Bled dry
The true cost of being a junior doctor
As a final year medical student, with a head full of textbooks, I didn’t much consider my future pay. Back then, I had more on my mind. Working under supervision, as a student, I felt safe. In the wild land beyond med school, as a doctor, I’d feel less so. Soon, I could misinterpret a test result, or miss a diagnosis, and wages can seem trivial, when you’re bound up in the fate of James or Tariq or Joan.
Stage fright aside, I felt suited to the job, and buoyed by the gratitude of my patients. There was a sense of familial pride too, as a lowly but vital member of the NHS. Graduation, though, had a sting in the tail. Turned out, my new job was pricey.
Most people are surprised to learn that there are massive financial expenses to bear, most of them mandatory, for NHS doctors in Britain today. You get a taste of what’s to come well before the ‘Dr’ slots in agreeably before your surname. Rising student debt has impacted all graduates, but with five years of undergraduate training, junior doctors are disproportionately burdened. The pressure to pimp up a medical CV, bettering your chances in an academic and competitive field, where the losers may have to settle on a different region, or a different field of medicine, lures many to add diplomas or masters or intercalated degrees, costing even more. Whilst I took some time away from medicine, driven in part by fear of what the unrelenting intensity might do to me in the long term, I have been working as a doctor for almost 11 years now. I’m still a ‘junior’. Every month, my payslip reminds me: I’m still paying my student loan off too.
After university, the metamorphosis: from student to physician, foetus to infant. It’s a gratifying moment, and even when you discover that the medical license itself costs you money, it hardly diminishes the delight. Joining the General Medical Council register provisionally, as we all do in year one, is cheaper than it will be for the rest of your career. Before long, junior doctors are forking out £433 annually to the GMC, a fee unmoved regardless of where you are on the medical hierarchy.
For the GMC, a watershed moment came in 2002 with one Dr Shipman. The succeeding inquiry catalysed the dramatic reforms my profession badly needed. And whilst the careful oversight of doctors gets everyone’s support, what started as a wave of reorganisations and procedures gathered momentum, swelling, over the years, to a tsunami. Junior doctors are now plagued with admin, endless assessments and appraisals, multiple costly exams, revalidation, relentless scrutiny. Junior doctors pay, in time and money, for the pleasure. As with medications, admin comes with side effects too. For the jammiest of junior clinicians, NHS Trusts have allocated time in the rota to tackle some of it, further diminishing a workforce 8000 doctors-short; others sacrifice their leave to form-filling (sorry, ‘professional development’), jacking up their risk of burnout, or departure.
Perhaps the GMC fee would bite less if doctors trusted it was being spent justly. Of the GMC outgoings each year, over half goes on investigating complaints and sanctioning doctors accused of failing in their duty to the public (a poxy 9% goes on overseeing the quality of training). The GMC’s decisions have been under increasing scrutiny of late — with unsettling parallels to the Met Police, it investigates a far higher proportion of doctors from ethnic minorities, breeding accusations of bias. Medicine is no different to other fields: the Swiss Cheese model of accident causation holds true, and errors tend to arise when the holes align — yet the GMC has made scapegoats of individual doctors, and minimised system-wide failings — it’s relatively simple this way, less political, and sates the public mood. This is something of a morale-killer. Doctors under investigation frequently suffer extreme anxiety and depression, with five taking their own lives between 2018 and 2020.
Early in the career of a junior doctor — typically after a year or so — the first in a career-full of exams arrives. In theory, you could decide not to sit them, but then you would remain on the lower rungs of the career ladder forever, as would your pay. The cost of progression is dizzying. Specialising in Acute Medicine, I faced a three-part exam — collectively the ‘MRCP (membership of the royal college of physicians)’ — each part to be sat at least 4 months apart, to get me on my way. The first two MRCP written exams cost £460 each at present and for many they involve learning deep into the night, after working all day, sometimes chewing through annual leave. The final part, a practical exam called PACES costs £657, but this is a snip of what it costs to train to be an anaesthetist, who pay £2,140 if they pass their exams on the first attempt, or a trainee surgeon, who pay over £1000 per clinical exam.
The pass rate for both the MRCP part 1 written exam and PACES exam is around 50% — half of doctors resit these exams alone — a pleasure which comes without a discount. Could the pass rate and the price be related? Nations can turn a profit from war, pharmaceuticals from pandemics, educationalists and administrators, it would seem, from us. Call it the Medical-Education-Industrial-Complex: the online tests, websites, journals, conferences and courses, enhancing the chance of passing exams whilst pillaging a doctor’s salary, without subsidy. For practical exams, most doctors will take a course: it’s the only sure way to get acquainted with the system, the performative nature of the exam, the marking scheme, get feedback, and meet patients face to face with unusual clinical signs. One and a half thousand pounds is a fairly standard course fee. Fail an exam, as legions do, and you must study harder, squander more leave, and pay dearly again, so the cost of the courses are deemed, by many, inevitable.
