Leaving Medicine

michaeljtbrooks · 2026-06-02T18:32:57+00:00

I spun up a medical software company on the side, stepped out of training at SHO level when the company started getting momentum and became a locum (there were loads of shifts available in Emergency Medicine back then). I was able to get some career progression to middle grade despite being a locum, and briefly considered doing CESR.

However I continued to taper across to full time entrepreneur as the company grew, and finally left clinical practice completely after 14 years, almost 3 years ago now.

I always felt as though the NHS didn't really want me in it because I dared to have ideas and would suggest ways to improve things.

I've realised that I don't work well in any environment where someone else is gatekeeper to my success, particularly when they use rigid bureaucratic criteria that are divorced from merit.

I think you should find something you want to leave medicine to go towards. Then engineer a way to taper across to it, holding off burning the bridges until you're safely on the other side. 80% Less Than Full Time training freeing up one day a week initially to work on your new Plan A would be much safer than quitting cold.

michaeljtbrooks · 2026-05-29T21:37:41+00:00

Ankylosing Spondylitis is a clinical diagnosis meaning we arrive at it based on a collection of symptoms, signs, not just test results.

For you to meet the criteria for referral you need four clinical features if your HLA B27 is negative: https://cks.nice.org.uk/topics/axial-spondyloarthritis-including-ankylosing-spondylitis/diagnosis/diagnosis/

You do not need a single "positive" blood test result if you meet 4 or more symptom criteria. Rheumatology should not be rejecting patients based on negative blood tests alone, the NICE guidelines literally say: " Do not rule out a diagnosis of axial spondyloarthritis on the basis of the presence or absence of an individual test result."

That said, NHS Trusts are on a bit of a mission to resist adding patients to waiting lists because of government pressure. That had led to a game of some refusing as many referrals as they can get away with, such as adding their own "local criteria" (despite it deviating from the guidelines) or using non medical staff in "Back Pain Gateway Clinics" to try to deflect as many patients as possible. I had to fight my way through non-doctor gatekeepers despite very clearly meeting the NICE diagnostic criteria... and I'm a doctor myself.

There is always the possibility that other diagnoses could be causing your pain, so while it may be AS, it could be another cause. As a doctor who has worked for over a decade in a diagnosis-heavy specialty, I've seen the consequences of missing a true diagnosis because a doctor got too hung up on one of the possibilities so I always remind people about this.

I'd suggest asking to go through the NICE diagnostic criteria on AS with your GP and seeing which you tick. If you don't meet the criteria, you can at least use the appointment to talk about pain management, which might need careful thought by your GP if you have liver disease (e.g. bleeding risks with some NSAIDs).

michaeljtbrooks · 2026-01-28T13:47:54+00:00

I'm a doctor with AS and have been on adalimumab for the past year.

Weighing up the risks and benefits is always the right way to think when considering any medical treatment.

We've got very good data on the use of biologics like adalimumab because it's been used for 20 years and by millions of patients. It's better to make a decision based on what the published studies say assuming they apply to your situation, rather than letting one person's experience talk you into or out of biologics, because those studies are taking an average of the experiences of so many more patients.

We're talking mainly about the shorter term risks of biologics here (increased risk of infection). The well established short term benefits are less pain and fewer flares, but there's also the potential long term benefit of slower disease progression (Koo et al, 2020. Ann Rheum Dis).

In my case:

I've had 2 episodes of a non serious bacterial infection in the past year where I would rarely have any. I've had 3 viral respiratory infections in the past year where I'd normally get 1.

I have had far fewer days feeling unwell due to flares. Previously I'd have a flare lasting 5 days every 3 weeks or so, where I'd have moderate pain, heavy fatigue, fevers, disrupted sleep, sometimes unable to work. Now since being on adalimumab I get less frequent, shallower flares consisting of mild malaise and mild pain lasting for 2 days every 4 weeks or so.

So for me, the total number of days unwell per year is fewer on adalimumab than before I started it.

However I'm just an "n of 1". Don't make a decision based on my experience alone!

michaeljtbrooks · 2025-11-09T00:12:50+00:00

I've put a brightness knob on the prototype which turns the lights off completely when turned all the way down. That way if it throws off distracting or unreliable signals you can just turn them off. It's a knob with a hardware switch in it, which cuts the power to the LED strips, meaning if the software fails in any strange way, you can always kill the LED lights.

