Reasons to be cheerful


It’s grim oop NHS.

You can’t spend more than a few minutes looking at facebook or twitter on the topic of the NHS without people mentioning crises, battles or strikes.

You can’t look at a newspaper without seeing headlines about huge deficits, failing trusts, closing hospitals, doctor shortages, spiralling waiting times, implausible efficiency savings or politicians with their heads in the sand.

As a new batch of raw medical students climb onto the bottom rung of the career ladder, it’s hard for the more seasoned professionals to summon up much enthusiasm about what they have in store.

But there are some reasons to be cheerful.

  1. Your country needs you


The UK is short of doctors. It has fewer doctors per member of the population than most comparable countries, and that’s before you take into account the job vacancies that can’t currently be filled, and the disillusioned people apparently planning to walk away. And although they won’t admit there is a shortage of doctors, the government is so worried by this that they are talking about chaining new medical graduates to the NHS for four years after graduation. And it’s nice to be wanted, right?

  1. Your patients need you

An emergency department crammed with patients. Screaming babies, whining children, grey-faced adults, beeping monitors and alarms, and somewhere the sound of retching. It’s not a recipe for relaxation, but they all need your help and attention. And (see point 1) it’s nice to be wanted, right?

  1. Helping people

If you turn up at your medical school interview and say you’ve chosen medicine because you want to help people, you’re more likely to be met by rolling of eyes than by open arms. But most doctors choose medicine at least partly for this reason. It’s great to do a job that seems so unequivocally good, even if the government sometimes seems to be trying to get in the way. When did superman ever complain about having to battle against the forces of evil to help those in need?

  1. Governments and politics are temporary

Yes, it’s a pretty depressing time for the NHS. If you listen to people around you, you’ll hear talk of privatisation, of rationing, of cuts to services, of departments struggling to cope with the weight of demand. But governments change, and politics change. Meanwhile, the NHS has been around for 60 years, and in many ways is bigger, better and stronger than ever. Outcomes are still better than in many other health systems, and the vast majority of patients are receiving excellent care. The NHS will still be there when Theresa May is nothing more than a political memory.

  1. Medicine is a broad church

No, not that kind of Broadchurch…

So you make it through medical school and discover that talking to patients drives you mad…don’t panic. You can always be a pathologist (only interact with dead patients, or removed bits of living ones), a radiologist (only interact with pictures of patients) or a microbiologist (only interact with microbes). If patients are your thing, you can sit and listen to them (psychiatry), drug them (medicine) feed wires, balloons and tubes into them (cardiology), put them to sleep (anaesthesia) or cut them up (surgery). If you leave medicine completely, you’ll find that those letters after your name stay with you, and banks, consulting firms, and pharma companies welcome you with open arms. What career could offer more options?

  1. Getting paid…just about enough


If you didn’t know that medicine pays less than other comparable professions, you didn’t do enough research before you applied. If that bothers you, you probably won’t be a doctor for long. Doctors’ salaries in the NHS aren’t huge, but they are enough. Whether that will remain the case as NHS costs are cut, while student fees are hiked, remains to be seen. In the meantime, before you moan, next time you’re at work in a hospital, look around you and you’ll see many people working just as hard, for less money.

  1. The NHS

Imagine telling a patient they have a treatable condition but there is no money to pay for their treatment. That’s a reality for many doctors, in many countries. It’s worth taking a step back and remembering that this was the case in the UK too, before 1948. And if you happen to be uninsured, it’s still the case in the US. But in the UK, despite what the Daily Mail may claim, this doesn’t really happen. If a treatment is proven to work, we can offer it even if the patient is penniless. It’s a privilege to practise medicine in this environment. Long may it continue.

  1. Transferable skills

More or less as soon as you put those magic letters after your name, the world is your oyster. Not literally – that would be slimy and unpleasant. But a qualified doctor can walk into a well-paid job in many many countries. If you find you’ve had enough of working in the UK, isn’t this a reason to be cheerful?

  1. Amazing science


All doctors have had that depressing conversation with a patient or their family. The diagnosis is clear, but nothing can be done. Those situations will always occur – people will never be immortal. But technology, drugs and our understanding of science are accelerating faster than ever before. Untreatable conditions are becoming treatable. If you’re starting your medical career now, who knows what advances you will see before you retire? It should be an amazing journey.

