There are times I may have been the doctor I did not want to be. I have to accept that it was me who ignored a patient telling me he did not want to be alive during a busy surgical ward round because I did not know what to do with it, that it was me who ignored the distress of a colleague falling ill. It was me and not someone else. Just me. The doctor I did not want to be. When I ask myself these questions, over and over, and think of the possible answers, the self-compassion I told others to apply to themselves has provided forgiveness for some of my shortcomings.
The consultant
Burnout is an unlikely phrase, because it implies that the effects are loud and obvious, raging like a fire for everyone to see.
Most burnout, however, is quiet and remains unseen. It exists behind a still and mirrored surface, deep, out of reach, unnoticed by everyone – even, sometimes, by the one who is burning. You might catch a glimpse of it if you look carefully. You may say that someone is acting out of character or is unusually short-tempered. You may curse a co-worker for constantly missing deadlines or for being too easily distracted. You may notice that someone is always very early (or always very late) and you may detect that they have a lack of interest in the work in which they once took pride. Or you may notice none of these things. You may walk alongside a raging fire, day after day, without seeing even a trace of its existence, until a time when something happens and the flames can no longer be kept under control.
Gill was a patient in a side room on Ward 8. We were the same age, almost to the day.
As children, we’d watched the same television shows and saved our pocket money to buy the same records. We had grown up with the same posters pinned to our bedroom walls and we knew all the same lyrics to all the same songs. The only difference between Gill and me was that Gill had metastatic breast cancer and I did not.
On the ward round, I would stand by Gill’s bed in the side room and write in the notes as the consultant spoke. As I wrote, I would think about all the past birthdays and past Christmases. How we each had marked our lives with the same tape measure, and how we had both assumed the same guarantee. I thought about all the lyrics to the songs, and as I looked across at her, it felt as though I was staring into a mirror. The reflection in that mirror was almost unbearable, but I had to keep looking. I needed to find another difference between us, because, if I didn’t, I was worried I would never be able to turn away.
Gill had been in hospital many times over the past few years. With each visit, the entries in her notes became shorter and shorter, and the hope became less and less. We were now at the point where the only outcome of Gill’s treatment would be to prolong her life by just a small amount. We were also at the point where the small amount of life she had left would be ruined by the very same medication that delivered her that time. It’s a decision many terminally ill patients will inevitably face. Quality or quantity. To live by clocks and watches or to turn away from them and find another measurement. It is not for you or I, or any doctor or nurse, to say what we would or wouldn’t do in that situation: it’s always up to the patient to make that decision by themselves. When I walked into Gill’s side room late one afternoon in November, I knew immediately that a decision had been reached.
I had been called to reinsert a cannula. The old one had failed and needed to be changed. Gill lay in the semi-darkness, exhausted from treatment that made her sick and weak, that made her too drained to lift her head or to bear even the tiniest fraction of light from the window upon her face.
I removed the old cannula and, on a blue sheet, I laid out the equipment for its replacement. Swabs and gauze, syringes, water, tape and bottles. As clinical and sterile as it seems, taking blood or inserting a cannula is such a personal, intimate act, because the first thing you do is to search for a vein, and in order to do that you need to hold the patient’s hand. The times I have taken the hand of an elderly, lonely patient and held it in mine to look for a vein, and they have immediately squeezed my hand back in return.
I held Gill’s hand and looked at the tired, worn veins for a possible candidate. I even checked the vein just below the thumb, affectionately known as ‘The Houseman’s Friend’. There was nothing.
‘You don’t need to find a vein,’ she said.
I looked up. Her face was as pale as the pillow, and she was so frail it seemed as though she was slowly disappearing into the bed. There are terms used in cancer, for example sarcopenia and cachexia – the wasting away of lean tissue and muscle mass – but there is also a certain look you can spot in someone who is terminally ill. It doesn’t have a textbook name or an official definition, but to someone who has walked the wards for long enough it’s unmistakeable. It’s a look that tells you this person does not have very long left. Gill had that look.
