Notes from a GP

Tag: health

  • The truth about weight loss is it’s not really about weight

    The truth about weight loss is it’s not really about weight

    The Truth About Weight Loss Is It’s Not Really About Weight

    Weight loss is one of the most common topics discussed in healthcare and one of the most misunderstood.

    Most advice revolves around calories. Eat less. Move more. Count everything.

    Whilst energy balance clearly matters, I have increasingly come to believe that focusing solely on calories misses the bigger picture. If weight loss were simply a mathematical equation, far fewer people would struggle with it.

    The reality is that weight management is influenced by hormones, inflammation, sleep, stress, muscle mass, food quality and metabolic health. Understanding these factors helps explain why some approaches succeed whilst others fail.

    Perhaps the biggest misconception is that all body fat is the same.

    It is not.

    The Fat We Should Be Talking About

    Most people judge their health by looking in the mirror or stepping on the scales. Yet the fat that concerns me most is often the fat we cannot see.

    Visceral fat accumulates deep within the abdomen around the internal organs. Unlike the fat stored beneath the skin, visceral fat is metabolically active. It releases inflammatory chemicals and hormones that contribute to insulin resistance, type 2 diabetes, cardiovascular disease, fatty liver disease and a state of chronic inflammation.

    In many ways it behaves less like a passive energy store and more like an active organ.

    Visceral fat is also considered a form of ectopic fat, meaning fat that is being stored where it was never intended to be stored. Similar fat deposits can occur within the liver, pancreas, skeletal muscle and around the heart.

    These ectopic fat deposits are strongly associated with metabolic dysfunction and many of the chronic diseases that dominate modern healthcare.

    This is why I encourage patients to think less about weight and more about body composition, which simply refers to what the body is made of — fat, muscle, bone and water — rather than weight alone.

    The number on the scales tells us surprisingly little. It cannot tell us how much muscle we have. It cannot tell us what our bone density is. It cannot tell us how much visceral fat we are carrying. It cannot tell us whether our metabolic health is improving.

    Why BMI Often Misses the Point

    This is also why I have become increasingly sceptical of relying solely on Body Mass Index (BMI).

    BMI simply compares height and weight. Whilst it may be useful when studying large populations, it tells us very little about an individual person’s health.

    It cannot distinguish muscle from fat.

    It cannot identify visceral fat.

    It cannot tell us where fat is being stored.

    Two people can have exactly the same BMI and vastly different levels of metabolic health. One could have a high proportion of muscle and very little visceral fat. Another could have the same BMI but carry significant visceral fat and very little muscle. Who is metabolically fitter?

    For this reason, waist-to-height ratio is often a far more useful measure. Excess abdominal fat is one of the strongest indicators of insulin resistance and metabolic dysfunction, making waist-to-height ratio a simple but powerful marker of future health risk.

    The goal should not simply be to become lighter.

    The goal should be to become healthier.

    The Role of Insulin

    To understand weight gain, we need to understand insulin.

    Insulin is one of the body’s most important hormones. Its role is to help move nutrients into cells and store energy when food is plentiful. In a healthy system, this works beautifully. The problem arises when insulin remains elevated for much of the day. When insulin levels are high, fat cells receive a signal to store energy. Accessing those energy stores becomes more difficult.

    To release stored fat, insulin levels need to fall.

    This is one reason why I advocate fasting.

    For most of human history, periods of feeding and fasting were entirely normal. Food was not available from dawn until bedtime. The body evolved mechanisms that allowed us to switch between storing energy and using it. It is part of religious practice all over the world. It is not a new concept or fad, but a natural physiological process that allows the body time for repair, recovery and metabolic regulation.

    Today many of us live in a constant state of feeding. Breakfast. Snacks. Lunch. More snacks. Dinner. Something in front of the television. Our physiology was never designed for that pattern.

    Periods of fasting create a different hormonal environment from simply eating smaller portions throughout the day or calorie restriction. With prolonged calorie restriction, the body may adapt by reducing metabolic rate and breaking down muscle as well as fat. Fasting appears to trigger different hormonal pathways, allowing insulin levels to fall and stored fat to become more accessible.

    Fasting is not starvation.

    It is simply allowing the body time to do what it was designed to do.

    Inflammation: The Missing Link

    One of the reasons visceral fat is so harmful is that it contributes to chronic low-grade inflammation.

    Inflammation is a normal and essential part of human biology. It helps us fight infection and repair damage.

    The problem occurs when inflammation becomes chronic.

    Many of the foods associated with weight gain are also among the most inflammatory. Refined sugars, ultra-processed foods and refined carbohydrates provide large amounts of rapidly absorbed energy with relatively little fibre, protein or nutritional value.

    They also tend to trigger larger insulin responses and contribute to a cycle of hunger, inflammation and energy storage.

    When we remain in a state of chronic low-grade inflammation, many of the body’s normal repair and recovery processes become disrupted.

    I often joke with patients that if most of the food on your plate is beige, we may have a problem. Bread. Biscuits. Pastries. Cakes. Sugary cereals. Crisps. Processed snacks.

