So what happened to me in 2015 that made me stop blogging? I promised in my last post that I would tell you and I’m going to now, because I think it might be important for you to know about.
In September 2015 I made this video, introducing myself and talking enthusiastically about the fact that I had been accepted to do a Special Interest Training Module (SPIN) in Gastroenterology, Hepatology and Nutrition (GHN).
Two months later, in November 2015 I resigned. I’m still trying to understand how that happened.
At the time I was an ST6 trainee in Paediatrics and Child Health. That means I was six years into an eight-year training scheme to become a paediatric consultant in the NHS. Although, because I was working part-time, I actually had five years to go before I would have finished. And because I had taken some time out, first to do a masters degree and then to have babies, overall I’d been a trainee for thirteen years already (i.e. since 2002). My girls had just turned five.
I started my post in gastroenterology in March 2015 for one year, and because I had to give a three-month notice period, I left in February 2016. Initially I had hoped to apply for higher specialist training in GHN, but I was then told that because I had spent six months in a respiratory post at the start of my ST6 year I was not eligible. The SPIN was second-best really, although I tried to be enthusiastic about it.
But in any case it rapidly became clear to me that being a plant-based paediatric gastroenterologist might turn out to be not only a difficult path to navigate, but actually a completely impossible one. It became increasingly clear to me that some of the things I believe are fundamentally incompatible with the practice of gastroenterology in its current form in this country. I simply couldn’t reconcile my conscience with what I was being asked to do.
I probably need to be very clear and specific about this, so that nobody starts making any assumptions about what I might be meaning here.
Our ward rounds were often very long. It was a busy department and they often lasted well into the afternoon. At lunchtime the wards would fill with the smell of chicken nuggets and chips: maybe fish fingers or baked beans. Trays of nutritionally void beige food would be put in front of our patients while we were talking to them, and their beds would often be covered with crisp packets and chocolate bars too.
For our inflammatory bowel disease patients, the departmental position was clear: there was no evidence that diet impacts on the onset or natural history of the disease. It was not discussed at all.
One young patient with stricturing crohn’s disease who was facing surgical resection was told by one of our dieticians that it didn’t matter what (s)he ate: cake or McDonalds were equally fine as long as (s)he got enough calories.
One day I was asked by one of the consultants to prescribe a powerful anti-inflammatory drug that he had decided on the ward round to start. It was his clinical decision but my name was on the prescription. This is a very common scenario in medicine: junior doctors doing the actual prescribing of drugs they themselves have little experience of on behalf of someone more senior. It shouldn’t happen actually, but it happens everywhere all the time.
It turned out that it shouldn’t have been prescribed to that child, who went on to develop a serious side-effect that was predictable because (s)he had suffered the same side-effect from a related drug before.
It wasn’t my fault but I felt responsible. I apologised profusely to the child’s mother and we both cried while (s)he slept. The child got better but I was left wounded.
That was when I sat down and really read about the fairly horrendous side-effect profiles of the drugs we were using as standard first line treatment. We weren’t consenting families for these drugs. It is a very paternalistic medical system that says “the doctor knows what is good for you” (I’m quoting Dr Ranj from CBeebies here because children have this drummed into them very early). We weren’t telling people the risk profile, because the view was that there was no other option, but I didn’t believe that.
The thing is, when your back is against the wall you will try anything. When you have nowhere else to go it is time to take these drugs. So I’m not saying never – they have their place – but I wouldn’t give them to my children until all the other ducks were in a row, and they were still not getting better. I just couldn’t square their routine prescription with the ubiquitous chicken nuggets and chips. And you can change diet overnight: this isn’t something that needs to take years.
Then a mother of a child with some kind of as yet unspecified inflammatory bowel disease asked me what I thought about diet. She was having the same kinds of thoughts that I was, as it turned out. That prompted me to go away and do some research: to turn what had hitherto been just a vague sense of discomfort into hard science.
Only the science in the field wasn’t very hard yet. There had been a few small studies: none terribly well designed or convincing. Overall they began to point in the direction of a role for diet in mediation of the disease process, even if not for its actual causation. What that means is that the thing that triggers inflammatory bowel disease might not be diet, but your nutritional status may very well have a significant impact on disease course and progression: it might, for example, be the difference between having half your colon removed or not.
Really all I could say to the mother who had asked me was that there were other people who were interested in the question, and that some studies had started to be done but they were not conclusive. Different dietary patterns were being discussed, so it wasn’t possible to be definitive about which was the best, but probably it wasn’t chicken nuggets and chips, cake or McDonalds.
In the end I compiled a 35-page report detailing the results of my findings, and I offered to present these locally to the department. To be fair, one consultant in the team did express a vague (though not very enthusiastic) interest in this, but by that stage I had already decided to leave, so it never happened. I did write it up here though, so you can read that if you are interested.
It’s probably also fair to note here that the department was enormously overworked. Many of my colleagues routinely stayed until 8 o’clock at night to finish the day’s jobs (when their shifts ended at five), and I couldn’t do that because I had five-year-old twins I had to collect from childcare at six.
All of these events fed in, but it was also the case that from the point at which I had children, working a shift rota with nights and long days and no regularity became incredibly difficult. I am not the only female doctor with young children to leave the training scheme in our region, which does rather suggest to me that there might be a problem here, particularly when you consider the facts that half of paediatric trainees are female, the youngest you can become a paediatric consultant if you run straight through from medical school without any breaks or diversions is about 33 years, most paediatricians like children and want to have their own, and female fertility begins to decline precipitously after the age of 35. Almost all female paediatricians who have babies have them during their training years.
