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Reflecting on my first ten years as a doctor

Ten years ago today (eleven by the time this is published), I learned that I had passed my medical school finals and became a doctor. It doesn’t feel like it was a decade ago.

At work, I recently happened to have a meeting with someone I worked with as an F1 doctor but haven’t seen since. It felt like we worked together a month ago rather than a decade. I still occasionally say “hi” in the street to the porter who used to comment on my “Bird’s Custard” colour tie as an F1. And yes, somehow my F1 year was long enough ago that ties weren’t yet banned in hospitals.


I think the Simon of ten years ago would be amazed to find that I’m now working in public health. I didn’t enjoy the occasional public health bits at medical school, and I wasn’t even really aware that it was it’s own specialty until I came to pick a career path. Public health always struck me as worthy, dull, and far removed from anything that actually had any measurable impact on patients.

It was only after a serendipitous run of F1 hospital rotations that I started to see the point. My first job was in upper gastrointestinal surgery, a subspecialty involving seriously brutal surgical interventions to treat cancers with very poor prognoses. My second job was in stroke medicine. My third was in gastrointestinal medicine, a speciality in which a large proportion of the patients had end-stage liver disease as a result of alcoholism.

I think it’s impossible to go through that sequence and not feel slightly despairing: hospital medicine comes too late for most of these patients. Their lives very often cannot be pieced back together: as one particularly insensitive consultant used to regularly say, for those patients “the party’s over”.

The most effective treatment for these patients would be to rewind time and tackle their problems before they were ill. This initially pushed me towards General Practice, until I realised (late) that this was the point of Public Health. My realisation of this came so late that I didn’t really know what public health doctors did all day, but stuck in an application to the specialty anyway… as well as general practice.


After long essay-style application forms, written exams and half-day intensive interviews known as “selection centres”, it somehow came to pass that I was offered places on both the GP and public health training schemes. I had 48 hours to decide between a familiar career path and one which sounded fascinating but that I barely understood. In truth, I hedged: I went with public health because general practice always under-recruits, and I was pretty confident that a re-application to GP would be successful in 12 month’s time if public health turned out to be awful.

I was also put off by the obsession with portfolios in General Practice. My experience of clinical portfolios was that doctors were judged too much on their ability to write and present evidence rather than on their practice of medicine. I was, even if I say so myself, great at presenting portfolios of glowing assessments as a Foundation Doctor, but this felt a bit flat. It seemed to me that people in public health were known by results and reputation, and I liked that idea. I’m not so sure that was an accurate assessment of either speciality, but it certainly played a part in my decision-making at the time.

Leaping into public health felt brave at the time, even if it seems like hedging in retrospect: no end of people were telling me that I’d be “wasted” in public health and that my skills with patients meant that I’d be a fantastic GP. Some of this was subfusc whispers in my ear, some was formal written feedback, some was mildly paternalistic advice. Only a minority were enthusiastic. Luckily, once I set my mind on something, I’m pretty strong-willed.


Public health wasn’t awful. I mean, it had its moments: within weeks of me accepting a place, the coalition Government announced an intention to move public health outside of the NHS. This may have been the right decision, but it was terrifying for me as an NHS doctor to know that my NHS career path had been cut off just as it was beginning.

As I progressed through my training, I came to really enjoy health protection, the part of public health which deals with outbreaks and other biological, chemical and radiological threats to the population. I liked the combination of clinical-style short-term pressure, thoughtful balancing of risks, and the close association with clinical colleagues (and occasionally patients). I wrangled the system to spend almost half of my training in health protection placements, and since 2016 I’ve been a consultant in health protection. It is—by far—the most enjoyable and rewarding job I’ve ever done, in which I’m surrounded by a brilliant team who never give anything less than their best.


So, in career terms, I could not be further from where I thought I’d be ten years ago. But I also couldn’t be happier with the choices I’ve made. I don’t really know that there’s a lesson in that.

