‘And how do you say, “I miss you”, he wondered, when you don’t mean “I want to come back”.’

To say 2020 has been a mind-fuck would be an understatement.

It would be difficult, I know, to find someone whose life hasn’t been affected by the global situation this year. But for us, 2020 heralded a complete change in direction, even prior to the pandemic.

In February, I was finishing up work, after an incredible 18 months in Melbourne, ready for 6 months of travel and a relocation back to the UK in August to finish my training. We got engaged (yay), and were planning a wedding in the new year. Fast-forward a few weeks of rejected visa applications, reapplication for a job I had left only days previously, and an epiphany on my part of what is important in life, and we were looking at the next half-decade in a place which, only weeks prior, I had been happy to be leaving.

It is baffling and beautiful how much change can be affected by one unforeseen circumstance. The rejection of Emma’s visa for the UK initiated a cascade of emotions that I didn’t realise I had in me. My overriding reaction was one of relief. I had an out. I could choose this comfortable, well paid, easy life. I wasn’t choosing Melbourne over home. It was out of my hands. Comfortably and conveniently ignoring the fact that I was choosing to not appeal, to not reapply. I was choosing to stay.  

I am fully committed to this life now, and it simultaneously feels voluntary and inevitable. I’m not a great believer in fate, but am convinced that sometimes The UniverseTM decides things for you. The Universe really fucked with my plans for 2020, and somehow I am very grateful that it did.  

It is a weird feeling to acknowledge that somewhere is a better fit for you than the place you call home. Don’t get me wrong, I miss London and the UK in an extreme, visceral sense. On a daily basis I yearn for the familiar culture, time with the best of friends, the simple feeling of being at home. However, Melbourne has afforded me the luxuries of spare time, disposable income, and the feeling of being part of a family again.

Emma and I have known for a long time that our lives will be inevitably split between two countries. Living in this one gives us the ability to spend time in the other. I want my time in the UK to be full of friends, and fun, and holidays. I don’t want to return to the shell of a human being I was when working in understaffed, under-resourced Emergency Departments, coming home and collapsing without a word to say to my partner. Feeling guilty for calling in when genuinely sick. Selling my soul to attend best friends’ weddings. Giving so much of myself for so little return. Being 5 years post graduate in one of the most desirable professions and still living paycheck to paycheck.

I was at peace with my decision. You cannot have everything you want in life, and this seemed to provide the best of compromises. Living in a place that wouldn’t be my first pick, in order to have a sustainable, enjoyable existence, to allow me to spend time at home each year, and actually have meaningful interactions with the people I value in my life.

And then the travel ban hit.

It is a very different feeling to be choosing to stay in a country when you have the luxury of being able to leave. The last few months have been hard. Of course, it has been difficult being in lockdown in Melbourne. It has been devastating to read of the Covid toll around the world. It has been horrendous to see people in the UK suffering, to see how hard the NHS is working and to not be part of it. Resentment has definitely crept in about the lockdown in Melbourne, which, no matter your views on realism or effectiveness, is really fucking hard to live through.

Uncertainty over the opening of international borders is wearing me down. I don’t really care if I can travel more than 5km from my house, I couldn’t care less about going to a restaurant. I want to know when I can go home. And that is an impossible question to answer. I understand social distancing, I understand mask wearing despite the lack of evidence, but even the end of the road map to “covid-normal” mentions nothing about international borders.

I have been trying to fill my time with productive things; applying for training here, applying for a Partner Visa to give us that much sought-after feeling of stability. I feel a little like I am consistently giving away parts of myself though. Applying for recognition of prior training is a lengthy process bound to end in disappointment when the Australian college inevitably decides my 5 years in the NHS aren’t worth crediting. The Partner visa processing time of 25 months is, frankly, laughable. Their assumption that I would be pretending to be in a relationship in order to remain in this country is infuriating.  

Things could be much worse. Things can always be worse. I have a stable job, a wonderful fiancée, a place to live. Big decisions have been made this year, cementing our love for each other, our ability to reason through difficult choices, and to tolerate each other at our snappiest and least appealing. At baseline we have discovered that we still enjoy spending time together, even when that time is in the same four walls for months on end, with no one else to buffer us. I call that a win.

I know I am lucky. Lucky to be in a place where I can live comfortably, love freely, feel part of a family. One day borders will open again, and I will be able to spend time with the people I am missing so terribly now. And yes, I am missing them. But given the choice between my life there, and my life here, I choose here.

You can do everything right, and still be wrong

I haven’t had the best time at work the last couple of weeks.

