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My Last Day as a Doctor - Reflections

2020-08-06 · Long video (solo, talking head or whiteboard) · Ali · recording, 33:13 · watch on YouTube

Topic: Medicine and his doctor years (also: Money and investing, YouTube, writing online and creators) · mode: Answering questions · tags: Family

On the day of his last shift as a junior doctor, Ali explains why he is taking at least a year out of medicine (no rush to become a consultant, keep options open, grow his online businesses), answers Instagram questions on the good and bad parts of the job, mistakes, rewarding moments and expectations, and shares his worries about the year ahead.

What is said

The parts of the video and what is said in each (★ — how much it matters to the video).

00:00:00 — Feelings on finishing his last day of work as a junior doctor

  • ★★★ Ali has just finished his last day of work for quite a while, ending two years as a junior doctor in the UK's National Health Service. — 00:00:00 · NHS, Foundation Programme, United Kingdom
  • ★★ Ali feels a little sad at leaving: he spent the last 12 months at a hospital in a small town and the 12 months before at a big hospital in Cambridge. — 00:00:31 · Cambridge
  • ★★ Ali finds the end of his job bittersweet: after long looking forward to the moment of freedom, it feels anticlimactic, as finishing exams always has for him. — 00:00:59
  • ★★ Ali is worried he will wake up with no good reason to get out of bed, because work is such a huge chunk of our lives. — 00:02:02
  • ★★ Leaving his job leaves a hole that work filled (something to do, some fun, social interaction, using his brain), which Ali will have to fill with several different things. — 00:02:24

00:02:53 — Why he is taking a year out: travel, the USMLE, Australia, no rush to be a consultant

  • ★★★ After his two foundation years as a junior doctor, Ali has decided to take a break from medicine for at least a year. — 00:02:53 · Foundation Programme
  • ★★ Taking a year out after the foundation years is common, Ali says; people usually do something medical, such as working in Australia, research or a one-year job in London, or travel the world. — 00:02:53 · London
  • ★★★ Before the coronavirus pandemic Ali planned to travel the world in his year out; now he is not sure that will be possible and needs to find something else to do with his time. (hedged) — 00:02:53 · COVID-19
  • ★ Visiting friends around the UK will tide Ali over for a while, but having no specific medical goal to work towards feels weird. — 00:03:42 · United Kingdom
  • ★★★ A move to America would take at least two or three years of applications and Ali has not fully decided on it; for the next few months to a year he will prepare for the USMLE, the US medical exam. — 00:03:42 · USMLE, United States
  • ★★★ Ali would like to work in Australia for a while to gain emergency medicine experience; he is applying for jobs, has a call with an agency the next day, and asks anyone in Australia who would give him a job at their hospital to let him know. — 00:04:20
  • ★★ UK medics go straight from school to medical school: Ali applied at 16 or 17, studied medicine full-time at Cambridge from 18 to 24 and has worked full-time as a doctor from 24 to 26. — 00:04:49 · University of Cambridge, Cambridge, United Kingdom
  • ★★ Ali describes one school of thought among senior doctors: get all your training out of the way and become a fully qualified consultant as soon as possible. — 00:05:13
  • ★★ The earliest a UK doctor can become a consultant is about age 33 or 34; consultants have more clout and freedom, such as dropping their hours or working part-time. — 00:05:37 · United Kingdom

  • ★★★ Ali is in the camp that there is no rush to become a consultant: nobody cares how long it took, medicine is a lifelong career, so taking a year out to explore other interests does not matter. — 00:06:09

    “this whole medicine thing is not a race. It's a marathon.”

  • ★★ Ali expects to qualify as a consultant in his late 30s or early 40s, hopefully married with kids by then, when it is much harder to travel the world or stop working on a whim. (hedged) — 00:06:42

  • ★★ Ali likes the idea of less than full-time training, which many UK hospitals and specialties now promote against burnout and attrition; emergency medicine and obstetrics and gynaecology are known for high burnout. — 00:07:11 · Obstetrics and gynaecology, United Kingdom
  • ★★ Less than full-time trainees work, for example, 80%: training takes 20% longer but they get a day off every week, and those Ali has spoken to say it is great. — 00:07:40
  • ★★★ On his deathbed, Ali says, he is very unlikely to wish he had been a consultant for three more years or to regret travelling and exploring his other interests. — 00:08:07
  • ★★ After two years of UK medicine comes a natural break to apply for a specialty; Ali does not know what he wants yet, though he leans strongly towards emergency medicine, where he has never worked. — 00:08:57 · United Kingdom
  • ★★ Ali's mother asks him whether he realises he has no direction in life, and he agrees that he does not know what he is doing. — 00:09:22 · Ali Abdaal's mother
  • ★★★ Ali's current view is that he should keep his options open and pursue what seems interesting now but also has long-term benefit, rather than go straight into a training programme without knowing what he wants. — 00:09:43
  • ★★★ In his year out Ali means to pour fuel on the fire of his YouTube channel: diversify revenue away from YouTube, focus on his blog and make more courses, which he hopes will be fun, done while travelling and assets that compound. — 00:09:43 · YouTube

