Ishan Jain's Thoughts

In my field of work, more and more people seem to be going ‘less than full time’. Nobody ever seems to regret it. So, why am I here working ‘full time’?

When you start to play with the idea of going less than full time with other people, there are both pros and cons discussed.

Some who are full time seem to look down on them, ‘jokingly’ calling them ‘slackers’, perhaps feeling they have to work more than them, but not realising it is an active choice they have made. Some say the money is important to them and their lifestyle. Some have dependents who need this to continue their current lifestyles too. Everyone’s financial situation is unique. Some say the training becomes unbearably long on top of an already long programme. Some say the experience you gain is less as a result. Some say seniors and rota coordinators don’t always support the decision due to staffing difficulties.

But the ones who are less than full time seem to be happy. They are less stressed. They have more time for their loved ones. They have more mental capacity to think. They never look back to full time work.

I think the terminology doesn’t help either. Unconsciously, I feel ‘less than’ if I go ‘less than full time’. I feel like I am 80% of a doctor rather than a ‘full’ doctor if I do 80% of the hours for 80% of the pay. Of course, this isn’t true. It’s a construct that is arbitrarily defined to be ‘full time’ or ‘100%’.

In an ideal world, my hours wouldn’t be so defined by someone else; there isn’t a ‘minimum’ number of hours to put in to pass some boundary somewhere. I understand experience is key, and learning through experience hands-on is irreplaceable. I love being a doctor, I love working and making a difference.

Currently, I don’t feel as though 100% of my time at work is loved, or is valuable to my learning, but a lot of it is. It would ultimately be a compromise for me to go ‘less than full time’, but I think it is a worthy one to make. For the sake of my loved ones, my time, my mental capacity and my value.

I am a junior doctor who selfishly chose to work the strike days. I did this partly to not lose out on my salary on these days, partly to minimise my ‘time out of training’, but mostly to learn. I thought that with so many seniors around, it would be a great opportunity to learn and ask questions in a supported environment. During strikes, I saw more seniors than ever in the hospital. They’re incredibly valuable as teachers, mentors, colleagues, but moreso as people.

I learned this today that experience, both in work professionally, but also in life, personally, is incredibly key. I’ve started to value this more and more in my family too, with my parents and grandparents, and really listen to what they have to say, way more than I did as a teenager.

Today, my consultant told me about this idea of the ‘Banality of Evil’ coined by Hannah Arendt. He told me to remember this the next time a colleague is angry or short with me. I think it can be applied to patients too. Anyone who is part of a system. Which I guess we all are in one way or another.

Essentially, this idea means that the underlying reasons and motivations of ‘evil’, or antagonists in general, are inherently mundane. Boring, simple, uninspiring. The shouting colleague doesn’t want someone else to shout at them, or punish them, for not doing their job. And I guess, to go another layer deeper, they don’t want to be shouted at and feel unvalued, unappreciated, or maybe not get paid as a result of not doing their job. Being shouted at makes us feel unsafe, threatened, unwelcome. The conflict becomes uncomfortable, for both sides really. I am unsure whether a positive release is experienced after shouting or getting angry or annoyed at someone else. I think it’s more of a survival mechanism. Fight or flight.

A couple hours after my consultant told me this idea, I was shouted at by a senior for ‘not doing my job’. I was simply helping someone else, i.e. doing my job, just not for him at that time. He felt overwhelmed by a busy department. By computer tasks he couldn’t perform. By not wanting to do the menial work.

I knew all this. It becomes difficult to remember that his underlying interest was not to antagonise, not to be ‘evil’, but was to not feel overwhelmed, to not feel out of control of the situation, so that nobody shouts at him and he keeps his job and gets paid.

But once I remembered this, I felt calm and under control of the situation. I felt like I understood him, read between the lines, and that if I disengaged, if I didn’t rise to the situation, and fight or flight, then I would be okay. I would survive the situation, while also defusing it.

The system, the NHS, has created this environment where lots who enter wanting to do the right thing and help people become irritable, angry, not their normal self. Lots of people don’t become these types of people too. They control themselves. They think about the bigger picture. They rise above it. These people become some of our role models. I am lucky to be working in a hospital where these people are actually largely the norm. They all tell me it is not like this everywhere. They all tell me to appreciate it while it is here. They all tell me who to look out for, and who to look up to.

