Can a sick note make you better? Dr Gavin Francis on the power of convalescence
While training to become a GP, Gavin Francis became ill with a severe sinus problem. In acute pain and exhausted as he waited for an operation, he chose to reduce his hours to three days a week. “I persuaded myself that there was no point risking burnout for the sake of sticking to a schedule,” he writes in his new book, Recovery: The Lost Art of Convalescence. “I qualified all the same, albeit a couple of months late.”
This strikes me as an unusually proactive “physician heal thyself” attitude for a junior doctor. But Francis’s whole approach to practising medicine feels unusual. Growing up in Fife with a passion for science, he chose to study medicine because “I wanted to have a job that would give me a kind of trade; all the men in my family seemed to have a trade of one sort or another.” Then there’s the fact that on qualification, after a year as a junior house officer, he headed off to explore the wildest parts of the world for a decade, visiting the Arctic, motorbiking across Asia to New Zealand, and working for the British Antarctic Survey.
“It was so peaceful,” he says of his time there when we speak over Zoom. “There was so much time for contemplation.” He missed the buzz of clinic life, but he already knew he did not want to return to emergency medicine. “I didn’t want to go back to that highly pressurised environment of resus and ambulance sirens.” Now he tells medical students to “look at the doctors around them, look at the lifestyle they have and imagine if they want their lifestyle to look like that in 20 years’ time. I suppose it would be fair to say I was quite good at doing that early on.”
In his work as a GP, Francis spends half the week in a small practice in Edinburgh, including a morning a week at a clinic for the homeless, which he’s just left when we speak. Two or three times a year, he helps out in remote Hebridean island practices, immersed in the wild, landscapes and big skies he believes help him stave off burnout. The rest of the time he spends with his primary school-age children and his writing: essays, reviews and books, on travel and wild places, and on his experiences at the frontline of general practice, including the gripping, tender, bestseller Adventures in Human Being, described by Hilary Mantel as “sober and beautiful”.
“I love practising medicine,” he says. “And I can’t imagine stopping, but it’s quite emotionally exhausting. I discovered early on that a really wonderful way for me to do medicine that made me more effective as a doctor and also helped me flourish, I suppose, as a human being, was to do a full intense day and then to have a day off to think about it and contemplate it.”
Francis devotes time to his own recovery from a job notorious for burnout and never more so than now, as an underfunded, traumatised NHS faces another winter of Covid firefighting. (“The days of people clapping on Thursday are long gone,” he says. “People are getting really, really tired after two years of this.”) Avoiding getting depleted to a point where he is “exhausted and inffective as a doctor” is both for his own and his patients’ benefit. “I needed to find a way of doing medicine that helps my patients, too, that is a much more sustainable, creative, mutually helpful relationship.”
This makes him the ideal person to explore the “lost art” of recovery and convalescence. It’s also something that has been in the forefront of his mind for a while. “In 2020, I spent such an extraordinarily large amount of my time talking to people about recovery and convalescence, not just recovery from Covid, but from all the crises of mental health that were provoked by lockdowns and just also talking to people about recovery from surgery, from emotional crises in their life… It came up again and again.” He wrote his latest book, he says, because “I realised there are huge numbers of things I take for granted in those consultations that my patients don’t, and I wanted to put them all in one place.”
The slim volume he has produced – a collection of reflections, really – is humane and thoughtful. Combining personal reminiscence, hard science and history, it explores the architecture of convalescence, rest, treatments and placebos, the healing power of nature and the transformative impact a sick note can have. I particularly like this section, I tell him, which provides a powerful counter-narrative to tabloid tales of malingering and fraud. It was influenced by Francis’s early working experiences in Muirhouse, an area of socio-economic deprivation.
“One of the GPs there taught me that sick notes can be the most powerful prescription I ever write. Most people try and go back to work too quickly; the amount of abuse in the sick note system is tiny, about 1%. It can be a lovely thing to actually reassure somebody, ‘You need time, you need to give some respect to this process.’” He likes, too, the fact that a sick note can be deliberately left vague. “Quite often, I’ll put ‘life crisis’. If somebody’s basement is flooded, their cat died, and their wife left them all in the same week, that’s a life crisis.”
