What? You can’t quit being a doctor!

A lot of very clever people have written about the topic of leaving medicine. There are now several resources available for doctors who are thinking of leaving clinical practice. It’s a reasonable thing to consider.

Plug: Indeed, if you are a doctor who can write Python code, and can charm people and show how a product meets their needs, then I’d like to hear from you (contact me).

Five years ago when I stepped out, there wasn’t so much advice around. Every deanery (bureaucratic body which governs doctors in “training”) in the UK was supposed have a careers adviser.

I emailed our deanery’s career adviser, and was told that he was on sick leave for a few weeks, with no temporary replacement. When he did return, I rang up to arrange an appointment and was told “I don’t really know much about careers outside medicine, perhaps talk to someone who has done it”. That was it, no contacts given. It hadn’t occurred to the person who employed this chap that doctors could possibly want to do something other than clinical work.

So I was on my own. I agonised for a few weeks about the decision, then set sail out to sea without anything to guide me.

Issues I faced at the time of quitting:

1) Perception of parents:

I’m very fortunate to have understanding parents. They listened to my reasoning and allowed me to use them as a sounding board, but they couldn’t hide their disappointment in my decision to quit “stable employment” in a “noble profession”.

Looking back on those discussions now, I’ve realised that their positions were because of the generation gap.

When my parents were starting out on their careers, your job was your primary status symbol. People usually kept the same jobs for life. Once employed, you had regular stable income and were likely to ascend the ladder over time. There was still a sense of a class system. Self-employed people were the Working Class jobbing handyman down the road who got paid cash-in-hand, not university-educated high flyer. They had come from a Working Class background and had studied hard and worked up the career ladder as teachers to reach Middle Class. Quite simply, to them it was a step down if you left employment for self-employment.

Of course, in my generation, Medicine has changed. A secure stable employment has gone, because since MTAS in 2007, most doctors have to reapply competitively for their job every 2 to 4 years. And it’s not like a more senior post opening up in your employer’s company where if your application fails, you get to keep your existing role. No, in Medicine your existing job is set to expire whatever, and if you don’t secure a more senior post, you’ll be jobless. Repeat the gauntlet run every few years.

Also, the nature of self-employment (whether as a sole trader or a director of a company) has changed since my parents’ generation. Your self-employed plumber today can earn over £120 per hour, compared to the £14 per hour I was being paid to work as a doctor. Business success stories like Sir Richard Branson (Virgin) and Sir Brian Souter (Stagecoach) show that ideas and skill in execution can matter more than education. Up until April 2017, the tax burden of a self-employed director being paid in dividends was considerably lower than a person on PAYE/NIC employment.

Nowadays, Medicine is not a secure job (until you’re a Consultant), self-employment is no longer stigmatised, and your social status matters only to you.

2) Worries about paying the bills:

This is a completely understandable anxiety for anybody leaving full-time employment. You’ll not be given a payslip at the end of every month any more.

It turned out to be a total non-issue. That’s because anybody who is a qualified doctor can find plenty of work as a Locum (temporary post filling doctor). A degree in Medicine is a fantastic safety net.

I was staggered at how many offers for shifts I was getting after registering with just two Locum Agencies^. Initially I accepted pretty much every non conflicting shift that was offered, but quickly found myself working 25 days a month. I was also getting three times the pay compared to when I was full-time employed!

(^ Health warning: Locum Agencies will ring you RELENTLESSLY, even during the day after a night shift which they booked you on. Consider getting a cheap pay-as-you-go second mobile phone and give them that number instead.)

There are loads of Locum shifts available in Emergency Medicine, General Medicine and General Practice. This is because of the first rank mismanagement of medical careers over the past decade thanks to Modernising Medical Careers. While that’s another lengthy rant in its own right, in summary MMC has resulted in an insufficient number of training posts** for patients’ needs, a convoluted route to becoming eligible for most of those posts, and bugger all incentive for taking up a non-training post which would otherwise fill the gaps. So those empty shifts ended up going to the Locum Agencies, where market forces took over and pay rates climbed.