---

Where I learnt a bit more about this concept:

Hannah Arendt’s lessons for our times: the banality of evil, totalitarianism and statelessness | The British Academy

I liked being surrounded by people who were like-minded and interested in the same thing: making the communities we live in healthier. They were motivating and inspiring, and it was especially useful to see people that even looked like me in senior public health roles in the UK. It is possible!

Some talks really stuck with me, like conversations about communication. We often think of ourselves as medics as good communicators, but this talk pointed out that we aren’t with the public. Not as good as influencers online who grab more attention and shape people’s opinions, arguably more so than politicians and doctors and other professionals. Communication skills with the public vs the individual is a different approach. Framing the issue in a different light was something I hadn’t really considered. We tend to stick to facts and figures, but emotion, stories and memorability is what sticks with people.

The importance of system level change to create the right conditions in which we can be healthy makes so much sense. I would love to be part of this solution one day. Another point highlighted was trying to get our health points across to politicians in a way that grabs their attention too, which likely needs a different approach to the public.

I always used to think I hated politics. I disliked the way in which politics was done rather than politics itself. The excessive wording, the beating around the bush, the delays, the lack of transparency, the seeming lack of trust, the bureaucracy, the impersonal nature of some politicians, the lack of relatability sometimes, the waffle and false promises. I was told that as a doctor, if we want to influence policy to help health, it is difficult to avoid politics completely. Admitting I don’t know much about it is not a weakness. You can never be an expert in anything. I hate the word expert anyway because I feel like you can never know everything, so you’re always a student. What’s the threshold?

Someone else brought up the point of the vocal minority vs the silent majority. The silent majority we tend to think of as reasonable people, as people who are not making a fuss, who just get on with their own lives without trying to impose their views on others. You don’t really want to be the person who is imposing views on anyone. I guess as doctors, you gotta try and present the unbiased facts and call out the issue itself rather than blame any single person or company.

Sometimes, I have patients come to me and tell me things that make me think ‘Why are you here?’.

There are lots of times you hear doctors complaining about patients wasting their time or inappropriate referrals. You rarely hear of the patients that were a good use of their time or were appropriately referred to them. Nowadays, patients come to you with more expectations than previously, according to my seniors. This comes with the unlimited information available to people nowadays, with Dr Google or AI. Sometimes it’s well informed, and sometimes it’s the horror story in the news. I find it increasingly difficult to reassure someone because health anxiety is at, what seems like, an all time high. As is general anxiety about everything I suppose.

And so, when I find constant resistance to what I advise and say as a doctor, I tend to ask ‘So what is really the matter?’. Usually there is something else that’s causing their worries, but sometimes people don’t even realise they have health anxiety and constant worry and stress. The issue comes when what you think they have based off their answers to your history questions and your examination findings doesn’t match what they think they have. And if it’s a name of a fancy diagnosis that fits perfectly, that’s okay. If it’s simply ‘likely stress or lifestyle related’ causes, it becomes more difficult to have people leave satisfied. I think they feel some blame attached to those words, or feel dismissed, even if I’ve done a very thorough history and examination. I often find myself over-ordering investigations, such as blood tests, scans and samples for sputum, urine and stool, to rule things out or to put the patient’s mind at ease. Yes, rare things can happen, and yes, these investigations can be useful, but more often than not, these investigations do not explain the whole patient condition. This nuance can be difficult to portray to a person in just a few minutes.

Medicine and the human condition is unfortunately very multifactorial a lot of the time as it is so complex. We have more answers now than ever before, but we also seemingly have more questions than ever before. I guess that’s the beauty of modern day science, but nobody wants to be considered a science experiment either, and they shouldn’t get treated like that either. The truth is we are discovering more and more medical conditions and diagnoses, and there are more and more medications we can give and investigations we can order and interpret, and more and more specialists we can refer to.

Often, I need to tell myself that I am not a miracle worker, as much as I would love to be one. The most I can do is to try to understand and listen; make someone feel understood and heard. I can try and answer some questions along the way, and provide people with answers as and when I can, but sometimes I have to accept that I don’t know the answer, or I can’t help someone. The more you do for someone, the less they do for themselves.

It would be interesting to do a mass survey one day to ask people what they want or expect from their doctor…

I have met many patients with self- or officially diagnosed health anxiety. And it got me thinking I, and many others, probably have an element of this too.

