Energy Management: or why I’m not cut out for medicine

OK… you’ve got me. I like the inflammatory clickbait title. I don’t really think I’m not cut out for medicine. But maybe medicine is not currently quite cut out for me.

“Departure with the purpose of settling elsewhere”

Guardian article by Denis Campbell: https://www.theguardian.com/society/2021/may/03/nhs-faces-exodus-doctors-covid-pandemic-survey

“Exodus” is a pleasing word for what I am doing. It implies escape from some oppressive tyranny to a better and brighter tomorrow. Hand on heart, I am not sure either is completely true. I don’t have a bright plan ahead of me, and the “tyranny” has been me – more than anyone else – at this point.

I’ve ruled over myself with an iron will, holding myself fast against the pointy end of the knife whilst suffering 1,000 cuts of buying into the scam I was sold. Allowing myself to be the frog, my boundaries progressively scalded away, until I completely lost them and discovered I was boiled dry. I bought the rhetoric that I should be grateful of even the chance of being a doctor. That this excused what the job was, or how it affected me. What did I need sleep/food/to attend family events/my dying friend/a room to rest/space to write notes/to be treated like an adult/time and space to grieve significant losses (delete prn) for? Until I ended up ill, anxious, or burned out over and again. Even whilst this happened, I was encouraged to examine myself for the fault rather than the institution of medicine, the NHS, or its culture. Probably I wasn’t resilient enough. I should do some mindfulness, toughen up, or ship out.

In-out-in…

This isn’t the first time I’ve left clinical practice. With typical autistic honesty I have to make clear that, to date, I have never completely left. I’ve left a foot in previously and even now will probably leave at least a toe… at least for a while. I’ve found ways to make use of my clinical knowledge through medicine-adjacent work. But this will be the third, and perhaps final, time of leaving daytime General Practice behind. In truth picking this specialty was an “escape” in itself. An escape from being hospital doctor.

Can’t try harder: or why I couldn’t hack it in hospital

I admit a rocky start to clinical practice. Maybe there’s more to say on this topic another time. Although there were lots of other reasons the main reason I left hospitals for general practice was the working pattern. Namely nights.

My first job in hospitals included the dreaded 72 hour weekend on-calls. As a House Officer we were relatively protected – literally. We had “protected rest” from midnight til 7 am, although we could be woken if the SHO was overrun or for crash calls. Guess what? We often were. The rota changed within a couple of months of starting that job and we went from the crazy 24 or 72 hour on-calls to normal days, long days (on-call) and nights.

Normal days were long. Long days, longer but nights were an absolute killer for me. My silly autistic brain could not manage the enforced and alien switch over to nights. This was worse than jet-lag. I could never really sleep in the day, managing at most a broken 4 hours. When I realised this, my daytime insomnia got laced with even more anxiety over sleeping that spilled over to days as well. I got trapped in a series of viscous circles of shift-lag managing which left me too exhausted to do much more than barely turn up to work. I struggled. I got stressed out. I felt like a failure. I got ill. Colds, or sniffles, or worse. Complaining wasn’t an option. It was given short shrift; “Of course, nights are awful,” “Oh yes, I hate nights too.” Suck it up, try harder, keep pushing, bury your human needs for sleep, rest, recovery. Just pull up your socks, my girl. JFDI.

But those needs didn’t disappear. They festered away wherever I’d buried them. Their rotting stink activated my subconscious who, in a bid to allow them (me) the oxygen to breathe and live, snagged in lots of other reasons why I needed to get the hell out of there… I didn’t like the people, I didn’t like the way they approached caring for folks, I didn’t like the hierarchy, I didn’t like the repetitiveness, I wasn’t cut out for it…. but what it really was: my body needed to rest and my mind had to find a way to get me out of there so I could. Finally, a surgical membership later, it did and I found my way to the “least worst” option at the time; retrain to be a GP – they don’t do nights!

Do something different

Of course General Practice is more than not doing nights. As I settled into it I started to realise what an interesting and complicated soup GP was. It was a sort of crazy hybrid of medicine, ministry, anthropology, theatre and… witchcraft. The witchcraft being the special secret ingredient, a pinch of which had transformative effects. Or that’s how it seemed to me, until I read the Balint classic and realised that the special sauce is “relationship”. Cue existential crisis number two. I didn’t know that I wanted to be the medicine! And how could I be the medicine for others when I was not “medicated” myself?