(** a doctor in a “training” post does the same work as a doctor in a “non-training” post, except the doctor in training becomes eligible to apply for more senior posts in a few years time, whereas the non-training doc is stuck at that level.)

After a while, I had settled on a business idea and it was gaining momentum, so I pared back my Locum work to 7 shifts a month. I was still earning more for 7 shifts of work as a Locum, than for each month working “48 hour weeks” full time. Plus, I had 23 days each month to work on my startup. My startup could pay me nothing yet I would still be solvent!

Issues I’ve faced a few years on:

3) “What about the pension?”

For the first few years, I wasn’t putting anything aside for the future. That’s because as an ad-hoc Locum I’m not eligible for the NHS pension scheme. Sure, the UK Government have swung an axe at that three times (it was a final salary pension, now it’s an average salary pension; the pensionable average salary calculation included the 50% enhancement for working antisocial hours, now it excludes that; the retirement age was 60, now it’ll be 67 for me), but it was still a good deal relative to private pensions.

However, I genuinely don’t believe the pension fund will still be there when I’m 67. There are enormous black holes in pretty much every pension scheme, including public sector. Today’s pension contributions are paying for yesterday’s workers who are now in retirement. Will this really continue for another generation? Or will the governments of the next 35 years keep moving the goalposts so that the effective pension keeps being diminished?

I think the latter. I think we’ll see further increases to the retirement age, probably to 70 or 75, an age by which half of us will have died from the stress of the job. We’ll probably see many more years of salary freeze in the NHS, meaning a pay cut in real terms. That will hurt the average salary calculation further.

What I am doing now is paying into a SIP. This is essentially a bucket where you pay money into it, where it earns a bit of interest, to be withdrawn in retirement. Money is put into the bucket pre-tax and counts as a business expense, so it lowers your corporation tax if you are paid through your own limited company. The best thing is that it’s not a dodgy fund which may suspiciously disappear in the future, and it’s not really under government control. So there’s little chance of the Her Majesty’s cocks swinging another axe at it.

The SIP is really me hedging my bets. It’s Plan B. My main plan for retirement is to build an incredibly valuable company and keep a stake in that, and live either off the dividend or from the capital gains from selling the stake. Of all the downsides of being an entrepreneur, the upside is that you can make huge financial gains for the future if you play your hand of cards well.

4) “What if I’d stayed in Clinical Practice”

I’m at that age now where lots of my peers in Medicine are in senior registrar posts and getting to do exciting things like having their own smaller procedure lists in theatre, doing endoscopies / bronchoscopies and even angiograms.

I regularly get an overwhelming feeling that I’m “slipping behind”. While everyone else races towards the finish line of becoming a Consultant, I sort of wandered off the track somewhere at the 30m mark, and now am wondering why I’m so far from the finish.
First of all, it’s not exactly true. I’ve been able to ascend the ranks in Emergency Medicine on experience gained as a Locum alone, and now work as a Middle Grade (registrar level). Part of that is thanks to the desperate shortage of SpRs in Emergency Medicine, and part of it is because I work for open-minded Consultants who have seen what I am capable of clinically. So I get to do exciting stuff too: I run trauma calls, put in emergency chest drains, relocate joints and reduce fractures using sedation, shock people out of VT, plant IV lines in IV drug users under ultrasound guidance etc. Crack chests open and stitch up cardiac wounds… ok I’ve never had to do that last one (yet), but I’m ready if the day comes when a chest stabbing victim loses signs of life in my Resus room.

Second, the worries about falling behind are based upon a huge assumption: that it is somehow desirable to still be in the race and become a Consultant. It’s very easy to compare my life and its long hours in entrepreneurial solitary confinement, to the Facebook highlights reel of my peers.

In reality, being employed by the NHS full time in most hospitals is soul stripping. You are treated by HR (aka “Medical Staffing”, people who have never touched a patient) as a total commodity. You are just a number to fill a rota, a body carrying a bleep to them. They do not care about your personal career aspirations, or whether you are tired / stressed / have had a break. They just need a doctor to staff their ward and it doesn’t matter who that is so long as that person ticks the rigid eligibility boxes. Bullying is rife in the NHS, and if you don’t do as told, you’ll find yourself suspended without pay on abstract accusations of “gross misconduct”.

