Your Life In My Hands--a Junior Doctor's Story

by Rachel Clarke

  Only once I started my first year of practice, now as the mother of a toddler, did I discover how rigid and indifferent the NHS could be in its treatment of doctors in training. It was not that I wanted special treatment. I hadn’t slogged away for six years to be anything other than a devoted doctor, as committed and industrious as any of my peers. I just hadn’t banked on hospital management disregarding quite so blithely the way in which its approach to its staff could be, on occasion, unintentionally punitive.

  The excuse always given is ‘service provision’. Individual employees must be subservient to providing the service our patients need and what, in the NHS, could sound more reasonable than that? The problem arises when ‘service’ is used to justify an unnecessary blanket approach to treating staff as mere numbers on a roster, their own lives and needs being entirely disregarded. As any decent manager should know, this is a fast track towards a disaffected workforce.

  Junior doctors in particular – moving as we do from job to job every three, four or six months – live in perpetual frustration at being unable to plan our lives. Leave is frequently ‘fixed’ – handed out at the last minute, with no capacity for adjustment, making even booking a holiday impossible. Rosters can be allocated without any notice, so that one’s nights, weekends and evenings on call are not known until the first day of a new job. On occasion, a doctor will prepare for a new post by setting themselves up with a new home and amenities in their new town of work, only to find, days before they start, that they are now being sent somewhere a hundred or more miles away to do something entirely different. No explanation, no apology is ever given. Service provision requires it, so get over it.

  None of this is necessary, let alone dictated by ‘service needs’. It could all be avoided with a little forward planning. But, while some managers strive to provide this, many, in my experience, do not. All the doctors I know are more than happy to devote long working hours to their patients, but the casual thwarting of any attempt to plan one’s life by departments too disorganised to email out advance rotas is infuriating. And, since hospital medicine – with its long, erratic and antisocial hours – is one of the most childunfriendly careers, this can generate particular obstacles for parents who are attempting to combine being a doctor with caring for a family.

  Dave and I swiftly discovered that the net financial benefit to our family of my working was less than zero. By becoming an NHS doctor, I was losing my family around £5,000 a year since our childcare costs outstripped my income. One weekend on call could last thirty-five hours and cost close to £500 in childcare. Antisocial hours were only a part of it. To avoid being a clock-watching doctor, someone who raced out of the ward on the dot of five to reach the nursery before it closed, we paid for childcare that ran on into the evenings, since the workload invariably did the same, regardless of what were, on paper, our official hours. There was no other way to avoid becoming the kind of doctor who dumped on her colleagues or abandoned her patients if they took a turn for the worse at the end of the day. I simply could not do that. But paying for the privilege of working hours that I myself worked for free understandably exasperated Dave, who now found himself in the unenviable position of trying to provide for his family and subsidise his hardworking yet financial drain of a wife.

  ‘Why are you doing this, Rach? You come home exhausted and stressed, always three hours after you should do. You never see your son. You’re costing your family thousands of pounds. It’s completely insane.’

  I had no convincing answers. I loved my patients and I loved being a doctor. But, financially and emotionally, my family were paying for my decision to eschew time with them for endless hours in the hospital. On bad days, perpetually torn between my children, my husband and my patients, medicine felt less like a vocation than a folly. Cutting back my hours after my first year as a doctor felt like the only way to balance life, though an ostensibly 60 per cent job-share often resulted in my working in excess of the forty hours a week that typically constitute a full-time job.

  As the junior doctor dispute hotted up, I wondered how long it would take before gender surfaced as an issue. Sure enough, writing in the Sunday Times, columnist Dominic Lawson devoted his provocatively entitled piece – ‘The one sex change on the NHS that nobody has been talking about’ – to explaining why the real cause of the dispute was not chronic NHS underfunding, inadequate workforce planning, or inflammatory sniping from the Department of Health press office but, more surprisingly, oestrogen. According to Lawson, a hidden debate had been ‘raging for years’ within the profession about the malign effects of the ‘feminisation of medicine’.29 Oddly, in seven years of practice, the rage had passed me and all my colleagues by. Nonetheless, his argument centred on the alleged crisis in the NHS caused by the presence of too many female doctors.

  Once upon a time, all doctors were men. Women, as we know, used to be judged incapable of medicine. That changed in 1876, when, after a tenacious fight led by Britain’s first female doctor, Elizabeth Garret Anderson, the law was changed to prohibit women’s exclusion from medical schools. Now, more than 140 years later, female medical students outnumber men. Yet, according to Lawson, our predisposition to avoid antisocial hours and put family before career means we are more likely to work part-time, generating unsustainable staffing shortfalls. In essence, he seemed to be arguing, junior doctors were threatening the country with strikes because the fairer sex wanted to stay at home, cuddling our babies, at weekends. Worse, since each doctor costs so much to train, we part-time female doctors were overburdening the taxpayer with our inadequate productivity.

