The crux, for junior doctors, was the phrase ‘properly staffed’. We knew we were barely delivering a safe five-day service and yet, in Jeremy Hunt’s parallel universe, we now had to provide a seven-day one. The maths was simple. In the absence of additional doctors, the only ways to deliver new weekend services would be for our overall hours to increase, or for us to be removed from our patients from Monday to Friday in order to beef up the weekend workforce. Either way, Mid Staffs-style overstretch seemed inevitable, unless, that was, the ‘seven-day NHS’ was less a genuine commitment than an empty soundbite, a piece of slick electioneering with no underlying substance. Respected health commentators such as Nigel Edwards, the chief executive of the health think tank the Nuffield Trust, appeared to suspect the latter:
Even if there were significant extra funding available for the NHS, getting the critical mass of specialist staff needed to make seven-day working a reality would be likely to mean closures or mergers of local services, such as emergency surgery or maternity units.23
Later, when the junior doctors’ dispute was all but over, parliament’s spending watchdog, the Public Accounts Committee, issued a report excoriating the government and Department of Health for having no idea how many additional staff would be required for a seven-day NHS, let alone budgeted for them. It stated, ‘The department has not adequately assessed the impact on the clinical workforce of implementing seven-day services and so does not know if there will be enough clinical staff with the right skills.’24
The committee’s chair, MP Meg Hillier, encapsulated what many junior doctors had felt and argued throughout the preceding year, their concerns dismissed as self-interest: ‘It beggars belief that such a major policy should be advanced with so flimsy a notion of how it will be funded.’24
Militancy came at a price. The attacks in the press grew nastier. In one memorable diatribe, the Telegraph’s executive political editor, James Kirkup, variously described junior doctors who supported strike action as ‘stupid’, ‘selfish’, ‘selfindulgent’, ‘self-righteous’, ‘inept’, ‘dishonest’ and ‘infantile and self-deluding idiots’. We were childish, petulant and politically naïve: ‘How else to describe the howling anguish of people who don’t get their way?’25
Kirkup objected to doctors dabbling in politics, dismissing our linkage of contractual negotiations with the broader issue of how seven-day services would be staffed and funded as nothing more than a petulant strop:
Many, engaged in politics for the first time, cannot understand why the Government will not do exactly as they want; for them it’s unthinkable that others would not accept the doctors’ word on how to fund and structure the NHS as final.25
Sometimes, it felt as though the political columnists were revelling in the chance to take down the know-it-all doctors a notch or two. ‘When doctors go on strike we enter lands not of medicine, nor hospital management, nor even industrial relations,’ wrote Hugo Rifkind in The Times, and continued:
This, rather, is a place of politics. It is a battlefield of pressures and ideas; of public mood and political reality. And here, my medical friends, you are no longer the experts. You’re not even informed hobbyists. You’re day-trippers, and you’re out of your depth, and you’re in for a shock.26
At one stage, Danny Finkelstein went as far as claiming that the dispute for us had never been about the contract at all. Instead, it was:
simply a loud, angry protest about a very difficult job, which is emotionally taxing and physically wearing and sometimes just seems a bit too much. It’s impossible not to feel a little sympathy and impossible also not to feel a little bewildered about what to do about it.27
While I appreciated the sympathy, the mildly patronising tone was less welcome. As a forty-three-year-old mother of two who had spent a decade working in current-affairs journalism, my patience had worn thin pretty quickly with journalists’ gleeful disdain for the ‘tragic naïveté’ of junior doctors. On the other hand, I could see why the commentators were exasperated. I knew what I was personally willing to strike for: the dangers, as I saw them, of stretching the same number of doctors more thinly across seven days, not five. I was absolutely in favour of better weekend services, but only if they were coherently modelled, planned, funded and staffed. The BMA, on the other hand, had conceded behind closed doors the principle that our contract must deliver seven-day services ‘cost-neutrally’. Indeed, albeit under duress, it had signed up to cost-neutrality as one of the preconditions of contract negotiations. This made it look as though it had tacitly accepted that it was possible to deliver a seven-day NHS in the absence of seven-day funding.
