Look at what they make you give

Ed – We received this post just as the extent of the Coronavirus pandemic was becoming clear and thought it best to delay publishing until life in our Emergency Departments was slightly more “normal”. The author has asked to remain anonymous (not something we often do at St Emlyns), but once you’ve read it I am sure you’ll understand why. We are really grateful to the author for sending this to us and hope you take as much from it as we have. BW Simon.


There’s a scene in the first Bourne movie that’s been on my mind a lot recently. Jason, our amnesiac hero, is holed up in a French farmhouse on the run from the Police when he becomes aware that there is someone in the field hunting him. Using innate cunning (and the landing pattern of some birds) he works out the location of the assassin, soon has him in his sights and before long scrabbling in the dirt.

Jason, still completely unaware of his own identity, interrogates his hunter:


JASON BOURNE (Matt Damon): Who else is out here? How many have you got with you?

THE PROFESSOR (Clive Owen): I work alone, like you. We always work alone…… Do you get the headaches? I get such bad headaches. You know at night when you drive the car?…

Look at this. Look at what they make you give...


I am writing this blog post as a cautionary tale in the hope that those who read it might make different choices to those I’ve made, or at least consider them very carefully.

A few years ago I was made the Clinical Director of the Emergency Department (ED) where I work. In many ways it was my “turn”, but it was also a job I’d looked forward to and wanted to do well. All my predecessors seemed not to have really enjoyed it, but I thought I would be different. Not only that, I could make a difference.

At first the extra management time felt like a gift. A relief from the daily grind of shifts on the shopfloor. A chance to reflect, think and plan. A chance to make things better. The initial few months seemed to go well. After all, what could people expect? I’d only been in the job a short while – change takes time!

I committed myself wholeheartedly to the task. Knowing that “extra” non clinical time is seen as a luxury I made sure I was always at my desk. No days off for me anymore. My colleagues would pass by my office door on their way on and off the shopfloor and I would quietly sigh to myself – if only they had my dedication, maybe we could get something done. I would stay late, not that anyone would notice, but there was a chance they might. Moreover, if I wasn’t there and they wanted me, what would they think? Emails were answered immediately, whatever time of day or night they were received, and my phone never left my side.

The first winter was tough, but manageable. I’d always felt responsible for the department’s performance even before I was the CD so I just kept working at my usual clinical pace. I’d always thought “the target” a valuable aid to engaging others and, to be frank, getting money and attention from the Exec, as well as an admirable aspiration for our patients. Who wants to be on a trolley for hours? I did feel a little more pressure – how could I sit in meetings “defending” the ED if I wasn’t the most epic EPIC (Emergency Physician in Charge).

I’d recently separated from my spouse so evenings were generally spent either on my own or with my children. I wasn’t able to recognise it at the time, but I was gradually getting more and more physically and psychologically exhausted. I’d give everything at work, then everything to the children and there wasn’t much left for me. But hey, it didn’t matter – I was doing work that mattered. My time as Clinical Director would go down in history.

The pressure seemed to increase as the management wanted more and more from the consultant team. Anything that could “fix” our performance. I saw it as my role to protect my colleagues and I took everything the managers could throw at us, absorbed it and passed on only a fraction. It wouldn’t help them to know. And let’s not forget – I’m the lucky one with all the non clinical time – I needed to sort it out. Dave Brailsford at Sky Cycling has promoted the much quoted value of 1% marginal gains. Utter nonsense, it would be much better for me to give 100%. Then things will really get done.

The role as an ED Clinical Director is a curious one. You’re both the shop steward and line manager, serving two masters whose needs aren’t always the same. You need the trust and respect of both, although many would argue the former is much more important than the latter, the truth is without the ear of those who hold the purse strings you can’t get much done. There is a daily report of your performance, often on the front page of a newspaper or website and millions of pounds of extra funding can be at stake.

I kept going as best I could. Job planning, performance meetings, CEO briefings all become part of my routine, with regular “have you got a minute” impromptu requests on top. Alongside this I tried to maintain my energy on the shopfloor – always having to be the best of the best. Evenings were spent with a bowl of pasta, a large glass of wine (or three) and the television. I’d no energy for anything else.

Friends were kind, but there weren’t many social invites and, the truth is, even if there were I would’ve politely declined. The job (and my children) were more important than all of that. An opportunity for an intimate and important relationship was ruined as my partner at the time became frustrated at my inability to think beyond the next day or to make any sort of effort to be with them. I really liked them, but was struggling, just trying to keep my head above water. I hoped they’d understand but hadn’t got the energy to explain.