    Instead, try to focus on foods that look as though they came from nature.

    Vegetables. Legumes. Nuts and seeds. Eggs. Fish. Good quality protein. Healthy fats such as olive oil, avocado and oily fish. Fruit.

    In many ways, the Mediterranean diet remains one of the most extensively studied dietary patterns in the world. It is not really a diet at all. It is simply a way of eating based on whole, minimally processed foods that humans have eaten for generations.

    Why Exercise Matters

    Another common misconception is that weight loss is primarily driven by endless aerobic activity.

    Whilst aerobic exercise undoubtedly has cardiovascular benefits, resistance training is often the missing piece of the puzzle.

    Muscle is metabolically active tissue. Muscle improves insulin sensitivity. It supports metabolic health. It helps maintain mobility as we age. It protects bone density.

    Most importantly, resistance training helps preserve muscle, the very thing many people lose when they diet aggressively.

    The goal should not be to become a smaller version of yourself.

    The goal should be to become a stronger version of yourself.

    For many people, resistance training combined with regular walking or steady-state exercise, alongside occasional higher-intensity interval training (HIIT), provides an excellent balance for improving cardiovascular health and promoting body recomposition in a sustainable way.

    The Role of Sleep and Stress

    Many people do everything right on paper and still struggle with their weight. When that happens, I often ask about sleep and stress. Poor sleep alters hormones such as leptin and ghrelin, increasing hunger and reducing feelings of fullness. Chronic stress raises cortisol levels, encourages cravings and may contribute to abdominal fat accumulation.

    Once again we find ourselves back at inflammation and metabolic dysfunction. The body cannot distinguish between a genuine emergency and the relentless pressures of modern life. Work. Finances. Relationships. Caring responsibilities. Poor sleep.

    This is why successful weight management is rarely just about food. Calories in and calories out. How many steps we get in.

    It is also about recovery. Sleep. Stress management. Mental wellbeing. Healthy relationships. These factors influence our hormones every bit as much as the food we eat.

    A Different Way of Thinking About Weight Loss

    Perhaps the biggest shift in thinking is this: weight loss should not be the primary goal. Improving metabolic health should be the primary goal.

    Reduce visceral fat. Preserve and build muscle. Improve insulin sensitivity. Lower inflammation. Sleep better. Manage stress. Eat whole foods. Create daily periods of fasting.

    When these things come together, we create resilience, better health, strength, wellbeing and mental recovery.

    We may see a drop on the scales and often we will. But the number is not the most important outcome.

    Instead of asking, “How much weight have I lost?”, perhaps we should be asking:

    • Have I reduced visceral fat?
    • Have I improved my insulin sensitivity?
    • Have I preserved muscle?
    • Am I sleeping better?
    • Do I have more energy?
    • Am I metabolically healthier?

    Because ultimately the number on the scales is only one measure of health.

    Health is far bigger than a number.

    Where to Start

    For most people, the best approach is not to make dramatic changes overnight.

    Start simply.

    Aim for a 12-hour overnight fast. For example, finish eating at 8pm and have breakfast at 8am.

    Once that feels comfortable, some people choose to gradually extend this to 14 hours and later 16 hours, allowing insulin levels more time to fall between meals. During fasting periods, water, black coffee and unsweetened tea are generally acceptable. The goal is not deprivation. The goal is to recreate the natural cycle of feeding and fasting that humans have experienced throughout most of history. Equally important is what happens during the eating window. Focus on whole foods, adequate protein, plenty of fibre, healthy fats and minimising ultra-processed foods.

    Small sustainable changes repeated consistently will almost always outperform extreme approaches that cannot be maintained.

    Thank you for reading.

    If you enjoyed this article, you can find more reflections and articles on medicine, health and life in the Posts section.

  • The six pillars of perimenopause

    The six pillars of perimenopause

    Looking beyond hormones and taking a whole person approach to mid- life health

    There is no shortage of information about perimenopause.

    Open a newspaper, scroll through social media or listen to a podcast and you will find endless discussions about hormones, HRT and symptom checklists.

    Yet after more than 25 years as a GP, I have come to believe that whilst hormones matter, they are only part of the story.

    The women who seem to navigate this transition most successfully are not necessarily those taking the most medication. More often, they are the women who understand that perimenopause is asking them to pay attention to their health in a different way.

    This is where the six pillars of lifestyle medicine come in.

    They form the foundation of how I approach perimenopause in clinic and, in my experience, can be just as important as any prescription.

    Perimenopause can begin anywhere from the mid-forties, although for some women it starts earlier. Symptoms vary enormously and can include almost anything, which is one reason why it can be so difficult to recognise.

    The transition itself can last anywhere from a few years to almost a decade. Menopause is defined as twelve months after a woman’s last menstrual period and occurs at an average age of around 51 years in the UK, although there is considerable variation.

    There are also significant cultural differences in how menopause is perceived. In some societies, women are respected and valued for reaching this stage of life. It is seen as a time of wisdom and experience, bringing greater status and seniority amongst younger women. In other cultures, including some ethnic minority communities, menopause remains a taboo subject and is rarely discussed.