Recovery is fascinating, too, on the greater respect convalescence was accorded in the past. Francis describes the “glorious, sunlit, southfacing” wards and wide wheelchairfriendly corridors of the Princess Margaret Rose hospital in Edinburgh, which was designed in the 1930s for patients to recuperate from tuberculosis. Another convalescent hospital where he worked, the Astley Ainslie, “was set up in the 1920s not only to help patients convalesce after acute illness, but also to fatten them up before surgery. It’s amazing, now to get a single night in a hospital bed, you have to have a medical diagnosis and a plan in place that’s going to prioritise getting you out as quickly a possible.”
Of course, there are many things we do better now: “We’re doing mental health a lot better, the range of treatments we have available are fantastic, the fact that you’re not plunging your family into destitution every time you get ill, all those kinds of things are much better.” But the Victorians and Edwardians were more enlightened when it came to valuing rest and understanding how slow recovery can be.
The book is clear-sighted and accepting of the limitations of what doctors can do, particular in relation to chronic conditions and that slow, often non-linear, process of recovery. “People get a slightly inflated sense of the power of western medicine sometimes,” says Francis, “and they’re quite surprised we don’t have an answer. I wanted to lay that out – that lots of times in medicine we can’t cure what’s going on.”
This feels particularly timely, as a survey reveals there are 1.3 million long Covid sufferers in the UK, many struggling with the lack of effective treatment strategies. “People can get frustrated when I say we don’t understand the reasons for post-viral fatigue, we don’t really have a good grasp on what the mechanism is,” Francis says. “We are frustrated, too.” This is, he reminds me, not a new phenomenon. “The ancient Greeks talked about post-viral fatigue and we are not really a huge amount further on.”
The chapter called “Snakes and Ladders” reproduces the pro-forma NHS advice a long Covid-suffering friend also received, with its advice to: “Don’t rush, get fresh air, push, don’t pull, slide, don’t lift…” She found it both helpful and maddening, I tell him, reading out what she texted me: “Basically what you are told is, ‘Sorry your life sucks, that is just the way it is now and you have to deal with it.’”
Francis thinks it’s not quite that negative or judgmental (though he accepts it’s “typical NHS: one form for everybody whether you are 80 or 20”). “You’re in this predicament and here are some ways we’ve seen to be effective to get out of your predicament. I wish there was a pill for this but there isn’t.” He’s acutely aware how scary Covid has been for many sufferers: “I’ve had 25-year-old marathon runners take weeks to recover, have weeks where they were struggling to walk up their first-floor stairs. It’s frightening to be reminded of your mortality and how fragile we can be.”
Many patients take comfort, he says, in knowing they are not alone and that most sufferers make a good recovery in the end. “People recover from Covid. The figures are starting to come in. There’s a long tail, but it does continue to drop, the number of people still experiencing symptoms just goes down and down.” He promises me, too, that the pandemic will end, when I ask, plaintively, though a respiratory specialist colleague predicted we were in for five years when they spoke in June 2020.
Recovery is not a book that pretends to have the answers, other than the overarching message that healing – from anything – is completely specific to the individual and is a process that requires patience, from both sufferer and physician. Accompanying a patient on a long, unpredictable recovery feels to me like a different job and skill set than the one most people become doctors for. But for Francis, it’s absolutely part of the job. “If you go into medicine expecting to cure all your patients, you’re going to be disappointed very quickly. If my job can somehow ease suffering a little, or give someone a little more dignity or a bit more autonomy, even if I can’t do anything about their condition, then it’s probably worthwhile.”
Although “carbon guilt” may have put paid to some of the wilder far-flung adventures Francis would have undertaken 20 years ago, he’s planning to get back out for some “big overland trips” with the family when Covid allows and his children are old enough to enjoy them. In the short term, he’s planning a road trip to northern Italy’s Po Valley, to visit his wife’s family, and respecting the “really lovely rhythm” that works for him. “I would love to persuade more of my colleagues that’s a good model,” he says, but staffing challenges (“We need far more doctors and nurses in this country”) sadly make it unrealistic.
Even with all the frustrations of working in the NHS in 2022, Francis can’t imagine wanting to do anything different, as long as it is balanced with enough breathing space. “It’s a wonderful job as long as you can keep the pressures of it within certain bounds. It’s immensely satisfying, no two days are the same and you have this wonderful opportunity to meet all kinds of people and have sometimes transformational, sometimes quite mundane conversations with them and do something often quite modest, small and realistic about making their lives a little bit better… You can’t ask any better than that.”
Recovery: The Lost Art of Convalescence by Gavin Francis is published by Profile at £4.99. To order a copy for £4.23, go to guardianbookshop.com
Most people try and go back to work too quickly. A sick note is reassuring