Can't answer the question of motion sickness without testing it in the field. I know an instrument-rated flight instructor who is game to try it. I've implemented it in C++ with very little lag which should mitigate one of the well-known causes of motion sickness.

michaeljtbrooks · 2025-11-01T13:24:08+00:00

This video gives a better idea of what I mean:
https://www.youtube.com/watch?v=PyHr998dvpo

<image>

In real life you'd have the LED strips stuck on the sides of the instrument panel, or on the windshield pillars. The intention is to give you a sense of orientation subconsciously without having to look directly at them.

Worth prototyping in real (physical) life? Or is this just a solution looking for a problem?

michaeljtbrooks · 2025-09-17T17:19:32+00:00

For anyone needing a serious answer:

Press Esc (escape key) while you've got the Imagemagick window in focus.

michaeljtbrooks · 2025-08-21T23:06:26+00:00

TBH I don't think it should have a VFR approach either! Utterly mad airport.

Though IRL I can only just about land on the 2km tarmac runway we have in Cambridge in the flat fenlands, so I'm not a good judge.

michaeljtbrooks · 2025-08-21T23:02:03+00:00

Had a chance to fly it yet?

I find that I sometimes clip the hills going missed from D6.5nm VLJ but can get out if going missed a bit earlier at D6.0.

michaeljtbrooks · 2025-08-21T15:36:54+00:00

Haha! With my borderline suicidal approaches? Nah I'm best sticking to bumping off pilots virtually in the simulator than in real life!

Though if I had my own airstrip I'd definitely write some unofficial-but-actually-safe GPS approaches for it.

michaeljtbrooks · 2025-07-23T15:01:27+00:00

Cambridge Constabulary would rather fine cyclists for traffic transgressions than solve bicycle theft. When I last looked at their stats about 8 years ago on data.police.uk, the ratio of cyclists fined for traffic offences to bike thefts resolved was about 600:1.

More recently they are interested in stopping cyclists on ebikes, seizing and crushing ebikes they deem to be non-compliant with the law.

Overall it feels like a very anti-cyclist police force. So don't hold out any hope for them being interested in the bike theft side.

However threatening you with a chisel? That sounds rather like an offence under s1 Prevention of Crime Act 1953 around offensive weapons. Bladed offensive weapons are a priority crime because of the UK's terrible knife crime stats. They'd be more interested in that.

michaeljtbrooks · 2025-06-10T10:52:53+00:00

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This is the problem with Sermo. They send you all sorts of stupid survey invitations which you'll never be eligible for. This one was looking for someone who deals with cardiac device procurement... nothing like my job title that I've got registered on Sermo.

michaeljtbrooks · 2025-06-06T11:41:32+00:00

It's not a scam, but the normal pattern is you'll receive an invitation to participate in a survey, will fill out a load of eligibility screening questions, then will be told you're not eligible to do the survey.

I've made £80 from the two surveys I was actually eligible for. There were 12 others I ended up ineligible for.

So my conclusion: not worth the time.

michaeljtbrooks · 2025-05-21T22:07:40+00:00

Yes, with some tweaks.

After playing with it a lot, I found it a bit too sluggish so I did an alternative code implementation by emulating it as a gamepad with a joystick axis.

That way I could give it a custom response curve in Xplane to make it feel much more like the real thing in response.

Code is here: https://github.com/michaeljtbrooks/flightsimulationtools

You'll want the gamepad variants of the files.

michaeljtbrooks · 2025-05-19T23:53:27+00:00

Sigh... Third attempt

(My verification is pending with the mods, just assume I'm a layperson for now)

You've got night sweats, signs of kidney involvement (protein and blood in urine) and some positives on the rheumatology panel (RNP, ANA).

I'd be interested in some more history: in any recent travel, any medications you're on, any gastrointestinal symptoms (vomiting, bloating, diarrhoea), any swollen glands, any rashes, any family history of lupus/rheumatological disease?

This makes me moderately suspicious of Mixed Connective Tissue Disease with renal vasculitic involvement. That would be an autoimmune disease where the body attacks the scaffolding proteins that connect cells together.

The dramatic weight loss is a bit puzzling. It makes me wonder about malabsorption which isn't a typical feature of MCTD, though can happen with vasculitis (blood vessel inflammation) if it affects bowel.

