I suppose to be more precise this should say, 'Why I Chose Not To Work in the NHS', as I actually left the UK immediately following graduation from medical school. But that's not as catchy a title, so you know...
The National Health Service (‘NHS’) of the UK is justifiably held up around the world as an example for countries everywhere. It is free at the point of care for all who need it, it doesn’t discriminate based on ethnicity, gender or religion, and it produces health outcomes comparable to most health services throughout the world at a fraction of the cost. Wait… you must be reading the wrong article here, right? You thought this was supposed to explain why I left the NHS, but instead here I am harping on about how great it is. Fear not, you are in the right place! Let me explain.
In life (much like in hospital canteens) there is no such thing as a ‘free lunch’. No one type of healthcare service anywhere in the world is perfect. The NHS provides a tremendous amount of benefit to the people of the UK… so what does it have to sacrifice for this? In my opinion (and that’s all this blog is of course) there’s one main answer to this.
Now, anyone from a non-medical background out there is likely rolling their eyes at this statement. “Those poor, unlucky little UK doctors, wiping their tears with wads of cash no doubt…” For the record, I am in no way trying to suggest that doctors are second class citizens in the UK, or that they are struggling to put food on their tables. But the harsh truth of the matter is, when compared to similarly qualified colleagues in fields such as dentistry, law or finance, medical doctors in the UK earn less money, and earn money far later in life. Not only do doctors complete the longest of nearly any professional degree (5 or 6 years depending on your University), they then enter the perpetual tunnel of postgraduate training that can last anywhere from a minimum of 5 to a maximum of around 12 years of supervised practice until they become ‘Consultants’. During this time, they have the honour of being called ‘Junior Doctors’ (“you’re doctors… but you’re just junior, okay?”) It doesn’t matter that most of us will have this label until our mid-late 30s, at which point our friends in dentistry will own their own houses…
And it’s not just the money. The winding road of postgraduate training in the UK seems to have been specifically designed to prolong the length of time you can be considered a ‘trainee’ so that they can justify paying you less. Let’s take the example of a fictional doctor called Laura. Laura got to the end of medical school and she was certain she wanted to be a dermatologist. Laura gets given her F1/F2 rotations and finds out she is doing 4 months in GP, 4 months in Radiology, 4 months in Ophthalmology, 4 months in Elderly Care, 4 months in A&E and 4 months in Lower GI surgery. She then has to start her Core Medical Training, and spends 2-3 years on Geriatrics, Heme/Onc and Cardiology wards. Almost 5 years of her life will have passed since she graduated as a doctor, and she will have had almost no chance to pursue any training in dermatology at this stage. Only after she has sacrificed these 5 years will she be allowed to become a specialist registrar and then spend 4-5 years training in the only specialty she has been passionate about all along.
“But it makes you a more well-rounded physician… you’ll see all sorts of skin conditions in those other rotations!” I don’t think this truly is the intended purpose. After 5 years of specialty training in dermatology, I doubt you will remember anything meaningful about cardiology or oncology that will benefit you in your future specialised job treating skin. I agree with perhaps 1 year of general medicine before specialising, to help contextualise your medical knowledge and get a better sense of how ‘real’ medicine works rather than just from a textbook. But 5 years…? The thought of this was too much for me. I wanted to find an opportunity to train in the field I’m most passionate about earlier on in my career, and to get a specific educational curriculum targeted to this area rather than a scattergun assignment of medical rotations that would give me little benefit in my future career.
Finally, the day-to-day job of Junior Doctors that I witnessed during my medical school rotations in the UK also made me question whether it was the right place for me to train. Each doctor was responsible for often >20 patients at a time. They would spend big chunks of the day drawing blood, placing cannulas or inserting catheters. The amount of protected didactics/ teaching time in their schedules was usually only around 1 hour per week (and that, too, just a Grand Rounds session where two senior doctors would argue amongst themselves and the juniors sat around sheepishly grazing on sandwiches). The Consultants, Junior Doctors, nurses - everyone, seemed to be stretched to their limits, so much so that any formal training was secondary to a heap of mundane admin tasks. If you got lucky, you might have a Consultant who was truly passionate about teaching and you would end those 4 months with them having become a better doctor. Otherwise, oh well! It seemed clear that your role as a Junior Doctor was service provision, to keep the NHS afloat, and to keep the patients safe.
Although it sounds an awful lot like it, this is not a criticism of the NHS. This is an inevitable consequence of having a health service that is so generous and widely-available. It’s not just how it happens to work out, it’s how it has to work out. The lower salaries, the intentionally long training pathway so you can be used as transferrable low wage labor, the understaffing levels forcing doctors to be stretched to the limit doing tasks so they don’t prioritize formal training. These are all specific decisions made by policy makers to allow the UK to offer universal free healthcare to its population. I understand it. I even respect it.
But it wasn’t for me.
You might describe it as selfish, but I wanted to make the most of my medical degree. I wanted to pursue the field I was most passionate about (dermatology) early on in my career. I wanted to get specialized, structured and protected training in that field. And I wanted to be paid what I consider a fair wage, one that would be in keeping with colleagues of mine who are at the top of their fields in law, dentistry and finance (well… close to them, you’re never catching the finance folks if we’re being honest!) So I chose to leave the NHS and pursue residency training in the US instead.
To those doctors who choose to stay in the NHS, you absolutely have my respect - it’s through your sacrifice that the system stays afloat. I just hope people continue to recognise and appreciate your tireless efforts (and not just during a pandemic!)
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