So I left. Although, in my typical autistic ‘hiding in plain sight’ it didn’t look like leaving. I had an “out of programme” experience. Which sounds much more exciting than it was. I spent a year beginning to learn the ropes in clinical “leadership” and management – my second career. I went back to GP though jumped right into the deep end being effectively single-handed in an under-doctored (read deprived) area.

The ketamine blew my mind': can psychedelics cure addiction and depression?  | Health & wellbeing | The Guardian
Picture credit: Frieda Ruh/The Guardian

Long story short: it burned me out. Medicine being medicine though, and having had my OOP (!), I found a way progress into my second career whilst keeping my hand in GP-ing via out of hours telephone triage and just a skosh of day time GP.

Unfinished business

“Just when I thought I was out, they pull me back in!”

Michael Corleone, The Godfather: Part III

Clearly having forgotten what had happened (or perhaps, sneaky unconscious, being ready to do something different this time) a few years ago I thought it would a great plan to get back in to daytime GP. So I did. I started with a day a week before finding a four session job. Just as I was settling in, personal tragedy struck and my cunning plan suddenly wasn’t quite so cunning, wise or even survivable after all.

You’d think in a profession that cares about patients all day long they’d take good care of their own. Well… you’d be a bit off the mark there I’m afraid. Maybe in some places they do… some places are more like a family. But mostly the culture is, “Chin up!” “Keep buggering on!” “It’s all about the pts (not about you).” Suddenly, and in stark relief with my office job, it was obvious – even to my conscious mind – that I needed to pull myself out of this job that required that I put myself away every day, ignore my needs and tend to others suffering the same fates, even as I languished.

I dropped a session. In doing this I lost a bunch of opportunities. “You can’t have your cake and eat it,” you may say. Fair point. So on realising this, and noting which side my bread was buttered, and how exhausting I find GP days (the reasons just keep a-coming) I sought to row back to the safe and manageable shores of middle management, by dropping a session. Tell us Les, how does that go down with my practice colleagues: our survey says ❌

Family Fortunes' Les Dennis unimpressed by Gino D'Acampo revival
via digital spy

But really… subtext… prize if you spotted it as I hide it, even from myself, it’s not really about where my bread is buttered. In many ways I prefer my GP job. But, in one significant way, I don’t: it exhausts me. I struggle with sustained spells in GP. It drains me beyond an “I’m tired” sort of way. In a “I can’t switch off and unwind” way, due to having gone deep into my reserve tank. And what accelerates this are the invisible ‘energy sucks’ that other folks don’t generally share.

Energy sucks

The insightful amongst you may have begun to notice that I have a finite resource of energy that appears to get spent fast. On top of that, like an exasperated accountant, I get prickly if I give to others from my savings account. Many don’t have this internal, protective character who I have expended additional energy on locking up in a distant office. Wilfully deafening myself as I raid the coffers to toe the line of guidelines-based, disjointed and overly brittle practise that medicine has become.

Leading the spending spree is another character of my management board, my colourful, creative neurodivergent Ops Director. She is incredibly and full of joy, but her ADHD means I struggle with some things that many other people will consider ridiculous when you think that, at times, your life may be in my (competent) hands. I am great at decision-making over treatments and work, but I am terrible at things like… getting out of the house in the morning, or planning meals. I can get thrown off track by the slightest thing. Time is not linear to me but snakes around going from ‘plenty of time’ to ‘defying physics to arrive on time’ in a blink. It takes a monumental effort to keep trucking along the ‘get up-brush teeth-shower-dry-dress’ etc. track that essential pieces often get dumped along the way. Things like ‘make lunch’ or ‘eat breakfast’ are frequently sacrificed. The more jumbly I get in my head, the more likely the wheels will come off. I’m left investing all my effort to do what most people don’t even think about. And that’s before I’ve even got there. Then there’s the journey, parking and the place I am going. We’ve not even got to the protocolization of medicine, defensive practise or constraints of the NHS and regulators yet.

So I’m running on fumes before I arrive. Thankfully, I can surf the adrenaline wave of wanting to do a good job, and thinking on the fly whilst I’m at work, but the old surfboard keeps getting dinged up. Again, on invisible obstacles – or obstacles that aren’t so damaging for someone who isn’t already just about holding on by a thread.