    Whatever our cultural background, perimenopause is a very real part of life and can bring with it a multitude of physical and emotional symptoms that many women find extremely challenging.

    During perimenopause, oestrogen, progesterone and testosterone levels begin to fluctuate. In the early stages, oestrogen levels may remain relatively normal whilst progesterone levels often decline first. This is one reason why treatment needs to be tailored to the individual and why symptoms cannot always be explained by hormone levels alone.

    For some women, hormone replacement therapy can be life-changing. For others, non-hormonal approaches, lifestyle measures or a combination of strategies may be more appropriate.

    Equally important is recognising that not every symptom occurring during midlife should automatically be attributed to “the change”. Other medical conditions can develop at the same time and symptoms should never simply be ignored.

    In fact, only recently I saw a former patient who perfectly illustrated why menopause can be so difficult to navigate.

    She was 46 years old and had been struggling for around nine months with poor sleep and a feeling of anxiety or dread first thing in the morning. Once she was up and moving, the feeling largely settled. She had no hot flushes, no night sweats and none of the symptoms most people traditionally associate with menopause.

    She had sought help but found it difficult to access a GP appointment. Blood tests had been arranged and she had subsequently been started on oestrogen gel. Yet she felt she had never really had the opportunity to sit down with someone and explore what might be contributing to her symptoms. 

    What struck me was not whether the treatment was right or wrong. Medicine is rarely that simple. What struck me was how quickly the conversation had become focused on hormones and how little time had been spent exploring everything else that might have been influencing how she felt.”

    We talked about sleep, work pressures, stress, exercise, relationships and overall wellbeing.  We also reviewed her contraception and discussed whether her Mirena coil was still appropriate if it was being relied upon for endometrial protection alongside oestrogen therapy.

    This highlighted another challenge within menopause care. The guidance around contraception and HRT can be complex, and what is appropriate for contraceptive purposes is not necessarily the same as what is appropriate for endometrial protection when oestrogen therapy is being used.

    It served as a reminder that menopause care is rarely straightforward and that individual circumstances matter.

    By the end of the consultation we had agreed to pause, step back and start again.

    This is not an argument against HRT. For many women it can be incredibly effective. Rather, it is a reminder that good medicine starts with listening.

    One of my concerns is that menopause has become increasingly medicalised. Of course, there is absolutely a place for HRT and other treatments and for some women they can be transformative. However, I sometimes feel we have become so focused on finding the perfect prescription that we risk overlooking the foundations of health that were there all along.

    The challenge for clinicians is to remain curious.

    When a woman presents with symptoms such as anxiety, poor sleep, fatigue or low mood, it can be tempting to immediately view them through a menopausal lens. Sometimes that assessment is entirely correct. At other times, the picture may be more complex.

    Our role is to look beyond hormones alone. To explore lifestyle, stress, relationships, physical health and emotional wellbeing alongside hormonal factors. To ask what else might be contributing and to resist the temptation to reduce every symptom to a hormone deficiency and every solution to a prescription.

    Good menopause care should not be about choosing between HRT and lifestyle medicine. It should be about understanding the whole person and using the right tools for the right individual at the right time.

    No hormone can compensate for chronic sleep deprivation, a diet high in ultra-processed foods, unmanaged stress, loneliness or complete physical inactivity.

    This is why I am such a strong advocate for lifestyle medicine.

    Lifestyle medicine is based on six pillars: nutrition, physical activity, sleep, stress management, healthy relationships and avoiding risky behaviours. These pillars can be applied to almost every chronic condition we encounter in healthcare, but they are particularly relevant during perimenopause.

    I often describe perimenopause as one of life’s lightbulb moments because it creates an opportunity to pause and take stock.

    Research has shown that lifestyle interventions can significantly reduce future disease risk. One large study demonstrated a 23% reduction in cardiovascular disease risk through lifestyle measures alone. We also know that healthy lifestyle choices can reduce the risk of osteoporosis, improve body composition and support long-term physical and emotional wellbeing.

    Perhaps menopause is less about hormone deficiency and more about a message.

    A message that the strategies that got us through our twenties, thirties and forties may no longer be enough. The body starts asking us to pay attention. To rest. To move differently. To nourish ourselves better. To put ourselves somewhere on a very long list of priorities.

    Pillar One: Nutrition

    Hormonal changes affect weight, energy levels, bone health, mood and blood sugar control.

    Rather than focusing on restrictive diets, I encourage women to think about nourishment.

    A Mediterranean-style diet rich in vegetables, legumes, whole grains, fish, nuts and olive oil provides an excellent foundation.

    Prioritising protein with meals helps maintain muscle mass and promotes satiety. Choosing high-fibre carbohydrates rather than refined alternatives helps stabilise blood sugar and insulin levels, which can reduce weight gain and energy fluctuations.

    Bone health becomes increasingly important during this stage of life. Calcium-rich foods such as dairy products, fortified plant milks, tofu and leafy green vegetables, alongside adequate Vitamin D, can help maintain bone strength.