Inevitably, given this fundamental concession, the BMA appeared fixated on Saturday pay, while grassroots doctors like myself and many others continued to give interviews in which our key concern was the perils of expanding services across seven days without an appropriate expansion of staff. No wonder overall our messaging sounded muddled, or that the Department of Health press office often ran rings round us.
Long before we even went on strike, it was clear that many commentators regarded junior doctors’ arguments about safety as nothing more than our own clumsy efforts at spin, a cynical strategy to transform a grubby pay dispute into something more noble and admirable. After all, they intimated, we were contemplating using what was, fundamentally, the weapon of our patients’ misery – denied their operations and appointments on strike days – to contest the contract. But I didn’t want more money. The salary I’d chosen to give up when I’d left television ten years previously was three times the one I earned now. What I desperately wanted was for the understaffing that already plagued my working life not to be exacerbated. If it were, I feared not only for my patients but also for my future in medicine.
CHAPTER 9
OESTROGEN
It is always around 4 a.m. that my brain begins to malfunction. I can walk, talk, perform medical procedures, but my ability to synthesise and weigh information briefly grinds to a halt. Once or twice, while writing an entry in a patient’s notes at this time, my pen has started to veer off the page as my eyes have drifted shut mid-sentence. Clearly, from a patient-safety perspective, this is far from ideal. Diet Coke, a chocolate bar, cold water on my face, a quick slap to the cheeks all help. But everyone has a point in their night shifts at which they are at their most tired and vulnerable.
A few weeks into my first year as a doctor, I was called one night to cannulate a patient at my 4 a.m. nadir. Almost sleepwalking towards his bedside, I hoped for easy veins. He was, I suppose, in his early fifties. Well enough to twinkle with delight at the arrival of the female house officer. I should have noticed that his smile was more of a leer, and that licking one’s lips was an unconventional way to greet the arrival of the doctor at your bedside. But I was exhausted and the warning signs escaped me. Crouching down in concentration, with the curtains closed around me, and the ward in darkness, I was oblivious to everything but the veins I scrutinised beneath the feeble NHS sidelight. As I was on the brink of piercing the skin of his arm with my needle, a hand suddenly gripped mine. Startled, I stared up at a sneer.
‘Ooh. I bet you like being down there, don’t you? Down on your knees in front of me?’
Slowly, deliberately, again he licked his lips. I realised his other hand was rubbing his genitals. Without making a sound, I stood and walked away from the bedside. Had it not been 4 a.m., had I been my normal self, I like to believe I would have torn strips off him, not least to make him think twice before sexually harassing the next lone female doctor. But I’m not certain. Humiliation is a powerful thing and my overwhelming impulse was get away from him. I told no one, cried briefly in a corridor, felt grubby and defiled, and moved on.
Though this is exceptionally unusual behaviour from a ward-based inpatient, in the cut and thrust of the Emergency Department, we are steeled for every shade of abuse, particularly after the pubs close. I’ve seen doctors spat at for the colour of their skin, nurses physically assau
lted, porters restraining someone who threatened to kill them, the list goes on and on. A few weeks before starting my first six-month stint in emergency medicine, I ran into a friend one morning, just as she finished an A&E night shift.
‘Are you OK?’ I asked, concerned. She looked on the brink of tears.
‘I just wish,’ she said bitterly, ‘that I could get through one shift in this place without a member of the public calling me a cunt.’
I found the more abusive visitors to the Emergency Department less of a problem than I’d expected. At night, invariably, there would be some kind of racism, misogyny, ignorance or filth to deal with – sometimes all of it at once – but usually from patients who were drunk, high or in the grip of a mental or physical illness that rendered them distressed, aggressive or disinhibited. It was an unpleasant part of the job, but I never took it personally. Once, though, while I was in my third trimester of pregnancy, the most senior nurse in the department that night refused to let me see the next patient.