I exaggerate. It’s not always like this, but at its almost worst, it is. At its worst, I’m not there. I’m burned out, blaming myself for having failed to “buck up”. For not having tried hard enough to keep the show on the road. For throwing away a job that millions dream of.

There’s another, final part to this energy suck, “the show”, if you like. The part that I feel most guilty about “failing” at. The part that evaporates as the job starts to erode my inner resources – the part that requires that I care.

Am I some sort of monster?!

Now I know I’m not a monster and I do genuinely do care… But I care within limits that are appropriate to me. The truth-telling, autistic, part of me has absolutely no desire to pretend this is more or less than it is – I feel a bit suspicious of NT colleagues who I feel are going “too far”. So it seems as if my approach is “not good enough” for the profession of which I am a member. The expectation of going “above and beyond”, “fighting the good fight” and travelling the “extra mile”. Lads – I’m above and beyond all the time. We passed my extra mile about 50 miles ago. And did anyone else catch the moral high ground tone of these statements. So not only am I not capable of pushing further, am I morally bankrupt because of this? Am I simply not “cut out” for medicine? And if I’m not, who else gets cut from the team? Can the profession, indeed the sector, truly view difference and disability as moral failings?

Of course the wiser, more grown up part of me knows that I don’t have to go any further than I already do. Sure, the expectation may be for a theoretical 8 hour day to be more like 10 or 12 hours long in practice, but I can opt out, right? Wrong. If everyone is bought into this ethos of sacrificing yourself on the alter of “caring for others” then I am stuffed. If the contract says 8 hours but the workload says 12, I’m stuffed if everyone else JFDI’s it. Or that they can do it. The more we stretch me past what I think I’ve agreed to, the more wonky this little train becomes. The wheels come off fast and sparks begin to fly. Nothing that harms patients, but things that affect all the areas of my life – relationships, health, sleep, well-being etc. I get prickly with any extra request or any minor difficulty. I start to fiercely defend my rights and turn down additional work. I go into ‘protect and defend’ mode. Which is not my favourite place to operate from.

Hierophant reversed

So what now?

Having finally cottoned on to all this, to the mismatch between my needs and the job’s expectations, I’m bowing out for a while. I cannot swim upstream any more. I don’t have the energy.

I’ve painted a pretty bleak picture there. The saddest part to this is that I am a really creative, intuitive doctor. I’m good at that job. I just can’t do it for more than a couple of hours every day. And that, my friends, sadly does not cover my mortgage. Especially when I can do my other job pretty much full-time, no bother. It doesn’t come loaded with a bunch of energy sucking craziness. My other job uses some of my background and knowledge and applies it on a grand scale. Pretty nice! But it doesn’t always give me that special, on the fly, intuitive, applied holistic medicine feeling that I get from time-to-time as a GP. That feeling where I know I’ve made a connection with another human, one that might in a small, or large way, have made a meaningful difference to their life.

And therein lies the rub. Being a GP is a wonderful job. One I enjoy. But one that absolutely drains me. I’d love to do it more, but I need the flexibility to do only the amount I can do. These jobs don’t exist. People have a thousand suggestions. I’m not stupid: I’ve tried, tried and exhausted all the options. Retainer, locum, salaried, sessional, out of hours… you name it, I’ve tried it. The bottom line is I just can’t make it work right now. And that is a crying shame. I’ve spent 20 years investing in a career that is simply inaccessible to me because it costs me – if you’ll bear the drama – my life. Of course I’ve gone back and gone back, trying to make it work… but the pandemic has made me realise, I simply can’t. I’ve tried everything. Perhaps it’s just not for me.

Finding “elsewhere“

Like I said, I’ve another job that makes use of my knowledge. Now that I am stepping back from the battling to make GP work for me, I feel pretty sure a third way will present itself. I’m not sure it will be the traditional GP role I’ve been used to, but I know what the parts of that job are that I like, and the parts that I don’t. This is new information that the pandemic sharpened my attention to identify. I’m not the only one. Many are looking elsewhere. Some aren’t as fortunate as me to have a well-established “side gig”. But although my side gig pays the bills, it lacks something I kept going back to GP for. This clues me even more on what I need to find to supplement my work-life. I’m going to get there. But the first part of setting out on something new is saying goodbye to everything you know.

I’ve never been great at endings or goodbyes. They trigger an anticipatory nostalgia which is particularly bittersweet. But I am ready for the next part now. The bungee cord is not so elastic anymore. In fact, it might have even been cut.

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