  1. The most interesting job in the world

There are days when every patient blurs together. But there are also days when people stand out. The former fighter pilot with an aneurysm and a remarkable world view. The priest with prostate cancer and a serene attitude to his illness. The dancer with a spinal tumour and a determination to live a normal life in the face of adversity. What other job would introduce you to such extraordinary people in such an intimate way? What other job would pay you to help the people who need it the most, at the most difficult time of their life?

I wouldn’t trade my job for any other, and that is certainly a reason to be cheerful.


If you find this post overly optimistic, please try Abrainia’s reasons not to be cheerful!

Follow Abrainia via WordPress (left hand menu) or on twitter (@abrainia)


Herding Cats



If you take a group of doctors and ask them all the same question, you can expect to hear more than one opinion. Even a single specialist, when faced with a tricky treatment or diagnostic decision, might offer more than one answer. We are trained to think hard and independently, to take difficult decisions seriously, and to communicate our thoughts clearly. We’re also trained not to force our views on others.

Until recently, there had been remarkable unity among the ranks of junior doctors in their contract dispute with the department of health. The original contract proposal seemed disastrous in every way – safety, pay and equality all suffered. Government allegations of the British Medical Association misleading its junior doctor members were, well, misleading. We read the plans ourselves and we were horrified. And if the facts alone were not enough to unite us, there was Jeremy Hunt, centre stage, conducting an orchestra of spin-doctors, calculated press releases and herd-following tabloids, firing out dubious statistics and allegations, trumpeting his imaginary plans for a “truly 7-day NHS”.

The story today is rather different. A year has passed. Several strikes, and many weeks of negotiations later, we have a contract that a sizeable minority of junior doctors feel they could live with (42% voted to accept it, 58% to reject it). Jeremy Hunt appears to have realised that his unifying effect is working against him, and has kept uncharacteristically quiet. And the BMA Junior Doctors Committee has been busy tying itself in knots, changing personnel like disposable gloves, and announcing strikes that then get abandoned within days.

And while the BMA vacillate, the NHS is in crisis. Nursing bursaries have been cut. Senior doctors are again being attacked via the media. Junior doctors are increasingly taking time out, or emigrating, even before the new contract has been brought in. Waiting times are reaching record highs, hospital are bursting at the seams with patients, and some departments have been unable to find enough doctors to stay open safely. Increasing numbers of senior NHS and even government figures are publicly admitting that the current trajectory of funding is going to lead to a train wreck.

There’s an excellent reason why the BMA appear uncertain what to do. It’s because it really isn’t clear what they should do. We were all prepared to strike against a contract that everyone could see would be a disaster. But what about a contract that nearly half of us think might be ok? Perhaps a series of rolling 5-day strikes in that context seems a bit – radical? But after fighting so hard for so long, should we really roll over and accept a contract that a majority of junior doctors voted against?

It’s important to remember the achievements of junior doctors during the last year. Without giving up our (quite demanding) day jobs, we have organised and fought a campaign including unprecedented strike action. We have maintained public support while up against a Government spin machine working at full tilt, helped by a compliant majority of the media. During strike action, doctors set up free classes to teach CPR to grateful members of the public. Doctors have attended marches, written blogs and made videos, appeared on TV, written articles in newspapers, set up a table outside the department of health and manned it for weeks waiting for Jeremy Hunt to appear for negotiations. But the most significant achievement was forcing the Government to return to negotiations, and getting a better deal for our contract. Not perfect. But better. Think 42% satisfaction, compared to 2% satisfaction with the original.

With the appetite for strikes fading, perhaps the junior doctor contract battle is over. A year ago, it felt like this dispute was at the centre of the crisis in the NHS. Now, with an improved contract, and worsening problems elsewhere, it feels peripheral.



The future of the NHS feels less certain than at any time since it came into being in 1948. A debate is needed about how health care in the UK will be funded in the future. Junior doctors need to rediscover that elusive sense of unity, and make our voices heard.


Follow Abrainia via WordPress (left hand menu) or on twitter (@abrainia)

The festival of Britain


Britain. 1950.