‘Seriously, Rach, go and see the next on the list,’ he told me. ‘Believe me, you don’t want to see this guy.’
It turned out that the man in question had just traumatised a young and inexperienced student nurse who had pulled the curtains shut around his bed in order to check his observations. While sequestered out of sight with her, he had inveigled her into examining his penis, which, he assured her, was in need of medical attention. Around the root of his grotesquely swollen, purple member was wrapped not once but three times a ‘Britain First’ rubber wrist bracelet – an idiosyncratic expression of patriotism, to say the least. The nursing staff were livid. The perception that someone had preyed on one of their own brought out a fierce, almost familial loyalty. And, in truth, the bonds you form with your A&E family – the people with whom you witness all the trauma and sorrow and ugliness that life can hurl your patients’ way – are as strong as any. The camaraderie forged from this shared experience is second to none.
When it comes to sexism, every group has its outliers, and doctors, like patients, are no exception. Rarely have I encountered overt misogyny among my medical peers, though the few occasions on which I have done so are memorable. Once, just before I sat my finals, an old-school male breast surgeon, close to retirement, gave us a revision lecture on breast cancer. Amid the bleak statistics about the second-biggest cancer killer of women in Britain, he suddenly flashed up a slide of a young blonde woman sitting coquettishly in front of a mammography machine, her naked breasts displayed prominently.
‘Of course,’ the surgeon commented ruefully, ‘most of the patients I see in my clinic are in their fifties at least.’ He paused, eyes twinkling mirthlessly at his student audience. ‘Nothing like as nice as this one is to look at.’
The gasp from the student audience was audible. The sole purpose of the slide appeared to have been to enable the consultant to crack this joke. He continued as though he had said nothing abnormal. Quite apart from the fact that I knew that the mother of at least one of the students in the room was currently receiving treatment for breast cancer, this apparent contempt for women from a man who performed mastectomies for a living was difficult to stomach. To their credit, the medical school leadership took seriously the deluge of complaints that followed and the surgeon in question never taught medical students again.
The old-school are still at large in the medical hierarchy and often, on account of age and seniority, residing near the top of it. Recently, Jen, one of my female junior doctor colleagues, attended a medical dinner at an Oxbridge college. She remarked in passing to her fellow guests that it was striking to observe the low proportion of women seated at the high table. Only two of the forty or so spaces were occupied by women and these, Jen noted, were not present due to academic merit but because they were married to fellows of the college. The implication that medicine might in any way be sexist infuriated Jen’s neighbour, himself a consultant in orthopaedics who led a prestigious department of spinal surgery.
‘The trouble with women in surgery,’ he said, ‘is that they haven’t got the temperament for it. Surgery requires hard work and dedication that women are incapable of. The reason they don’t get to the top is because they’re not cut out for it.’
That such views still exist in Britain’s biggest employer in the twenty-first century struck the surgeon as entirely unremarkable. He was simply stating facts, he argued, and could certainly not be described as sexist himself since he had female juniors working in his service. When challenged with the argument that perhaps attitudes like his own might be driving women away from his speciality, rather than seeking to excel in it, he dismissed this as mere political correctness.
‘There is a temperamental difference between men and women,’ he insisted, ‘that means women do not make good surgeons.’
Later, over drinks in the senior common room, another male consultant who had overheard the conversation sought Jen out to express how greatly he admired her forthrightness. Alas, his approval came with its own particular kind of gender stereotyping. Without a trace of irony, he told her, ‘You really are a feisty hussy, aren’t you?’
‘Honestly,’ she told me afterwards, ‘it was like being in a bloody nineteen-fifties gentlemen’s club. Without the gentlemen.’