Having been in Melbourne, at the same hospital, for over a year now I have somewhat gotten into my stride. I have stopped second guessing myself and adjusted to the new way of practicing medicine, which if anything has been refreshing. I have enjoyed being able to be a diagnostician instead of a triage monkey.

As is inevitably the case, just as I feel confident, I have been hit with several difficulties in the last fortnight. There have been multiple patients whom I have seen, discharged home, and who have then represented with really weird, serious stuff.

Going over the cases with the head of ACEM (who by the way just happens to work at my hospital 😍), it is decided that I didn’t miss anything the first time around. Far from finding this reassuring, it is freaking me out.

I have always been able to deal with the uncertainty of medicine better than most. I am lucky in that I very rarely take my work home with me, and it is unusual for me to be thinking about patients after I have discharged them.

However, I naively thought that the degree of risk and uncertainty would decrease throughout my career. I hoped that with my increasing knowledge base and experience, I would become more sure of myself. Instead, the opposite has occurred.

It turns out that with more experience comes more uncertainty. You can risk stratify to your heart’s content and still miss important diagnoses. You no longer run your thinking past seniors in the same way, and as such the risk of missing things rests squarely on your shoulders.

It would be easier to deal with if I was being told that I failed to request a certain blood test or scan, or missed a vital detail in the history. But instead, I am being faced with the reality that you can do everything right and people will still surprise you.

Everyone that I have discussed my recent cases with has commented that they would have done the same thing, but the fact remains that I have a group of patients that I have seen over the last 2 weeks, who have represented and had adverse outcomes, and I am not sure how to make myself ok with that.

You have to be able to accept a degree of risk as an emergency doctor, and I don’t think anyone who I work with would say that I struggle with making decisions. Maybe I have just had a bad run, but it has significantly knocked my confidence and in my most recent set of nights I have noticed myself over-investigating, stalling, and keeping people for observation, whereas a week ago I would almost definitely have discharged them.

I am sure it is a medical coming-of-age; a realisation that you will never be good enough to prevent bad outcomes 100% of the time, but it is a difficult adjustment period and I have lost all faith in myself. I’m sure my equilibrium will be restored soon, but in the meantime I would be grateful if all my patients could show their cards early, and obviously, so that I don’t compound my lack of faith in medicine.


In the spirit of Pride month, I am trying to be more proud of myself. This includes, but is not limited to, pride in my sexuality, my relationships, and my life choices.

I have always found Pride uncomfortable. It is too in-your-face. Too attention grabbing, too all-encompassing, too obnoxious. The topless, glittering, overtly sexualised parading. The garish, crass, flag. It all makes me very awkward. Maybe I am just British – slightly prudish, uncomfortable with drawing attention to myself in any way.

Until recently, I never really had any gay friends. I didn’t, and still don’t, frequent any place with “gay” in the title. Ostensibly, I didn’t want my post coming-out identity to revolve around this one aspect of me. I wanted to retain the same friends, the same experiences, the same interests. But I am coming to realise that a lot of this standoffishness was a result of living with a deep sense of shame, and an inability to accept myself. And this shame stemmed from the inevitable reaction of the two people I cared most about in the world.

It is now a little over 4 years since I came out to my parents. Prior to that conversation, pretty much everything I did in my life was geared towards making them proud of me. They lived through me from the moment I was born, outside identities eschewed, focus entirely on this formative tiny human they had created. I received an extreme, and unhealthy, amount of love and attention. My successes were their successes, and my failures theirs too, and boy did I know it.

My mother views my sexuality as a failure. A failure on her part to raise a “normal” child, and a failure of mine to conform to societal norms. I honestly believe that a part of her thinks I am doing this entirely to hurt her. She doesn’t know how to be authentic with me. She can only manage surface conversation, avoidance, and silence. To this day, she hasn’t spoken about it with any of her friends. For my mother, appearance is everything, and she is now so ashamed of her daughter that she cannot speak of her. I have been waiting for her to come to terms with it, to decide that her relationship with her daughter means more to her than other people’s opinions. To love me, unconditionally. But she is stuck, insular, betrayed.

My father is little more than a footnote to her feelings. Lacking extreme views himself, he validates hers. Chooses his wife over his daughter. Adds exponentially to the pain through silence and avoidance. Seeks absolution under the guise of passivity.

These people, the most important people in my life, the people who taught me what love is supposed to be, can’t bear to accept me. I am only just beginning to process what that means. It turns out that unconditional love does, indeed, have conditions.

And so, I must seek to make myself proud. Seek to validate my own decisions. Seek a new family. I don’t believe I will ever have the strength to sever ties with my parents, but I need to reach a place where I don’t need their approval to give me worth. Where their inability to love me for who I am no longer leaves me feeling betrayed. I have a lot of work to do. But it is important, and necessary. I am stuck in a world of ‘what if’s and ‘if only’s. Lamenting that things aren’t different, looking backwards and not forwards.