Someone once told me that the most important thing in career planning is to do what you enjoy and collect certificates along the way. Delayed gratification is rarely worth it in career terms: the gratification might never come. But its hard to ever regret doing something you enjoy, and collecting certificates provides tools to make a “leap” to something else when the first thing stops being fun.

I don’t know whether that’s good advice or not, but it roughly correlates with my experience over the last ten years. Let’s hope that I’m still enjoying things as much ten years hence – whatever I’m doing then!


The picture at the top is obviously my own. It was from my graduation which was, of course, a little later than the day I found out I’d passed.

This 2,450th post was filed under: Health, Posts delayed by 12 months, , , , .

Californian taxis, gun ownership and democracy

A couple of days ago, Wendy and I took a taxi from our hotel in San Diego to the airport, very kindly paid for by our hotel. The taxi driver was a chatty fellow and struck up the traditional “going to the airport” conversation beloved of taxi driver across the world.

Wendy mentioned that she was from Northern Ireland, which led to all the usual questions: Is that part of the UK? Is all of Ireland in the UK? Don’t the Northern Irish fight with the UK? Is Northern Ireland part of Brexit?


But then: What do people in the UK make of Trump?

Now, I thought we were on safe territory here. We were in California. Even I, as an uninformed Brit, knew California to be a true blue Democratic state. No Republican presidential candidate has won California this century.

Nevertheless, I played it safe with a politely non-committal response, suggesting that while Trump wasn’t personally very popular in the UK, Brits respected the outcome of the election, and the country is so interested in his impact that he’s rarely out of the British newspapers.

The taxi driver’s equal non-committal, “he’s surely shaking things up,” didn’t give any immediate indication of the transgression I’d made.


It was harder to remain neutral on his follow-up: “So what have you thought about guns while you’ve been here?”

Wendy’s eyes widened slightly as I admitted that I’d been slightly uncomfortable to see so many people with guns, from policemen on the streets to the border control officer who’d stamped our passport. This, I explained, was very different to the situation in the UK.

“But police are armed in the UK, right?”

I explained that a small number of officers carry weapons, and that there are armed rapid response units, but that the average police officer on the street carries nothing more threatening than a truncheon.


I’m afraid, dear reader, that this provoked a rant from our driver.

Firstly: “So that’s why you have so many terrorist attacks!”

Secondly, he asked whether I have heard of the campaigns in the UK for wider gun ownership. When I admitted ignorance, he blamed “the liberals that control your media”.

Thirdly, returning to California, he described his incredulity at the fact that he, both in his capacity as a private citizen and as a professional taxi driver, was not permitted to carry a concealed weapon. He told us how he was once, some years ago, robbed when getting out of his taxi. This would not, he suggested, have happened had he been carrying a concealed weapon.

Fourthly, he told us how Trump wants to allow anyone to carry a concealed weapon, and that this made him a great President. Our driver wasn’t sure that unrestricted concealed carrying of weapons would be allowed any time soon in California, because that state had “crazy laws” and a “corrupt Democratic governor”. He claimed that the Governor “hates guns and doesn’t want anyone to have them”.

Fifthly, he asks if we in the UK had ever heard of Crooked Hillary? “They call her that for a reason,” and one of the reasons is that she wanted to take away all the guns. Which would only lead to endless terrorist shootings like in the UK. He didn’t say that she should be locked up, but he might as well have done.

When I could get a word in edgeways, I pointed out that we had had no recent terrorist shootings in the UK. The driver said I was lying, that there was that arena attack in Manchester when all the kids were shot. I had no chance to point out that guns weren’t involved.

Sixthly, our driver told us that the many school shootings “around the world” were only being effectively tackled in the US, where upstanding citizens with guns shoot dead the shooters.

At this point, we pulled up outside Terminal 2 of Lindbergh Field and Wendy and I barrelled out of the taxi while thanking the driver excessively in a very British manner.

As he drove away, Wendy and I looked at one another and breathed. I think we were both in a sort of mild shock. The conversation made us reflect on how one can’t really have a sensible political conversation with someone whose factual frame of reference is so divorced from reality.

