I have a box full of paracetamol in my bedside drawer. I am so scared of letting my parents down, I worry I might not be able to stop myself from taking them all.
The medical student
I have driven home many times after a night shift without feeling safe to do so. The rota doesn’t allow enough time between working days and working nights for your body clock to adjust, and so you feel permanently tired. It affects my judgement – not only when driving, but when dealing with patients. Occasionally, I have slept for half an hour in the staff car park before setting off, because I’m worried I will kill myself or, worse still, kill someone else. Everyone is the same, but you can’t speak out because you would be seen as a troublemaker.
The junior doctor
My experience after medical school was marked by compulsory military service and of meeting many others of very different backgrounds who saw me not just as me but as the doctor. For the majority, a figure of comfort, but for some a figure with power that needed to be controlled or used if not abused in order to get something – control or special privileges. The period that taught me that conflict was part of being a doctor.
The consultant
Medical school was over.
Exams were taken, dissertations were handed in, practical stations were tested. For the past few months we had all lived in a knot of anxiety. Waking in the night to check something in a textbook, breaking under the weight of so much knowledge, yet secretly believing we knew absolutely nothing. Blistering in the heat of so much pressure, not only our internal pressure but the unintentional external pressure from those around us.
Each time I sat an exam, I would ring my mother as soon as I came out.
‘How did it go?’ she would ask.
‘It was awful. Everyone said how awful it was.’
‘Yes, but … you do think you’ve passed … don’t you?’
If I had failed and I was the only one who needed to come to terms with it, it wouldn’t have been a problem, but – like everyone else at medical school – it was the spectators I was worried about. All the people who had stood at the side of the pitch for five years, cheering us on. The parents and husbands and wives and friends. All the sacrifices and the understanding, the support and the kindness. We wouldn’t have failed just an exam, we would also have failed the people we cared about most in the world.
That pressure split apart the fracture lines that had already begun to appear. We tried to hold each other up through the revision and the self-doubt. Looking out for those around us. Trying to spot when someone was falling. We weren’t always successful.
If you had asked us on that first day of medical school, if you had questioned us about the journey ahead, we would have told you it was going to be the longest one of our careers. Five years sounded like a lifetime, but it was finished in the blink of an eye. I walked to my car after the final exam, back to the place where I had parked every day for the past five years, and I sat for a while in the silence. I had, hopefully, reached the finishing line – although I wouldn’t know if I had passed my exams for a few weeks – which meant I might be driving home as a student for the very last time. It felt like there should be balloons and banners all the way down the A50. Instead, of course, the world continued with its day all around me and I went home to wait for the outcome.
I didn’t go to the medical school on results day. Instead, I opted to stay at home and receive an email. Most people went in, however, and slowly a trickle of posts began appearing on social media. Champagne and hugging. Tears. Smiles. Joy. Relief. Finally, my email came through. I hunted down my mother.
‘I’m a doctor!’ I said. ‘I’m a doctor!’
As though it were that simple and, in the space between one second and the next, we all became someone new. There is no other degree that changes your identity, that somehow manages to alter your perception of who you are. There is no other degree that carries with it such a glorious history and that ushers you into its celebrated, but occasionally notorious, fraternity. Alexander Fleming, Joseph Lister, Elizabeth Garrett Anderson, Christiaan Barnard. Conan Doyle and Keats.
There were doctors whose impact was so great that we borrowed their names and gave them to the conditions we had just learned about. Hans Asperger. Burrill Bernard Crohn. George Huntingdon. Alois Alzheimer. We looked at ourselves in the mirror, brand new and shiny, barely harvested junior doctors, and we wondered if we would make even a tiny fraction of that impact.
The next time I went to the medical school, it was for graduation day.
I had been chosen to read the Declaration of Geneva. I have no idea why they picked me. I certainly wasn’t representative of my cohort, because, as well as my age, each evening for the past five years I had got into my car and I had driven away from a large part of medical student life. I didn’t live in halls. I’d never set foot in the Student Union. I belonged to no societies or clubs and, although I had enjoyed the time I did spend with other students, our lives weren’t knitted together in the same way they might have been.
Reading the Declaration still remains one of the proudest moments of my life. I stood in a hall filled with hundreds of students and families, teachers and lecturers, and I led the doctors’ oath, a version of which had been repeated hundreds of times over the decades. We recited the words, but we couldn’t understand the true impact of their meaning or the many different interpretations which could be drawn around them.
I solemnly pledge to consecrate my life to the service of humanity
I will practise my profession with conscience and dignity
I will maintain the utmost respect for human life.