    Gut health matters too. Fermented foods such as live yoghurt and kefir may support a healthier microbiome and overall wellbeing.

    Many women also find that reducing alcohol, excessive caffeine and highly processed foods improves symptoms such as hot flushes, palpitations and disrupted sleep.

    Pillar Two: Physical Activity

    Exercise is one of the most powerful tools we have during perimenopause.

    Resistance training helps maintain muscle mass, strengthen bones and improve metabolic health. Weight-bearing exercise can increase bone mineral density and reduce the risk of osteoporosis, whilst cardiovascular exercise supports heart health, mood and energy levels.

    The best exercise is ultimately the one you enjoy enough to continue doing consistently.

    Pillar Three: Sleep

    Poor sleep is one of the commonest complaints I hear from women during perimenopause.

    Sleep disruption can worsen anxiety, brain fog, fatigue and irritability. Maintaining regular routines, reducing alcohol and caffeine intake and keeping the bedroom cool and dark can all help.

    Improving sleep quality often creates a positive cycle in which many other symptoms begin to improve too. Better sleep supports hormonal regulation, reduces cortisol levels and improves overall resilience.

    Pillar Four: Stress Management

    Modern life places enormous demands on women.

    Many are juggling careers, relationships, children, ageing parents and countless other responsibilities. Chronic stress elevates cortisol levels and can worsen many menopausal symptoms.

    Walking, mindfulness, yoga, breathing exercises and spending time in nature can all help calm the nervous system.

    Sometimes, however, the answer is even simpler.

    In a previous post I wrote about the art of doing nothing. It sounds almost absurd in today’s world, but many women are exhausted. We readily recharge our phones when their batteries run low, yet often ignore the signs that our own batteries need recharging too.

    Rest is not laziness. It is a biological necessity.

    Pillar Five: Healthy Relationships

    One thing I have learnt both as a doctor and through my own life experiences is that we are not meant to navigate difficult transitions alone.

    Talking openly with partners, friends, family members or healthcare professionals can reduce feelings of isolation and help women realise they are not alone in what they are experiencing.

    Sometimes simply feeling heard, understood and supported can be therapeutic in itself.

    Pillar Six: Avoiding Risky Behaviours

    Smoking increases the risk of cardiovascular disease, osteoporosis and earlier menopause. Excess alcohol can worsen anxiety, sleep disturbance and hot flushes.

    Reducing or eliminating these behaviours can have significant benefits both for menopausal symptoms and long-term health.

    We also know that smoking, obesity, diabetes and socioeconomic deprivation are associated with more severe menopausal symptoms. Women from more deprived backgrounds and some ethnic minority groups may experience menopause earlier and face additional barriers to support and treatment.

    Perhaps the greatest lesson of perimenopause is not about hormones at all.

    Many women reach this stage of life after years spent looking after everyone else. Careers have been built, children raised, ageing parents cared for and responsibilities carried. Often there has been very little time left over for themselves.

    Maybe that is why this phase can feel so uncomfortable. It asks us to stop and pay attention.

    Not because we are failing.

    Not because we are broken.

    But because our bodies are reminding us that we matter too.

    Perimenopause is not a disease to be cured. It is a transition to be understood.

    And whilst there is no single path through it, perhaps the women who navigate it best are those who stop fighting the journey and begin listening to what it is trying to teach them.

    Thank you for reading.

    You can find more practical health articles in the Practical Health section of the blog, including my article on Perimenopause: The symptoms no one warned you about.



  • What matters most

    What matters most

    The opportunity that came along was almost too good to ignore and what happened next changed the course of my career.

    A local GP was approaching retirement and was looking for somebody to join the practice with a view to taking over when he stepped down a year later. His son had originally been expected to take over but had decided instead to move to Australia, leaving the future of the practice uncertain.

    For me, it felt like a remarkable opportunity.

    The surgery was within walking distance of home. The children were older, life looked very different from when I had made the difficult decision to let go of my first practice and, for the first time in years, I could see a way of combining practice ownership with family life.

    It wasn’t a decision I took lightly. Taking over a practice meant increasing my hours considerably and accepting a huge amount of additional responsibility. As a family, though, we talked it through and decided it was an opportunity too good to miss. In many ways, it felt as though life was giving me a second chance.

    My husband, who had been made redundant and had started his own management consultancy, initially agreed to spend a couple of weeks helping me review the business side of the practice. Two weeks became a month, a month became several months and before long he had become an indispensable part of the team. Eventually he gave up the consultancy altogether and became my practice manager.

    Looking back now, I honestly don’t know how I would have done it without him.

    Together we developed the practice and gradually grew the patient list. By the time I eventually left, we were caring for around 4,000 patients with a very small and dedicated team. It was general practice as I had always known it and I loved it.

    The children spent a lot of time at the surgery. We were both working and there were many afternoons when they would arrive after school, appearing in reception, doing homework in spare rooms or helping themselves to biscuits and cakes that patients had baked for us. At times it felt strangely familiar and I would often find myself remembering my own childhood.

    Without consciously planning it, I had recreated something remarkably similar to the world I had grown up in. It wasn’t just a practice. It was part of family life.