‘I don’t want another cannula,’ she said. ‘I’ve had enough.’
It was discussed with the consultant and the Macmillan nurse, and with Gill’s elderly parents, who were never very far away. It was agreed and decided. There were tears and sadness, but also, it seemed, a strange sense of liberation, as if Gill had finally taken back the reins. Cancer makes so many decisions for you, it must be empowering – even in those distressing circumstances – to make a decision for yourself.
I was on a set of nights that week, and the first thing I did before my shift began was to visit Gill and also her parents, who had set up home in the little side room – her mother on a pull-out bed and her father sleeping in an armchair. Sometimes they had a question about the medication that was keeping Gill comfortable, sometimes I think they just needed the presence of someone else in the room for a while, a reminder of life outside the hospital and a conversation about the mundane and the ordinary. A few minutes of escape. I would see them occasionally during the night, walking out anxiety and cramped joints along the long, silent corridors, and every evening when I arrived for my shift, I would expect to see Gill’s name missing from the list of patients. She held on. We waited.
After my run of nights, I had a day before I was due on call. On the rota, that day looked like a day off, but in reality it was just twenty-four hours in which to try to recalibrate and adjust your body clock to being awake in daylight again. Before I headed into A&E, I went to the ward and sat at one of the computers, and I’d just started scrolling through the patients waiting in the emergency department when Gill’s mum ran down the corridor to the nurses’ station.
‘Could you come now,’ she said. ‘Gill’s breathing has gone funny.’
If you have ever sat with someone at the end of their life, you will know what Gill’s mum was hearing. Textbooks try to describe this kind of breathing. They give it a name and attempt to analyse it, but you can’t imagine its distinctive sound until you witness it for yourself.
I looked at Gill. She lay back with her eyes closed and her face was ironed of all the agony and the pain she had been through. She was more relaxed than I had ever seen her before and, in those moments, I saw a glimpse of what Gill was like before the cancer. When she was just Gill.
‘I don’t think it will be very long now.’ I turned to her parents. They looked small and broken. ‘Would you like me to sit with you?’
I didn’t think for a moment they would say yes.
‘That would be lovely, Jo,’ said Gill’s mother. ‘If you wouldn’t mind?’
Of course I didn’t mind.
Her parents sat either side of the bed, and I put my bleep on silent and stayed on a plastic chair against the far wall. The windows of the side room looked on to a little path that led to the staff entrance of the hospital, and I could hear footsteps beyond the drawn blinds. Everyday chatter. Laughter. Clocks that hadn’t stopped.
Over the top of this was Gill’s breathing. Slowing. Leaving.
Gill’s mother looked at me. ‘I don’t know what to talk about,’ she said.
‘Why don’t you talk about Gill before the illness?’ I replied. ‘Things that made her laugh, adventures you had together, what she was like as a child. Then the last thing she’ll hear is happy memories.’
For the next few minutes, I listened to a life lived parallel to mine. Paths never crossing, but knitted together by pocket-money stories and camping holidays, and posters pinned to bedroom walls. And as the stories unfolded, the time between Gill’s breaths became longer and longer.
Until.
‘Gill hasn’t taken a breath for a long time, has she?’ her mother said.
‘No,’ I replied. ‘No, she hasn’t.’
I walked over to the bed and held my fingertips against Gill’s skin. I watched for the rise and fall of her chest, for the slightest flicker of movement. We stood, the three of us, only for a couple of minutes, but it felt a forever time. I knew, even without the checks and the watching, because the air was different. The room had changed.
‘I am so sorry, Gill has died,’ I said.
The footsteps on the little path outside and the sound of the ward beyond the side-room door all seemed to fade for a moment, and we were held still in the quiet. Perhaps the noise continued to be there, but the weight of the room made it unable to be heard, or perhaps Gill needed the silence in order to leave us. The next sound I was aware of was Gill’s mother crying, very softly. The crying of a person who has lost someone they love to this brutal disease – a mixture of relief at an end to their suffering and despair at what might have been. Grief for the disappearance of hope and a lost future.