The vast majority of the doctors I have encountered respect their male and female colleagues equally. Indeed, medicine has a justifiable reputation for being one of the UK’s more progressive professions when it comes to gender equality. But that does not mean medicine is a level playing field. As with so many jobs in Britain, it has an established gender pay gap as well as a gendered distribution of doctors among the various medical specialities, with many of the more ‘prestigious’ roles such as neurosurgery and cardiology remaining predominantly male. The disproportionate number of men in these roles increases the higher ones climbs up the hierarchy. While 57 per cent of junior doctors are women, only 30 per cent of surgical trainees are female, for example, and a mere 11 per cent of consultant surgeons are women.28
Though it takes a special kind of doctor to argue these days that women are temperamentally inferior to men, I have frequently heard colleagues explain away the existence of a glass ceiling in medicine as the result of women choosing to prioritise having a family above their career, rather than being the product of any structural or societal inequality. If, so the argument goes, we will insist on taking time out for maternity leave or to work part-time in order to be with our children, then our relegation to lesser roles within the profession is only to be expected.
With its long and unpredictable hours, hospital medicine is undeniably difficult to combine with family life. Indeed, the first hurdle is often making a family in the first place. I have two friends, Sarah, a female orthopaedic surgeon, and Nick, her anaesthetist husband, whose little girl is the same age as mine. Their daughter’s conception required such relentless commitment, such spirited defiance of impossible odds that I secretly wish they had named her ‘Immaculate’. Both parents at the time were junior doctors who worked punishing oncall rotas, often spending seventy-two-hour stints at a time inside the hospital. They quickly realised that attempting to align the rare moments when they were both at home with Sarah’s ovulation was a strategy doomed to failure. Statistically speaking, the only reliable route to parenthood was sex inside the hospital.
This undertaking was not for the fainthearted. Contrary to the impression given by Grey’s Anatomy, doctors’ on-call rooms in the NHS are at best shabby, at worst a squalid health hazard. Nonetheless, at precisely the right time of the month, Nick and Sarah arranged an on-call-room tryst at six o’clock that morning. He was finishing his night shift, she was due to start hers an hour or so later. With a bit of luck, there would be a sufficient lull in the night’s anaesthetic emergencies to permit the act of procreation.
Sarah waited impatiently on cheap hospital sheets whose cleanliness she chose not to question. A cockroach squatted in a corner of the room. She bleeped her hus
band. Stuck in theatre, said the scrub nurse. She tried again half an hour later. Still stuck in theatre. By now, her own on-call shift was close to starting. Irate, frustrated, another month squandered, she was about to change into her surgical scrubs when there was a frantic tap on the door. Sweaty and dishevelled from sprinting up seven flights of stairs, Nick had finally made it.
‘Quick! I’m going to be late for my shift. Come on!’ she ordered.
‘I – I don’t know if I can,’ he told her and, under the circumstances, who could blame him?
‘Oh, for God’s sake! There’s no time for that. Just get over here and do it.’
In an act so swift and primal it was surely worthy of narration by David Attenborough, Nick and Sarah mated. Immediately afterwards, she leaped up to pull on her scrubs.
‘Shouldn’t you, you know, lie on your back with your legs in the air for half an hour or something?’ he asked her.
‘Are you kidding? There’s no time for that: my list is about to start in theatre.’
With that, she was gone and the rest is history, the phrase ‘doing a level seven’ immortalised in one particular family from that moment for ever more.
I was the first student in my medical school to have a baby, the first house officer in my Trust to be a parent, and the first to ask permission to work part-time. To my relief – and I’d felt uneasy about how the news would be received – not once was I aware of my medical school judging or frowning upon me. Quite the opposite. In a supportive and liberal university environment, combining my studies with motherhood felt, if not quite easy, then certainly manageable. The local nursery hours meshed with mine and the sleep deprivation felt like early training for all those imminent nights on call.
Your Life In My Hands--a Junior Doctor's Story Page 13