Relentless night shifts take their toll, and my daughters didn’t start sleeping through the night properly until they were about four years old. I was totally exhausted, and not at all impressed to be told that I was not pulling my weight because I couldn’t stay back late every day to work extra, unpaid hours.
Interestingly, I recently came across this article, which was written in October 2015, highlighting 12% of rota gaps in paediatrics at the time. The stats are interesting in this context, but I don’t agree with the sentiment that maternity and paternity leave can and should be shared equally. That only works if you formula feed, and as paediatricians we should not be promoting formula feeding: we should be setting an example by doing what we are asking all mothers to do.
When there is a “practice, policy or rule which applies to everyone in the same way, but it has a worse effect on some people that others”, putting them at a particular disadvantage, this is called indirect discrimination. Enforcing an eight-year training scheme comprising entirely of shift work on men and women equally is arguably such a policy.
Also arguably, having to go every week to the gastroenterology Monday morning meeting, where everybody would bring cakes and doughnuts and other things I couldn’t eat to share, and nobody ever thought to bring anything I could eat for almost a whole year, could be classified as another form of indirect discrimination. It wasn’t direct, in that nobody said anything nasty to my face, but it did make the point that I was not welcome in their tribe.
But at that time I didn’t know about indirect discrimination, or the serious effect it can have on people: how it can wear you down. I hadn’t heard of the International Vegan Rights Alliance (IVRA) either, and I thought I was the only vegan doctor in the country.
And then, in December 2015, I did a multi-source feedback exercise (also known as a 360). I had already decided to leave by then, but as this is something all doctors have to do these days I went along with the process.
This exercise involves asking 15 or so colleagues to complete a form commenting on your practice anonymously. Nobody has to be accountable for what they say, and if they do not explain themselves at the time there is no potential for clarification. This practice is a breeding ground for covert discrimination, but it is big business right now despite the critics.
Anyway let’s just say this brought it all out of the woodwork. It was helpful to see in black and white what I already knew people were thinking. But looking back, if I had recognised what was happening earlier, perhaps I could have fought harder?
I don’t know. At the time I was completely alone, and hindsight is a beautiful thing: especially when armed with this recent paper by Arie Levine et al. Thank you to Dr Alan Desmond, a plant-based consultant gastroenterologist based in Devon, for furnishing me with this recently.
On the 30th June 2018 Dr Desmond gave this talk at the Plant-based Health Professionals UK conference in Glasgow entitled ‘Treating Inflammatory Bowel Disease With Dietary Intervention’. Watching this talk was healing for me, as has been my recent discovery of Plant-based Health Professionals UK, and your related Facebook group ‘Vegan Doctors of the UK’, which currently has 162 members. I am writing this with you in mind, although I am aware that other people may read it too.
So what I want to say here to the vegan (or plant-based, if you prefer) doctors of the UK, is that we are still pioneers, all 162 of us, and forces that will oppose us are out there and they are strong. Sometimes they will come in the form of big corporations: sometimes they will be our parents, our partners, our colleagues and our friends. Sometimes the opposition will be obvious, and sometimes it will be more covert. We will need to work together and to support each other: there is plenty of work to be done. And we will each need to decide how much and when we can give, and when we can’t: when we can take the lead, and when we need to step back and look after ourselves, and our families.
I am a practicing Buddhist, and in the Buddhist canon there is a concept called the Three Obstacles and Four Devils. It goes something like this:
“There is definitely something extraordinary in the ebb and flow of the tide, the rising and setting of the moon, and the way in which summer, autumn, winter, and spring give way to each other. Something uncommon also occurs when an ordinary person attains Buddhahood. At such a time, the three obstacles and four devils will invariably appear, and the wise will rejoice while the foolish will retreat”.
[The Three Obstacles and Four Devils: Writings of Nichiren Daishonin Volume 1, p636-640]
What does it mean “the wise will rejoice” in response to the appearance of obstacles to our practice? I have always understood this to mean that when we try to do good in the world we will inevitably face opposition. We should welcome this because it tells us we are trying (and perhaps succeeding) to do some good in the world. The alternative is inertia: doing nothing. By doing nothing we will avoid obstacles but we will also change nothing.
And the harder we try the bigger the obstacles we face. If we take on Goliath we will get correspondingly gigantean obstacles. Don’t be put off by this, but also, don’t be surprised when they happen: they tell
us we are on the right track.
I have been told that in my NHS job I must only give standard NHS dietary advice. I have been told that I must not impose my dangerous views on vulnerable patients. The only answer to this is evidence: it is pulling the evidence together in a coherent, intelligent way. This is a big job. It is good work in the world. It is a great mission for many people working together.
I’m going to finish with a poem, because I like poetry and because it seems appropriate. I wrote this for someone who took on Goliath in the NHS, and tried to do something different in the face of huge opposition:
Three Obstacles, Four Devils
I didn’t know how to say this,
so I didn’t say it:
how the hurdles get higher the higher you’re able to jump.
How the faster you are
the harder the races you enter
(or are entered for – or do we do this to ourselves?)
So what I’m trying to say is
you would not have taken it on were you not
strong enough to withstand the fall.
This does not apply to racehorses
in the Grand National, who have no choice,
so when they fall and break their necks
the camera pans away quickly
to avoid upsetting the punters
(thousands gather to place their bets
on who will cross the finish line first, but not
on whose vertebrae will concertina into themselves
or who will take a bullet to the head).
But you: you will keep that round black lens
focused on what is broken,
and you will do this because you are
a woman with a mission, who understands
that for each positive action there is
an equal and opposite reaction,
and for every good intention there’s a devil
(when you see him you know you’re on the right track)
crawling out from under the starlight.