Solidarity

[Epistemic status: I am not British, it’s been years since I’ve been in the HSE, and the HSE is not the NHS. All of this may be misunderstood or outdated.]

I don’t usually blog on labor disputes here, but I want to talk about one on which I have a tiny bit of inside knowledge.

Last month junior doctors in Britain went on strike for two days, protesting imposition of a new contract. There’s a lot of anger about this, and admittedly when you’re being rushed by ambulance into the emergency department for sudden onset chest pain, “doctors are on strike today” is not something you want to hear. My normal instincts would be to question whether this is really necessary. My experience tells me it is.

“Oh, you’re a junior doctor. Of course you would support a doctor’s strike.” Okay, but I’m not a British junior doctor. I work in America, where I would describe conditions as “tough, but fair”. Sure, Dr. Cox yells at you a lot, but only because he secretly thinks you’re one of the best doctors ever to pass through the doors of this hospital. My own specialty of psychiatry is a lot better than most and overall I have little to complain about in my own life.

But that’s not to say that I don’t have any special knowledge here. I went to medical school in Ireland, where I worked alongside junior doctors in a system very much based off of the British one. And it was pretty shocking.

Technically European law caps junior doctor work weeks at 48 hours a week. Then again, technically American law caps junior doctor work weeks at 80 hours a week. My first week on a non-psychiatry service as an American junior doctor, I worked a bit over 100 hours – and so did everybody else I encountered. When I asked about the law, everyone just gave me that “oh you sweet summer child” look.

Such caps seem to be honored more in the breach than in the observance, and this is the British custom too. Physicians Weekly describes it as “the 48 hour trainee work week sham”, and the Telegraph and The Daily Mail both seem to agree that many British doctors are working 100 hour shifts. They seem to circumvent the law either by giving them a few weeks off afterwards and saying it “averages” to 48 hours/week, or else by doing what my hospital did – carefully schedule a 48 hour shift in big bold letters, assign 100 hours worth of work, and then get angry if anyone goes home before their work is done.

Many of the junior doctors I worked with in Ireland were working a hundred hours a week. It’s hard to describe what working 100 hours a week is like. Saying “it means you work from 7 AM to 9 PM every day including weekends” doesn’t really cut it. Imagine the hobbies you enjoy and the people you love. Now imagine you can’t spend time on any of them, because you are being yelled at as people die all around you for fourteen hours a day, and when you get home you have just enough time to eat dinner, brush your teeth, possibly pay a bill or two, and curl up in a ball before you have to go do it all again, and your next day off is in two weeks.

And this is the best case scenario, where everything is spaced out nice and even. The junior doctors I knew frequently worked thirty-six hour shifts at a time (the European Court of Human Rights has since declined to fine Ireland for this illegal practice). Dr. Brid McGrath (my lab partner in medical school) has been collecting some stories for the Irish media:

My stories are like my colleagues’ stories: working through illness, personal turmoil, and deprivation of sleep, food and toilet breaks. The worst stint was working 73 hours within an 82 hour period. I have been bullied, and to my shame, bullied others. I realised I was falling into the trap of treating others the way I had been treated. My self esteem faltered and I began to believe I truly was a nasty person. I had the insight to get help, but not everyone is so lucky.

I came to talk to you about the imminent arrival of your very premature baby, at just 24 weeks. I held your hand and passed you tissues as we talked about his name, how tiny he was, how hard his life could be, but how we would try to give him the best possible chance… and how we might also have to accept the reality that he might not make it. That same day, I’d worked a 28-hour shift while I was 24 weeks pregnant myself. I fought back tears before I saw you. I worried about how I would cope with your pain and distress, barely able to think about the baby growing inside me. I had dinner a 1am, and worked on. An incredible nurse sat me down for a glass of water. She had to force me to. I was so busy.

The other night, after a particularly busy 16-hour shift in the Emergency Department and Theatre, I went up to the wards to take blood samples for a patient. I’d had no dinner. A patient in the same room was handing around coconut buns, and gave me one. I inhaled it, it smelt so good. She then pushed the box into my hands and said “You look like you need them more than me!”

Imagine having to decide between going to the bathroom or getting a bag of crackers from the vending machine because you don’t have enough time between cases to do both. Imagine having to remember the difference between nephritic syndrome and nephrotic syndrome (two totally different things) after ten hours of work, after getting three hours of sleep the night before. Imagine that you’ve just admitted a neurotic old woman to the hospital and you know in your heart that you should take her hand and explain to her in a soothing voice that everything is going to be okay, except that you already feel like every nerve of yours is beaten raw and you have three patients left to go before you can so much as sit down for a few minutes. Imagine your attending yelling at you because you got something wrong and saying you need to spend more time studying, and you trying to keep your mouth shut instead of telling him that you literally have only a half-hour in the day that could be considered free time by even the broadest stretch of the imagination and you are damned if you are going to spend that studying endocrinology.

The psychological consequences are predictable: after one year, 55% of junior doctors describe themselves as burned out, 30% meet criteria for moderate depression, and 12% report considering suicide.

A lot of American junior doctors are able to bear this by reminding themselves that it’s only temporary. The worst part, internship, is only one year; junior doctorness as a whole only lasts three or four. After that you become a full doctor and a free agent – probably still pretty stressed, but at least making a lot of money and enjoying a modicum of control over your life.