I will be turning 30 in October, and my goal is to be able to enter the next decade of my life confident, proud, and truthful. I now own a pair of rainbow Pride converse, so am considering that a reasonable start.


Melbourne Musings

I have now been in Melbourne just over a month.

I have settled into work at one of the teaching hospitals. We have secured a cute little flat within walking distance from work and a nice little coffee shop down the road. We have even taken our first trip to explore outside of Melbourne – heading to McLaren Vale and buying an unacceptable volume of Shiraz.

A couple of my new colleagues have discovered this blog, and one sent a screenshot to me asking if I wrote it. Aside from being amused at my now international almost-recognition, it led to me re-reading my last post, and I can’t believe how defeated I sound. I already struggle to recognise the Sheri who wrote it, barely 2 months on. I feel a little as if I am emerging from a thick fog. Things in healthcare here really are as good as people made them sound.

Traditionally this blog has been used to voice my annoyance at the general state of the NHS. It is odd to begin writing a post filled with positives. There are, however, in addition to the much nicer working environment, negative aspects of living in the Antipodes. I will probably end up comparing and contrasting more than just medical-related things over the next few posts.

Here are the things that have struck me thus far.

The COFFEE. Dear Lord, the coffee. I knew it was better. I was excited about sampling it. What I wasn’t prepared for was how difficult it is to get a mediocre cup of coffee in this city. Every small coffee shop has more delicious brews than the next. Chains like McDonalds (Maccas to my new friends) serve better coffee than independent shops back home. The Aussies are so focussed on superior caffeine, that even on night shifts there is a coffee truck that does the rounds of the Melbourne hospitals from 10pm to 6am supplying excellent beverages to all the night workers. Never will I be reduced to instant coffee again. Pure genius.


The rota (roster, as I am intermittently learning to call it). The shift pattern is just as terrible as back home. If anything, it is worse. I arrived in the country and immediately worked 3 consecutive weekends and then went straight onto nights. However, several vital factors mean that this did not bother me as much as it should. Firstly, you are paid fortnightly (hooray). The pay you receive varies depending on how many out of hours shifts you have worked that week. As such, weeks where you have worked weekends/nights provide you with a noticeable increase in your take-home pay. I know it supposedly works this way in the UK too – your annual salary is calculated to include your out of hours work, but you never see it directly. Seeing those extra dollars in your bank account after a weekend shift makes it exponentially easier to cope with.

Additionally, the workload is so much less. There is constantly more than adequate staffing, with time to make a cup of tea and have a little chat with your colleagues even during the “busiest” of shifts. I no longer feel as if I am continually chasing my tail and getting nowhere. There is time to properly assess, investigate and treat patients, instead of feeling as if you are providing a triage service where people are either referred or discharged without so much as a diagnosis considered or a brain engaged. People are less overworked, and as such more amenable to being contacted about patients for advice, even if you are not referring. There is more of a culture of friendliness and openness.

We are all used to the post night shifts breakfast where you get boozed and form the best bonds with your colleagues, dissecting the previous shifts and getting increasingly tiddly on espresso martinis, but in my hospital here, the Consultants foot the bill for these social engagements. There is a cap of $100, but it definitely shows appreciation for the night work. They can do this comfortably, and claim it back on expenses. Which leads me nicely to the next point:


Salary packaging. For those working in healthcare, you can set up a system whereby you can pay for certain expenditures such as rent/entertainment from your gross salary, prior to taxation. There is a cap of around $9000 per year, which gives your take-home money a significant boost, and again adds to the feeling of appreciation of your hard work.


I have left a training programme in a major teaching hospital, where there was a commitment to providing me with teaching and training experience, and am now working as a trust doctor in a smaller unit. One would assume that the teaching and training opportunities would have decreased. This could not be farther from the truth.

Despite the fact that I do not have a college affiliation, I have access to 5 hours of protected, PAID FOR, teaching on a weekly basis. What is more, the sessions are actually useful. Additionally, the ED registrars are all rostered to spend time in theatres, ensuring we keep our intubation skills up to date. It makes sense that you would want to keep practicing a skill that you rely on in an emergency, and I can’t believe we don’t do that in the UK.


You are much more responsible for your patient here. While the patient is in ED, regardless of the team they are under, you continue to make all the management decisions for them, obviously with consultation as required. If someone needs intubating, you do it. You put the lines in, initiate the treatment, and then call ICU for admission. It is so much more hands on, and exactly what we all signed up for when we wanted to become emergency doctors. It feels so good.