    There were a lot of hats to wear. On any given day I might be a GP, a practice owner, a wife, a mum and a daughter to ageing parents. Like most working mothers, I spent years juggling surgeries with school runs, parents’ evenings, sports days, packed lunches and trying to work out what everyone was going to have for dinner.

    It wasn’t always easy. Running a single-handed practice was hard work and the responsibility never really left you. We rarely took proper breaks, the days were often long and there was always another problem waiting to be solved. Yet there was also a freedom that came with it. I planned my own diary, I knew my patients well and, although there were difficult days, there were many more good ones.

    The practice gradually became our second home. More than that, it was ours. We grew it together and, despite all the challenges, there was something deeply satisfying about creating something that reflected our values and the way we believed general practice should be.

    Over the years it became increasingly difficult to find locums willing to provide cover as general practice moved steadily towards larger organisations and group practices. I found a couple of old-school colleagues who were happy to cover sessions, which helped build a little resilience into the system. Being the only doctor on site still meant there was nowhere to hide. If an emergency arrived, you dealt with it. If several problems landed at once, you prioritised and managed them. There was no colleague in the next room to ask for help.

    You learned to stay calm, make decisions and carry responsibility and, with all of that in mind, very little really fazes me these days. I rarely get stressed or panicked about anything. I’ve always told my children that they can tell me absolutely anything and I will never be shocked because, between life and medicine, there is very little I haven’t either experienced myself or heard about from somebody else. And they do.

    What I loved most, though, was always the patients.

    Not once in my career have I stopped feeling privileged when a patient walks into my consulting room and trusts me with their story. It is the first lesson I teach medical students. Never lose sight of what a privilege that is.

    There are very few professions where people sit down in front of a stranger and tell them things they may never have told another soul. Perhaps only priests experience something similar.

    People never cease to amaze me. Over the years I have listened to stories of courage, resilience, humour, heartbreak and despair. Some have been uplifting, some tragic and some so complicated and extraordinary that they could easily have come straight from a television drama. General practice gives you a unique window into people’s lives and sometimes I would leave a consultation thinking that no scriptwriter could possibly have invented a story quite like it.

    So the second lesson I try to teach students is that patients will teach you far more than any textbook ever can if you take the time to listen. Looking back, much of my real learning happened on the job. Not just the social side of medicine, but the practical side too. The clinical decision-making, the examination techniques, developing my own style of consulting and learning how to navigate complex symptoms all evolved over time. I often found myself creating mental maps to help make sense of seemingly unrelated problems and gradually learned that medicine is as much about pattern recognition and curiosity as it is about knowledge. Patients were some of my greatest teachers.

    I realise that what I valued most about those years wasn’t the ownership, the independence or even the flexibility. It was continuity. It was the privilege of knowing people over years and sometimes decades, of understanding not only their medical history but also something of their lives, their families and the things that mattered to them.

    Perhaps that is why I struggle with some of the changes that have taken place in general practice over recent years.

    People often ask why I chose not to continue working in the way modern general practice is evolving. The answer is complicated, but at its heart it comes down to relationships.

    I have never really believed that people can be reduced to a ten-minute appointment or a list of isolated problems because life simply isn’t that neat. One appointment, one problem sounds sensible on paper, but how do we know that problem number two isn’t connected to problem number one? How do we know that the tiredness isn’t linked to the bereavement, the headaches to the anxiety or the stomach pain to the stress of caring for an elderly parent?

    Continuity matters because it allows someone to join the dots. It allows a doctor to know what happened last year, what happened ten years ago and what might be happening beneath the surface today. I worry that something important is lost when nobody holds the whole picture.

    Patients need somebody who knows them, advocates for them and takes responsibility for helping them navigate increasingly complicated systems. Someone who notices when things don’t quite add up.

    At least, that is the sort of doctor I have always tried to be.

    I am a very emotional person. At happy times and sad times, at weddings, family speeches and all sorts of occasions, any member of my family will tell you that I am almost guaranteed to cry. My husband carries a hanky just for me whatever the occasion. The same is true in the consulting room and over the years there have been many occasions when I have sat with a patient and cried alongside them, not because I lacked professionalism, but because sometimes being human is exactly what the moment requires.

    Perhaps that is what I value most about general practice. The privilege of sharing in people’s lives at their best and at their worst.

    That is what drew me to medicine in the first place and, all these years later, it is still what keeps me there.

    The practices have changed. The NHS has changed. The way medicine is delivered has changed beyond anything I could have imagined when I first started out. But the things that matter most have remained remarkably constant. People still need to be listened to. They still need kindness. They still need somebody willing to walk alongside them when life becomes difficult.

    The story of what happened next is, in many ways, the story I told in my very first post. Perhaps I wrote the ending before I wrote the beginning.

    Looking back now, I realise that the practices, the buildings and even the different chapters of my career were never really the important part. The important part was the relationships I built, the people, their stories and what a privilege it has been to hear them.

    In the end, that is what mattered most.

    Thank you for reading.

    You can find more reflections on medicine, health and life in the Posts section.

