heartedly, appreciating my efforts, and hauled himself off to bed.

It cannot be right that, only a couple of months after six years dedicated to learning how to be a doctor, a young medic is left sobbing on a sofa. It was not Samir’s proximity to suffering that broke him that night, but his responsibility for too many patients. It was not that he lacked resilience, but that the workload to which he had been subjected had been unsafe, unfair and inhumane. The remedy, on this occasion, was glaringly obvious. Not a tick-box course designed to toughen him up, just another doctor on the rota.

After his dismal set of nights, Samir managed to rally and move on. But not every young doctor is so lucky. Some quit the profession before their first year is out, others end up lost beneath the feeling that life is no longer tolerable.

In February 2016, the day after Jeremy Hunt announced the imposition of his contract, Rose Polge, a junior doctor only six months out of medical school, took her own life. Her job and its workload had become too much to bear. As her mother, Heather, put it, Rose, ‘became overwhelmed with acute anxiety about the expectations, demands and responsibilities of her job. This broke her spirit.’45 When news of her suicide broke in the media, junior doctors nationally were horrified. Every one of us at one time or another has either felt sheer desperation ourselves or known another young doctor who has. I thought of Samir and his shame at his tears. Of another doctor friend who called me once to tell me he was going to hang himself. The near misses, the prevalence of desperate distress. Rose could have been any of us.

It emerged that Rose had been midway through a shift at her hospital when she vanished one Friday afternoon, leaving a suicide note in the glove compartment of her car, then walking into the sea and drowning herself. The note mentioned Jeremy Hunt. During the inquest into her death, her boyfriend described how, the night before her disappearance, Rose had talked about quitting medicine and, finding sleep impossible, had walked alone on the beach where, the next day, she took her own life. Her online history showed she had visited suicide sites.

At her inquest, Rose’s family called for action to address the crisis in the health service precipitated by doctors’ fatigue and punishing workloads. The words Rose’s mother would later write about her daughter’s death struck a painful chord with us all:

I thought back to my time on the understaffed Surgical Emergency Unit, tears dripping onto my young son as I tried to shake away the toll of a hundred-hour week and be a semblance of the mother I wanted to be; I wondered whether, without him and my husband to love me, it might have been horribly different. And I could not shake the thought from my head of the beautiful twenty-five-year-old woman who beamed radiance and life from the photos in the press, yet placed her clothes in a pile on wet sand and walked away her life in the spray.