In addition to the above point, you can also do so much more for your patients here. Due to a combination of everyone being much less overworked, and funding being distributed differently, I have had none of the old frustration of knowing someone needs an outpatient review/further investigations and being unable to arrange them. Need to see a cardiologist? No worries. Need outpatient investigations ordered? Easy. Need an MRI for your ligamentous knee injury? No dramas.


I haven’t quite worked out how I feel about the public/private healthcare system. Honestly I don’t quite understand it. Perhaps it will become clearer the longer I am here. The private system definitely takes the strain off of the public hospitals, and provides fast and easy access to investigations, and prompt treatment for those able to pursue it, however, there are also negatives. Unnecessary admissions and investigations being one. I have had several conversations along the vein of “well, they don’t really need admission but if they are private we can bring them in for a few days and investigate.” And I am uncertain how I feel about that. You are obliged to encourage people to use their private insurance instead of taking a place in a public hospital. I understand the logic of that, but I am not used to feeling like a healthcare saleswoman, and I feel that it damages my integrity a little, especially if I do not feel the admission would be any different for the patient, or that the tests are unnecessary. I have had so many ridiculous conversations with extremely twattish private Consultants who clearly don’t care either way about their patients as long as they are being paid. Watch this space for more thoughts as I come to understand the process better.


Brand names. Dear God, Australia, learn what paracetamol is. Every drug is exclusively referred to by the brand. Not just by the public, but in healthcare too. The electronic prescription system requires the brand name to prescribe. You type Panadol, Voltaren, Lyrica etc. It drives me nuts that nobody knows what drugs they are taking and it’s even worse that the brands are so prevalent within the ED. I needed some metaraminol the other day and got nowhere until finally someone told me they call it Aramine here. It is a daily struggle.


Inherent racism/homophobia/intolerance of difference. This is a BIG factor for me. Australia is a developed country, with tons of educated people, and a net immigration per inhabitant of 4.5% (for reference the UK and US are roughly 1.5-2%). One in five Aussies were born abroad. It is therefore completely baffling to me that there is this degree of intolerance. People who I socialise with, who I consider to be well educated, largely with left-leaning politics, and a similar worldview to my own, have no problem voicing incredibly racist and offensive terminology. I have heard the word ‘wog’ in casual conversation more here in the last month than ever before in my life. I am not sure that I will be able to make my peace with that. I am told it is much worse in other parts of Aus, and that Melbourne is relatively tame in this regard, and that makes me feel sick. I am sure that their most recent Prime Minister and his anti-immigration, anti-marriage equality, extreme religious views is not about to improve the situation any time soon.


On a lighter note, it is VITAL that I pick my AFL team. I didn’t care much about footie teams back home, and assumed the same would be true here. But AFL here is life. It permeates every conversation, people form impressions of you based on your affiliation. Pretty much every conversation includes references to the players/games. It probably doesn’t help that I have arrived around finals season, but I clearly need to pick a team.


That’s it for now. I will keep you posted on further impressions as we go, but now I need to go out for coffee. Peace out.

If Nye Bevan could see us now…

Today, on the 70th Birthday of the NHS, I called in sick to work. Due to sheer exhaustion, and a complete loss of all the fucks I have left to give. I am a danger to patients. I have complete empathy fatigue. I have worked 80 hours in the last week, and I am broken.

I am annoyed by everything. How dare people be ill? I have lost my ability to make decisions. Juniors are asking me for advice, and I am struggling to comprehend the simplest of ideas. I can’t even decide what to eat for lunch.

I woke up this morning, and the thought of going to work actually made me cry. I have never had that before. Sure, I have had days when I would rather stay in bed, but I have never experienced such a negative, visceral reaction to the thought of doing my job. A job which I chose, and I used to enjoy.

I am simply exhausted. Doctors rarely call in sick, and when we do, there is an unwritten rule that you don’t call in on a night shift or a weekend, as they are traditionally understaffed and you leave your colleagues unacceptably short. For the last few weeks, every shift has felt like a night shift. We are chronically understaffed, and it is only getting worse. The retention of staff is at an all time low, locum shifts aren’t being filled in the rota due to the London wide pay-capping, and those of us left on a permanent rota are filling in the gaps.

We have over 3 hour waits as the norm now. Patients are defensive and angry as a starting point. They immediately rant at you for how long they have been kept waiting. If, as is often the case, they do not need to be seen in ED acutely, they are furious that you have kept them waiting so long to tell them to go somewhere else. The idea that A&E is not the correct service for your problem seems to be equated with us not caring that you are ill. That is simply not the case. No one is more frustrated than doctors when they see a patient, know exactly what they need but are unable to organise it. Referring back to GP is not laziness; it is an unavoidable necessity. Blame the lack of funding, not the clinician seeing you.