Cities are still pock-marked by rubble-filled bomb sites. The country is peppered with disused airfields and military bases. There is still rationing, and compulsory military service. The Cold War is heating up. The Morris Minor is the family car of choice.


The Labour government, which is about to lose out to Winston Churchill’s Conservatives in the 1951 general election, has nationalised the rail networks and the coal mines. British Airways is under government control. King George VI is sits on the throne, and will rule for two more years before being succeeded by his daughter Elizabeth. As well as being King of England, he is the head of a shrinking empire that still includes many African and Middle Eastern countries.

The first commercially available programmable computer won’t be launched for another year.  The first email won’t be sent for a decade. No one has heard of rock and roll – Paul McCartney is 8 years old. The first commercial mobile phone is more than 20 years away from launching.

The government decides to fund a celebration of all things British – the Festival of Britain. And, in Twickenham, a group of women put together a tapestry consisting of 100 squares, each square with a picture and text representing a year from 1851 to 1950.


Detail of the tapestry

Some years were easier than others to assign. 1914 to 1918 was dominated by the Great War, with events like the invention of the tank and Armistice Day. Technology and transport feature heavily, with the Wright Brothers, Louis Bleriot and Amy Johnson each getting a square (see above). 1928 celebrates equal voting rights for women.


Just two years after its inception, the square for 1948 is given to the “National Health Act”, with the word “FREE” dominating the square. It’s clear that people recognised the nascent NHS as something special, even when it was only two years old.

Of course, predicting the future is a tricky business. The decision to give 1948 to the NHS may be uncontroversial in retrospect, but the square for 1949 was allocated to the Brabazon, a huge propeller-powered airliner designed to revolutionise trans-Atlantic travel. There’s a reason why you’ve never heard of it – only one prototype was ever built, and development was quietly abandoned in 1952. The prototype was sold for scrap.


Brabazon prototype

The NHS has aged better than the Brabazon – it is approaching its 70th birthday. It’s not in such bad nick, for a near septuagenarian. Let’s hope it has many more years to live.

The tapestry is on display and can be viewed for free in London’s Royal Festival Hall foyer.

Follow Abrainia on twitter: @abrainia

Follow Abrainia via WordPress (left menu bar)

Collective Abrainia


abrainia image


It’s been a pretty strange few weeks in the world of politics. Theresa May is about to become Prime Minsiter of the UK, and her key virtue seems to be that she hasn’t said or done anything stupid in the last month. All she needed to do was keep quiet and wait for her rivals to come down with politically fatal collective abrainia* and sabotage each other and themselves.

Amidst the huge publicity around the EU referendum and Brexit, there has been another referendum and another resignation that has largely slipped through unnoticed. Unless, that is, you are a junior doctor.

The achievements of junior doctors during the last year have been remarkable. Without giving up their (quite demanding) day jobs, they have organised and fought a campaign including unprecedented strike action. They have maintained public support while up against a Government spin machine working at full tilt, helped by a compliant majority of the media. Doctors have attended marches, written blogs and made videos, appeared on TV and written articles in newspapers. They set up a table outside the department of health and manned it for weeks waiting for Jeremy Hunt to appear for negotiations. During strike action, they set up free classes to teach CPR to grateful members of the public. And doctors everywhere have engaged the public in this debate and helped to educate them about the issues.

After months of political to-ing and fro-ing, of strikes and marches, of the Government sitting down to negotiate, walking away, then returning, it was finally announced that a compromise had been reached. And then, the shiny new improved version of the contract, which was agreed between the government and the BMA junior doctors’ council, was put to the vote among junior doctors…and was rejected by 58% to 42%.

Johann Malawana, the chair of the BMA junior doctors’ council, who led a moderate and reasonable fight against the original unfair contract, has followed David Cameron’s example and resigned. He had supported the new contract as a reasonable compromise, but he couldn’t persuade his electorate to agree. The metaphorical removal vans are drawing up outside BMA House as I type.

Some no-voters have genuine concerns (for example that the new contract will discriminate against women, and that limits to working hours will be poorly policed), but many were fuelled by non-specific anger. “Is this really what we’ve been fighting for?” was the collective response to a contract that seems underwhelming, and similar in many ways to the original hated proposal.

