Given his determination and his loyalty to his family, he had pushed himself for a decade, ignoring the evidence that he wasn’t really interested in being a doctor. Someone less driven, less able, and less attached to his family might have given up years earlier. But Deepak would only stop when he became too unwell to continue. I wondered whether the panic attacks were a deep roar from his unconscious telling him that enough was enough.
I met Deepak on only four occasions. By the end of the second session, Deepak started to see the panic attacks in a different light (they soon stopped). Alongside the glaringly obvious need to consider a switch to a legal career, we also discussed a few other options (patent attorney, or working for a medical devices company). By the end of the third session, Deepak had decided to retrain as a solicitor, and by the end of the fourth he had researched a number of different law firms that offered fully funded training contracts, and had already submitted five applications. A couple of months after that, he emailed to tell me that he had been taken on by one of the firms, who would completely fund his legal training. He was going to be a solicitor.
I was delighted but not surprised. Deepak was the sort of person who could push himself to achieve the near-impossible (both parts of the surgical exams) when he wasn’t even interested in the subject. Once the passion for the subject was there, as it was with law, he was unstoppable. To use Owen’s analogy – Deepak was no longer attempting to move forward with the handbrake on.
I spoke to Deepak recently to ask permission to tell his story. There had been a few hiccups in his training as a solicitor; some of the tasks he was required to do had been quite menial, and not all the partners were committed to training their juniors (much like surgery, in fact). But he’d qualified without any difficulty, changed firm, and now was enjoying working in corporate law. Deepak also told me that initially his family, and in particular his mother, had concerns about his change of career. Why would he want to switch from medicine to law? How could he be sure that he wouldn’t want to change again? But they had seen how much happier he was, and now the family fully accepted his decision.
*
It’s difficult to leave medicine behind. But as we’ve seen throughout the book, it can also be difficult to stay. As in my conversation with Deepak, I often have an image of somebody in the middle of a tug-of-war; on the one hand there are powerful forces pulling doctors towards remaining in the profession, whilst on the other hand there are equally powerful forces which pull them in the opposite direction.
The ‘remain’ forces include fear of failure or of disappointing family members, anxieties that all the years of training will be wasted, pride in being a doctor, uncertainty about whether one will find another job and, if one does, whether one will actually be any happier, an appreciation of the security of medical work, and constant input from senior clinicians saying that it will definitely get better soon. The ‘leave’ forces include the terror of making a clinical mistake, exhaustion, resentment about the impact of a medical career on one’s private life, an unwillingness to move around the country in order to progress one’s career, and sometimes a fundamental lack of interest in the profession.
And the end result?
Pulled between equal but opposing forces, doctors stay put.
The rates of doctors leaving medicine – in both the UK and the US – are actually very low indeed. A 2013 survey carried out by a group of epidemiologists at Oxford University concluded that ‘UK doctors rarely give up a medical career within 25 years of graduation1.’ In the US the 2015 Graduation Questionnaire completed by all medical graduates reported that only 0.2% of respondents didn’t intend to practise medicine2.
That old adage ‘Once a teacher, always a teacher’ should actually be about doctors, not teachers. Unlike doctors, in the UK nearly one third of teachers who joined the profession in 2010 left within five years3. (I should know, as this was precisely how my own teaching career panned out.) But ‘Once a doctor, always a doctor’ says it as it is. People who start out as doctors tend to end their careers in the profession.
Of course this isn’t the message you get from reading the mainstream press. On both sides of the Atlantic, newspapers frequently warn us of a medical exodus: ‘Almost half of junior doctors reject NHS career after foundation training’ (Guardian, 2015)4; ‘Why doctors are sick of their profession’(Wall Street Journal, 2014)5. And in the UK (but not, of course, in the States), the cost to the taxpayer of training doctors who then leave the NHS is invariably mentioned.
It’s undeniable that training doctors is extremely expensive. The total NHS investment in each fully qualified hospital consultant is estimated to be over half a million pounds6. That’s a lot of money to spend on one doctor, if he or she then turns round and leaves the NHS. And with NHS budgets facing unprecedented pressures in the UK, it’s not surprising that the issue of doctors leaving the profession makes headlines.
So why do the newspapers consistently get it wrong? One reason, in the UK, is a simple misreading of the foundation data. Each year doctors in the second year of the foundation programme are surveyed about their career plans. It is clear that the proportion of doctors progressing straight from foundation into specialty training is in a steep decline (83.1% in 2010, 64.4% in 2013 down to 50.4% in 2016)7. It is this figure that gets widely reported each year, and contributes to the conclusion that doctors are leaving in droves. It’s also clear that the number of doctors taking a break after foundation is on the rise. But the numbers reporting that they have ‘permanently left the profession’ are vanishingly small. In the six years between 2010 and 2016, this figure never reached 1%8. (Sadly, the exception to this general rule is the response of doctors from the European Economic Area (EEA) after the Brexit vote. They may not be leaving the profession, but more than 40% of them are considering leaving the UK.)9
Other research in the US suggests an additional reason why the numbers of doctors exiting the profession tends to be exaggerated. Using data obtained from the American Medical Association, a group of researchers in California followed up nearly a thousand doctors who had ticked the ‘I intend to leave clinical practice’ box on a questionnaire. The researchers found that those doctors who were more dissatisfied with their careers were more likely to express an intention to leave the profession. Hardly surprising. But ticking the box didn’t predict the actual probability of leaving, when the doctors were followed up three years later. ‘Self-reported intention to leave practice may be more of a proxy for dissatisfaction than an accurate prediction of actual behaviour,’ concluded the researchers10.