Her mother stood up and pointed. ‘Could you straighten Gill’s necklace?’ she said. ‘It’s crooked. She hated her necklace being crooked.’
Gill was wearing a very fine chain with a small amethyst pendant. Her birthstone. My birthstone. I gently reached around her neck and adjusted it so the clasp was at the back and the tiny stone lay flat. It was the kind of thing you’d do for a friend or for your mum.
‘I am so sorry,’ I said, because I felt the tears overwhelm me. ‘I am so sorry.’
There are times when you can force crying back inside you somewhere, when you can make it wait for a while, and there are other times when you feel unable to hold on to that control, when the emotion overpowers you with such force that the only thing you can do is to let go.
The tears weren’t just for Gill. They were for the elderly couple who had just watched their only child take her final breaths, they were for the injustice and the misery and the broken system. For all the times I’d forced the crying back inside somewhere.
‘It’s so unprofessional,’ I said. ‘I am so sorry.’
Gill’s mother put her arms around me. ‘You are a human being first and a doctor second, and I can’t tell you what a comfort it is knowing how much Gill meant to you.’
There we stood, the three of us in curtained light. All crying for someone who deserved so much more of life.
I left Gill’s parents to say goodbye and I walked back on to the ward. The light and the noise and the cruelty of an ordinary day felt like an assault. I was still crying. I wasn’t sure I would ever be able to stop.
The other junior doctor took one look at me and lifted the bleep from my hands.
‘Go,’ she said, because she was kind and understood. ‘Go!’
I left the ward and pushed through the doors on to the little path outside Gill’s room. I climbed a steep bank, where a shortcut had turned the grass into mud, and I walked to the far side of the car park. My car was the only place I could think of where I could be alone, and I sat in the driver’s seat and I sobbed. Huge, angry sobs that made my body fold and retch, and my lungs hungry for air.
I stared over at the hospital and wondered how I had ever imagined I could do this. Perhaps it might have been possible to face the misery and unfairness inside it each day with the right support. Although there were wonderful, kind doctors working inside that building, there were also the ones who passed you in the corridor without a backward glance at your welfare, whose spit landed in your face, the ones who seemed happy to watch you fail. These were the people who walked through your mind in the early hours, who kept you from sleep, who disallowed you the joy and the privilege of your job.
Perhaps, as juniors, they had been bullied too. Perhaps it was a family heirloom they felt obliged to pass down to the next generation, or perhaps not all good doctors are good people.
I knew as I sat there that I couldn’t stomach another mouthful, and every ounce of self-preservation told me to start the engine and drive away. Although I didn’t know where I could go. I couldn’t return home and display my own failure and inadequacy for everyone to see, but there was nowhere else I belonged, and I wondered momentarily whether it would be easier, perhaps, just to disappear. I sat with the engine running for a long time, searching for a thread of something to keep me there. Eventually, I found it. The patients.
Being with Gill’s parents was a job I had done well. If I managed to make the tiniest difference, if I helped to make the most traumatic experience of their lives even the slightest bit more bearable, it meant that I was learning to be a good doctor after all. (I didn’t know it then, but a week later her parents would thank me in Gill’s obituary in the local newspaper.) Gill’s death was one of the worst days I experienced as a junior doctor, but it also reinforced my decision to work in psychiatry. As a medic, you are responsible for monitoring your patient’s blood pressure and calcium levels and pain relief, but you are also responsible for monitoring their worries, their emotions and their hopes. As part of a patient history, a doctor will always ask – among many other things – about the history of a presenting complaint, about the patient’s medication and about their previous illnesses. Tagged on the end, along with drug allergies and smoking status, there is a small section in which you are required to ask about the patient’s emotions. In another of medicine’s wonderful acronyms, it’s known as ICE (ideas, concerns and expectations) and it’s often given the least time and has the shortest answers of all. Perhaps it would be better to start the consultation with ideas, concerns and expectations – and not only those of a patient, but also of a patient’s family and friends. And perhaps this section of a history should be the one that is given the greatest weight and time, because these are the things that shape both our lives and our health. This is the lesson I learned that day, and, having the privilege of meeting Gill and her parents, and waiting with them in that curtained side room, made me appreciate that medicine is so very much more than a science.