  • The long way round

    The long way round


    Time passed quickly and before I knew it I was no longer the most junior doctor in the hospital. I had become a Senior House Officer, or SHO as we were known then, and life settled into a rhythm of six-month rotations. Every few months brought a new specialty, a new hospital, new colleagues and a new rota to learn. Some jobs I enjoyed more than others, but each taught me something different about medicine and about myself.

    One specialty that surprised me was Accident and Emergency. Looking back, I genuinely loved it. For a while I seriously considered making a career of it. There was an excitement to the work that was hard to match anywhere else. You never knew what would come through the doors next. One minute you might be dealing with a child with a high temperature, the next a major trauma, a stabbing, a psychiatric emergency or somebody who had managed to injure themselves in the most extraordinary way imaginable.

    Life in all its forms arrived through those doors.

    I enjoyed the pace and the unpredictability. I liked making decisions, often quickly, and I became reasonably good at the practical side of medicine. I could usually find a vein when everyone else had failed. I enjoyed procedures and liked the challenge of working under pressure. I learned how to calm distressed patients, reassure frightened relatives and keep my head when things became chaotic around me.

    For a while I thought perhaps this was where I belonged.

    One particular shift at King’s Hospital stays with me. In those days we had to clock patients in and out. The aim was efficiency. Assess the problem, deal with it and move the patient on. There was always another patient waiting and a busy department depended on keeping things moving.

    An elderly lady came in after a fall. Fortunately she had not fractured her hip and medically there was very little wrong with her. The obvious thing to do was assess her, reassure her and send her home.

    Instead, I found myself sitting and talking to her.

    I wanted to know where she lived, whether she had family nearby, how she managed day to day and what support she had at home. The more we talked, the more concerned I became about what would happen once she left the department. The bruised hip that had brought her to hospital seemed far less important than the fact that she was returning home alone.

    None of that was really my job. My job was to assess the injury. Yet those wider questions were exactly what interested me most.

    Later, during a feedback session, one of my consultants told me that I spent too long with some patients. It was fair criticism. In a busy casualty department speed matters and I wasn’t always as efficient as I should have been.

    The funny thing was that the very things slowing me down were the things I enjoyed most.

    I was fascinated by people’s stories. I wanted to understand not just what had happened to them, but who they were, how they lived and what would happen to them once they left the department. I realised that I wasn’t simply interested in diagnosing and treating problems. I was interested in people.

    Looking back, that was probably the moment I started to understand where I belonged.

    I continued working through a variety of hospital specialties, but my direction was becoming clearer. I started choosing jobs that would help me develop the skills I would need in general practice and before long I secured a position as a GP registrar in a local training practice.

    Things were very different then. There were no national ranking systems, anonymous multiple-choice assessments or computer-generated allocations. One job often led naturally to another and opportunities frequently came through the relationships you built along the way. Looking back now, I don’t think I ever really had a formal job interview.

    General practice felt like a different world altogether.

    Compared with hospital medicine it seemed remarkably civilised. There were occasional Saturday surgeries, but the endless on-calls and sleepless weekends were largely behind me. I had longer appointments, my own patients and the opportunity to follow people over time. There were home visits too, which I loved, and I spent the year working towards my MRCGP, which I was fortunate enough to achieve during my registrar year.

    When my training finished, I was offered a position in the practice where I had trained. It was a generous offer but I turned it down. The practice was large and, although I couldn’t fully explain it at the time, I knew I wanted something smaller. I liked continuity. I liked communities. I liked knowing people.

    I started doing locum work in local practices, many of which I knew through Dad.

    I think Dad always hoped that one day I might take over his practice. We never really talked about it directly, but I knew. Part of me felt guilty because for a long time I wasn’t sure what I wanted. Emergency medicine had been a genuine possibility and I didn’t want him waiting for me to make up my mind.

    To his credit, he never put me under any pressure. Not once.

    In fact, he did the sensible thing and planned his future without making assumptions about mine. He took on a partner with the expectation that they might eventually take over when he retired.

    As it turned out, life had other ideas.

    By the time I had completed my training and finally realised where I belonged, circumstances had changed. I joined the practice and worked alongside that partner for a period before they eventually moved on. In a rather roundabout way, the practice found its way back to me after all.

    Looking back now, it seems strangely fitting. The journey was far less straightforward than any of us imagined, but somehow I ended up exactly where I had always hoped to be.

    Taking over the practice was never something I was expected to do. It was something I wanted too.

    It was a dream.

    Of all the moments in my career, one stands out above almost all others. After his retirement, Dad occasionally came back to do locum sessions for me. We would run evening surgeries in adjacent consulting rooms in what had once been his practice and was now mine.

    General practice was very different then. Most surgeries ran from 9 until 11.30 in the morning and then again from 4 until 6.30 in the evening. In between there were home visits, paperwork, phone calls and whatever else the day brought. It was busy, but it felt manageable in a way that medicine often doesn’t now.

    After morning surgery I would usually finish my visits or administration and then head over to Dad and Mum’s for lunch. We would sit together, watch Neighbours, catch up on the news and chat about whatever was going on in our lives. Looking back, those ordinary afternoons are some of the memories I treasure most.