Yet, whilst it may be relatively rare, some doctors do end up leaving the profession. And when they do, the pain of the decision can linger for years. To quote from a 2004 study carried out by the British Medical Association11:
An unexpected finding from this study was how traumatic the decision to leave medicine had been. Many of the doctors interviewed still felt bitter or disappointed and still considered medicine to be their first love. Some were visibly distraught at interview …
For many the feeling on leaving medicine was of relief, combined with sadness. Sadness because ‘it was such a waste’ or because medicine remained their real love.
References to ‘first love’ and ‘real love’ show the depths of feeling involved. And just like a fraught love affair in which either or both partners half-heartedly threaten to leave on many occasions before making the final break, the whole process can drag on for years. It took Owen over fifteen years before he left the profession. And Bijal, whilst recognising his significantly improved mental health, still expressed sadness at how things had worked out.
*
Zoe was a doctor who came to see me four years after leaving medical school. The university that Zoe attended had an old-style traditional curriculum, with minimal patient exposure early on. Zoe found the first couple of years extremely dull and began to ask herself whether she had chosen the right profession. Like other doctors who have doub
ts, she took a break between the pre-clinical and clinical years, and by chance got a job as a physician’s assistant. This role involved a considerable amount of contact with patients, and Zoe felt she learnt more that year than in the previous three years at medical school.
With renewed enthusiasm for the profession, Zoe returned to medical school in order to complete her degree. She graduated with distinction in both medicine and surgery and won a number of prizes. The first year as a foundation doctor was extremely tough, but Zoe enjoyed the camaraderie of her colleagues, as well as the sense that at last she was putting what she had learnt at medical school to good use. The thought of leaving the profession didn’t cross her mind. The second foundation year was at a different hospital and although she was less well supported, she was still happy at work. After the foundation programme she climbed up to the next stage of the career ladder, progressing into a two-year ‘core medicine programme’. It was towards the end of this phase of her training, at the point when she needed to decide on her final specialty, that she first contacted me.
There were lots of reasons why Zoe had become unhappy at work. She was fed up with working so many nights and weekends, and especially with the impact this was having on her personal life. And whilst she had applied to an oncology specialty training programme, she was unsure whether this was the best way forward. Although she found it rewarding to treat patients with a cancer diagnosis, sometimes she felt that oncologists persisted with treatment when it would have been better to encourage a palliative approach. ‘Flogging the patients to death,’ was how she put it.
We met once at this stage in Zoe’s career, and following the session Zoe emailed to tell me that she had accepted the oncology training post, but deferred starting for a year. She intended to use the year out of training to complete a Master’s in medical ethics, and would also work as a locum in order to keep her clinical skills up to date. She needed a bit of a breathing space, and time to decide whether or not she really wanted to commit to oncology.
During the first session Zoe had told me that previously she’d struggled with depression and anxiety, and had undergone a period of CBT. We discussed at length whether she might find the psychological demands of treating patients with cancer too demanding. Given her previous history and the fact that she had seemed exhausted by the demands of her core medical training, I wondered whether she might struggle with oncology. Zoe wasn’t sure either (hence her desire to take some time out), but on balance she felt that she could manage.
Over a year later when she was two months into her oncology training she contacted me again. This time, it was a very different Zoe I encountered. She was finding the clinical work traumatic; each night when she went home she couldn’t stop thinking about her patients. She was also shocked by the physical decay that the disease caused when patients were nearing the end of their life. On reflection, she wondered whether she needed a less demanding line of work.
Building on her recent Master’s, Zoe told me that she wanted to find work as a medico-legal adviser helping doctors who were on the receiving end of a patient complaint or who were facing disciplinary action. She no longer thought her job satisfaction was dependent on treating patients and she was interested in the complex legal and ethical problems that medico-legal advisers encountered. Zoe duly applied for a medico-legal job but wasn’t appointed. Feedback from the panel was that her heart was still in medicine. Zoe was disappointed, but as she had been told that her chances next time would be greater if she finished her training, with great reluctance she decided to continue with oncology.
The following year Zoe contacted me again. She had been involved in a car accident and sustained significant injuries. After a month in hospital she had moved back home with her parents for a period of rehabilitation. During this time she had done some hard thinking about her career. For the first time in her life, she understood – from the patient’s perspective – what a huge difference medical care can make, and this had been transformative. In other words, it was being a patient that rekindled her desire to be a doctor.