Usually, there’s an underlying reason for it. A bad experience with healthcare, an ill family member, a late diagnosis or reading about horror stories online.

All of these things could be extrapolated to many other types of experiences in life. A car accident could make someone (understandably) very anxious about driving, or a nasty comment about your looks can make you very self-conscious.

As Inside Out 2 showed very well, anxiety is a normal human emotion that we experience from time to time. When it starts to impact your everyday life and you feel you can no longer function as you once did, it starts to become a medical disorder and something that likely requires professional help.

My own health anxiety originated from an incidental finding of aortic regurgitation (a leaky heart valve), which can happen to anyone really. It did trigger endless health and wellness research for me which led me to learn a lot of things about health, but also resulted in a lot of anxiety. I started waking up and not listening to how my body was feeling, but what my Whoop Score said. My health tracker became my boss that I was scared to disappoint. And that’s not the way it should be at all. It’s not healthy.

There’s a fine balance with these things, and I find once people have health anxiety, or any medical diagnosis, it becomes the boss of them too. They start blaming everything on it, rather than listening to how they feel, how their body feels, how their mind feels.

It’s taken me a long time to come to terms with my health, my sense of control over it, and controlling my thoughts around it to not let my health or other anxieties be the boss of me. We do have the power to be the boss over them. I like reminding people of that whenever I meet them.

“Independence is true wealth” – Morgan Housel.

I heard this quote today and it spoke to me very clearly.

I have thought many times since starting working how great it would be to simply wake up, not really feel like working, and then simply not go to work. I could sleep some more or spend some time with my partner or outside or doing chores or a million other things. The classic response when someone says this is a scoff and disbelief that it is possible. Yet, lots of people live this way. However, it might be a bit more difficult in our career, when you’re working with patients in particular.

Many doctors nowadays go less than full time. They do 80% of the job for 80% of the salary, and they almost never regret doing so. The money is made up by doing the odd locum shift, and the time is irreplaceable. Sounds great, doesn’t it?

Perhaps with technology and increasing telemedicine, and being involved in research and independent projects, independence is more possible than it once was.

We’ll have to see. But that’s the ultimate goal. Autonomy and control over my time is a new priority I didn’t realise I wanted.

I am lucky to be in a job where I am surrounded by seniors. By people who are in the role I could be working if I followed their career path. They help give you a tangible visualisation of your potential future. Sometimes this is helpful and inspiring, sometimes it is the opposite and makes you question everything. The inspirers seem to be increasingly rare in my day-to-day job. Maybe this is because of the overworked NHS staff, the impossible goals governance teams set them and the ever-changing nature of work resulting in constant adaptations to new pathways and technology. Maybe my threshold for inspirers has increased. Maybe inspirers are simply rare.

Rather than coming across a recent inspiring mentor, I came across an inspiring doctor speaking on a podcast, Dr Guy Leschziner, a neurologist specialising in sleep disorders among other things. The way he spoke about patients and the art of practising medicine made me believe again. It brought out a desire in me to aspire. I want to take such an interest in my patients’ lives and learn from them, sharing my reflections with the world in a non-judgmental manner. This approach was my key takeaway from how Guy spoke – to treat people with kindness, empathy and curiosity. His explanation about the uniqueness of everyone’s experiences coupled with everyone’s unique brain structures and neurone patterns resulting in everyone’s perceptions of the worlds being unique was nothing new per se, but it was refreshing to hear. This is how doctors should be, rather than taking a binary or black-and-white approach to doing ‘the right things’. I often feel like people should be given more credit for living their lives.

I would love to be an inspirer myself one day. I hope I have the remaining energy to do so.

I am, like many others, concerned for my health. I want to optimise it, to have it perfect so that I have ‘nothing to worry about’ and am ‘healthy’ and live injury- and disease-free. Wouldn’t that be great?

I have consumed a lot of health and ‘wellness’ (which is just health) content over the last couple years. I had a scare where during a teaching session at med school, the teacher caught something on my heart scan – an ultrasound showing aortic regurgitation – a leaky heart valve. Which for those who don’t know, isn’t something too major to worry about, especially if it’s asymptomatic, i.e. not really affecting my life. But, at the time, as a final year medical student, I suddenly felt like I had been given this ‘bad luck card’ by life and a life-shortening sentence. Now, there are many many worse medical conditions and things one can be told, and I knew this rationally, but there is this vulnerable feeling as a patient that all logic and rationality goes out the window briefly and you think ‘Is this it?’, ‘Am I going to die?’.

