#7 False advertising: Is medicine "cool"?
In this issue: Changes to the newsletter, and I ask your thoughts on whether medicine is COOL. Not the people who practice it, they are overwhelmingly nerds, but the subject matter itself
“The most scandalous case of false advertising since Prince William referred to the Royals as a fairly normal family” – that’s what people are calling the ‘Monthly’ in the name of this newsletter. Yes, it is true that the Princess of Wales and I have both been MIA at the same time but please, we must quash the rumours that she and I have opened a Wellness Clinic together. That’s simply not true. It is actually a retreat for celebrity Photoshop addicts. Thankfully Kensington Palace released an official photo for the occasion.
Dear reader, it has actually been over a YEAR since I last darkened your inbox and, as ever, I predict a large proportion reading even this far have no recollection of signing up. Oh! Did you feel that? The bittersweet sensation of being moved to the spam folder. I feel like Luke in the New Hope trash compactor, except the dianoga monster is made of emails that begin “Greetings of the Day”, from The Worldwide Journal of Global Science Medicine International, or brand deal offers from Temu traders specialising in continuous faeces sugar testing kits promising to “unlock the secrets to optimal health” (discount code below). Yes, the Star Wars trash compactor monster was called a dianoga, so you have learnt at least one thing from this pitiful email.
You can skip to the next subheading if you signed up to read my semi-serious medical musings; the next few paras are fairly boring BTS thoughts about why I’m changing the newsletter.
The interval might’ve been even longer if I had not come to three realisations:
Firstly, that establishing a routine for this will help me more than it helps you, and I am motivated by nothing more than selfishness. Several things have been bothering me, and I believe that rediscovering a writing habit will ameliorate them. I had been putting this off, as I had started to view the newsletter in the same way I have come to view the videos on my main channel, full-length essays which dive deep into a topic. When you are time-poor, setting yourself a goal of writing a 5000 word email is a sure fire way to never achieve it.
Secondly, while I enjoy long-form writing, I suspect most people actually want to read something a bit more concise when scrolling through their emails. So from now on, I am going to fundamentally change my approach to this newsletter, and not view it as a full form essay; more of a short missive that just tackles one or two brief subjects. What I’m saying is, I’m going to be far lazier.
And finally, in this ever-changing dystopia of social media hellscapes, seven thousand of you have signed up for more medlife in your inbox and even though this is only the seventh email I’ve sent out, that decision of yours means a great deal to me, and I send my sincere apologies for having taken it for granted. This will of course sound like pompous waffle if the next email I send is in 2025. We shall see.
If you read similar media sources to me, I imagine you’re fed up of hearing about twitter, so suffice to say I decided I was done with the platform last year. I found I simply wasn’t enjoying it anymore – and bear in mind I am someone who literally gave keynote talks at national medical conferences and published in the BMJ about how insistently I recommended doctors should use twitter – so losing that outlet has been difficult. I have not found any of the twitter clones have developed a medical community, and to be honest I have not attempted to replace twitter, in an attempt to prioritise what I really derive pleasure from. Obviously family life first and foremost, but beyond the relentless and punishing joy that is being a parent, writing and making videos is something that brings me great enjoyment. Social media, less so. But the fact remains that I’m a self-important windbag and miss having an outlet for my world-altering edicts.
Almost a year ago, a suspiciously similar timeframe to my newsletter absence, I became the big scary boss at work, the lead for the whole department. Well, I’d love to be scary but I don’t think anyone else sees me that way goddammit. In spite of my protestations, no one has agreed to call me Chief of Cardiology and prostrate themselves on the floor, and frankly this is why British medicine is in such a state. And it really is. I said above that I left twitter last year, but I did return recently to send one tweet which simply read “what a f*cking farce”, in response to one of the oldest medical societies on the planet shamelessly betraying thousands of doctors who have their whole careers ahead of them. I hope to write about this some time, or perhaps make a video, but it is such an incendiary time in UK medicine right now – you may be aware that doctors have gone on strike multiple times over the last year and morale is at an all-time low. It is a deeply demoralising time in the NHS, and everyone is working harder than ever. There are many reasons, but ultimately it does mostly return to 14 years of underfunding. The NHS has had problems for a long time, but it still functioned to a more than acceptable degree just a decade ago, and it was also a pleasant place to work. I believe this is a fight that requires my input, especially as departmental lead, and that steals me away from other things.