In Britain, this consolation is denied most junior doctors. Everyone works for the government, and the government has a strict hierarchy of ranks, only the top of which – “consultant” – has anything like the freedom and salary that most American doctors enjoy. It can take ten to twenty years for junior doctors in Britain to become consultants, and some never do. In Ireland (I don’t know about the UK) there was a very scary distinction between “training” and “service” positions, the former of which were always in short supply. Imagine that you’re a freshman in college, and your university announces that due to budget cutbacks there are only about half as many sophomore positions available this year, so the top fifty percent of freshmen can go on to become sophomores, and the rest will have to stay freshmen until more money comes in. Also, there are no other colleges in the entire country so you have no choice but to follow along and hope for the best. This is what being a junior doctor is like.

Faced with all this, many doctors in Britain and Ireland have made the very reasonable decision to get the heck out of Britain and Ireland. The modal career plan among members of my medical school class was to graduate, work the one year in Irish hospitals necessary to get a certain certification that Australian hospitals demanded, then move to Australia. In Ireland, 47.5% of Irish doctors had moved to some other country. The situation in Britain is not quite so bad but rapidly approaching this point. Something like a third of British emergency room doctors have left the country in the past five years, mostly to Australia, citing “toxic environment” and “being asked to endure high stress levels without a break”. Every year, about 2% of British doctors apply for the “certificates of good standing” that allow them to work in a foreign medical system, with junior doctors the most likely to leave. Doctors report back that Australia offers “more cash, fewer hours, and less pressure”. I enjoy a pretty constant stream of Facebook photos of kangaroos and the Sydney Opera House from medical school buddies who are now in Australia and trying to convince their colleagues to follow in their footsteps.

Upon realizing their doctors are moving abroad, British and Irish health systems have leapt into action by…ignoring all systemic problems and importing foreigners from poorer countries who are used to inhumane work environments. I worked in some rural Irish towns where 99% of the population was white yet 80% of the doctors weren’t; if you have a heart attack in Ireland and can’t remember what their local version of 911 is, your best bet is to run into the nearest mosque, where you’ll find all the town’s off-duty medical personnel conveniently gathered together. This seems to be true of Britain as well, with the stats showing that almost 40% of British doctors trained in a foreign country (about half again as high as the US numbers, even though the US is accused of “stealing the world’s doctors” – my subjective impression is that foreign doctors try to come to the US despite barriers because they’re attracted to the prospect of a better life here, but that they are actively recruited to Britain out of desperation). Many of the doctors who did train in Britain are new immigrants who moved to Britain for medical school – for example, the Express finds that only 37% of British doctors are white British (the corresponding number for America is something like 50-65%, even though America is more diverse than Britain). While many new immigrants are great doctors, the overall situation is unfortunate since a lot of them end up underemployed compared to their qualifications in their home country, or trapped in the lower portions of the medical hierarchy by a combination of racism, language difficulties, and just the fact that everyone is trapped in the lower portions of the medical hierarchy these days.

If Britain continues along its current course, they’ll probably be able to find more desperate people willing to staff its medical services after even more homegrown doctors move somewhere else (70% say they’re considering it, although we are warned not to take that claim at face value). I work with several British and Irish doctors in my hospital here in the US Midwest, they’re very talented people, and we could always use more of them. But this still seems like just a crappy way to run a medical system.

I don’t know anything about the latest dispute that has led to this particular strike in Britain. Both sides’ positions sound reasonable when I read about them in the papers. I would be tempted to just split the difference, if not for the fact several years of medical work in the British Isles have taught me that everything that a government health system says is vile horrible lies, and everybody with a title sounding like “Minister of Health” or “Health Secretary” is an Icke-style lizard person whose terminal value is causing as many humans to die of disease as possible. I can’t overstate the importance of this. You read the press releases and they sound sort of reasonable, and then you talk to the doctors involved and they tell you all of the reasons why these policies have destroyed the medical system and these people are ruining their lives and the lives of their patients and how they once shook the Health Secretary’s hand and it was ice-cold and covered in scales. I don’t know how much of this is true. I just think of it as something in the background when the health service comes up to doctors and says “Hey, we have this great new deal we want to offer you!”

(I remember reporting into the hospital one day and seeing almost a carnival atmosphere, and one surgeon who had never been known to do anything but yell at his subordinates gave me a friendly nod and smile as he passed me in the corridor, and I started to worry I had walked into some Stepford Wives bizarro-world. Finally I learned that, the evening before, the Irish health minister had resigned in disgrace. This is the only time anyone ever saw that surgeon happy.)

[EDIT: a strong argument that the junior doctors have the right of it and the NHS’ position is based on a misunderstanding of patient care statistics here]

Whatever caused this latest dispute is probably relevant mostly as a straw that breaks the camel’s back. If British junior doctors today are anything like the Irish junior doctors of a few years ago, all of their complaints are legitimate and they’re also hiding several dozen other legitimate complaints you have yet to hear about. I sort of sympathize with the government’s complaints that they don’t have enough money to make a system where doctors don’t have to work a bunch of 36 hour shifts, but I feel like if you don’t have enough money to run a health system that treats its employees like human beings, maybe you shouldn’t be running your country’s health system.

Labor disputes suck, and I have no good theory of them. Part of me is outraged at people being mistreated, and another part of me worries about a world where anybody who can convince the media that they’re being oppressed can force other people into paying them whatever amount of money they think they deserve. I long for some kind of principled system that will solve these problems more elegantly than letting everybody shout their grievances at each other and seeing which ones stick. I long for something that will take care of the deeper problems underlying unfair labor practices like dualization of entire industries. This is why I find libertarian ideas like letting competition among firms determine people’s pay and conditions so attractive.

But these may or may not work, insofar as they do work they only work in certain situations, and insofar as they do work under certain situations a 100% socialized industry run as a government monopoly probably isn’t one of them. So we’ve got to do the thing where people get mistreated and have to cry out for redress of their grievances. And my experience tells me the grievances of British junior doctors are copious, horrifying, and entirely valid.