In the last 2 weeks alone, I have been called names ranging from “unfuckable dyke” to “racist cunt”. I accept anger and abuse as the norm. In A&E, we see people at their worst, and so to deal with that we have to be at our best. It is hard to be at your best when you are working 80-hour weeks with minimal staffing. It is hard to be at your best when you can’t complete the simplest of tasks without being interrupted consistently by people asking how much longer the wait is. It is hard to be at your best when patients would rather believe an internet diagnosis over the one you give them. It is hard to be at your best when you are operating on 6 hours sleep and you see more of your work colleagues than you do your family.

So as I sit at home today, on the NHS’s 70th birthday, about to leave the UK to go and work in another healthcare system, I am torn. I am incredibly proud to come from a country that is synonymous with free at point of access healthcare. I am overjoyed that so many people still think the system is worth fighting for. But I am also approaching my limit of physically being able to work within it. Goodwill and pride only take you so far, and as a bare minimum, I would like to ask everyone who has been marching in favour of the NHS this week, to try and be a little more understanding to your healthcare professionals when you see them in A&E. We are doing our best, and some of us are broken from trying to keep this system afloat.

I’m not a girl, not yet a woman.

Through our years of medical training we have assessments that are designed to give us feedback, both on our clinical skills and on our personal traits and interactions within the department. It is a testament to how poorly they are generally completed that I am in my 5th year of training, and in the last 2 weeks have received my first ever genuinely constructive, slightly negative, feedback.

And it wasn’t enjoyable.

There is a tendency in medicine towards feeling that negative feedback is a reflection on your character. Nobody likes to receive criticism, however constructive, but as a medic you spend the vast majority of your life attempting to be a good doctor, to manage patients in an appropriate and empathetic fashion, and you are continually striving to be the clinician you want to be. We go weeks and months, if not years, without useful direction or advice about our clinical skills, and speaking for myself, are fooled into thinking that no news is good news. Then along comes an appropriate feedback session, and you learn that you are not as good as you think you are. For someone with chronic imposter syndrome this means you feel like the shittest doctor in the world.

My current stage of training is a funny one, I am at the end of my SHO years and from August, if I stayed in the UK, I would be embarking on registrar training. I feel competent as an SHO and totally out of my depth as a registrar. In the words of Britney – “I’m not a girl, not yet a woman.”

My current department gives ST3s (my year of training) the opportunity to step up as registrars. However, they quite unhelpfully don’t distinguish on the rota or in practice between an ST3 and an ST6 – a doctor with 3 more years of emergency medicine experience. As a result, in an already very stressful environment, you feel like you are consistently underperforming and being held to an unacceptable standard.

I personally do not feel that it is appropriate for me as a doctor with a total of 20 months of ED specific training to be leading a resuscitation room alone in a major teaching hospital. I don’t feel that I should be managing majors alone and making decisions about all the patients seen by the more junior doctors. I definitely shouldn’t be doing this without appropriate induction or training. This is where it feels different to other specialties. I have friends in medical and surgical specialties who become registrars at this level. However, they have had much greater exposure to their chosen profession (at least 2 solid years prior to becoming a registrar), plus, I hope they will forgive me for saying, their knowledge base and patient variety is not as vast. As emergency medics we have to know a bit about everything, and be confident risk stratifying everything from chest pain through to ectopics. This takes time, and patient numbers, to achieve with any degree of certainty or safety.

I have really struggled with this year, and that was unexpected. I came from a hospital that had a bad reputation and no senior support, into an emergency department with some of the best consultants in the country, with 24hour consultant cover, and I expected more.

My first 6 months was in paediatrics and I had the best time. The teaching was unparalleled. The department was super supportive, and I never felt outside of my comfort zone without knowing exactly who to call about it. Admittedly, I had no paediatric experience, so they weren’t trying to get me to act more senior than I felt.

Going from that state to leading a busy ED area is stressful for anyone. And then when you receive feedback that you are not doing that effectively, it makes you defensive, and you fail to see the usefulness or accuracy in the feedback you are given. No I am not performing at ST6 level, and nor should I, or anyone else, be expecting me to. However, there are things that I can strive towards improving, in order to perform better and eventually become a competent registrar.