As someone who has always been a bit scared of death and its unknown, this question did go through my mind. My friends and my cardiologist reassured me. Dr Google reassured me too. But, it did spark my first real interest in taking ownership of my own health. I’d never considered myself unhealthy until this moment. And even then, I didn’t label myself like that.

I started to trawl through the minefield that is health and ‘wellness’ content online to try and take control, and work out what I could do to help my own heart. I was told a month before running the Stockholm Marathon not to do it by my cardiologist. I naturally had the question ‘wait, so how much exercise is good for my heart?’. I’d always thought marathon runners were the epitome of health, but this information was now telling me otherwise.

Since then, I have read infinite articles, read many books and listened to countless podcasts about health. I have a natural interest in it as a doctor too, but this was mostly stuff you don’t really get told at medical school. You get told to eat healthy, to sleep, to ‘look after yourself’ and to ‘not be stressed’. But, what does that actually mean? I then learnt of this whole new world where many people, some doctors, some health professionals, some not-so health professionals were sharing and preaching about what to do for health. Some things sounded mad, some things were viral, some things were incredibly popular and some things weren’t. Everyone seemed to be an expert. And I felt like I knew nothing after 6 years of med school.

Two years on, I know feel like I’ve reached the stage of full circle in my reading. I’ve sorted through a lot of information, I’ve picked up some bits, I’ve developed my bullshit filter, I’ve used some first principles from my own education and I’ve come to some conclusions. But it is an ever-developing space with some really exciting research about microbiomes, epigenetics and DNA-editing.

From all my reading, and constant bombardment from Instagram and social medias of ’99 habits you need to know right now to live longer’ which get me, I ended up:

• Buying:
  • 2-year Whoop subscription
  • 1-year ZOE subscription
  • Lingo monitor for 2 weeks
  • Lumie Bodyclock 100
  • Scalp and body scrubber
  • Several sleep masks
  • Ear plugs
  • Mouth tape
  • Several books
• Downloading the apps:
  • Don’t Die
  • NBack
  • Medito
• Listening to lots of:
  • The Diary of a CEO
• Subscribing and unsubscribing to several email newsletters:
  • ZOE
  • Dr Karan Raja
  • Blueprint
  • British Society of Lifestyle Medicine
  • Wim Hof
  • Dr Mindy Pelz
  • The Doctor’s Kitchen
• Following:
  • Way too many health influencers on Instagram

It’s been an expensive and tiring journey. Both for me and those around me.

I’ve learned a lot, that’s for sure. There is a lot that we can do to take care of ourselves and look after our health. A lot more than I realised. But also a lot of it is common sense and is basic. Yet, many make many thousands and millions selling courses, products and a lifestyle that is maybe ever-so-slightly more healthier than a free one.

The main summary I’ve taken away from all this is:

• Sleep, exercise, eat and drink well
• Brush and floss
• Go outside
• Keep yourself and your spaces clean
• Don’t take things too seriously
• Don’t live the same day again
• Try things, learn things, make things
• Be kind to others
• Be kind to yourself
• Be yourself wholeheartedly

I really enjoyed the start of my GP rotation, but now at only 2 months in, I feel drained. The end of each day drains me more and more. This wasn’t what I expected, as I was going into this rotation thinking it could be a potential career. But now, I’m not thinking that. I have a newfound respect for GPs and how they deal with the constancy of their clinics and days. There is endless admin, follow-ups, typing, letters, referrals, organising tests, meeting patient expectations and quick diagnostics. I don’t see anywhere near as many patients as an F2 that actual GPs do, and I still feel like this.

But, there must be something else. Not working Fridays, weekends and nights must be better, surely? Coming into this, I thought that working on my own seemed great, no one telling me what to do, learning constantly, having my own independence, but I guess I was wrong. Each patient is unique, and I do like speaking to people, generally. Some parts are repetitive, I don’t love typing so much and working at a screen all day isn’t ideal.