It made me reflect on the threat of “fake news” – a problem long before social media came along, but perhaps amplified by it. Continual exposure to counterfactual stories shifts one’s frame of reference, and make seemingly illogical conclusions entirely rational.

It made me reflect on how much more difficult political life must be these days: how can a politician ever thrive if their views are misrepresented even by their supporters and to their supporters? A politician cannot deliver on a promise they have never made, and cannot defend themselves against false accusations when every correction is percieved as a “cover-up”.

This conversation was something of an epiphany for me, helping me to see how broken this part of our society has become. In decades past, we lived in a world where the means of publication were (to all intents and purposes) controlled, and we could (by and large) distinguish fact from fiction. Today, anyone can publish anything, and few people have the will or means to verify any of it. We’ve moved from a world of limited reliable information to a world where every scrap of information is at our fingertips, but we can’t tell which morsels are fact and which are fiction. And yet, in a democracy, we rely on the population making that distinction accurately in order to make the right decisions for society.

I have no solutions to offer for any of this. In his book, Ryan Holiday suggests that subscription-based news is the answer, as it places value on truth over page views. The BBC likes to present itself as part of the answer. Tech companies sometimes suggest that the algorithmic triangulation of stories can play a role. People with minds more radical than mine might suggest that this is the time to find some other form of democracy than directly voting for a legislative representative.

I’ve no idea who is right. But in the course of one taxi journey, I’ve been convinced more than ever that an answer is urgently needed.


The taxi image at the top of this post is by Ad Meskens. It gives the slightly misleading impression that Wendy and I were travelling in a yellow cab, when in fact we were in more of van. The gun hoslter image in the middle of the post is by Takeshi Mano. Both images are used here under their Creative Commons licences.

This 2,448th post was filed under: News and Comment, Politics, Posts delayed by 12 months, Travel, , , , , .

Crossing the US-Mexico border

Yesterday, while Wendy was busy presenting at an international conference, I crossed the border from California to Tijuana to go exploring.

From San Diego, this was very straightforward. The Blue Line on the San Diego Trolley took me directly to San Ysidro, the district on the US side of the US-Mexico border. The Trolley stop is maybe 200 metres from the border crossing point, and there are helpful signs to put the way. There are also lots of slightly threatening signs from the US Government about covert monitoring.

There are, in fact, two pedestrian border crossings: one near the Trolley station, and one a short walk away by the Border Outlet Shopping Centre. I took the former (better sign-posted) option, walking up what felt a lot like a back alley behind a coach station to the border crossing point.

On entering through the slightly threatening no-return gates, I entered a border crossing, reminiscent of a typical airport border point. There was a very long queue for people with Mexican passports, but nobody in the queue for people who, like me, had foreign passports. This phased me a bit: I knew from my prior research that I needed to fill in an immigration card, but could see neither a card nor anywhere to fill it in. In the end, I just approached one of the border agents’ desks, where a friendly officer told me not to worry, it was quiet, and I may as well fill it out at her desk, which I did while she checked my passport.

We made small talk about this being my first time in Mexico (she was amazed), her previous experiences of visiting London and the sights of San Diego I’d seen so far. Before long, she’d stamped my paperwork and sent me on my way. After this point, customs x-ray searched any large luggage, but as I had none I was straight back outside and in a new country.

From here, it’s typically a 20-minute walk to the touristy area around Avenida Revolución, but I went a bit wrong, crossing over a highway on the footpath of a road bridge rather than the more direct pedestrian bridge, so it took me about half an hour. This walk is not through a particularly attractive area. I was pestered frequently by disabled and often elderly beggars, street sellers, and taxis pulling up alongside me to offer me lifts. Looking down on the vehicular border crossing, I could see stall upon stall with sellers plying their trade to people waiting in the long, seemingly stationary queue for the US border.