  As evidence to back up his claims, Lawson cited a Dr Chris Heath, a ‘40-year NHS veteran’, who had written to him to say, ‘Women doctors don’t like weekend rotas … This is one of the reasons why paediatric units are failing: 70 per cent of their junior staff being women and therefore frequently off on maternity leave.’ It’s true, I’m afraid. When you pop out twenty or more babies over the course of a career, that’s a significant proportion of your time spent breastfeeding. Clearly, the main issue facing the NHS was women like me who first flooded our medical schools, then spawned babies with impunity, and finally abandoned our patients for a lazy part-timer’s life.

  Inspired by the phenomenally successful ‘Like a Girl’ video from Always, the sanitary-towel company, which was screened at the 2015 American Superbowl30, I decided to lampoon Lawson on social media by starting a satirical hashtag, ‘#likealadydoc’. To my immense satisfaction, I watched #likealadydoc trend internationally as female and male doctors from all over the world expressed what they thought of such sexist claptrap. Some of my favourite #likealadydoc tweets from fellow doctors included:

  I apologise on behalf of my uterus for its role in NHS under investment and fragmentation of services.31

  ‘I got all confused & got 3 degrees + 2 royal college memberships. I only popped out for a new frock.32

  ‘Poor husband left to do all the women’s work at home while I’ve spent 26 hrs at the hospital this weekend covering a rota gap.33

  This weekend, I checked every major decision about a patient with a woman. My consultant. My boss. My role model.34

  Beneath the scorn, of course, was a serious point. Once, men deemed women too weak-minded to be capable of medicine. Now, apparently, our fatal flaw was to be insufficiently economically productive, lured by our ovaries towards part-time working. Lawson’s argument neglected to consider the notion that perhaps, in twenty-first-century Britain, some fathers as well as mothers longed to share in childrearing. Many modern men – men like my husband – would dearly love to have the option of balancing their workplace commitments with spending time with their children. Flexibility in the workplace is not, in short, a woman problem: it is a human problem. But in a society bereft of affordable childcare in which part-time working is the exception, not the norm – and cultural expectations are largely that men should be full-time breadwinners – the burden of sacrificing career for childre
n continues to fall disproportionately on women.

  When Dave and I considered our options, part-time working was unavailable in his workplace. So either he quit work, which was financially untenable for us, or I worked part-time, or both of us accepted that our children would grow up spending more time in care than with their parents. My ‘choice’ to cut back my hours was framed accordingly. Arguably, if social and cultural barriers did not deny men the choice to work as flexibly as women, the ‘problem’ with women in the medical workforce would cease to be a gendered one.

  Lawson’s implied solution to the problem of the ‘feminisation’ of medicine – though he chose to insinuate rather than state it explicitly – was to address the diminished productivity of female doctors by reversing their increasing prevalence in the NHS. Perhaps, to ensure the taxpayer received the biggest bang for their buck when subsidising doctors’ training, it would indeed be better to revert to a more virile time when medicine was predominantly male. After all, limiting women’s encroachment on the profession would certainly minimise the problem of part-timers. One of the most disappointing aspects of the junior doctor dispute was that the government, far from ensuring the NHS remained a trailblazer for gender equality, turned out to be just as willing as Lawson to cast female doctors as a financial barrier to a seven-day NHS.

  After his 2015 general election victory, David Cameron briefly sought to present himself as the face not only of compassionate conservatism and family values, but also of female emancipation. He took an impressively progressive lead on gender equality by vowing unequivocally to ‘end the gender pay gap in a generation’.34 But the insincerity of that commitment was swiftly exposed when, in early 2016, the government belatedly published its equality assessment of the new junior doctor contract. The assessment, a legal requirement under European law, analysed whether any specific groups were likely to be systematically disadvantaged as a result of the new contract.

  Surprisingly, given the government’s apparent advocacy of gender equality, the Department of Health did not attempt to hide the discrimination against women at the heart of the new contract. In fact, the Department’s own analysis admitted that women might lose out disproportionately, while dismissing that fact with the statement that, ‘Any adverse effect on women is a proportionate means of achieving a legitimate end.’35 In essence, the pay of part-time doctors, 80 per cent of whom are women, was set to rise more slowly under the new contract, even though their antisocial hours would increase, creating a need for expensive additional childcare. The new contract would therefore widen the very gender pay gap the Prime Minister had pledged to eradicate. Women’s salaries, it turned out, were mere collateral damage and women, in David Cameron’s eyes, were almost equal to men – just that little bit cheaper.

  While admitting the new contract would, ‘disproportionately disadvantage those who need to arrange childcare’,35 the government proposed an outlandish solution. They helpfully invited doctors who were carers to find, ‘informal unpaid childcare arrangements in the evenings and weekend’ – as if the country were littered with people clamouring to do ad hoc, unpaid nannying at three o’clock on a Sunday morning. To someone who had lost count of the number of times she had scrabbled in panic to find childcare for her erratic shifts, whose job had put considerable strain on her marriage, and who had become a net financial burden to her family by working as an NHS doctor, this statement – and its utter ignorance of what life was like on the ground for junior doctors – could not have been more demoralising to me. Even under the current contract, I had already discussed with my husband whether I would be forced to quit medicine, given the financial hit of my career to my family. If the new contract meant that women with children would become less able, financially, to continue working as doctors, then medicine, after all those years of emancipation, would indeed be set to turn more male, overturning generations of doctors’ fighting for gender equality.