I think it’s the feeling of progressing towards something that’s missing. Each person, each patient, each case just has so much delay to finding out the answer. In reality, people are so much more complex than a clinical vignette. They have so much going on sometimes that it’s overwhelming. Or they don’t have much going on at all, and it’s not intellectually stimulating. I have yet to find that sweet spot of challenge and curiosity at my skill level in GP to find it enjoyable. If things I advise and do help, you never hear from them again. If things I advise don’t help, I will be sure to be the first one to hear about it. The way this is just is not satisfying. I understand that is the system.

But, it would be nice to be able to hear that things you said and did actually helped. It would be nice to get more positive reinforcement. Them never coming back doesn’t feel like enough. I want to track their lives in a way. I am so interested in finding out what is happening behind the scenes, outside the appointment.

Maybe there is a way to do this in the future. Maybe I just need to audit my own work to find out, call each and every patient I’ve met so far on GP and see how they’re getting on. That would be nice. I do remember most of them.

I think another thing that’s missing from GP is the camaraderie. Everyone has a million things to do, so always seems in a rush. I have met lovely people and it is nice chatting through patients with supervisors that care. I didn’t expect to miss that. You start and end the day on your own. A small handover at the end of the day would be nice. Some clinical and some not so clinical chat. I’m grateful to at least have this when I go home.

I guess another aspect of GP is that it is pure service provision and ‘customer satisfaction’. I haven’t met GPs here that have other projects going on, research or wider goals. Maybe they do and I just don’t know it. But, I’m almost too drained after each session to even socialise with them and learn these things.

We’ll get there. Wherever there is. We’ll find a way to forge a meaningful path in this thankless career, one way or another.

My dad had a cataract surgery in one of his eyes today. It’s a short, routine procedure that’s under local anaesthetic so what’s the worry, right? The main fear of surgeries is never waking up again from general anaesthetic. Yet, there was palpable anxiety from all of us in the family, me included. What if things went wrong?

Experiencing the other side as a ‘patient’s relative’ was humbling and maybe also exactly what I expected too. For a procedure taking about 30 minutes in total, from start to finish, we were there for 6 hours. Yes, it was free and yes, it was complication-free (so far, touch wood) for which I am grateful. But, there wasn’t much kindness towards us today. From being greeted at reception coldly to not being allowed to go in to see him afterwards ‘because it’s too busy’, it felt like we’d turned up on the wrong day to the wrong place. The hospital was one of the nicest NHS hospitals I’ve ever seen – no complaints about the decor or cleanliness, but kindness and warmth from people were lacking today in our experience.

It made me really think all the times I’ve spoken to patients and their relatives as a doctor, and I feel I do try to be kind and empathetic, but I know there’s not always time for it. I’ve never denied a relative a chance to visit, even if it’s ‘too busy’ or the ‘wrong time’, and I will continue to do this, even if it goes ‘against policy’. It isn’t the right thing to do. It isn’t the best thing for the patient.

Another point of reflection was about vision. Eyes. Sight. My dad came out wearing an eye patch and tape over his eye, like a battle wound was covered up. Luckily we were there to drive him home, read the medication instructions and give these. It did make me feel for those who didn’t have family or friends to do this for those out of surgery. Without vision, the world is very difficult and very different. Do we look after our eyes? I don’t. Not as much as I know I could. Using screens all day long to work and not to work while not using the 20-20-20 rule is probably killing my eyes slowly. I do try to eat a healthy diet and I don’t smoke, so that’s something at least. And I don’t itch my eyes as much as I used to – they do look less red than before. I’m getting better at contact lens hygiene too, and wearing those less and less too. I’m prioritising my sleep a bit more too. So hopefully that’ll help. I should go out in the sun more though, apparently a bit of that helps too.

My experience of the world would be so subdued without my vision. I want to be more grateful for what I see. For seeing. I remember the first time I tried on contact lenses, and I could see completely clearly, I cried. I was 12 years old. The optician’s room was just so beautiful. The colours were so vivid. The world looked so rich and full of life. I still occasionally feel like this when I put my contacts on. I feel free. I’m seeing the world in HD. 4k even. Most of the time now I’m just furiously wiping my glasses lenses with my t shirt I’ve worn all day and wondering why they’re not clean.

Being an eye surgeon and gifting people their sight must be magical. Must be impossible to train as one because who wants someone who isn’t an experienced expert operating on their eye? That’s one specialty I have a lot of respect for. But it’s not for me. Too many micro movements.