I walked through expanses of largely deserted civic architecture with broken fountains and such surrounded by closed up shop units. It was a bit eerie. I’m not sure whether this is attributable to me visiting on a Sunday or to the significant downturn in the Mexican economy in the decades since Tijuana was a real draw for tourists.

Here and there along the way, there were small stores and restaurants whose seemingly desperate owners practically begged me to come in and look at their wares, often offering free alcohol as an enticement. I’m afraid I declined.

My own idiocy in taking the wrong bridge notwithstanding, it was actually quite easy to navigate to Avenida Revolución thanks to the visible-from-everywhere Tijuana arch, which stands right in the centre. Rather disappointingly, the sign in the middle seems to have changed from the famous ‘Bienvenidos a Tijuana’ on a Mexican flag background to something “modern” sponsored by Samsung.

The area around Avenida Revolución was lively in every sense, with performers drawing large crowds, street vendors enthusiastically shouting about their products, and bars and restaurants making keen efforts to attract the passing traffic. The famed decorations around Santiago Argüello lent a party atmosphere to the whole area.

And yet, I found it hard to forget the scenes of deprivation and desperation I’d walked through to get to this point, not least as I knew I was going to have to walk back the same way before too long. This left me feeling a little melancholic. Nevertheless, I had a good wander around, aimlessly soaking in the atmosphere rather than rushing into any of the frequently advertised tourist attractions.

I got far less lost on the way back thanks to very frequent signage to the US border. I crossed back over at the other of the two border crossings I mentioned.

There could hardly have been a more marked difference between the manner of the crossing in the two directions. As soon as one stepped through the gates to the US border crossing complex, frequent stern signs forbade the use of mobile phones and cameras. Crossing back into the USA involved a walk through a labyrinthine concrete corridor ending with an almost whimsical spiral concrete ramp to even reach the border crossing point. I had to queue for a little over an hour to meet the US border agent, who questioned my intentions in crossing the border in some detail. He also seemed a little confused by the fact that my passport was for both the United Kingdom and Northern Ireland, which hardly inspired confidence, but he did eventually let me through.

The fact that the US-Mexico border is the first controlled land border I’ve ever crossed probably says more about the remarkably peaceful times in which I’ve lived that it does about me personally. At the time I crossed the Denmark-Sweden border it was technically manned, but this just involved someone passing through my train cursorily glancing at passports. Some pundits currently predict something similar will be in existence between Northern Ireland and the Republic by the time this is published: I think that’s nonsense, but that’s perhaps a post for another time.

At the moment, I’m part-way through Rutger Bregman’s Utopia for Realists. In this book, which argues for a borderless world, the US-Mexico border is cited specifically as one which inflicts economic harm on people on both sides. I found the apparent difference in living standards quite shocking: it seems mildly crazy that people living in two developed countries and so physically close to one another can have such different life experiences and prospects.

There has been much written over the last few months about the level of poverty in California, despite its reputation as a liberal state. Wendy and I have both been quite surprised to see the seemingly high number of homeless people in San Diego. Crossing the border, I felt as though there was a far greater degree of profound poverty in Tijuana, but perhaps California’s poverty is just better hidden than Tijuana’s. Appearances can, after all, be deceiving.

I’m glad I took the time to visit Tijuana while I’m over here in California. The experience wasn’t at all what I had expected: rather than a tacky pastiche Mexico “mini theme park” which I had thought would exist on the other side, the reality has left me more pensive and reflective than I would have expected. And that’s no bad thing.


Fairly obviously, all of the photos in this post are my own.

This 2,446th post was filed under: News and Comment, Posts delayed by 12 months, Travel, , , , , , .

When public health measures pass me by

In this morning’s Monocle Minute, there was a fascinating bit about a public health measure in Pakistan which had completely passed me by:

Pakistan’s Punjab province has taken an intriguing step to discourage its citizens from chugging too many cans, demanding that brands such as Red Bull and Monster remove the word “energy” from their packaging and replace it with “stimulant”. The move comes from the scientific advisory panel of the Punjab Food Authority (PFA), who ruled that the word was misleading. The PFA decided that the drinks do not provide people with nutritional energy per se, rather that the caffeine, taurine and guarana merely stimulate drinkers.