Last winter was harder. Much harder, Every day the corridors were full of patients. The daily “SitRep” worsened and we slipped further and further down the “league table” published by NHSI (yes – this is a thing! A daily league table). The calls from the Exec became more desperate. Something had to be done.

My clinical shifts become longer and more tiring than I’d ever known. I took our performance incredibly personally and every moment on the shopfloor was spent trying to “fix it”. I took more risks than I was used to – do the most good for the most people I thought. If I can’t get some of these patients out I won’t have space to see the others. Mostly I got away with it, but once I didn’t.

I knew as I discharged the elderly woman who’d fallen that she wasn’t right, but hey, she’d probably be ok wouldn’t she? And there are another 30 people waiting. It was all too telling that it was a huge relief when a senior nurse gently told me that the patient wasn’t well enough to go home. She was transferred to majors and a CT revealed a significant injury that required high dependency care. She didn’t come to harm, but had come very close. Afterwards, I was shaken and cross, and disappointed at myself but did all the things that I knew you were supposed to do (it was important I set an example) – I filled in a Datix about myself and informed the Governance lead. Colleagues were supportive – “don’t worry, it could happen to any of us”.  Yes, but it didn’t happen to you, did it?

I’ve always tried to keep the “target pressure” to myself on the shopfloor, but its relentless nature meant my previously inscrutable facade was slipping. On a few occasions I snapped at senior colleagues, and immediately apologised. I thought they would understand and forgive me. After all, I am the Clinical Director, they know the pressure I’m under. Don’t they?

As winter passed (meteorologically if not metaphorically) and the pressure eased a little I knew things hadn’t been going well. I had an appraisal with a trusted colleague and cannot describe the relief when he said he would talk to the Divisional Director on my behalf. He told me to drop a session and to make more time for myself and for a short time I thought I was on the mend. A few small changes and I could still be The Best Clinical Director Ever.

Life went on. The demands the same. I noticed the weight I’d put on and resolved to get fitter with my diet of carbohydrate, chocolate and wine. Vague memories of podcasts past surfaced and I thought about making a well being plan, although smiled knowing it would be tricky to fit it in what with work and the children…..

Then the bombshell.

I was called to a meeting with the Divisional Director. People were worried about me and my welfare, he said. Something needed to be done, he said. He’d asked senior colleagues for a statement about their concerns, which they had duly produced. But remember, he reiterated more than once, this all comes from a good place where they are worried about you. A referral to Occupational Health was agreed and a suggestion of extra support offered. As I sat there I was grateful that someone was worried, although not really sure how this would help. No one can do the job the way I do.

Our meeting finished and he handed me The Folder. “It’s only fair you see it” he told me as we parted company.

As I opened The Folder, sitting alone in my car, I was rather surprised to find four pages of closely typed prose. The first paragraph made some reference to my welfare, then the rest detailed all the reasons why my colleagues felt I was a risk to the department’s reputation, that my behaviour was poor and most upsettingly I was a risk to patient safety. It matters not that many of the statements were either untrue or taken out of context, all I could see was a witch hunt, or the justification that if I did ever do anything to harm others (or myself) at least my concerned colleagues could say they had done something. It didn’t read it so much as a concern for me as a dossier compiled to destroy me. There was no mention of anything positive I’d achieved at all. I could barely remember how to start the car and have no recollection whatsoever of that drive home.

My whole belief structure was destroyed. Didn’t they understand what I had given up for them? Time with my children and a genuine chance of love. What was the point of it all? God, I’d been so stupid. How could I not have seen it? I’m no different to the others. I’m not special. I’m just another medic with the dubious honour that is the “development opportunity” to be Clinical Director. Three years of my life that I will never get back. Lost friendships. Lost opportunities. I was lost.

The truth is the ED will keep going whether I am there or not, my tenure as CD will soon be forgotten, those to whom I seemed so important and necessary will now pass me in the corridor without so much as a smile and my once valued opinion will no longer be sought.

My rehabilitation is only just starting and may take some time. I have a few friends at work who I trust but will no longer assume anyone else’s loyalty. I took some time away from work (well, a combination of colleagues and my GP told me I needed time off) and disconnected my phone from work email. Suddenly, I realised that everything a few people had tried to gently tell me in preceding months was vividly true. There is more to life.