It was a grand auditorium, with red velvet seats and a pipe organ. Giant beams stretched above our heads. Gowns and mortar boards scattered over the seats and spilled out into the hallways. Parents cried. Everyone clapped. As each name was read out, there were cheers and shouts. We repeated our oath and made our pledges with the utmost sincerity. Each sentence was meant, each vow considered, but words are always defined by their landscape, and words said in a grand auditorium with red velvet seats are very different to words remembered in the rush of a crash call or at the bedside of a dying patient. We thought we knew what those words meant, but their meaning would evolve with every step we took as doctors. There would be times ahead when we would need to turn away from our consciences. Over the years, the meaning of dignity and respect would be examined and we would take their definitions and turn them over in our minds. In our darkest hours, we would even begin to question the existence of humanity itself.
Since our graduation, the Declaration of Geneva has also altered and evolved. It now contains the vow: I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.
Perhaps of all the vows and promises this is the most difficult one to keep.
For all their training, for all their knowledge and expertise in sustaining good health, attending to their own well-being is something that doctors are not especially good at. The focus is always on the patient, solving the puzzle of the person in front of us, not resting until we find our answer. Sacrifice and the surrender of the self are woven into the job, and going without food and water and sleep are also vows every junior doctor seems to be expected to uphold. Look after yourself, we are told and then we are placed in a situation where self-care is impossible, and even seen by some as unpleasantly self-indulgent. Protected mealtimes say the leaflets we are given, as the bleeps and the phone calls and the requests never stop. Get home safely they advise us, as more than half of junior doctors report accidents or near misses when driving or cycling home from a night shift, purely due to sleep deprivation. In a 2017 survey, a third of doctors reported having no rest facilities at the hospital where they worked, and in one of my jobs, all the beds were removed from on-call rooms in order to prevent doctors from taking a break.
I started hallucinating on the motorway, one junior doctor told me.
I stopped at a set of traffic lights and the next thing I knew, a driver had pulled alongside me and the sound of his horn woke me up, said another.
Since 2013, at least three trainee doctors have died in car accidents following night shifts. At the inquest into one death, it was reported that the doctor was singing on the drive home, to try to keep himself awake.
A few years after graduation, I found myself working in A&E as a junior doctor. I had been there for twelve hours without eating or drinking – something that wasn’t unusual and was certainly not considered an issue by anyone in the department. However that day, perhaps through the accumulation of many days filled with twelve-hour shifts, I began to feel faint. Waves of nausea tumbled through me and a rushing sound began to fill my ears. My hands were shaking too much to even write in the notes and I certainly didn’t trust myself to take blood from someone or insert a cannula. It was affecting my judgement, my reaction time. Extreme tiredness and lack of food have the same effect as being drunk and I was worried that I would make a mistake.
I finished dealing with my patient and I looked around for a chance to escape, just for a minute. The department was in chaos. Every bay was filled, every bed occupied, and a line of paramedics and their patients snaked down the corridor, through the double doors and into the car park. The sense of guilt and shame was overwhelming, but the sense of imminent collapse overwhelmed me just a fraction more. I could be back within three minutes so I had just managed to talk myself into making a run for it when my consultant appeared and told me which patient I needed to clerk next. It was late at night and I knew the canteen would be closed in ten minutes. I didn’t want a three-course meal; I didn’t even want a sandwich. A bar of chocolate. A biscuit. Something I could eat while I worked. Something to bring me back to being able to function safely. Something to make me useful again.
‘I really need to eat something,’ I said in a very small voice.
He stared at me. ‘There are patients waiting.’
‘It’s the patients I’m thinking of,’ I said.
The look of disgust on his face was so clear and so obvious I can conjure it up at a moment’s notice even now, years later. I never asked for food again.
Medicine is a vocation, not a job, we are often told. The reality is, it is both, but when the conditions of the job become unbearable, when the demands made of us are likely to put our own lives at risk, not to mention the lives of the patients in our care, we are expected to continue to bear it because of a deep-rooted sense of purpose. A calling to serve and heal, and to fix. Or perhaps we are drawn to fixing others, because, by doing so, we might inadvertently succeed in fixing ourselves.
Graduation felt like the end. It felt as though we had arrived at our destination and the journey had reached its conclusion. Little did we know that the past five years had just been a prologue, a short introduction to what lay ahead. In our minds, we had passed the finishing line, but in reality we had only been walking, very slowly, towards the start of the race.
In a beautifully circular pattern, the same professor who had delivered our opening lecture at medical school and who had welcomed us to the first day of our medical career, also delivered to us the final words we would hear as students.
He stood on the stage in the grand auditorium, he leaned on the podium, and it felt as if he managed to look each one of us straight in the eyes.
‘Now,’ he said, ‘the hard work really begins.’
Once again, he was right.