A year or so ago I was ill. It turned out not gravely, but enough to keep me off work for several months. After an initial and shocking diagnosis, some surgery and its embarrassing aftermath and recovery, and huge support from family, friends, colleagues, clinical staff in Leeds and Maggie’s Centre, I started to feel both physically and psychologically back to normal. After six awful weeks, I was well enough to get back to work though there was still some treatment to get through and the advice I received was that I should not (must not!) go back to work until all of my treatment was complete. This advice was correct, delivered kindly and was taken, albeit grudgingly.

So toward the tail end of 2023 I found myself at home, not working for the first time in years, and wondering what to do, because all of a sudden not only had I (temporarily) lost my work, I’d also lost my identity. If I was not working as a Doctor, an Interventional Radiologist, a medical leader and all the other professional roles I had cultivated so carefully in my work over the years, what was I? What was I for?

Medical identity is ingrained into the stories we tell ourselves as a profession. It’s there in literature, drama, art and popular culture. It’s about the competition for access to a medical career, the sacrifices we make, the hours we work, the lives we affect. The narrative is that these experiences are qualitatively different from the experiences of other professionals. Any divergence from the stereotype of a heroic medical figure going the extra mile for her patients is jarring. At its extreme it can be almost indistinguishable from parody.

Is this justified? People employed in healthcare are hugely and uniquely privileged. We share intimate moments in our patients’ lives, from birth to death, before and after. We experience things no-one else does: the exquisite filigree of capillaries on the surface of a pulsing human brain; the knowledge of someone’s future before that person themselves knows, determined in the greyscale of a scan or the banal data of a test result; the attention to private confidences, fears, triumphs and insecurities. It’s in the role distinction that allows us to assault, probe and pry into the lives and bodies of our patients in ways that would result in prosecution for others.

But in many ways, we are no different from other employees and professions, contributing to society. I know many non-medical people who also competed hard to get where they are, who work much more than their contracted hours and who care deeply about what they do. Why are there not such strong identities associated with (for example) teachers, educating and enlightening generations of schoolchildren; entrepreneurs providing jobs and opportunity; lawyers navigating people through statute and caselaw; actors entertaining tens of thousands over a career or politicians struggling to lead in the face of conflicting constituencies. Comparisons of added value are destructive and obviously pointless, but there seems to be something in medical professional identification that is seen (and sees itself) as qualitatively different.

Some might justifiably scoff at this pretence, at the implied self-importance, at the hubris. This is why we laugh at the character of Dr Price in ‘Fawlty Towers’ when he demands his breakfast just because he’s medically qualified with the non-sequitur “I’m a doctor, I’m a doctor and I want my sausages”. But while Dr. Price is a pompous ass, I think most doctors internalise their profession to some extent. We rarely describe our employment as ‘a job’. It’s ’a vocation’ or ‘a calling’ with all the baggage that goes with that. Many years ago during some resilience tuition close to the end of my radiology training programme, I (with hindsight embarrassingly) admonished the facilitator for suggesting medicine was a career like any other. No, I told her: it’s part of me, it’s who I am.

So what? Does it matter what we tell ourselves? Who cares? In many ways, other than making us boring dinner party guests and drinking companions, it doesn’t. In other ways it matters hugely.

Managing change in any organisation usually involves developing awareness and urgency around the need for change and building a ‘core coalition’ of people to begin to deliver it. Change also involves ending, losing and letting go. Where people are invested personally in a project or service, challenge to that service (whether internal or external) can result in a grief reaction, beginning with denial and anger. This is amplified when the service subject to the proposed change is enmeshed with professional and personal identity. The (flawed) logic sees change as a threat, not only to professional practice but also to who you are. Change becomes personal and therefore more challenging to manage and deliver.

Some examples:

• Pooled waiting lists challenge a surgeon’s identity that only she is capable of operating on her patients.
• Advanced practice and physician associates challenge the identity that some jobs can only be done medically qualified people.
• Checklists and other initiatives to flatten hierarchy and improve safety challenge the identity of doctors as the primary source of organisational clinical accountability.

These operational and governance issues are complex enough without identity complicating them further.

Much of change management (and the NHS Change Model) is focussed on understanding and articulating high-order aims to identify commonalities in purpose and to co-create solutions, but even when aims are agreed, identity can confuse the solutions proposed. No-one would argue with the statement ‘patients should not wait a long time for their surgery’ but if the surgeon frames a query about operating theatre efficiency as identity (“I am a slow surgeon” or worse “they say I’m a slow surgeon”) solutions become so much harder to enact. Opportunity is perceived as threat and self-interested or self-preserving responses, disengagement or even conflict are more likely. Progress is slowed. One of the challenges of leadership in healthcare is harnessing an overarching passion for improving patient care while still attending to the beliefs of those whose day-to-day work will be affected.

Identity is also why some doctors take complaint, criticism and inevitable error so personally (something I discussed in this blog). A criticism about who you are is bound to cut more deeply than one about a service to which you contribute, and is more likely to elicit a defensive response than productive enquiry and exploration of the cause and effort to improve.

So medical identity matters. At a personal level it matters because the one certainty of a career in medicine is that it will end: what does that leave you with if your identity is your work? At an organisational level it can hinder progress. So pay attention to your identity: medicine is (just) a hugely fulfilling, privileged and important job that done well can deeply affect the lives of many people. But when you disappear down its rabbit hole too far, when your job becomes who you are, you’ve got a problem.

I’ve been slowly realigning my identity away from my assertion twenty years ago that my job is who I am. I’m also a father, husband, son, friend, cook, host, occasional writer and enthusiastic (but average) cyclist. One of the few good things to come out of my illness was to accelerate my preparation for the day when I have to let go permanently that part of my identity that says I am a doctor.

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Note on the image:

Why an iceberg? For an example see this post or search ‘Identity Iceberg’