All we can each do is our best, but that includes doing the best for ourselves too. I’ve reached out to lost friends (and for those of you fond of romance I’ve reached out to my lost love too). But the road back will not be straightforward, whilst trying my hardest to help those at work who I felt needed me, I had completely neglected those things and people that made me happy. I didn’t feel I was allowed to have things for me. I thought my purpose was higher than that. I was wrong.

I’m telling this tale in the hope it may reach anyone out there who might be like me. As medics we are chronic high achievers and want to be the best. All I ask is that you think about what it means to “Be The Best”.

I now know that I need to be the best for me, a prospective partner, my children, my friends, and then ultimately my work will get the best of me too. In case of emergency you need to put the oxygen mask on yourself first before you can help others.

Thankfully, I don’t feel that I am drowning anymore. I’m quietly sitting in a life raft working out how I can learn to surf.



Cite this article as: Simon Carley, "Look at what they make you give," in St.Emlyn's, August 12, 2020, https://www.stemlynsblog.org/look-at-what-they-make-you-give/.

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Posted by Simon Carley

Professor Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester

  1. Wow. Extremely powerful stuff and something I think many Clinical Leads/CDs will relate to. Very glad to hear you are on the mend, and totally agree with your new priorities. If I’m being honest, I think the CD role is an impossible task.

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  2. Dr. Noorul Aboobucker August 13, 2020 at 1:05 am

    Thank you for this powerful message. I feel angry and sad you had to go through that! Very glad you’re on the ’mend’ and that you reached out to a potential other half. God bless and a big hug. Ever since I was a child I have wanted to do something that made a difference but I’ve also always been conscious of what I call the tendency of everything around us to create a ‘hamster in a wheel’ phenomenon. I have accordingly taken care to not become that and consequently find myself happier in ED.

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  3. A profoundly moving article. It is sad the price that medicine often exacts upon Doctors. I hope you are well on the way to recovery and I wish you all the very best. Thank you for such a profound article.

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    1. A moving article: Thank you. My view ( for what it is worth) is that the experiences relayed in the article reflect a system which is fundamentally flawed and has been for decades. With regard to the Emergency Department, senior NHS management appears to judge us and our performance solely by means of the 4 hour target. This unreliable metric still weighs too heavily in senior NHS management thinking : no matter how much we may point out how flawed that might me. NHS middle management ( who often have to spend 6 months or so managing an ED) will often find their career progression dependent on success ( or failure) of this figure. Clinical Directors also find themselves judged by those above them solely on the basis of this figure.
      Surely what is required is a detoxification of this figure, with ED departments and their performance judged on a much wider and fairer range of clinically based metrics (e.g. time to fascia Illiaca block in #NOF, time to PCI in STEMI, etc) But hold on , wasn’t this tried meant years ago?? Time for a revisit me thinks 🤔?

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  4. This is a profoundly moving piece and a lot of the author’s frustrations are echoed in Senior EM Colleagues across the country. It’s so sad that no one recognises the sacrifices but they’re quick to jump on the shortfalls. It’s so sad that no one accepts the humanity of Doctors and the ‘all-too-quick’ reply is ‘well… you chose the profession and God knows you’re paid well enough…’. Sincerely wish the author the very best and thank you for being a voice.

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  5. Thank you for your honesty!! So glad you helping you and feeling better for you. I’m realising more and more that medics need to be kinder to themselves.

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  6. Thank you for this post and your honesty. It can’t have been easy to write. Although I am the most junior A&E bod ever there is still a lot for me to take from this post. Loving the job and being wanting to do the best for our patients and support our colleagues drives us to give so much of ourselves. I can relate to being called in before seniors who are concerned about me. Somehow, it’s easy to make ourselves the exception. We watch others who are doing to much and it’s obvious. We tell them to stop, take a break and how work isn’t the most important thing in life and how they need to take care of themselves. It’s not always so easy with ourselves. I will try and remember this important quote:

    ‘The truth is the ED will keep going whether I am there or not.’

    And this one:

    ‘All we can each do is our best, but that includes doing the best for ourselves too.‘

    It’s certainly the part I always forget.

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  7. I was also the clinical lead of an ED for three years. I recognise pretty much everything you describe, particularly the thankless nature of it. I stepped down, then reduced my hours and finally quit as the enthusiasm I once had for the specialty could not be regained. I still feel I have let ‘everyone’ down by resigning but at the same time feel a massive weight lifted off my shoulders.

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  8. Why is anyone surprised when good clinicians fail at management? Send a manager out to be a clinician without support and specific training/ education and see how that goes…

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Thanks so much for following. Viva la #FOAMed


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