Letter to my (former) patients {Part 2}
Duty, sacrifice, joblessness, and more love.
Settle in, lovely readers, this is a long one.
Last week I published the first part of my Anatomy of a Decision introductory letter, explaining some of the background to my decision to leave behind my life as a surgeon:
The most obvious question to explore in Part Two today then, is why? Why would I give up this career I once loved? That I had worked towards for most of my four decades on this Earth? The truth is that there isn’t one single answer. Trying to pinpoint a single moment is akin to a swarm of children wielding paper tails at a children’s party outline of a donkey. Otherwise, perhaps I would have come to this decision much sooner and saved myself and my family some expensive exams and years of painful vacillation. Like many of the most important decisions in life, though, this was not one to rush.
“The only way to do great work is to love what you do.” – Steve Jobs
Perhaps the simplest – if least satisfactory – explanation for my decision is that, like any pairing in a worn-out relationship, medicine and I have fallen out of love. In fact, to continue the metaphor: the reason it took as long as it did for me to take my suitcase and walk away? Just like the many couples who stay together longer than they ought: I stayed for the kids. As I discussed last week, the privilege of being a surgeon – and in particular, I think, a paediatric surgeon, where we are invited to the inner circle of a family to walk with them through some of the most challenging moments they will ever face – is immense. Human connection is the very essence of life, it is what makes us human. It follows then, that for me, it was those thousands of patients: babies, children, and their families that got me out of bed every morning (and many a night). But my love affair with the profession itself? I think that died when it began to take more of me than I had left to give.
The concept of medicine as a vocation dates back some 20,000 or so years to the paleolithic1 era. The Oxford English Dictionary definition of the term vocation2 highlights the problem with applying this term to one’s work:
“a strong conviction that it is one's duty or destiny to follow a particular profession, way of life, course of action, etc” - OED
If our work is a duty and a destiny then is there an expectation that it should demand our sacrifice? Many careers require sacrifice, of course. Long hours and late nights of persistent concentration are not unique to medicine, indeed they are common requirements in law, business, finance and more. Physical toil is prevalent among the craft professions and in many industrial workplaces, and I note that medicine’s sister profession – nursing - reaches second on indeed.com’s3 list of most physically demanding jobs. Many careers including those in the armed or emergency services carry significant emotional strain and add in an inescapable element of personal risk. Perhaps, then, an expectation of sacrifice for one’s work is reasonable? The trouble is, there is no sacrifice-meter to judge how much is too much. Is it acceptable if the sacrifice is all ours? What about if our work asks for sacrifice from others, though? From our partners? From our children? When do we stop, and say, ‘enough’?
The latter part of my training years saw me deeply unhappy, for a very long time. In the earlier years, I had enjoyed the rigours of a challenging work life. Surgical training is long, and it is gruelling, but this was balanced by my excitement that I was constantly learning new, interesting skills. I was at the coal face, seeing patients every day and doing valuable, energising work. Most of the time, I felt well supported and that I had the back up of a system and resources that allowed me to provide good care. As time went on, these positive drivers began to erode. Morale across the workforce was struggling, even long before the extraordinary trials brought by the pandemic.
“Never quit on a bad day” – Ben Crawford
Towards the end of my training path, much of what made my work enjoyable was outweighed by a workload that increased far beyond the resources we had at our disposal to provide quality, safe, care. The workplace culture was frequently hostile. I found myself questioning if I should continue on this uphill treadmill. The trouble was, I had no idea what else I could do. There was also a relentless… hope, that the difficult years would all be worth it if I could just get to the end. Perhaps life really would be better as a consultant?
It is both comforting and concerning to know that I am by no means alone in my evolving dissatisfaction with medicine as a career. The reality of medicine today is a very different one than the profession I chose to enter. A paper published during my first year at medical school - more than twenty years ago now - reports that among 1970s graduates, a great majority of hospital doctors and more than three quarters of GPs stated a ‘definite’ intent to stay practising for at least another five years4. That is not the case today. Recent reports from a variety of sources reveal a constellation of troubling trends: more doctors are struggling with workload5 than ever before, doctors are feeling less valued6, more are leaving to work abroad78, and among the most senior and experienced cohort, many more are choosing to take early retirement9. There are countless factors driving these changes: an ageing population, crumbling hospital estate, development of increasingly complex – and expensive – treatments and a difficult economic climate among them. These challenges are not new, and for a long time their effects have been mitigated by the goodwill of the NHS staff who have readily donated billions10 of hours of unpaid overtime. The trouble is that it is not possible to sustain this for long without running head first into burnout, and I was not immune.