I mention my dubious promotion and the wider context to convey why I’ve made so few videos, leave aside writing newsletters. My career has become all-consuming and overwhelming. Apart from the management aspects, I do still love what I do – don’t worry this isn’t a cry for help! In fact, this is a segue into the main email subject. I enjoy work, there’s just too much of it. I’m working about 160% of a typical consultant contract. And while I’ve refused to sacrifice on family time, this has meant the hobby I love has taken a back seat so far in the back it’s in a rail replacement bus two towns behind me.
Therefore, I decided that in the long gaps between videos, perhaps I can try to make some shorts and write some more newsletters, so here I am. Not Shorts in the highly-polished and engaging way you’re used to by now, with how many talented creators are in the field, but the zero-effort, haven’t-even-bothered-to-prepare-or-comb-hair, super-chill-gen-Z-still-lying-down, audio-recorded-underwater-on-a-1998-logitech-pencil-mic way. Some are going on the main channel, but some are on my second channel (did you know I have a second channel?) and (gasp) tiktok or instagram. What might’ve once been a twitter thread will now be a haphazard short video, and, whisper it quietly, I’ve even come to accept vertical video.
So after all that noise, here is attempt number 1 to harmonise my efforts:
Should doctors love pathology?
I could have phrased this title ‘Should doctors love what they do?’ Or ‘Should doctors find medicine cool?’ But those are rather leading questions, and I wanted to canvass unbiased opinions. I’d love to hear your thoughts (comment on this post rather than email, if you are happy for it to be public).
I had great fun attending an event at one of my alma maters last weekend, UCL, where I ‘battled it out’ in a good-natured way with several other doctors, each of us representing our own specialty. The students then voted on the winner and in the most foregone conclusion since Jake Paul announced he was stepping into a ring with Mike Tyson (corruption notwithstanding), I emerged victorious. Victory to the heart! Death to other organs! (Literally what would’ve happened if the heart had not won) I posted words to this effect on instagram and got a response that mentioned paediatric cardiology which prompted me to record the following video, where I talked about one of the most amazing sights I’ve ever seen in my career.
In a nutshell, I recounted witnessing a tiny baby, born with what would’ve been a fatal cardiac malformation just a few decades ago, suddenly decompensate to the point of near-death, and a taciturn and serene senior paediatric cardiologist coolly thread a tube from the baby’s leg to their heart and deliberately tear a hole in the thin wall between the left and right atria. This manoeuvre allowed oxygen to enter the blood being supplied to the body and in an incredible demonstration of the textbook physiology I had learnt a few years earlier in medical school, a blue-grey baby went pink in mere seconds. They went onto have formal corrective surgery and is probably well on their way to becoming a tween tiktok star by now.
I have experienced something similar, although it’s impossible to top the emotional drama associated with saving a baby. Cardiac tamponade (very different to tapenade) is one of the most dreaded emergencies by doctors of all stripes, even cardiologists. It is where fluid or blood collects in the sac surrounding the heart. Even 100-200ml can compress the heart to the point where it can no longer pump. It can cause death within minutes or hours. The treatment is draining the fluid out by, to put it inarticulately, sticking a long-ass needle through the skin and navigating it into the centimetre or two where the fluid is. Rule Number 6 of the House of God (an infamous 1978 novel by Samuel Shem and the inspiration for Scrubs): There is no body cavity that cannot be reached with a 14 gauge needle and a strong arm.