What next?

nobody knows

Much like the vote for Brexit, doctors who have voted “no” have voted for the unknown over the known. They have not voted for any particular alternative, because none has been presented.

Hunt has said he will impose the contract. There is still the question of whether this is legal, and a group of doctors are mounting a crowd-funded legal challenge. The new chair of the BMA junior doctors’ council has said that strikes are back on the table.

A separate question is whether Hunt will stay in charge of the NHS under a new PM. Doctors will be hoping that the answer is no. If he goes, his replacement will inherit a mess.

A new person in charge of the Department of Health, with a new Prime Minister above them, could go some way to repairing the huge breakdown in trust between doctors and the Government. Rebuilding some of the bridges between medics and politicians that Hunt has napalmed in his tenure as Health Secretary should be their first priority. Once that is addressed, they could move on to dealing with the more trivial issues such as the ongoing financial meltdown in the NHS and understaffing in many hospitals.

I hope that the contract dispute can be resolved, and junior doctors can all get back to doing what we signed up for. But after the month we’ve just had, it would take a braver person than me to make any predictions.


Follow Abrainia on twitter @abrainia



* Abrainia: an illness in which the sufferer, usually a healthcare professional politician, behaves as if lacking a brain


A Walking, Talking Miracle


It was a normal working day, and I received a very normal phone call. A new patient needed to be admitted by a doctor, and that task would obviously fall to me, as the newest and most junior member of the surgical team. I looked at the clock – half past four. This would hopefully be my last job of the day.

Up on the ward, I glanced at the patient’s details. His name didn’t mean anything to me, but I saw that he had come in for a hernia repair the following day. Most hernia repairs are done as a daycase, so I guessed if he needed to come in the night before the operation he must be quite frail. I looked across at his age. 42. Odd.

He didn’t look frail or sick. We ran through the surgical details quite quickly. When it came to asking about his past medical history, he answered the question quite oddly.

“I don’t have any health problems now” he told me, “but I used to have cystic fibrosis”.

I learnt about cystic fibrosis at school, and again at medical school. It’s a genetic disease, caused by inheriting two faulty copies of a specific gene. People with the condition suffer from a build-up of mucus in the lungs, and tend to suffer from repeated chest infections. Antibiotics and physiotherapy help, but I had thought the underlying condition was incurable. I asked for an explanation.

He told me that during his teenage years and as a young adult, he had spent almost half of his time in hospital on heavy duty antibiotics. He was not expected to live many more years. After a particularly bad infection, during which he nearly died, he was offered a lung transplant. He pulled through the operation, and had never looked back. Since he had been discharged after his transplant, he told me, he hadn’t spent a single night in hospital. “Each morning” he told me “I wake up, take a deep breath in, and feel lucky to be alive. I’m a walking, talking miracle”.


Modern medicine is pretty amazing. We have drugs that can render you unconscious so you don’t object to being opened up and fixed. We have (for now) drugs that can get rid of unwanted bacterial freeloaders. We have drugs that kill off cancer cells, but spare their healthy neighbours. We have telescopes that can peer into pretty much any orifice and take samples of your internal organs. We can feed wires into your arteries and open up blockages. Often, we can fix damaged organs with medicines or with surgery.

But if we can’t fix what is broken, we now often have the option of giving you a new one. Kidney failure..? Have a new kidney. Liver failure..? A liver transplant. Severe burns..? A skin graft. Your pancreas, heart, lungs, even limbs can be transplanted.

Of course the surgery, in someone who is usually pretty sick to start with, is dangerous. Transplants usually require the recipient to be on life-long medication to prevent the new organ from being rejected, and the new organ may not last forever. But it is still one of the most amazing things that modern medicine is capable of. I left hospital that day with a renewed sense of wonder at my job.

You might donate a kidney to a loved one, but in the world of transplant living donors are the exception rather than the rule. Each transplant might represent a miracle for the person receiving a new organ, but many transplants are born from tragedies. In England, only about 60% of people who could donate an organ actually do so. Often, if they haven’t expressed any advance wishes, the decision is left to their families. It must be an agonisingly difficult decision to make.