There is a reticence to acknowledge when we are out of our depth. Not the crushingly scary, sick patient in the middle of the night, out of our depth – everyone recognises that, if they don’t they have no business being in medicine. I am talking about the consistent, low grade effects of repeatedly operating just that little bit out of your comfort zone, and feeling unable to voice it because everyone else seems to be coping fine. Not having anyone check on you and make sure you are ok. Being the only senior in a department for others to ask questions to because the consultant is in resus. Just being expected to cope.

It takes a lot to voice unease when everyone around you is giving the impression of you being able to cope. And you can cope. But really, coping isn’t what we should be aiming for. Confidence is the aim. And my experiences this year have totally stripped me of mine. I have been made to step up into a role that I was eager to take, without any significant training, without acknowledgement that this was new and difficult, without someone touching base to see how I was going. And I coped. And now I feel less confident in my medical abilities than I have in a long time.

I am grateful to be taking some time out in August. The thought of continuing to ST4 training is enough to make me hand in my training number. I am approaching this move to Melbourne as an opportunity to see more patients, hone my diagnostic skills, and come back a better, stronger doctor and person. Or alternatively I will run away to the sun forever and never come back…

This week I have been mostly reading…


One of the unexpected bonuses of my article being run by The Guardian, was that a psychologist got in touch with me asking if I would review her new book, which will be published later this month. Caroline Elton has worked with doctors for many years, providing counselling and occupational career support, and she is writing about the psychological effects that medicine has on those who work in it.

I read her book, “Also Human” on my way to and from work last week, and it was a surreal experience. So many themes in my life, and so many of the ways that I approach and justify situations, that I had assumed were unique to me, were on the page in front of me. The themes of the book are explored through her interactions with various doctors over the years, and her unique insight as an outsider commenting on the peculiarities of medical training really made me take stock. Several of her observations resonated with me – from the assumption in medical school that you will make a good doctor purely because you have an aptitude for science and perform well on standardised tests, to the lack of psychological preparation for medical students as they are flung into their first foundation jobs, and have to cope emotionally, as well as practically, with people’s lives depending on their decisions.

She explores the issue of empathy fatigue, which is something I am struggling with at the moment, and the comment by one of her patients that “Medicine is a bit like a cult”, struck a chord deep within me. Often, staying in medicine is easier than leaving, and sometimes that is all that keeps us going.

The lunacy of all new doctors starting on the same day in August, and allowing senior doctors to take leave that week; the lack of psychological evaluation for prospective doctors, and the unwillingness to accept that some medical students just may not have what it takes to complete their training – whether academically or emotionally. The inability to accept that doctors are human, fallible, and capable of falling sick, and above all, the reticence to call it a day, and change profession. Even when it is psychologically damaging, and we know beyond doubt that medicine is not for us, still we persist.

I would encourage anyone considering medicine as a career, and anyone within medicine feeling unfulfilled, or considering a change, to read this book. It contains within it things that we all know, but fail to consider, and it has truly changed the way I think about medical training.

Blame Culture

Today we woke up to the news that the GMC has won its appeal to the High Court, and has struck off Dr Bawa-Garba.

Imagine, if you can, returning to your job after a prolonged leave of absence (maternity leave in this case), beginning your role afresh in a new environment with which you are not familiar, and being told that your colleague couldn’t be in today, and could you please do their work too? Additionally you find out that your boss is uncontactable, the other members of your team all started 2 weeks ago and are just finding their feet, and the IT systems are down. Someone else, in a different team, makes a mistake for which you are punished, and at the end of a gruelling workday you make an entirely avoidable mistake, which leads to catastrophic consequences. Are you no longer qualified to do your job? Do you lack the qualities and experience necessary to carry out your day to day duties? Or are these exceptional circumstances, and an entirely understandable lapse in judgement?

This is what happened to Dr Bawa-Garba. She made a mistake, on the back of incredibly hard working conditions over the course of a 13 hour shift, and a 6 year old boy died. Initial investigations into the case found that her mistake may not have influenced the end result of the resuscitation effort – the outcome may well have been the same. As so often happens in medicine, the SUI team found multiple contributory factors leading to this horrific outcome, and ruled that no specific person was at fault. However, Dr Bawa-Garba was convicted of manslaughter, suspended from the GMC register for a year, and has now been completely struck off.

We hold clinicians to a higher standard than most. It is understandable – our mistakes carry higher stakes. There are horrendous consequences to our failings. However, can we blame individual doctors for an outcome that has occurred in a working environment that no sane person would find acceptable?