Cardiology and anaesthetics both always appealed to me due to their instant demonstrations of physiology. You can actually see physics, chemistry and biology playing out in real time in front of your eyes. Often we rely on our observation machines to show us blood pressure, heart rate, heart tracing, oxygen levels and so on, but when it comes to cardiac tamponade, all you need are your eyes. The first time I did an emergency drain for tamponade, a 42 year old man was lapsing in and out of consciousness. His blood pressure was unrecordable, but my most abiding memory was simply his colour. He looked grey. A deeply unnatural colour for any living human. And without help he would not be a living human for much longer. With expert guidance from a boss (who would go on to stab me in the back when I applied for a job elsewhere, the delightful world of academic cardiology!) I drained off about 300ml of blood, and it’s hard to explain unless you see it, but I saw the life return to his body. The only time I’d ever seen anything like that before was when, as a much more junior doctor, I watched that baby undergo the same colour change. Except this time, I was the one that did it. He went home the next day.
I had never felt any apprehension telling this story until recently, but doctors tend to spend a lot of time talking to one another and can certainly lose track of what is acceptable conduct in normal society. I have now attracted criticism on many occasions, and seeing as I want to make a video soon about an aspect of medicine I find especially “cool”, I thought I’d share what dissenting voices have said.
Now, perhaps an indictment of what the algorithm thinks I want to see, but my instagram seems to be full of science communicators finding the most offensive troll comments and making whole clap back sassy responses which are thinly veiled attempts to simply show off their achievements, which…is fine I guess? I mean, social media is 90% people just showing off, so I’m howling at the moon here. Needless to say I find it narcissistic and fairly tiresome, but as such, you might think me doing this is hypocritical. It quite possibly is (that’s never stopped me before).
A comment, which I believe was meant sincerely, gave me pause for thought:
This is just the latest example. When I have posted on twitter in the past about fascinating pathology, interesting cases, unusual scans, bizarre diseases and so forth (all anonymised of course), I have received similar replies. And I did think about them. I understand where the criticism comes from. People might see doctors calling unusual findings in a patient “exciting” or “crazy”, but to that patient they may be life-altering. Doctors might refer to hugely invasive and painful procedures as “cool”. Doctors might collect rare X-rays or CT scans* to share with like-minded individuals at a conference or in a journal, detaching that grossly enlarged liver or infected brain from their owners, who are people with jobs, families, and lives.
*I do, however, detest the practice of posting X-rays of things up butts (which I hasten to add is often not done by doctors). There is no educational value whatsoever and it clearly is at the expense of the patient. It is simply done to mock and humiliate. This is the whole shtick of awful tiktok accounts like ‘steveioe’, which project such an appalling and literally harmful image of the medical field, as people will be more reluctant to seek help.
Is doctors discussing cases in this way wrong? I do not think so. Can it sound callous or cold? I am sure it can, and medical professionals should always be mindful of the setting for their discussions. I think many forget social media is a public place if most of their contacts are other medics. But here is why I believe you should want your doctor to use these superficially inconsiderate adjectives when talking about your medical problems:
A doctor who is thrilled by a jaundiced patient is not happy the patient is sick, they are expressing their love of the science they have devoted their lives to studying. By witnessing the discolouration of their skin, the doctor is appreciating the clinical significance of pathways they learnt in a sterile lecture, removed from the real world. They are putting a face to what they know about the breakdown of red blood cells, the conjugation of bilirubin, the anatomy of the liver and gall bladder. Now that complex pathophysiological process has a face, a name, a life.
When I teach medical students and junior doctors how to examine the heart, obviously always with patient consent, I try to instil in them the power of examination. Hundreds of years of medical progress have led us here, and while technology offers so much, there is still a wealth of information available using simply your eyes, hands, and a stethoscope. Some patients, especially those who volunteer for exams, positively revel in being “rare cases” or “must-sees” and join me in grilling the candidates on what they found! Others are a bit bewildered but nevertheless understand how medical education could not progress without them, and for that - we medics are eternally grateful.
You want a doctor who is passionate about what they do, and that includes excitement at seeing a white frost appear on the skin in kidney failure, smelling breath like musty nail polish remover in liver failure, or hearing “the sound of footsteps in fresh snow” through their stethoscope in inflammatory heart disease. The case report has been a staple of medical journals for hundreds of years. Doctors love interesting cases, there is no denying that. But we remain mindful that behind all the exciting medical science, there is a human being to whom the unusual findings belong. They are, of course, the whole reason the field of medicine exists.