In Wales, the law recently changed so that consent for organ donation is assumed, unless someone has chosen to opt out. Opt-out rates are very low, and the number of transplants has jumped up by around a third in the six months since the new law came in.

It’s a small good news story, at a time when they are rather hard to come by.


If you live in the UK, sign up to the organ donor register here. Unless you live in Wales, in which case there is no need! Don’t forget to discuss your decision with your next of kin.

Follow Abrainia via WordPress (left hand menu) or on twitter (@abrainia)

When breath becomes air – Paul Kalanithi


A book review

This book opens with a stark scene. Dr Paul Kalanithi, a neurosurgeon about to finish his training with flying colours, studies a CT scan. The scan shows a body riddled with cancer. He’s seen hundreds of similar scans in his training. But, he remarks with characteristic economy and understatement, this one is different. It is his own.

After this startling opening, the book looks back to his motivation for becoming a doctor and scientist, inspired by philosophers, poets and writers more than by his cardiologist father. His literary background is clear from his writing style, full of quotes from poems, plays and novels.

With his terminal diagnosis, Kalanithi has time to confront his imminent death. All that he has worked for, for so many years, is snatched away by his ill health, just when it seems within his grasp, but he still wonders whether he should feel grateful for his cancer, as an answer to his constant self-questioning about the meaning of life.

His reaction to his cancer diagnosis is to re-evaluate his priorities in life. He is frustrated by the lack of a precise prognosis. If he had only months to live, he might spend it entirely with his family. If he had a year, he would write a book. If he had ten years, he would keep pursuing his medical career. In the end, he does all these things. He has a baby, conceived by IVF while he is having cancer treatment. He doses up on painkillers, and goes back to finish his residency as a neurosurgeon. And he writes his book, this book, in snatched hours between shifts in the operating theatre, between cancer treatments, in waiting rooms waiting to see his oncologist, and on the chemotherapy unit.

The doctor-patient relationship occupies a lot of his thoughts in the book. As both a patient and a high-flying doctor, he sees things from both sides. A resident he encounters forgets to prescribe one of his cancer drugs, and then refuses to rectify his error because it will mean admitting it to his boss. By contrast, Kalanathi’s oncologist, Emma, gets almost everything right. She is optimistic and practical, and it is she who correctly predicts that he may wish to return to operating after his first cancer treatment. But later, after he has a bad reaction to a chemotherapy treatment, she recognises his need for emotional rather than practical support. Having steadfastly refused to give him any survival statistics, she comes out with the line that he still has five good years. He knows she is lying, but is still grateful.

“There we were, doctor and patient, in a relationship that sometimes carries a magisterial air, and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss”

That “abyss” is something that we can only learn about from second-hand experiences, as people who have entered it don’t tend to write about it. Doctors, and particularly neurosurgeons, have more second-hand experience of death than most people. Kalanathi finds that his experiences can’t tell him what he wants to know about death itself. But the way he faces his mortality tells us a great deal about life, and how to live it.

Paul and his partner have put off having children until the end of residency – after his cancer diagnosis, knowing that his time is short, they decide to have a baby.

Don’t you think saying goodbye to your child will make your death more painful?” asks Lucy. “Wouldn’t it be great if it did?” he replies.

In an email exchange with a friend, he quips that he’s already “outlived two Brontës, Keats and Stephen Crane. The bad news is that I haven’t written anything.” He sets about fixing this in the time he has left, and his elegant memoir is the result.

The book begins with a jolt, and it ends with a jolt. Abruptly, Kalanithi’s wife takes up the pen, and describes his last few days. He didn’t know how little time he had left, and neither do we as his readers. The loss of his voice, after getting to know and like him over the course of the book, hits home just as hard as the details of his death, laid out with a bare simplicity that perfectly complements the style of the rest of the book.

The shortness of the manuscript is bittersweet – there were certainly many more words he would have liked to have written. But his diagnosis forced him to make every one of them count.




Follow abrainia via twitter

Winning the battle and losing the war


I can recall the exact moment I first heard about the new junior doctor contract.

I barely believed what I was hearing. Pay cuts, after years of pay falling behind inflation. Barriers to unsafe working hours removed, after they had proved so successful. Discrimination against women, from one of the few UK employers that offered equal opportunities. Could it really be true?