We, as doctors, often work shifts where you go 13 hours without eating, drinking, weeing, or sitting down. I have often joked, whilst on call, that I am treating a patient for hypoglycaemia or acute kidney injury, but that my blood tests may well be worse than theirs. We prioritise the need of our patients consistently above our own basic, human needs. We work in conditions that you would be sued for trying to impose on any other profession. And the worst thing is, we impose those conditions on ourselves. We consistently state that our working arrangements are unsafe, no one in their right mind would think that staffing a 500 bed hospital overnight with a medical team of 3 people is a good idea. Wards of 30 beds go from a team of 3-5 doctors during the day, to sharing the 3 on call doctors with the other 470 patients in the hospital. Even on days when the rota is fully staffed and all the systems are working, it is a disaster waiting to happen. Medical ward cover consists of running from one fire to the next, never feeling like you are winning. How are you supposed to prioritise your need to eat when a succession of patients are, literally, trying to die on you?

But hungry, exhausted, overstretched doctors make mistakes. It should not be news that we aren’t at our best when our last meal was 12 hours ago. I remember clearly finishing one day on call on the maternity ward, and passing out on the walk to my car. On reflection, I hadn’t had a meal since dinner the previous night. I was concerned about my ability to drive, and called a cab home. 45 minutes previously I had been responsible for resuscitating a patient, solo.

During my time as an intensive care doctor, I frequently covered a ward of 14 critically unwell patients, with no Consultant cover on site. I started the job, on a night shift, with no induction to the computer-based notes system, no idea how to review medications or change doses. No understanding of how the filtration machines or ventilators worked. The fact that both I, and the patients, survived those on calls is testament to the incredible standard of nursing care. The nurses on that unit saved me more times than I can recall. But it should not be the responsibility of the nurse to educate the doctor. By that logic, there is no point in me being there. I reflect on that unit, and the fact that nobody died as a direct result of my lack of training or experience is frankly baffling.

The GMC has gone on nothing short of a witch-hunt. Bowing to tragically bereaved parents, making an example of someone who did nothing more wrong than any one of us has done on countless occasions, but got away with due to circumstance. The CEO of the GMC released a statement following the outcome:  “We are totally committed to engendering a speak-up culture”.

How do you expect to foster a culture of speaking out, when you victimise people attempting to reflect on, and learn from, their mistakes? Doctors are human. We will all make errors in our careers. I have personally made management decisions that have contributed to a patient’s death. We are a cohort of professionals that go into medicine in order to improve people’s health and lives. Nobody can make us feel worse about our failings than we already do. Nobody can berate us more than we berate ourselves. We worry about doctors’ mental health. We worry about a culture where no one wants to accept responsibility or blame. And then we have a doctor, with an exemplary record, who reflected on a difficult case, gave evidence to an investigation panel, and then had her reflective evidence used to bring a court case against her.

We are all Dr Bawa-Garba. I don’t need to know the case specifics to know that similar situations are happening across the NHS on a startling scale. That the people responsible for safe staffing and rostering are not the people living with the effects of shortages on the frontline. That the people who have made a scapegoat out of this doctor get to go home at 5pm each day, and never have to hold a person’s life in their hands while trying to remember the last time they had something to eat.

It’s okay not to be okay.

I am British to a fault.

I have been ruminating on aspects of our character that we may be unaware of. My other half is an Aussie, and when we first got together we had numerous arguments based around the different connotations of the word “fine”. Myself, a Brit, would tell her that something was fine, and expect her to infer that it was anything but. She, in typical Aussie fashion, took everything at face value and then was unable to understand why I was miffed (another classic British understatement).

When she moved over here she commented on our typical British greetings “Hiya, you alright?” and how there was no acceptable response to that other than “Yeah fine thanks, you?” We are not asking after the other person’s well-being, and if someone were to deviate from the script it would be awkward to say the least.

These discrepancies can be amusing, but our idiosyncrasies sometimes inhibit our ability to let other people in. This can have devastating consequences, particularly in Medicine. In addition to the British avoidance of talking about feelings, people in Medicine are also reticent to admit what they perceive as weakness, and emotional responses and feelings often get bundled away and taken home, not aired and explored in a positive atmosphere. Mental Health is still not addressed as it should be, and we continue to perceive the demonstration of emotion as a sign of fragility.

When you work it every day, it is easy to forget how emotionally taxing our job is. We see people at their worst, both physically and emotionally, and the range of conditions we have to deal with on a daily basis can often be a complete mind-fuck. You go from treating 4-day-old babies with sepsis, to trauma calling a teenager who tried to commit suicide, to dealing with the aftermath of a neglect case. There is often no time to think about it, no time to dissect your feelings about a case, and definitely no time to deal with the emotions that either of those actions would inevitably stir. You have to develop a way of coping that allows you to move on to the next patient, the next parent, and the next disaster. It is a fine balance. We traditionally shut off the parts of ourselves that struggle to process the things that we see, and we notice ourselves become less affected by our daily exposures. But this is not healthy, and it only takes a small thing to tip the balance.