00:10:30 — The good parts of being a doctor: busy days, teamwork, patients, bending the system, proposing plans

  • ★★ Ali enjoys busy days as a doctor, such as ten patients arriving at once, when he must triage and decide who needs scans first to minimise waiting. — 00:11:13
  • ★★ Teamwork is Ali's favourite part of being a doctor: hanging out on the wards with junior doctors and nurses and making friends with senior doctors over coffee and lunch. — 00:11:13
  • ★★ One of the main reasons Ali did medicine was that he did not want a job that kept him behind a computer screen all the time. — 00:11:58
  • ★★ Helping obstetrics and gynaecology patients through difficult problems, as part of the whole team, is a real privilege and joy for Ali. — 00:12:27 · Obstetrics and gynaecology
  • ★★★ A junior doctor makes a difference by learning how the hospital system works and occasionally bending its rules for patients, such as getting a worried woman scanned after the scan department closes at 5pm, Ali says, rather than swooping in to save the day like Derek Shepherd in Grey's Anatomy. — 00:13:21
  • ★★ Early on Ali hesitated to suggest plans to his seniors; after eight months on obstetrics and gynaecology he is comfortable proposing a plan, and the senior doctor usually approves it. — 00:14:01 · Obstetrics and gynaecology
  • ★★ Ali gets a lot of fulfilment from packaging up a case and proposing a plan while taking basically none of the risk, since the senior doctor approves most of his decisions. — 00:14:47
  • ★★ Flow state brings fulfilment, Ali says: making YouTube videos, editing and website work get him into it, and so do medical conditions he knows well enough. — 00:15:18 · YouTube
  • ★★ As in any full-time job, a junior doctor becomes almost a slave to the rota: to take time off Ali must negotiate with the rota coordinator. — 00:15:18

00:15:41 — The bad parts: the rota, admin and logistics, mistakes and ruptured ectopic pregnancies

  • ★★ Under the emergency rota for the coronavirus, three doctors were needed every day out of the four senior house officers on Ali's placement, so getting annual leave was a real problem. — 00:16:07 · COVID-19
  • ★★★ There is far more admin and logistical paperwork than Ali guessed: maybe 10% of his time goes on seeing patients and 90% on typing notes, arranging scans and labelling bloods. (hedged) — 00:16:29
  • ★★ The hospital's logistics matter because the system cures the patient, not the individual, but its inefficiencies, such as printers that do not work, frustrate Ali. — 00:17:07
  • ★★ An ectopic pregnancy grows outside the womb, usually in a fallopian tube; past a certain size it can burst, and the woman bleeds into her abdomen and pelvis, which can be life-threatening. — 00:18:04
  • ★★★ Sending home overnight a woman with normal vital signs who may have an ectopic pregnancy is scary for Ali: when a ruptured ectopic reaches theatre next morning, he gets a sinking feeling that she was a woman he sent home. — 00:18:25
  • ★★ Medicine has no real culture of blame, Ali says, whether you are a junior doctor or further on in training: when something bad happens to a patient, the question is why, what can be learned and how to avoid it next time. — 00:19:49
  • ★★★ For Ali the main gap between expectation and reality as a doctor was the large amount of logistical admin, which medical school does not prepare you for at all. — 00:19:49

00:20:02 — Expectations versus reality: admin and guidelines instead of Dr House

  • ★★★ Before medical school Ali imagined diagnosing like Dr House, but most work follows guidelines: about 95% of early pregnancy bleeding cases fit a guideline, and only the 5% of edge cases need harder thinking or a senior. — 00:20:18
  • ★★ Plugging numbers into guidelines and scoring systems is how evidence-based medicine should be, Ali says: a well-designed system rests on its own tightness, not on individuals' competence. — 00:20:50

00:21:12 — Regrets: mistakes in a training system

  • ★★ Ali recalls that Paul Kalanithi's When Breath Becomes Air discusses whether an operation is done by a junior or a senior, since less experienced people must operate to gain experience. (hedged) — 00:21:48
  • ★★ If his mother needed surgery Ali would still want a consultant to operate, but that works only for an individual: not every operation can be done by the most experienced consultant. — 00:22:46 · Ali Abdaal's mother
  • ★★★ Ali has no real regrets from his two years as a doctor: he made a few mistakes he wishes he had not, but they are part of learning, and mistakes across a training system are inevitable. — 00:22:46