I think there is much to be done around the regulation of food packaging, as it often seems pretty misleading. But most of what I’d thought about previously was around claims about the “healthiness” of foods and claims about calorific content. In fact, I’ve had previous publications ranting about both the food industry and the public health response on the latter point, but don’t have any clear answers of my own to offer. I’d never really thought about the connotations of “energy” drinks as a name, so I think the story above is a really interesting development and I’ll be intrigued to see whether it spreads more widely.


Sometimes, even those of us in public health miss public health developments in our own country. I only recently because aware of the fact that liquid laundry detergent capsules are now packaged in opaque containers not because of changing consumer preferences but because of very sensible European legislation, designed to reduce their attractiveness to children.

That’s a public health legislative win by anyone’s yardstick… and while most had realised the packaging had changed, no-one in my office was even aware that the legislation existed. It’s amazing how much public health measures can pass by even those of us working in the field – we perhaps don’t do enough to celebrate public health achievements that aren’t badged like that.


A year or so ago, my friend James O’Malley wrote a great article revealing that Fuller’s pubs had gone sugar-free on soft drinks – years before the Soft Drink Levy came into force. This was a voluntary public health measure by a private business. Wouldn’t it have been great if, say, Public Health England or the Faculty of Public Health had seized on this as an example of responsible action and praised the chain – rather than simply ignoring it? Just a thought.


The photo at the top is a cropped version of this photo posted to Flickr by Mike Mozart. I’ve edited and re-used it above under its Creative Commons licence.

This 2,442nd post was filed under: Health, News and Comment, Posts delayed by 12 months, , , .

‘Inappropriate’ A&E attendances

A couple of years ago, I wrote a post for the Fuse Open Science Blog about the system failures which lead to patients ‘inappropriately’ presenting at A&E, and how this is often blamed on patients who are expected to self-triage with a high degree of accuracy. I’ve thought of this today because it popped up in my Facebook ‘memories’.

This has prompted a couple of completely disconnected thoughts.


My first thought is that what I wrote then remains true today, and has become even more relevant with ever-increasing pressure on NHS Trusts. Effective triage of patients to the ‘correct’ NHS services is a nut that remains stubbornly uncracked.

More money has been ploughed into putting GPs in A&E departments, despite mixed evidence on cost and patient throughput. Some companies are experimenting with triage chatbots for the NHS which feels to me like an unlikely solution to the problem of sorting acutely unwell patients. The NHS Choose Well campaign keeps steaming ahead at various levels of the NHS as though doing more of the same will result in a completely different outcome.

Anecdotally, clinical colleagues tell me that last winter was ‘better’ than others in recent years, in as much as A&Es were over-filled with patients who should be there rather than patients who shouldn’t be there. Of course, that means departments are more pressured. Perhaps the fear of long waits and ‘chaos’ puts off ‘inappropriate’ attendees. I’m certain that it puts off some ‘appropriate’ attendees and that this will, at least in a very small way, have contributed to excess winter deaths for 2017/18.


My second—unrelated—thought is that I have absolutely no memory of writing or publishing that Fuse article. I mean, I know I wrote it, but I have no memory of constructing it, or of looking up the stuff about Joseph Hodgson and drawing a parallel between misuse of historical charitable hospitals and the modern NHS.

I’m always bad at remembering things I’ve worked on in the past, but to have such a complete absence of any memory for something I wrote (and clearly put thought into) only 24 months ago is remarkable even for me.

I can only assume I was knackered when I wrote it… which would also explain the slightly crap call-back pun in the last line. I can see what I was trying to do, but reading it now, I think it slightly missed the mark.


The picture at the top is a cropped and edited version of a photo published on Flickr by gwire. I’m using it under its Creative Commons licence.

This 2,433rd post was filed under: Health, News and Comment, Posts delayed by 12 months, , , , , , , .

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