So Zoe went back to her oncology training. She worked part-time at first, as she was still recovering from the accident, but slowly built up to full-time work. I thought that would be the end of the story. But it wasn’t. A year or so later Zoe emailed me again. She was in a particularly unsupportive hospital, and once more was finding it exhausting to witness the suffering that some cancer patients endured. She also didn’t see any female consultants whose life she wanted to emulate:
‘I don’t want to be finishing late, eating kebabs and going home to an empty house,’ was how Zoe put it.
So again she was wondering about medico-legal work. Or perhaps she would retrain as a solicitor or even a management consultant. She was desperate to find a career she could enjoy.
‘The only reason for me to continue in oncology is that it might open the door to other options in future,’ Zoe said.
We discussed at length whether she might be depressed but Zoe felt that this was not the case. So Zoe and I explored her feelings about her current job in great depth, and we also worked out how she could research some of the other options.
At the same time as she was giving serious consideration to leaving medicine, Zoe’s training required her to move on to a team in a district general hospital. To her surprise she found the environment much more supportive, and a month or so later, she wrote to tell me that perhaps she had found her niche for the future:
I really feel that I’ve looked in all the ‘corners and cupboards’ now and properly explored my career options, in a way that I haven’t before. It was so useful to speak to management consultants, solicitors, etc. and get a feel for what else is out there. I have to say I’m surprised, but very pleased indeed, to conclude that, for me, the grass is not greener elsewhere.
I received that email two years ago. I have spoken to Zoe since, and she told me that she was relieved she didn’t end up leaving clinical practice. She’s been appointed as a consultant, and combines part-time clinical work with a role in teaching medical ethics. In our recent conversation, Zoe also told me about something that had happened during the year she was studying for her Master’s.
One evening shortly before Christmas a twelve-year-old boy was brought into the A & E department where she was working as a locum doctor. He had a fever, felt unwell, and developed a rash. Zoe correctly diagnosed that he was suffering from sepsis and she followed the protocol for the management of this condition in the resuscitation bay. This included applying an oxygen mask, taking blood samples and inserting various lines and catheters into his body. Unfortunately, despite these urgent interventions, the child started to become drowsy, after previously talking quite coherently. Rapidly his condition deteriorated, and the crash team was called. Tragically the resuscitation failed, and the boy died.
Zoe was traumatised by this sequence of events, and her mind kept returning to the fact that in the early part of his treatment he had been able to talk. Different questions kept on circling through her mind: How aware was the boy that he was dying? What happened to his family that Christmas? And, crucially, what else could she have done to save his life?
The death was fully investigated by the hospital, and it was concluded that it could not have been avoided. Zoe was not deemed to have been at fault in any way – but this made little difference to how she felt. She couldn’t bear to think about what happened, or to talk about it to anybody. The hospital didn’t offer her any support, nor did she seek any for herself. She could now see that it had affected her deeply, both before and after she started her oncology training, and had doubtless contributed to the difficulties she had in her first post and beyond. Six years on she was able to talk about it in a way that previously had been impossible. ‘When I’m under pressure, I’m happy to be asked questions about my clinical approach or to ask others for help,’ she told me. ‘It’s made me humbler – a better physician.’
*
Zoe
was not alone in experiencing distress following the failed resuscitation of a child. A survey of emergency physicians in the US found that 64% reported feelings of guilt or inadequacy after an unsuccessful paediatric resuscitation12. Doctors’ hearts are not made of stone.
Of course it is not just doctors working in emergency medicine who suffer when things don’t turn out as planned. And unexpected events are far from uncommon in medicine. A recent study of over 600 anaesthetists found that 62% of respondents had been involved in at least one anticipated death or serious injury within the last ten years and 84% had experienced a similar incident at some time in their career13. Despite the fact that the majority of anaesthetists had therefore experienced incidents of this type, these events still had the power to cause significant emotional distress: ‘More than 70% of respondents experienced guilt, anxiety and reliving the event … and 19% of respondents reported never having fully recovered from the event.’
Even when subsequent investigations concluded that the adverse outcome was unpreventable, the majority of anaesthetists in the study still felt personally responsible. What this shows is that the emotional impact of an adverse outcome (feelings of failure, or of being personally responsible) was not linked in a simple way to an independent external assessment of whether the event could have been prevented. Which is exactly what happened to Zoe; being exonerated from blame by the subsequent investigation didn’t stop her blaming herself for years.
Twelve per cent of the anaesthetists reported that they considered changing career. A similar figure was found in a study of the impact of perinatal death on obstetricians14. What is perhaps most shocking of all is the lack of support for doctors in these situations. ‘We have very little in place to allow for proper physician care in the aftermath of adverse events,’ concluded the authors of the study of anaesthetists. These words could equally have applied to Zoe.
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