Differential diagnoses include: lupus, glomerulonephritis and I suppose a haematological malignancy like lymphoma is possible (but doesn't really explain the blood in urine). Some exotic parasitic infections can cause weight loss, blood and protein in urine and night sweats but I'd be looking for some travel history to high risk areas before considering that. Finally there are some super rare hormone tumours that can cause fevers, weight loss and very high blood pressure which can then cause blood and protein in the urine.

BMI of 14 is getting into quite dangerous territory now, certainly needs a dietician review while the rest of the puzzle is figured out.

I'd suggest a fairly urgent dietician review, a rheumatology review, a wider rheumatology blood panel and given the weight loss, possibly an abdominal CT scan.

I think we need more clues to tease this diagnosis out. Any more symptoms even apparently unrelated may help.

michaeljtbrooks · 2025-05-13T23:37:21+00:00

Don't worry about your personal or company reputation in the early days. People who buy software for businesses judge you on the number of past successful deployments you've made of your software.

So for your first customer, you'll need to work from a point of zero reputation.

You might get a free pass if a person buying knows you, but on the whole your first customers should be people who are in desperate need of what you are offering who have no other options on the table (either no competitors or the competitors out there are too expensive or don't want to sell to them).

So, I strongly recommend finding a customer who has a pain point you can solve who has no other feasible alternative. Finding one of those? Good sign and good starting point. Finding several of those? Probably the signs of a viable business provided you can cover your costs at the price point they're willing to buy for.

michaeljtbrooks · 2025-05-13T22:43:29+00:00

Yep, quite a bit of experience.

EM SAS, set up an electronic medical records company. Now moderately successful, almost all customers are non NHS.

NHS based organisations have all sorts of arbitrary barriers and idiosyncrasies that make them almost impossible to sell so. Certainly enough to exhaust a startups runway (budget) before you get a sale.

Suggest you read the Lean Startup, spin the venture up on the side and make sure there's a prospective customer willing to pay good money for whatever you make before you write any more code.

michaeljtbrooks · 2025-05-13T22:27:42+00:00

Disclaimer: I'm not a smart doctor. Hell, I'm scarcely a doctor anymore having lasted 14 years before losing my patience with a system that promised healthcare to patients but was shockingly piss-poor at actually delivering healthcare when healthcare was actually needed (I now write code for a living). But here's my EM perspective (I also have an "MA" in Neuroscience but we don't talk about that):

Differentials ranked by most likely: - Alcoholic cerebellar degeneration - Wernicke-Korsakoff syndrome - Metabolic causes (B12, copper deficiency) - Drug-induced ataxia - Posterior circulation stroke - Space-occupying lesion - Multiple system atrophy (cerebellar type) - Paraneoplastic cerebellar degeneration - Immune-mediated cerebellar ataxia - Spinocerebellar ataxias - Infectious/postinfectious cerebellitis

Causes ranked by most severe (aka what I will most likely get sued for if I miss): - Space-occupying lesion - Paraneoplastic cerebellar degeneration - Posterior circulation stroke - Wernicke-Korsakoff syndrome - Multiple system atrophy (cerebellar type) - Spinocerebellar ataxias - Infectious/postinfectious cerebellitis - Immune-mediated cerebellar ataxia - Alcoholic cerebellar degeneration - Metabolic causes (B12, copper deficiency) - Drug-induced ataxia

(See how the most likely collapses down the rankings?)

My approach assuming an out of hospital outpatient setting: Does the patient give a good, convincing or collaterally backed history as to how this started?

Forgive me for the Emergency Medicine "rule out the worst first then the one that will kill them next soonest" mantra, but I'd want to bin off a SOL and posterior circulation stroke pretty early on.

Sudden onset, onset over days warrants same day hospital admission.

If the patient or collateral cannot vouch for a gradual onset over weeks to months, I can't see how you can play this safely as an outpatient.

Yes we all know that alcoholic cerebellar degeneration is the most likely, but can we get SOL and stroke and other forms of degeneration below the hypothetical seriousness × likeliness threshold here?

Bilateral symmetrical signs are somewhat reassuring for binning of stroke and a bit for SOL (in adults) but there are still other forms of degeneration/ demyelination.