Between 10-20% of doctors become clinically depressed at some point in their careers, and there is a higher rate of suicide than in the general population; particularly in the acute specialties, where there is a “stiff upper lip” attitude and a tendency to push forward in the face of signs that we are perhaps not as okay as we seem.

This has repercussions not just for us as physicians, but also for the way that we treat our patients. Up to 50% of Emergency Medicine trainees resign prior to completion of their training. As a specialty we are seeing the highest rates of burnout in the history of the healthcare system. EDs are becoming like warzones, and our already fragile mental health is about to snap. The higher rates of burnout correlate with self-reported depression rates of up to 40%, with associated lack of empathy and altruism, and increased rates of errors. Over the last few months, I have actively felt myself becoming more cynical, and less motivated to help people. A parent books in with their sick child and I am annoyed that they are there. The very reason that I trained to do this job has become a source of irritation.

This façade spills over into our home lives too. I am so used to shutting off my feelings about things that happen at work, that I attempt to do the same with things that happen at home. Over recent months I have been endeavouring to insulate myself from my feelings about both issues at home and difficult cases at work. And my mind simply doesn’t have the capacity.

I have recently considered going to a counsellor to help me unpack all the emotions I carry around with me, both from my personal and professional life. It has taken an almost daily struggle to keep those emotions under the surface to illustrate to me how important it is to deal with your responses to situations instead of packing them away, and using the traditional dark humour to cover them up. I have been less than keen to address these issues, due to both an inbuilt, British avoidance of talking about “feelings”, coupled with a desire not to seem nauseatingly American by attending therapy; but also due to the inescapable concern that it makes me a weaker person. That other people are managing, and by my admission I am not. That this somehow makes me a lesser doctor, a lesser person.

Acknowledging emotions is not a sign of weakness. Unpacking your response to a patient, or a situation, or your relationship, is the healthy way to deal with it and move forward. We need to stop prioritising relentless, emotionless work ethic above the ability to be normal, functional, people. We need to allow ourselves to be human.

Some of this needs to stem from a revision of NHS culture, for the establishment to recognise that lack of debrief, lack of NHS counselling, lack of self-care for our emotional selves is damaging to our productivity as a workforce, but most of it can stem from us, as individuals. If we are affected by something, take the time to feel it. Discuss it, dissect it, and get different perspectives on situations. Maybe not at the time, but we should prioritise debrief, prioritise acknowledgement of an emotional response. Allow ourselves to care.

We need to recognise, as individuals, that we are not built to carry all our stresses around with us. That showing compassion towards our patients begins with showing compassion towards ourselves, that when you are saturated by stress and emotional baggage you lack the capacity to truly help the patients that put their trust in you. We need to understand that overexertion and dependence on 3 coffees to get through the day is something to be avoided, not romanticised. That working hard doesn’t have to mean running yourself into the ground, and that taking care of our mental health is paramount to being empathetic, successful physicians.

Paediatric Pearls

Things I have learned so far in kiddies ED:

  1. Bubbles have magical qualities and fix tachycardias ALMOST every time.
  2. There is no such thing as a “quick look” at a child in triage.
  3. Play specialists = HEROES.
  4. Early ametop application in triage is one of life’s greatest gifts.
  5. ALWAYS take a second cap gas because the machine demands one as a sacrifice.
  6. Sometimes kids just get rashes, and we don’t know why.
  7. All children in London are constipated.
  8. Parents never give paracetamol, for fear of us not believing that their child was in pain/hot. We berate them for it, and then don’t believe them that their child was hot at home if they aren’t hot here.
  9. I can now identify which antibiotics someone has been given based on what colour it is, what it tastes like, and what bottle it comes in.
  10. Suctioning bronchy babies and watching them instantly perk up before your eyes is one of life’s great pleasures.
  11. Sometimes a sympathetic face and time to listen is all it takes. Parents’ scope to worry about their children knows no bounds, and reassurance costs nothing. Be patient.
  12. A good number of midwives scales are broken.
  13. If the umbilical cord looks infected, it usually isn’t. When it is, it is a BIG deal.
  14. Getting a line into a 1 day old baby gives you the best high.
  15. Paramedics and GP surgeries NEVER have paediatric sats probes and this frustration will be felt DAILY.
  16. When you get cocky about your abilities you will inevitably do something insanely stupid like glue a child’s eye shut.
  17. When you finally know the doses for paracetamol and ibuprofen without looking them up you feel like a GOD.
  18. SOME babies ARE cute, and you have to remember to give them back to their parents when you are finished examining them.