More assessments are mandated, year on year. For Acute Medics, there’s now an exam at the end of training, pow: a £600 uppercut. To qualify as a specialist — and you’ll recognise the theme by now — most doctors must pay around £450 pounds, but for the thousands of doctors who did not land one of the limited training posts, and who must present a record of their experience via an alternative route: £1780 please. Exam fees are not covered by the meagre and dwindling ‘study budgets’ which are generally reserved for conference costs (the munificence of my last NHS trust extended to 200 quid for a six month post, covering a whole quarter of a conference fee), but are instead scraped from junior doctor’s salaries, which have fallen by over 26% in real terms since 2008. There has been no linked deflation in exam fees, and in many cases, fees have risen. An overseas doctor has it even worse: they face even more exams, at greater cost — you can double many exam fees, and the PLAB English Language exams themselves can cost over a thousand pounds — presenting another deterrent for doctors to work in a system that sorely needs more.
It’s not only exams which give doctors a leg up in the gladiatorial arena of medical training. Job applications include a box in which to fill with the details of medical colleges and societies of which you are a member. Colleges and societies open up important learning and networking opportunities, and membership shows dedication to a given specialty. This translates to extra points at interview, and assists in the vetting of candidates, often a hard task. I cough up a few hundred quid annually for membership of the Royal College of Physicians, The Royal Society of Medicine and the Society of Acute Medicine, draining more of that salary in freefall. We are also expected to attend courses and conferences, to accrue mandatory CPD points (Continuing Professional Development), costing hundreds of pounds. Courses like Advanced Life Support are obligatory for all junior doctors, a good thing: patients tend to like their resuscitators adequately trained. Sometimes outsourced from NHS Trusts to private companies, ALS can cost junior doctors in London £580 a pop. Chi-ching.
In order to progress, we keep an e-portfolio, evidence we have the mindset, skillset and experience to be future leaders and consultants. This contains our assessments from senior clinicians, reflections and a record of our practice. The most utilised record in my speciality is compulsory for trainees, who pay over £500 to enrol. If you do not have an official training post, but need access to the e-portfolio anyway, the Joint Royal Colleges of Physicians Training Board sting you for £172 every year, which reflects the pervasive attitude: that junior doctors are good for it. Vaguely, The JRCPTB states that it must ‘cover its overheads’, failing to explain how the cost of running a website comes anywhere near.
Cheaper, but more egregious, is the price junior doctors pay monthly for the so-called ‘doctor’s mess’, a room in the hospital — generally cramped, dark and unloved — a brief base for lunch breaks, if there’s time. Its cost is extracted directly from salaries in most cases. Recognise the model? It’s the budget airline, tipping on a slew of extra charges for the basics, the stuff that used to be included in the fare. But charging us for a place to fleetingly sit in, with a broken kettle, and half eaten pot noodles, devoid of tea, is like charging passengers for the wings on the plane. You wonder if we’ll be paying a toll on the corridors soon. Increasingly, the basics are in short supply. I have spent the last six months in a job without access to a locker to safely store my belongings. When I asked how I could get one, a colleague laughed in my face and said he thought they were hereditary.
There’s more: a steady flow of charges, each more jarring than the last. Hospital staff do not get free parking, and junior doctors who can afford a car might budget £1000 a year to park on site. If a doctor were to make an error, or be accused of one — and the NHS in its current guise, understaffed and overburdened, appears at times the perfect breeding ground for mistakes — it would be useful to have some form of medical indemnity cover, lest we end up in court. That might skim another £350 off a doctor’s wages annually. And then there’s the stethoscopes, ophthalmoscopes and the like, the tools of the trade. Given the circumstances, my BMA membership fee bites less than the rest.
Doctors could keep some of these costs at bay by working extra hours, as locums, beyond their contracted hours, spending their annual leave or rest days. In London especially, the prospect is less attractive than ever before, since a rate cap was fixed by hospital trusts. My inbox today has news of ‘black escalations’, bed crises, and desperate calls for locums to fill yet more rota gaps. Human Resources are hamstrung: they can’t lift the locum pay rate, which means more shifts will go unfilled, safety is compromised, and discharges will be delayed. The free-market principle of supply and demand has been neatly excised here, because it’s not convenient for a government who hasn’t trained sufficient clinicians to fill the gaps. The overall result — fewer shifts filled — is rationing of care.
In comparison to other nations, England has a pitiable proportion of doctors relative to population (the average number of doctors per 1,000 people in OECD EU nations is 3.7, England has 2.9), so it would be nice to hold tightly to the ones we’ve got. But the spiralling costs of training are driving doctors like me away to work overseas, ramping up the workload for the left behind, their chance of burnout too. Record numbers of foreign trained doctors are returning home after getting their NHS-experience. Pre-covid, in 2019, only 35% of doctors continued their training after their 2nd clinical year, most pressed pause or did something else, and the proportion that had been increasing, year on year, for at least eight years prior. It’s hard not to guess that the excessive costs of training have something, or everything, to do with it.
