Impossible times

During the COVID-19 pandemic health-care workers have often found themselves in the media spotlight. The pandemic has been framed as a war, and health-care workers have been labelled as soldiers on the front line. But using a wartime narrative to depict the pandemic is dangerous “None of you think you are soldiers, dodging spinning bullets shaped like pretty viral crowns”, asserts Roopa Farooki in her book Everything is True: A Junior Doctor's Story of Life, Death and Grief in a Time of Pandemic. Farooki writes with candid intimacy and eloquence about her experiences working as a newly qualified doctor in the UK's National Health Service (NHS) at the beginning of the pandemic.

Farooki describes an unsettling atmosphere of chaos and frustration in the hospital. Patients were too scared to go to hospital because of what they had seen on the news. Those who did seek care in the hospital encountered inadequate resources, miscommunication, and unclear, ever-changing guidance. Beds in intensive care units and personal protective equipment were in short supply, doctors were being forced to make impossible decisions, rotas were changed to unsociable, long hours, and training was suspended. Despite the public clapping for “NHS heroes”, and politicians claiming to provide unprecedented support to the NHS, “You feel nothing. Just numb,” writes Farooki. The experience Farooki describes was similar to my own, working as a doctor at another UK hospital.

Doctors, and all other health-care workers, have experienced great societal pressure and personal risk during the pandemic, with little attention to the protection of our rights. Health professionals have an absolute obligation to patients, but what about the duty of employers to protect health-care workers? And what happens when there is a conflict between our duty to care for patients and the duty to protect our own health and our family's health? In the UK, the General Medical Council defaults to doctors using their professional judgement in difficult circumstances and acknowledges that doctors might be required to work beyond the limits of their comfort zone. Farooki's Everything is True highlights the personal toll of the pandemic for doctors, and it is an important reminder that overstretching health-care workers and ignoring their wellbeing is ultimately detrimental to patients. Health professionals can choose to leave the NHS, patients are not afforded the same option.

Everything is True is also a meditation on grief. Farooki reflects frequently on her close, yet competitive, relationship with her sister who died of breast cancer in the months before the pandemic. The loss seems to contribute to Farooki feeling overwhelmed and isolated: “You’re constantly on edge. You can’t physically sit down, unless you collapse to sleep. It weirds out your colleagues.” Home is not a retreat since there is tension with her husband, who is fearful of her job. “Not all lepers have spots. Some wear scrubs in A&E. You’re like Marie Curie playing with her radium”, writes Farooki.

Patient safety depends on doctors’ wellbeing. Studies have shown that burnout increases the risks of making a major medical error. Yet there are still considerable barriers to seeking help within the profession, particularly in relation to mental illness, disabilities, and long-term conditions. Farooki comes into the hospital the day after her sister's funeral, but thankfully is sent home. The attitudes Farooki relates about physician sickness and wellbeing are saddeningly familiar to me. “You’re never ill, and you have always had an old-school sneaking suspicion that people who take sick days are frauds”, she writes. Yet it is not a weakness or a failure to become sick. Sickness presenteeism can compromise patient safety. One study suggests that trainees in particular were more likely to be motivated to work when sick to avoid appearing lazy or weak. Why are health professionals disinclined to follow the advice that we would presumably give to our patients?

A deep sense of uncertainty pervades the ending of Everything is True. COVID-19 cases and deaths were still rising rapidly and no vaccine was yet available. Farooki describes how “Death and deterioration has been impossibly normalised. You’re living in impossible times.” Today, as the COVID-19 pandemic continues to evolve, impossible times seem far from over. Equitable access to COVID-19 diagnostics, treatments, and vaccines does not yet exist in many parts of the world. In the UK, despite a successful COVID-19 vaccination programme, the backlog of work in the NHS is immense. The number of people on surgical waiting lists in England is more than 6 million and the staffing crisis has deepened. To face this crisis and achieve good outcomes for patients, unacceptable workplace practices must be challenged and meaningful, institutional change is needed to support the wellbeing of both patients and the health workforce.