The major trigger of my own episode of burnout in 2016 was a toxic cocktail of high demand, low reward, lack of autonomy and an intractable uncertainty stemming from the insecurity of fixed term contract working. Few outside medicine, even among the rest of the NHS workforce, are aware that UK doctors do not hold permanent work contracts until they are appointed to a substantive post – usually as a consultant, partner or salaried GP, or (and these positions are few) a permanent non-consultant specialist appointment. Almost all require completion of a lengthy training programme and entry onto the specialist or GP register. In my case, in all my 18 years of work, I only ever held fixed term contracts. The career timeline below demonstrates my path: each blue dot represents another application/interview process. Text in green represents formal training time; I was appointed to the specialist register in 2022 and went on to a nationally appointed training fellowship. As time went on; as I aged, married, became a mother, the desire to permanently settle, to feel secure, became overwhelming.
I never did manage to find the security I craved. Even my consultant post was a fixed term contract which ran for just over 14 months. Towards the end, I applied for an extension, but there were three consultants in these temporary posts in my department and only two ongoing jobs. I was not successful at interview. At the time, I was undeniably devastated. Now, though? I honestly believe that I am the happiest I have been in a very long time.
I feel immensely fortunate, that in the final year of my surgical life, I reached the high point of my career. I was appointed as a consultant surgeon at one of the best children’s hospitals in the world. I was finally able to use all of the experience and skills I had learned to make the decisions that mattered. I enjoyed having ‘my own’ list of patients at last – providing continuity of care that is not possible as a trainee when the day to day is managed according to a rota allocating your time to many different teams – and I became incredibly fond of many of my patient families. Best of all, I hit the colleague jackpot. I will always be glad that I got to experience a year of working alongside a group of exceptionally talented, skilled and kind professionals who were not only supportive, but actively welcomed me into the fold. I count many of those colleagues now as dear friends. I have no regrets that I did not rush my decision to walk away from medicine. There is a great clarity that comes from finishing on a high, I think. It has allowed me to leave behind the ‘what ifs’. The major cost of it? That was borne by my family.
As is the case for many, my career was not a vocation in isolation, as for the last seven years as a surgeon, I have also been a parent. As much as there is a societal sentiment that we can ‘have it all’, eventually, something gives.
Annabel Crabb eloquently describes the motherhood paradox in her book ‘The Wife Drought’.
“The obligation for working mothers is a very precise one: the feeling that one ought to work as if one did not have children, while raising one’s children as if one did not have a job.” - Annabel Crabb
I was lucky. For most of my years in training I was able to live in one home. Many resident doctors do not have such fortune, facing multiple distant rotations and relocations. I had some lengthy commutes, sure. Three years of Nottingham-Leeds – during which the major route was undergoing extensive construction work with the accompanying delays – not easy. When my children came along though, I was working and living in the same county and life was manageable.
In a small specialty like mine, consultant posts are few and far between. Post-training, after six weeks of unemployment, I was relieved to be appointed to one such post, which as I’ve described above, turned out to be a year of hope and healing. But as every rose has its thorn, my contract required residence within 30 minutes of a hospital more than two hours from my home. Full relocation would have involved uprooting my husband from his career, our children from school and leaving behind our home and support network, with major consequent expenses (and the post came with no relocation allowance). For a temporary position we decided that this was not a feasible option, so I spent that year paying half of my salary to rent a flat in my work city. Though my husband and I spent many hours driving, given my busy schedule and on call shifts, I was able to see my children only every 1-2 weeks. They were 5 and 2 years old at the time; my youngest, still breastfeeding.
The observation that perhaps surprised me the most about working as a consultant was that I had anticipated that the most ‘difficult’ part of the job would be the complex clinical decision making, the technically challenging procedures or the emotionally taxing conversations needed to explain a complication or break bad news to a devastated family. Though these could never be described as easy, these were the elements that I’d trained for, and which were in fact the most rewarding. The actual difficulty came from an ever-increasing administrative load, pervasive inefficiencies in a system running always at capacity, and in trying to find the time and cognitive space to make meaningful improvements.