Someone said to me that medicine is unusual as a science as it more applied – we are actually studying the causes of people’s suffering while they are suffering, rather than in a test tube or a Petri dish. This is true, but I doubt anyone would balk at a physicist describing a supernova as cool. That heartless sociopath cares not that billions of lives might have been extinguished! Oh no, it is the doctor who is cold and aloof!
The honest truth is that if doctors were not able to emotionally separate the pathology from the patient, the job would simply be soul-destroying. And it is absolutely true that doctors can stray into black humour and insensitive language, but to a degree much of this is necessary. That black humour angle has been covered countless times, but I thought this analysis of a doctor taking joy in what they see was worthy of discussion. I honestly believe if a physician no longer delights in seeing the weird and wonderful, if they do not feel a frisson of excitement when the emergency buzzer goes off, if they do not feel alive at the end of a brutal but rewarding shift (these are all things I would admit to), then their vocational love has waned.
Cardiologists certainly do not have a monopoly on moments of high drama and snatching a patient from the jaws of death. I have witnessed colleagues in all fields doing astonishing things. A hospital seems so far away from the strange online world of wellness and optimisation. Celebrity doctors and podcasters micromanaging the most banal and irrelevant health markers, or sexy medfluencers in tight designer scrubs sharing their morning routines seem to monopolise the public perception of “cool medicine”, but to me, nothing is as exciting as transferring the knowledge I imbibe about how disease affects the body and putting it into practice for a patient in need.
As for finding saving the life of a baby cool, I would be confident even most non-medics would agree with this description. If a doctor isn’t allowed to find saving a life cool, then you might as well quit, as that’s the best part of the job.
Before you go:
I wanted to thank anyone who watched, commented, shared or just thought about my last video (three months ago now!), which was about assisted dying. It was unlike any video I’ve made before, and the response has also been unlike any other. I still go back to read new comments now and again, and I’ve received many emails with often deeply moving and personal stories. Even though I’ve just written a rambling email about a negative comment, I was truly overwhelmed with how kind people were beneath this video. More than anything else I’ve put out there, when someone has written to me that I made them change their mind on this issue, it has meant a great deal to me. Because of your support, and the financial support from Nebula, I could make a nice fat donation to charity. While your comments often moved me to tears, donating to the Motor Neurone Disease Association brought a big smile to my face. Thank you.
Talking of Nebula, it’s been an absolutely incredible last few weeks for us, with huge announcements of new features and forthcoming Originals, being featured as one of Fast Company’s most innovative companies, press coverage and more. At the moment I have to settle for being a bit of a spectator to all this wonderful success, but if I can achieve the dream and reduce my hours at work (unlikely), I have so many ideas I want to make happen. You can join Nebula for only $5 a month here, and I will get a cut. I don’t charge for this newsletter (and you’d be pretty pissed off if I did considering it is currently less than annual) so this is a way to support what I do and access an ever-growing range of genuinely wonderful stuff.
Sign up at https://go.nebula.tv/medlifecrisis for only $5 a month.
See you in a vaguely-defined duration.
PS - After the surprising popularity of my little turn at being a rapper, I have written and recorded a new rap. I ain’t even kidding.
Dr. Francis, I've grown very fond of your turn-of-phrase, and of your outlook on many things. Certainly someone ought to be excited by palmary demonstrations of expertise in their field—and even better, really, if such a demonstration were to save a dying child. Also, I'm grateful that you made the longform video about dying by choice and with dignity; it disappoints me that people often think I'm both suicidal and arrogant when I mention that, at some point, I'd be more interested in dying when and how I like, if I could be so lucky.
Also: I think maybe "cardiac tamponade" might be a vampire's favorite preparation for tea.
I think witnessing a baby's life being saved is pretty cool, actually.
Glad you're back, Rohin.