Things are no better from what I hear at the Consultant level. Once again you are there to fill a void. Managers will chase you and chastise about hitting any of the myriad of targets (CQUINs / National Performance Indicators) which are relevant to your specialty. Your clinical autonomy will be limited by hospital policy, so you won’t be able to offer appropriate treatment X to patient Y because a piece of paper written by a non-clinician says so. You’ll be asked to do admin work which you’ll have no time allocated for, thus effectively be made to do some work unpaid. Your duty to your patients will be milked and exploited to get more free hours out of you. And if you object, then your lovely regular income is just one (vexatious) GMC referral away from being suspended.

The thing is, in Medicine if you play the game, sit the numerous post graduate exams, bide your time wearing the right badge with a training post written on it, reapply for a post every few years, you’ll get there. Clinical skill doesn’t count when it comes to medical careers, the only thing which counts is ticking the eligibility boxes, of which a big one is biding your time. So at the end, once you’re a Consultant, what have you achieved? Well you’ve walked down a path which has not only already been hacked, it has been smoothed and paved, and you’re walking behind a long line of thousands of others. Now you’re a commodity at the disposal of an NHS manager. Is that really an achievement? Sure the exams which you have to prepare for in your spare time are hard, the interviews for posts competitive, but I’ve always considered achievement is breaking new ground, not following others.

So on balance, do I really want to work in that kind of environment? No way. As an entrepreneur I get to shape the environment I work in. I know that every single bit of progress my company makes is 100% down to my team’s skills and performance, nothing else matters here.

5) “Am I wasting my life here?”

In a similar vein, I regularly find myself asking if the past 5 years of my life have been time well spent.

I could claim that “at least I’m happy”. I can with all honesty say that I am really enjoying life. The startup rollercoaster really does carry you from highs to lows and back again, sometimes within the space of a few days, but the challenge is enjoyable no matter where the carriage is.

To a cynic outside my little startup world, I’ve been fannying around in a makeshift lab like a crazed scientist tinkering around on harebrained idea which will no-one else understands and would never work. I should have been working in a city bank earning “real money” or doing world-changing lab research, or raising a family.

To me, I can see a bright future where electronic medical records are the currently missing input feed to computer data analytics with AI. Where I build the machine that can start finding evidence to direct the 85% of medical practice which currently takes place without any. It’s potentially world-changing, and I’m the only person who holds all the pieces of the puzzle. How exciting is that?

To a balanced realist, my startup may succeed, but also may fail. Nevertheless in the worst case I’d have gained a huge experience in software design, software engineering, product management, marketing, sales, small business finance, IT infrastructure, business administration; all for the cost of a few thousand pounds. That’s cheaper than an MBA and arms me with far more skills for me next adventure even if there is no big company sale payout. Any future business I start will be more attractive to investors because I’m already battle-hardened. I’m less likely to make mistakes in any future business, because I’ve already got experience to guide me.

Conclusion:*

When I find myself ruminating about whether stepping out of full-time medicine was the right idea, I make myself think back to the days when I was a full time doctor. I was permanently tired, I was earning £14 an hour at best, and I was being blamed for the ward-level consequences of NHS systemic failures. I would look up to my Consultants and see burnt out miserable shells.

My parallel universe self who stayed in the game would endure years of unpaid hours, studying in what little free time he had, and fighting to keep his job which he didn’t enjoy anyway, every few years. A world far apart from the one my parents worked in. Most of all, I’d see my parallel universe self looking back across the sixth dimension at me, asking “what if I had gone an pursued that burning business idea I had… would my life be more meaningful like his is?”

Some people were meant to wander off the trodden path. I’m one of them, and that’s okay.

 

*Jesus Mike, what are you doing? That’s the second time a rant has gone somewhere meaningful. FFS.
P.S: I’d also like to point out that I deeply love Emergency Medicine. Being able to do it part time when I’m awake and feeling fresh means it’s really enjoyable. Being a Locum means that the deal is totally clear to both sides: “I work hard for you as a doctor, you pay me well for it. I choose to come here, you choose to have me here. Everyone is happy.”
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