A junior doctor’s salary might seem reasonable, at long range, when you don’t appreciate the fine detail — the costs embedded in training, the real terms pay erosion, the limits on locum rates, the conditions of employment and the extent of time doctors are contracted to work. Most medical trainees are contracted to work an average of 48 hours a week, not the 40-hour standard (or 35, if you’re a GMC employee); the time-equivalent of working six days every week, not five (in common with most other professions, the diligent stay much longer, for nowt). This is worth remembering next time you see one of those graphics comparing a junior doctor’s salary to that of other professions, and why considering our salary as an hourly rate permits a fairer perspective. £14 an hour is what doctors get for starters, a figure which inches up as experience, and postgraduate expenses, mount.
Out of Covid-19, there came a rush to improve the wellbeing of NHS workers of all stripes… massage chairs arrived, access to therapy, sandwich vouchers. One morning, working in A&E, I was informed that a cute dog would be making the rounds, which we could stroke to alleviate stress — someone had confused us, apparently, for children with cancer. Wellbeing at work hinges, in part, on feeling valued; but feeling valued, and being bled at every opportunity, are at odds. Occasionally, I am asked to fill in a questionnaire to rate my wellbeing, my scores presumably graphed for some professional body, then roundly ignored. I tick the boxes, my wellbeing tanks, and I’m left with an overwhelming sense that nobody is joining the dots.
The system is skewed against junior doctors, and there is not one answer because the problems themselves are various. But whilst the study budgets could be ramped up, and the naked profiteering could be curtailed, and exam fees could be slashed, and colleges could reduce their fees in solidarity, and the GMC could be publicly funded, and we could train more doctors, this will make for a glacial, piecemeal solution. Right now, restoration of pay, after year on year of cuts, is the only acceptable way out.
The annual GMC report ‘The state of medical education and practice’ pays lip service to the financial concerns of doctors and the costs incurred during training — the regulator appears not to have noticed, or has wilfully ignored, their spectacular rise. Doctors worry constantly about whether they will be adequately prepared for the next emergency, or complex clinical situation. The more training costs rise, the less they will be.
And still the GMC ferrets away, generating more hoops for doctors to jump through, in tidy office-spaces, on shiny computers, antithetic to the clunky NHS versions I retrieve your grandmother’s blood tests on. GMC employees can get private medical insurance as a perk of the job (you’ll find the details on their website, along with a section on ‘medical ethics’). Relative to doctors, GMC executives get princely expenses ‘To provide a reasonable standard of travel, accommodation and subsistence’. This apparently includes permitting taxis when it’s ‘awkward’, parking reimbursed (it’s a thing!), £200 a night hotels (required if you would otherwise have to leave home before 7am or get home after 8pm — like doctors do routinely), and a ‘modest level of alcoholic drinks’. Nice to know, at the dog-end of another brutal night shift, that I’m paying for the rosé. The GMC ‘adheres to the principle that no one should be out of pocket over reasonable costs incurred’ failing to recognise that this principle is entirely foreign to the people they regulate, and who pay their salaries.
The hoary GMC is in need of a shake-up. Perhaps if it were publicly funded (it’s focus today is overwhelmingly public protection after all, less so professional support) accusations that it’s become sclerotic and bloated, over-powered, negligent at times, and prejudicial to those who suffer its verdicts, might be taken more seriously.
Action, reaction. Pushed thus far, we strike again. The question is not whether we can afford pay restoration, but whether we can afford to penalise doctors-in-training any longer. To some, asking for a 35% increment is extraordinary; to those who understand the facts on the ground, so are the cuts, and so is the context. When junior doctors appeal for fair pay, the government accuses the union of militancy, transparently a smear tactic, from a government unused to determination on this scale, given that 98% voted in favour of strike action, the highest proportion of any balloted union of late.
A study published in the BMJ over ten years ago put the personal costs of postgraduate training for junior doctors in my specialty at over £20,000, nearly the entire annual salary of a first year doctor, after tax, but not all the fees I pay were included in the research, and there is every sign that the figure has risen since then, alongside student debt, which now tops £100,000 for some of us. And whilst there are workers in the public and private sectors who have significant professional expenses to bear too, and whose pay has been unduly squeezed of late, I suspect junior doctors are in an exceptional situation, all told. The costs of postgraduate training are scarcely considered by the so-called ‘independent’ Review Body on Doctors’ and Dentists’ Remuneration (government-selected, and government-constrained), are dismissed by ministers berating junior doctors for industrial action, and barely feature in the public debate.
My job — which I love — has always had plenty to test me. There’s the emotional toll, the responsibility — a privilege at times, crushing at others — and hours of work, academic and clerical, performed off-shift. A financial load weighs heavy now too.
Take the edge off. That’s all we ask.