    Later in the afternoon, Dad and I would drive the short distance down to the surgery together and spend the evening consulting in neighbouring rooms. At the end of surgery I would often walk home, which was only a couple of streets away from the family home, whilst Dad headed back up the road.

    As a child I had watched him leave for work every morning. I had listened to stories about patients around the dinner table and grown up surrounded by medicine without really realising how much it was shaping me. Years later, after all the uncertainty, the hospital jobs, the on-calls and the doubts about where I might eventually end up, there we were, working side by side in the same practice.

    I know Dad loved it too.

    Looking back now, it feels like a dream.

    And I loved every minute of it.


    Thank you for reading.

    You can find more reflections on medicine, health and life in the Posts section.

  • What medical school didn’t teach me

    What medical school didn’t teach me

    Despite my dream of becoming a doctor, I managed to fail my final exams.

    Medical school itself is a bit of a blur when I look back now. The first two years were spent on the King’s campus on the Strand. Like many students experiencing independence for the first time, I discovered the bar, late nights, socialising and a busy social life. I made wonderful friends and thoroughly enjoyed myself.

    The move to King’s College Hospital in Camberwell brought another adventure. Living away from home, being close enough to pop back when I needed to and having a car gave me a freedom I had never really experienced before. I attended lectures when I could, enjoyed student life and generally had a wonderful time.

    The truth is that I wasn’t a particularly academic medical student.

    I had lots of friends, but very few of them were medics. Looking back, I think I was always drawn to people doing completely different things from me. When I moved to Camberwell, I lived in a large shared house at 95 Coldharbour Lane. It wasn’t just students living there. There were artists, engineers, people already working and all sorts of interesting characters passing through. It felt a million miles away from lecture theatres, anatomy textbooks and medical exams.

    There was something wonderfully bohemian about it all. Conversations around the kitchen table were just as likely to be about art, politics, relationships, music or somebody’s latest adventure as they were about work. Whilst many of my medical school colleagues seemed to spend every waking hour studying, I found myself surrounded by people who viewed the world through a completely different lens.

    Looking back now, I sometimes wonder whether that was part of the reason I struggled with medical school. Whilst everyone else appeared to be studying one syllabus, I seemed to be studying two. One was medicine and the other was life.

    Perhaps that sounds like an excuse, and it certainly wasn’t one at the time, but I can see now that I was learning things that would eventually matter enormously to me as a doctor. I was fascinated by people, by their stories, by the different ways they approached life and the very different paths they had taken to get there. Maybe that is why I always found it easier to learn from people than from books.

    The couple of friends I did have on the course and I would usually sit together in the back row of the lecture theatre, which looked more like a cinema than a place of learning, complete with comfortable red seats. If the lecturing became too much, there was always the second-floor bar. I spent more time there than I probably should have done.

    At lunchtime I would sometimes sneak back into the lecture theatre, put my coat over my head and have a quick snooze. On one occasion, what was meant to be a ten-minute nap turned into something rather longer. I woke up a couple of hours later surrounded by faces I didn’t recognise and listening to a lecture I definitely didn’t understand.

    It turned out I was sitting in the middle of an engineering lecture.

    Trying to remain composed, I gathered my things and quietly left, hoping nobody had noticed that I had slept through the changeover and remained there for the best part of two hours.

    Needless to say, I was never destined to be top of the class.

    Some subjects I took to naturally whilst others I struggled with enormously. Anatomy, for example, was a constant challenge. Spending a year dissecting a cadaver was not something I enjoyed and I found learning from textbooks difficult. Much of what we were being taught felt abstract and disconnected from real life.

    What I found hardest was that medicine seemed to be taught almost entirely in theory. We didn’t meet a real patient until our third year and much of what was discussed in lectures simply didn’t make sense to me because I had no context for it.

    Everything changed once I started spending time on the wards and meeting patients. Suddenly the conditions we had spent years reading about had faces, stories and families attached to them. The medicine started to make sense because it became real.

    Unfortunately, by then I was carrying the consequences of not having engaged with the earlier years as seriously as I should have done.

    When the final exam results were published, they were pinned to a board for everyone to see. I can still remember the crowd of anxious students gathered around it, all trying to find their names on the pass list. I searched once, then again and then a third time. At first I was convinced I must have missed it. I checked every line repeatedly, certain that if I looked hard enough my name would somehow appear.

    It didn’t.

    The feeling was awful. Not only had I failed, but everybody else could see that I had failed too. I remember feeling embarrassed, disappointed and frightened. For someone who had wanted to be a doctor for as long as I could remember, it felt as though the future I had always imagined was slipping away.

    More than anything, I worried about how my parents would react. I felt I had let them down.

    In reality, they were incredibly supportive. Perhaps part of the reason was that they understood exactly how I felt. Dad had failed his finals too, for many of the same reasons. He knew first-hand that a setback at the end of medical school did not define the doctor you would eventually become.