00:23:29 — Most rewarding moments: patients' thanks and praise from seniors

  • ★★★ Ali's most rewarding moments are patients' thanks when he had personal input, such as seeing them first in the emergency department, admitting them and assisting in their operation; thanks from patients he barely saw feel less personal. — 00:24:00
  • ★★ Praise from seniors is annoyingly rewarding for Ali: a few weeks ago a consultant complimented him, and a couple of weeks ago a registrar. — 00:24:00
  • ★★★ When he is a senior doctor Ali wants to compliment people on good work, because a little compliment goes a long way; seniors who never say "well done" are less nice to work for. — 00:25:21
  • ★★ It takes a doctor little effort to take an interest in medical students but makes a big difference to their day, Ali says, and he wants to keep doing it as he becomes more senior. — 00:26:04

00:26:24 — What he has learned since starting the channel: medicine for fun, not to pay the bills

  • ★★★ Ali has long not wanted his job to be what he must do to make money: he wants the option to do what he wants, with the money he lives on decoupled from how he spends his time. — 00:26:43 · work optional
  • ★★★ With the YouTube channel taking off, plus courses, Skillshare classes and affiliate products, Ali no longer needs medicine to make money, so he now practises medicine for fun. — 00:27:07 · YouTube, Skillshare classes
  • ★★★ Given the choice, Ali would not spend his life as he spent the last two years, 48 hours a week in hospital with an hour's drive each way; designing his life from scratch, he would do medicine two or three days a week because it is fun. — 00:27:32
  • ★ Ali's plans are subject to change: he has changed his mind about which specialty he wants many times, and nobody needs to have all the answers. — 00:28:11

00:28:19 — Worries: not enjoying a specialty, quitting medicine, a channel tied to being a doctor

  • ★★★ If Ali came to dislike a specialty, he thinks it would more likely be because he was not doing enough to enjoy it: we can often choose to enjoy what we do, as with studying for exams. — 00:28:40
  • ★★ Ali worries that because he has the option not to do medicine, he might exercise it and quit medicine completely, though he cannot see it happening. — 00:29:10
  • ★★★ Ali decided to be a doctor at 16 knowing nothing about it, but if he had his time again he would do medicine in a heartbeat. — 00:29:10
  • ★★★ Ali worries that people follow him on YouTube only because he is a doctor who went to Cambridge, and that his productivity and study tips lose value if he is not walking the talk. — 00:29:39 · YouTube, University of Cambridge, Cambridge
  • ★★ If he were not a doctor, Ali thinks his YouTube channel would probably not be as successful, and without Cambridge behind him it might not have gained momentum at first. (hedged) — 00:30:08 · YouTube, University of Cambridge, Cambridge
  • ★★ Ali cannot see himself leaving medicine, but he can see himself going very part-time. — 00:30:08
  • ★★ Even at its current size, Ali's YouTube channel and income streams still feel like a house of cards that could come crumbling down at any moment. — 00:30:08 · YouTube

00:30:54 — The stress of a business and his self-worth versus the analytics

  • ★★ From what he has read about startups, Ali says the stresses of running your own business are existential, such as whether the business will be alive two years from now. — 00:30:54
  • ★★★ When a video underperforms, Ali reminds himself that his self-worth is not tied to the analytics: a weaker video can still resonate, and 50,000 viewers is still a lot of people. — 00:31:25
  • ★★ Ali started his YouTube channel in June 2017, he thinks, with absolutely no idea what level it would reach. (hedged) — 00:31:55 · YouTube

00:32:00 — Thanks to everyone who has followed the journey since June 2017, and sign-off

Threads in this video

Where the stories that moved here went next

Mentioned

Central: Foundation Programme · Gap year

Also: People: Ali Abdaal's mother · Paul Kalanithi

Projects: Skillshare classes

Works: Grey's Anatomy · USMLE · When Breath Becomes Air

Organizations: Instagram · NHS · University of Cambridge · YouTube

Concepts: affiliate marketing · burnout · COVID-19 · ectopic pregnancy · Emergency medicine · Flow state · Less than full-time training · Obstetrics and gynaecology

Places: Australia · Cambridge · London · United Kingdom · United States

Characters: Derek Shepherd · Gregory House

Products: Medic Bleep

Also centred on Gap year: Reapplying to Medicine (UK) - A comprehensive guide

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