It may surprise many people to learn that the majority of a consultant surgeon’s week is spent nowhere near an operating theatre. In my 62 weeks as a consultant I had a total of 61 planned half day operating lists. Half a day; 10% of a working week. In addition to this I would be on call another 10% of the time. The rest? Taken up with clinics, with driving to peripheral hospitals for outreach work, with meetings, teaching, professional development and admin. It was commonplace that I would spend at least twice as much planning an operating list as I would spend doing it, often more with frequent last-minute cancellations and changes.
I also really missed learning. There are, of course, always opportunities to learn and develop in any career, but in the day to day work I was doing, there was just not enough to keep my heart singing. I began to find more joy in training others - especially around my areas of expertise such as trauma team leadership - or in trainee wellbeing and advocacy. Often, the elements of my work that felt the most valuable were not those that I was being paid for. In the end, it was the little things that helped me to make the decision that I need a new start. It was the fact that the resource limitation was so stark that I never had my own desk, instead having to check each day which of my colleagues were on leave so that I could borrow theirs. It was that in the shared consultant office, there were just two pairs of computer headphones, as the spending freeze prevented the purchase of any more. I frequently found myself joining Teams meetings on my phone so that I could use my own Bluetooth pair. Ultimately, it was the feeling I couldn’t shake of ‘is this really my life for the next 25 years?’.
“You are never too old to set another goal or to dream a new dream” - CS Lewis
When I was still working, I think I was too busy surviving the day to day that I rarely stopped to think about what I really wanted from life. What my core values are. How to show up in the world in a way that is authentic and meaningful. Not only that, even if I had, would I have been brave enough to walk away if my post hadn’t ended when it did? If I hadn’t been given this gift of time to work things out?
Last July, I became officially unemployed for the second time. There was a profound sadness as I left work after my final shift. The hardest part was knowing that I couldn’t be there for my patients, many of whom I’d built relationships with. I called some of my patient families to explain and apologise that I would not be present for their next appointment and had handed over their care to a colleague. On the last call to the family of a baby I had cared for since his birth almost a year earlier, I am not ashamed to admit that we ended up crying together. I do not believe that it is possible to be a good doctor without deeply caring about the people we meet along the way. There are very many whose stories changed me irrevocably, so I write this letter in thanks to all of the patients and families who put their trust in me. It has been the privilege of my life to be your doctor.
Once home in this void of joblessness, I recognised the need to stop, to sit in the space, and to take stock. I spent a wonderful, carefree summer with my family. I chose not to apply for any more consultant posts. The children are seven and four now; I have realised how much of their lives I have missed. There has been a lot of emotion to process. Grief, largely, for the career I once loved. Some guilt, too, that I am no longer using the specific surgical skills that I have, but there is more to me than a pair of hands. I’m starting to explore possible new careers where I can utilise the extensive skills and experience I have gained to have positive impact beyond one individual patient at a time; to contribute meaningfully in new ways. This publication is one part of this. My intention for this corner of the internet is that it will be a home for me to share the deep lessons I have learned about leadership, decision-making, and life. I hope you’ll join me here so that we can create a community of shared learning, for I have found such joy in learning! In this much needed time off, I have gone back to study and have learned things I’d always wanted to, such as how to code – I am very proud of my maximum grade in the University of Helsinki’s online Advanced Course in Python Programming course! I have found joy in collaboration and contributing to my community, and I have rediscovered a love for writing. I don’t yet know what will come next, but I will take my time and put myself in the way of opportunity wherever it may appear. I have a lot to offer to the world. I plan to stay curious, seek connection, and live in the moment. And I think that’s a pretty good start for the rest of this life. How about you?
Ah, Louise! I identify with much of this, the walking away from a vocation, the “what now?” questions. Mostly though, what you’ve written moved me so much because I was once that paediatric surgical patient. I spent a fair bit of my childhood at Alder Hey. I had the same surgeon from age seven until I was seventeen. Mr Green! God bless him. It’s fascinating for me to read the perspective from the other side. Wishing you joy, peace and fulfilment as you forge this new creative path. Cheering you on!
heading out, can’t wait to read it later xoxo