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See Pete's Hidden Curriculum Part 2 here.


“They can always hurt you more.”

This is The Fat Man’s Law Number 8 from the book The House of God by Samuel Shem. For those that have not read this book, it tells the story of Roy Basch, an intern at a hospital called the House of God, a fictionalised version of the Beth Israel Hospital, New York and set in the early 1970s.

It describes with humour the trauma of Roy’s residency training. His mentor is a senior resident called The Fat Man who imparts his wisdom in the form of a survival guide for the interns comprising 13 laws. In his law “They can always hurt you more” The Fat Man was essentially saying that everyone in the hospital is out to get you and things can always get worse.

For my hidden curriculum for the students I have created my own set of rules to follow to successfully navigate a career in medicine and remain sane. My first rule comes indirectly from The Fat Man’s law above. As every medical student learns, if the word “always” appears in the stem of a medical exam MCQ true or false question then the statement is always false and the law “They can always hurt you more” is not always true, as I shall explain.

My first rule is: “Future proof your career.” To illustrate the genesis of this rule I shall take you in my Delorean back to my first house job at a hospital on the English South Coast in 1995. I chose this location to work as, although it was known as “The Graveyard of Ambition” by the teaching hospital highflyer students, it was revered by others as a place to enjoy the seaside party atmosphere. What I failed to appreciate before taking up this post by the sea was that; 1. I would be so busy and tired that I would rarely get to the see the sea let alone enjoy any party atmosphere and 2. the main location in the UK that elderly people relocate to when they retire because of the climate is the English South Coast, and because it is generally the elderly that get sick, the workload was very high, especially in winter.

My rota in general medicine was a one in four with internal cover, which for non-medics meant that I worked all week and one night and one weekend in four, covering for colleagues’ holidays. I rarely got any sleep on call (I’ll get my violin out). I was more sleep deprived during this job than after the birth of my first child, and he didn’t sleep through the night for his first three years of life.

During the first week of my internship, I met very own Fat Man, a medical registrar who had clearly done several tours of duty and got his purple heart. He held court in an armchair in the safe haven of the doctors’ mess and passed on to me his sage advice. One afternoon during the first month I made it to the mess for a quick cup of tea and, bedraggled and shell shocked, collapsed onto a chair. He looked across at me and said with a wry smile “I’d like to tell you it gets better, but it doesn’t.”

Surely my Fat Man couldn’t be right? This couldn’t be it for me. I mulled over his words over the next few weeks with increasing desperation: the colder autumn days were drawing in and the wards were filling up. However, a chance encounter on call gave me hope and an exit strategy.



One Sunday afternoon in the autumn, I had finished the day’s phlebotomy round, resited all the venflons, rewritten all the drug kardexes and satisfactorily dealt with the medical emergencies. I seized the opportunity to take a break in the sanctuary of the mess. As I entered the mess there was a happy soul who cheerfully piped up: “I’ve got Leon out on video [1,2], anyone want to watch it?” No sooner had he said this than the kettle boiled and I was paged away to the ward again. This confirming to me what Logan 5 (Michael York) discovered in the movie Logan’s Run (1978) that “There is no sanctuary”. The pager can find you anywhere.

Two hours later I returned to the mess to get the cup of tea that I almost had two hours earlier. Cheerful Charlie Chuckles was ejecting the video from the machine and piped up: “Well that’s me done for the day, I’m off home now.” “I’m sorry,” I said incredulously, “you’re off home now, how come?” “Yes,” he replied, “I’m the ophthalmology SHO on call, I’ve seen the couple of inpatients, there’s nothing happening here, I’m off home.” This was my “Eureka!” moment. My own Fat Man was wrong, things could possibly get better. Although I was frustrated at having missed the movie Leon and jealously had to watch the ophthalmology SHO skip off home whilst I had to trudge back to the trenches, I had discovered that there were branches of medicine that did allow for a reasonable quality of life.

Ophthalmology as a specialty, for the most part, is a good choice for optimal work life balance. I didn’t go directly into ophthalmology but did Accident and Emergency (A&E) for a while both in the UK and Australia. I think I enjoyed my time in A&E more than any other job I have done. It was interesting and rewarding and there was great camaraderie amongst the staff. However, because of the relentless intensity of the work, I couldn’t envisage working in A&E for the rest of my career, and that’s where my rule for the medical students: “Future proof your career” comes from.

Burnout in medicine is a significant risk and is being discussed more than ever in online forums during this ongoing pandemic, with some specialties such as critical care at more risk than others. Therefore, I advise the students to think carefully about their career, and choose something that they can envisage doing for the rest of their working lives and well into their 50s and 60s.

The Fat Man from The House of God gave a careers advice talk to the interns and listed six specialties for them to consider which did not involve “touching, being tortured or killing yourself with night call”. These were “Rays, Gas, Path, Derm, Ophthalmology and Psychiatry”. It is reassuring that ophthalmology was included in his list.



1. For Gen Zers, prior to streaming and DVDs we used to watch movies on large cassette tapes called videos. This entailed going to a local shop such as Blockbuster Video to hire one like the ophthalmology SHO did with Leon. In the shop there was usually a lot of soul searching deciding what movie to choose, before getting home, watching the first 20 minutes and realising that a dreadful mistake had been made. A bit like what we do nowadays with Netflix except that it’s a bit more convenient.
2. I eventually saw Leon a couple of years later. It was good but I think I would have enjoyed it more if I had got to see it that Sunday afternoon on call.




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Peter Cackett

MB BS (London), BSc (London), FRCOphth, Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK.

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