If that same person had told me that the dispute would lead to the first all-out strike in NHS history, I would not have believed it. I would not have expected the Government to push a flawed contract so hard. And, if they did, I would not have believed an apolitical bunch of junior doctors could be so united.

But, here we are, after the all-out strike. To the surprise of the Daily Mail, and the Health Secretary, the NHS is still standing.  Our NHS colleagues covered expertly.

The unanswered question on everyone’s lips is – what next?

Here are some things that could happen now…

  1. More strikes

The last two days have proved the concept – an all-out strike by junior doctors can be achieved, without endangering patients on those days. So, why not have more?

Here’s the downside. For each strike, lots of planned operations, tests, appointments and scans have been cancelled, to focus on covering for the striking doctors. This disruption is necessary to keep emergency patients safe, and of course, a strike has to cause disruption to be effective. But the more strikes there are, the more people this will affect. What about the person with cancer who needs to see a doctor and start urgent treatment? What about the man with critical coronary artery disease whose heart bypass is cancelled?

If the junior contract as it stands is dangerous for patients, then  some temporary inconvenience to them now can be justified by their long term gain when the contract is fixed. But an all-out strike has already failed once to generate a reaction from Government, so why would a second one help?

And doing the same thing again risks losing the attention of the public. Top Gear gets fewer viewers when it’s repeated on Dave, and it was clear from the previous set of strikes that the Government (and the media) was less interested in repeats.

  1. Escalation

The all-out strike didn’t persuade the Government to back down. Another all-out strike probably won’t either. So, is there an argument for doing something bigger?

Some doctors think so. One junior doctor resigned live on television recently, and others have published their resignation letters on facebook and twitter. Mass resignations have been talked about. Not everyone will resign, but even a small proportion of resignations could make services very difficult to run properly.

There are other ways action could be escalated. An all-out strike that included nights and evenings would be much harder to cross cover with consultants. There has been talk about an indefinite strike.

But escalation comes with a downside too. The higher the impact of the action, the more damaging it is likely to be for patients. So far, the public support doctors. Raising the stakes further is a gamble, and the goodwill, once lost, will be hard to get back.

  1. Ceasefire

What will another strike achieve? It doesn’t seem likely to force the Government back to the negotiating table. There is no “nuclear option” that wouldn’t harm patients, which we won’t do.

In that case, perhaps further strikes would have no great benefit and the logical thing to do is to cease hostilities. But a temporary ceasefire doesn’t clearly lead to a resolution.


Winning the battle, losing the war


Looking into the Abrainia crystal ball, I see a drawn-out series of strikes, perhaps supported by the public and other NHS workers, but steadfastly ignored by the Government.

I see doctors refusing to back down, but refusing to escalate to any action that actually will harm patients.

I see a Government closing their ears, humming loudly, and pretending that they can’t hear. I see politicians who regard backtracking after a strike in the same way they regard negotiating with terrorists. Give an inch, and suddenly the whole public sector will be on strike. Better to make an example of the junior doctors, even if it drives them away from the NHS.

I see significant numbers of doctors leaving training, or declining to take up training posts. I see applications to medical school falling. I see the understaffing on all of our rotas getting steadily worse.

I see the Government triumphantly winning the battle and losing the war, imposing the contract while significant numbers of doctors walk away to look for a job where they are more highly valued. I see the chronically underfunded Health Service losing the goodwill of the people who hold it together, while the politicians celebrate in Westminster.

I see a generation of doctors profoundly disillusioned and disengaged from helping the Government build what we all want, which is a first-class health service.


“Your future is whatever you make it”


It doesn’t have to be this way.

Jeremy Hunt himself has claimed that the two sides were “90% agreed” (although he is not famed for his judicious use of statistics). The BMA representatives have repeatedly asked for more talks.

There must be a solution that is acceptable to both sides. But that solution can’t be found without more negotiation.

Someone needs to stop acting like a politician, and start acting like a leader. Someone needs to step forward from this mess and break the impasse. Mr Hunt? Mr Cameron? My hopes aren’t high, but please prove me wrong.

Follow abrainia via wordpress (left hand menu bar)

Follow abrainia on twitter @abrainia