By Dr Russell Foster, ASM Plus’s Medical Consultant and a member of its medical team. The first part of this blog was published on the ASM PLUS website in January 2019.

In my previous blog I introduced you to an amazing little book, a unique historic document, that every doctor working in the NHS should read. Actually, in my opinion, all doctors – working in the NHS or not – as well as all non-doctors should read it and reflect on its wisdom, contemporary relevance and proposed solutions. It may even be of interest to any passing politicians, especially health secretaries, actual or potential.

The book has the tantalizing title of ‘Angry Young Doctor’ and was published in 1957, nine years after the founding of the NHS. It was written by a member of a small and generally below the radar group of women and men, a ‘junior’ doctor called Dr Louis Goldman. Not only that, this doctor is, obviously, a published author, with few junior doctors appearing to hold this accolade. Sadly.

As an aside, I have tried to find out more about Dr Goldman, but apart from reference to him being a medical journalist, there seems to be very little written about “Dr G” as I shall now call him in an effort to be ‘down with the youth’ and to retain, sorry, try to evidence, any sort of street-cred. So, if anyone reading this can enlighten me, please do get in touch.

As a doctor myself with an interest in many things including history, especially the history of medicine, I am surprised and intrigued that comparatively few junior doctors have written about their experiences of training and working. Most medical history seems to be hagiography, usually about stern old men with beards who glare at us from paintings in gaudy frames on walls in apparently venerable and noble institutions. This unfairly ignores the much wider range of females, and non-geriatric, non-hirsute males who have also contributed much to the history of medicine, but generally these people are overlooked, especially if they are unfortunate enough to be junior doctors. In my opinion this is criminal, and Dr G is to be acknowledged in this regard as being one of the first junior medics to write about things as he saw them, and as far as I can tell from my research, the first to write about the life of the junior doctor in the newly formed NHS.

I myself have suffered the indignity of being a junior doctor (excuse me while I have a lie-down and a cup of tea in an effort to try to recover from the PTSD symptoms induced by the memory of the rather grim memories of my many years of servitude) and have written about my various misadventures as a medical minion. Sadly, I have yet to publish these, unlike Dr G. I have, however, been lucky enough to have my won book published, but this is a 500-page textbook all about blood tests, sadly unlikely ever to be in the league of Dr G’s seminal volume.  Actually, its potential as a cure for insomnia may well have merit, and I wonder if I should devote a future blog to this (yawn)…

But let’s move on. Previously I introduced Dr G’s book by quoting the words on its front cover, and now I would like to analyse part of his book in a bit more detail; I will do this by looking at how he described the NHS and reflecting about how (or, should I say, whether) things have changed in the 70-odd years since its founding. There is potentially loads I could say here, but I am not about to write a PhD about this, although I could easily do so. For your sake – and mine – I won’t, and having done a PhD already, I am really rather loathe to do another one. Actually, I rather enjoyed mine, unlike a certain Theodore Streleski, who, after spending 19 years trying to get his PhD, ended up murdering his supervisor – and not regretting it. Or Wilfred Cude, sadly recently deceased, whose experience of trying to get his PhD and failing to do so resulted in him writing a polemic about how awful PhDs are called ‘The PhD Trap’. It is an interesting read, by the way, even though it was published in 1987 and perhaps things have changed since then.

But I digress, so, let’s start with the introduction to Dr G’s seminal book. This comprises some four and a bit pages in which he starts thus:

Running through the hospitals of Britain today, invisibly linking doctors from one end of the country to the other, are three closely-woven strands of frustration, fear and despondency. Highly skilled though these men and women often are, they nevertheless go about their daily tasks in the bitter and frustrating knowledge that the future holds little promise for them in their chosen field of work…Despondency grows steadily year by year while the authorities continue to discuss their problem without apparently getting any close to a solution.

You must remember that these words were written at the end of the first decade of the establishment of the NHS and like all things historical, must be considered in context, from another’s specific point of view, without our current knowledge and worldview and so on. Yet have things changed? That junior doctors clearly have been angry more recently is evidenced by the recent junior doctor strikes in 2016, with a previous junior doctors strike taking place in 1975 in the context of a government proposal to reduce substantially the overtime payments for doctors. Interestingly, doctors in the UK are not the only ones to have gone on strike, and a brief gander through the wonders of the internet has revealed that doctors have gone on strike at various times in Australia, Belgium, Brazil, Canada, Finland, France, Germany, India, Israel, Jamaica, Kenya, Peru, Sudan, Sweden and Switzerland. This immediately raises all sorts of interesting questions, but sadly this will have to wait for another time and place. Or another blog from Yours Truly…

Returning to Dr G, the context of the introduction to his book is really about the real risks back then of ending up unemployed or worse, unemployable, something less likely nowadays with the current, severe shortage of doctors. In the UK in the 1950s, career progression for doctors was much more fraught than today, with, for example, as discussed by Dr G, insufficient consultant posts for the number of trainees.