    Those were also the days when university education was free. Repeating a few months was disappointing, but it wasn’t financially devastating. Looking back, I can see that whilst it felt like the end of the world to me at the time, it really wasn’t.

    Six months later, whilst many of my peers had already started their first jobs, I found myself standing in front of the same board once again.

    This time I only had to look once.

    My name was there.

    I had passed.

    It was the most incredible feeling. Seeing “Dr” in front of my name felt surreal. I changed my bank card and cheque book almost immediately, not because I wanted to boast, but because I was proud. I had wanted this for as long as I could remember. I practised my new signature endlessly and threw myself into my first job with all the enthusiasm and confidence that only a newly qualified doctor can possess.

    That confidence lasted until my first on-call shift.

    I remember my first night on call as clearly as if it were yesterday, even though much of those early years has now merged into one long blur of wards, bleeps, sleepless nights and exhaustion.

    In those days the junior house officer was very much at the bottom of the pile. We carried a bleep and were the first port of call for all sorts of things. Rewriting fluid charts, replacing lines, reviewing admissions and trying to stay one step ahead of whatever happened next.

    I quickly learned that one of the secrets to surviving hospital life was understanding that nurses were your friends. The young doctors who arrived believing they knew everything and that nurses were somehow beneath them often had a difficult time. I genuinely enjoyed talking to the nurses and learned a huge amount from them. They had knowledge, experience and common sense in abundance and they made many an on-call shift far more bearable.

    Despite that, it was terrifying at times. I was twenty-four years old and seeing things most people my age had never encountered. Illness, trauma, suffering and death became part of everyday life.

    I still remember the first time I was called to verify a death. Like every junior doctor of the time, I carried my Oxford Handbook of Clinical Medicine in the pocket of my white coat. It was our bible. I looked up what I needed to do before walking onto the ward.

    The lights were dimmed. The curtains were drawn around one bed.

    I remember pulling the curtain back and seeing a woman lying there looking as though she was asleep. My heart was racing. Three minutes is a very long time when you are listening for heart sounds.

    I am also an avid horror fan and a small irrational part of my brain was convinced she might suddenly open her eyes.

    Looking back now, I think about my eldest daughter, who is twenty-four, and I struggle to imagine her being expected to deal with something like that alone. We were so young and yet somehow we simply got on with it.

    Medical school had definitely not prepared me for working as a doctor. Nothing had prepared me for the fear of being called to see a patient on my own, the fear of feeling out of my depth or the responsibility of being the first person expected to make decisions.

    In those days the saying was “see one, do one, teach one”. Procedures such as inserting a line were often learned exactly that way. Looking back, it seems extraordinary. At the time it felt perfectly normal.

    Christmas on call was probably the hardest of all. Whilst family and friends were gathered together, we were often in hospital missing Christmas lunch and family celebrations. The hospitals were very different then too. If you missed the canteen opening times, that was often it. More than once I survived an entire shift on toast, coffee and tea from the doctors’ mess.

    I remember one night being on the cardiac arrest team. I had finally made it back to the on-call room at some ridiculous hour of the morning. I was fully dressed and had just lain down on the bed. I wasn’t just tired. I was exhausted beyond anything I had experienced before.

    Then the bleep went off.

    I hate admitting this, but I simply couldn’t get up.

    A whole group of us carried arrest bleeps and I knew others would be responding. As the most junior member of the team, I convinced myself they would manage perfectly well without me. The truth was that for that one moment I had absolutely nothing left to give.

    There were certainly times when I questioned what I was doing. Many of my friends worked regular hours, had weekends free and earned far more money than I did. Meanwhile I was spending nights in hospital, carrying a bleep, surviving on very little sleep and earning surprisingly little for the responsibility involved.

    Medicine certainly wasn’t a route to wealth.

    For me, and for many of my colleagues, it really was a vocation.

    And yet, despite everything, I loved it. I loved the buzz, the unpredictability and the fact that no two days were ever the same. We worked hard and we played hard. We went out, danced, drank, smoked and enjoyed ourselves. The friendships formed during those years were unlike any others because they were forged through experiences that few people outside medicine could fully understand.

    And then there was home.

    After long shifts, sleepless weekends and endless on-calls, I would return to the sanctuary of family. There I could sleep, be looked after and simply switch off for a while.

    Looking back now, I realise that the things which eventually made me a good doctor were not necessarily the things I learned in medical school. Medical school gave me the knowledge I needed and eventually, after a second attempt, the qualification I had dreamed of for so long. What it couldn’t teach me was how to sit with somebody who was frightened, how to make decisions when I wasn’t entirely sure of the answer, how to work as part of a team or how to cope when I felt completely out of my depth.

    Those lessons came later. They came from patients, nurses, colleagues, sleepless nights on call, Christmas shifts, difficult conversations and countless mistakes. They came from being exhausted, occasionally frightened and constantly challenged. They came from life.

    When I failed my finals, I thought I had failed at becoming a doctor.

    What I couldn’t see at the time was that becoming a doctor was only just beginning.

    The real education came afterwards.


    Thank you for reading.

    You can find more reflections on medicine, health and life in the Posts section.