I nearly drove away from medicine that day, but eventually I reminded myself that I was committed to this job, and I knew, no matter how I felt, that I had to go back inside. To desert the patients was unthinkable. To walk away from an obligation and a promise wasn’t an option, no matter how desperate I was, and so I walked again along the little path and through the double doors and the ward where Gill’s parents still sat with their daughter. I walked along corridors, past porters and nurses and medics and their ordinary days, past the clattering of laundry trucks and the wheels of patient trolleys, and through the swing doors of A&E. I took the first patient notes from the desk and I sat in a cubicle, behind paper-thin curtains, listening to the rest of the hospital happen around me. My hands shook and my eyes swam with too much seeing, and I wondered how someone could walk through a landscape and be at the very lowest point of their life and yet no one who passed by them even noticed.
I had two weeks annual leave.
It had sat in my pocket for the longest time, and I had almost given up being able to take it. Because there were so many gaps on the rota, it was down to us to find someone to cover our shifts if we wanted to take a holiday to which we were entitled, and it was almost impossible. Days were lost, much-needed breaks slipped off people’s calendars and disappeared, but, as I worked through my shift in A&E that day, I knew that I had to find some way to escape, even for a short while. If no one was prepared to help me, I had to help myself, and through bribery, promises and sheer determination, I eventually managed to put it in place. I had my fourteen days to recover.
During those fourteen days I didn’t go on holiday. I didn’t fly anywhere exotic or even book a little cottage by the sea. I just did what I love doing the most. I read. I did nothing but read. From the minute I woke, to the minute I went to bed. Thrillers, classics, poetry. Plays, autobiographies, essays. I filled my mind with other peoples’ words and thoughts, as many as I could, and at the end of those fourteen days I had read sixteen books.
I strongly believe in the power of words to heal and mend. We read stories to make sense of the world, to better understand our own situations and challenges. Every story we read follows a template, a prearranged agreement between author and reader that states that, despite many obstacles, the narrator will ultimately succeed on his journey, and the villain will eventually get his just desserts. We expect this. It’s part of the deal. When we read the last page of a book, we feel safe in knowing we will be given our happy ending, even if that happy ending isn’t always the one we might expect it to be.
We have followed this template since we were children, since the very first time we were told a bedtime story, and we take it with us into the real world, perhaps subconsciously hoping that the template will work out there too. It doesn’t, of course. The obstacles faced by many of my patients weren’t surmountable and none of their last pages felt like a happy ending. Perhaps our constant despair at the world, at the politicians, the deep lack of humanity and the many injustices of society, is felt more sharply because it fails to fit into the template we’ve believed in for so long.
Perhaps this is why reading is so important, because in reading we restore the possibility of hope.
After my two weeks were over, I prepared myself to go back to the wards. This time, however, I wasn’t jumping back into the turmoil of general medicine or surgery. Instead, I was heading where I had wanted to work since the first day of medical school, and perhaps even before that – since I delivered pizzas and typed letters, and chased people around department stores. Since before I dared myself to see if I was smart enough to be a doctor.
I was heading to psychiatry.
I had looked forward to this moment all the way through medical school. I had tried to focus on it as I walked through the agonies of my previous rotations. It was the whole reason I was there in the first place. Yet still the misery I had endured in the previous few months lay shallow at the surface and I decided I would give it a week. If, after a week, I felt the misery creeping back, I would unfasten myself from medicine forever. No matter the shame and the humiliation, and no matter the inevitable chorus of ‘I told you so’. I would give it a week. One whole week.
I was there almost a year. Until the junior doctors’ rotas changed and I was forced to say goodbye.
Psychiatry rescued me.