The introduction also states:

If the patients’ viewpoint alone is considered, it must be emphasised that the National Heath Service, for all its admitted benefits, has brought with it an accompanying train of bureaucracy, insensitivity and lack of personal consideration: all the unpleasing stigmata of what I have called “medicine in the mass” …

This again is something that appears not to have changed throughout the history of the NHS, and I suspect that things have perhaps got even more complicated, at least when the tentacles of bureaucracy are concerned. If you speak to doctors nowadays, at least some will mutter, rant, castigate, criticise and more about this. I suspect further that some will communicate their lack of joy with what they might feel is the latest means of making their lives more complicated, namely the idea of ‘revalidation’. In simple terms this means that doctors must prove their fitness to practice (and thus their worthiness of holding a licence to practice medicine) by obtaining various bits of evidence each and every year and also ‘reflecting’ on it in such a way that it pleases and satisfies their appraisers as well as someone called their ‘Responsible Officer’ (RO). While this all perhaps is a bit militaristic, failing to ‘satisfy’ the RO can result in sanction, including, ultimately, being struck off the medical register. Revalidation is such an important and interesting concept that I intend to write about this in a future blog, so stay tuned.

So sorry, it strikes me that I have not yet gone beyond the introduction to Dr G’s polemic and already there are several descriptions of circumstances that have a contemporary resonance. The good doctor goes on to state in his introduction:

there is just cause for anger at the dilatory tactics employed by the authorities in the consideration of young doctors’ problems and at the lack of consideration afforded to patients…no useful purpose would be served by an extravagant outburst.

Actually, nowadays an “extravagant outburst” may well result in referral to the regulator, the General Medical Council, and so it is no wonder that doctors, junior or otherwise, will often use a nom de plume when writing about their experiences of working in the NHS. But not all experiences in the NHS are necessarily bad and Dr G does admit that “setting up a mammoth organisation which employs over half a million people involves many complex problems of administration”.

What I think we can glean from Dr G, assuming that what he writes has at least some basis in truth, and just from his brief introduction, is that when the NHS was set up it had problems that have remained, not least when it comes to the world of the junior doctor. All organisations have systemic flaws almost by definition and here the NHS is possibly no worse than any other large body, public or private.  What is interesting however, is that the problems described by Dr G in 1957 were already there in the infancy of the health service and seem to have remained, ever resistant to change, despite various efforts, reorganisations, reviews and enquiries over the past decades. Here I am reminded of a quote I came across recently:

We trained very hard, but it seemed that every time we were beginning to form up into teams, we were reorganised. I was later to learn later in life that we tend to meet any new situation by reorganising and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation.

Guess who allegedly wrote this? No, not Dr G, but many sources say this is from one Gaius Petronius, a Roman courtier who lived between 27 – 66 AD who is remembered for his hedonistic activities in the court of Nero as well as writing a satirical novel, Satyricon. Yet others say that this quotation comes from Charlton Ogburn, an American writer and journalist, from a magazine article published in 1957, the same year as Dr G’s book appeared. Spooky or what.

Anyway, I suppose that the French expression, ‘plus ça changeplus c’est la même chose’ (the more things change, the more they stay the same) is rather apt here, and if Dr G is indeed correct, then analysing the history of the NHS from the point of view of the junior doctor is a worthwhile and interesting activity. There is lots more that Dr G has commented on in his wonderful book, and sadly I cannot do this justice in one or two short blogs. Indeed, I have only just considered the main points in the book’s introduction, and to get the true gist of it I suggest you read it for yourself and weep, read it and reflect (and use this in your next appraisal as evidence of ‘personal reading’, a useful ‘continuing professional development’ activity) or just read it and get angry. If you do get angry, though, and you just happen to be a young doctor, please try not to exhibit an “extravagant outburst”. If you do, possibly because you can’t help yourself, which I fully understand, the services of a trained and experienced mediator may well come in handy. And, by coincidence, I just happen to know one or two.…