  The publication of the equality assessment provoked a storm of condemnation. Professor Jane Dacre and Miss Clare Marx, the presidents of the Royal College of Physicians and the Royal College of Surgeons respectively, said in a joint statement,

  We are very concerned by the language in the government’s own equality analysis of the contract, which warns that features of the new contract ‘impact disproportionately on women’. Recent commitments from government to support women in business are greatly welcome. We view the wording of the equality analysis as incompatible with this approach.36

  Dr Maureen Baker, the chair of the Royal College of GPs, said, ‘I’ve always been incredibly proud of our NHS – general practice in particular – for being streets ahead of the corporate world and being true leaders in terms of gender inequality, so anything that threatens this must be taken very seriously.’37 The Shadow Health Secretary, Heidi Alexander, encapsulated many doctors’ anger when she commented that the equality assessment had led to ‘women rightly questioning whether they’ve woken up in a different century’.38 We were enormously proud of the strides our profession had taken towards gender equality, in spite of the problems that remained, and to watch the government riding roughshod over this felt – to a great many male and female doctors alike – sickening.

  To the government’s embarrassment, the condemnation provoked by its casual acceptance of gender discrimination spread beyond the UK. One of the directors of the World Health Organisation, Jim Campbell, stated on Twitter that, in his opinion, the government’s new junior doctor contract contravened the United Nations Commission on the Status of Women. Its ‘regressive policies’, he stated, meant ‘gender equity for junior doctors is at risk’ and ‘female doctors will face widening pay gaps with male colleagues and may be forced to quit medicine’.39

  Even if the government didn’t care a jot about gender equality, in crude economic terms it seemed exceptionally short-sighted of them to increase the risks of driving away female medics while in the midst of the worst doctor recruitment and retention crisis the NHS had ever seen. After all, women currently make up 60 per cent of the profession. One might have hoped that the imperative of safely staffing the NHS front line would have caused ministers to think twice about imposing regressive working patterns that made it harder for female doctors to continue working. But apparently not. A Department of Health source told me off the record that our outrage against the gender discrimination was regarded by ministers as manufactured – it was, they believed, nothing more than an opportunist stick we had latched onto in order to bash the new contract in the media.

  If that was true, it could not have been more wrong. As a child, a student, a journalist and a doctor, not once had I doubted I was as capable as a man. It took a dispute between doctors and the government for me to discover that, regardless of whether ministers viewed men and women the same way, when the principle of gender equality conflicted with that of reducing the size of the public-sector wage bill, they were willing to throw women under a bus.

  CHAPTER 10

  RESILIENCE

  You know something is not quite right in the NHS when the head of the General Medical Council likens modern medicine to war in Helmand Province.40 In 2016, after an internal inquiry revealed that twenty-eight doctors had committed suicide while being investigated for professional misconduct by the GMC, the doctors’ regulator announced new plans for would-be doctors to have to demonstrate their ‘emotional resilience’ before being allowed to practise.

  The GMC chair, Professor Terence Stephenson, stated that medics needed to learn from the armed forces, being formally trained, just like servicemen and women, in coping strategies for handling the pressures of practice. He told the Telegraph,

  Doctors see things that many other people will never see in a lifetime. Just as when soldiers go to Afghanistan, you don’t want the first time they see somebody who has suffered terrible injuries to be when they’re dealing with an emergency in the heat of the moment … Army personnel have told me that they would not begin resilience training jus
t as they’re about to deploy and I fully understand that. The army discovered some time ago that soldiers under pressure aren’t helped if they are just told to keep a stiff upper lip. It’s time medicine reached a similar conclusion – and acted on it.40

  At the time, being intimately acquainted with a member of the military myself, I turned to my long-suffering husband and asked him, ‘When you went through officer training, did they teach you how to be resilient?’ Dave’s snort of laughter was telling.

  ‘Are you kidding? We got taught how not to get bollocked by the drill sergeants whose main purpose in life was to whip us into shape and toughen us up the hard way. We got taught how to drag ourselves out of bed at five a.m. and be screamed at for a speck of dust on a windowsill without breaking down and crying in front of our mates. So, no, we did not get taught resilience. But we learned it pretty quickly, or we left.’

  Perhaps, in these times of austerity, the most efficient way for the NHS to deal with its haemorrhaging staff would indeed be, first, to weed out the weaklings through compulsory boot camp, ensuring only the toughest were permitted to take on employment in the NHS; but one senses the GMC had something else in mind. In fact, since my husband’s officertraining days, UK Armed Forces does now run courses on resilience and has even built a Stress and Resilience Training Centre at its defence academy in Shrivenham. But the NHS is not a battlefield, doctors are not soldiers and caring is not armed combat. Moreover, implicit in the GMC’s approach to doctor burnout and suicide is the assumption that the fault lies within the individual doctor, whose psychological inadequacies have somehow rendered them incapable of coping with the stresses and strains of medicine.