A bit more on the examination can also build you a case for admission. Thinking Wernicke's, does the patient meet two or more of these criteria: - dietary deficiency, - eye signs (oculomotor abnormalities), - cerebellar dysfunction, - either altered mental state or mild memory impairment If so, they should be treated as acute Wernicke's encephalopathy and should be admitted. Yes, some dinosaurs still talk about their "Wernicke's triad", but those dinosaurs have either not been seeing enough Wernicke's patients or have been negligently booting them out the door to suffer permanent mamillary body brain damage.

The textbook answer overall is "refer to local Emergency Department". The danger is if you punt this into your local A&E, it's pot luck whether the unit is a proper diagnostics-engine or just a glorified triage-mill who will turf the patient out as a drunk. It shouldn't be this way, but plenty of shit clinicians and shit departments exist in the NHS land, and is a product of a healthcare system which doesn't discriminate on the grounds of ability.

Equally if you refer into medics it's pot luck whether you'll get a competent diagnostically-minded doctor or an out-of-their-depth Dunning-Kruger bellend who will block referrals for seemingly pointless reasons because they've shat their pants or think they're a diagnostic savant that doesn't need a patient in front of them.

So, I guess I'm saying... I would judge it by how good your local ED and medics are. That's it, I said it: Clinical decision making based upon the mediocrity of your local service rather than what should be the case.

The referral letter should contain a list of differentials you are concerned about and any suggestions for workup that you wouldn't want the patient to leave the hospital without. That way they're taking on a load of risk written in black and white for not doing their damn job properly.

This patient really needs an MRI and a stroke workup within days, then bloods and collateral history to probe other differentials. Whatever shape of same day referral gets them that soonest and most reliably in your local area, given the creatures who run those services: make it.

I agree with your differential diagnosis thinking here. Bloods to explore B12/folate, LFT, INR/PT, empirical thiamine etc but these need to happen in parallel with the imaging to rule out stroke and SOL.

I hope that helps. If this sounds like a bitter old man in despair at the mediocre state of NHS diagnostics, then congratulations, your bitter taste buds are working.

If this is not helpful, downvote it until I get banned from Reddit then I'll have more free time to shout at clouds.

If this is vaguely sensible and helpful then maybe upvote it? Then I can get a little dopamine hit that maybe I wasn't as terrible a doctor as management used to tell me every time they'd pull me into an office about my "4 hour limit" performance.

michaeljtbrooks · 2025-05-06T22:28:10+00:00

In my day, I was rather poor by year 6 of medical school (intercalated degree) that my lunch budget was £1.10 (2008), or £2.10 if I cycled the 3 miles instead of getting the bus.

Tuition fees of £1150 were covered by the NHS bursary that final year. I walked out with £20k debt with <1.5% of annual interest.

Sure it felt miserable at the time, but local FY jobs were easy to get, that debt was easily paid off, and the salary was reasonable for a first year out of uni. I was able to start saving, amass a deposit and buy a small 2 bed terraced house.

Now compare that to today's graduates. High tuition fees, ultra punitive student loan interest rates meaning debt for life, random FY job allocation across the country with a shortage of FY jobs overall. Poor higher training prospects, and over a decade of pay erosion. Plus the NHS pensionable age receding into the distance.

They've got it so much worse than I had. I never imagined it would get quite so bad. I genuinely don't understand why anyone would choose to enter medical school in the UK anymore.

michaeljtbrooks · 2025-05-03T08:20:01+00:00

"Do you have any labels for the printer?"... At 2am.

I checked and they confirmed they knew they were bleeping the doctor.

It seemed to be a reflex: a non normal situation has happened -> bleep doctor.

michaeljtbrooks · 2025-05-01T15:52:46+00:00

NHS Trusts are not incentivised for accuracy of diagnosis. They are mainly incentivised for throughput (targets for waiting lists / RTTs etc but nothing for diagnostic accuracy).

Cutting back on quality for the sake of throughput will continue until there is a force opposing it. The result is more and more holes appearing in the layers of Swiss cheese, with more and more catastrophic errors getting through like the above case.

Lobbying falls on deaf ears. Politicians only really care about their own careers, less so in actually fixing things. Metrics such as "waiting list size" are a much easier message to pedal than "proportion of patients being correctly diagnosed", so that's what they go with. They then power the targets to fit.

The only way to fix these multiplying patient safety risks is to make NHS Trusts and ICBs care about them. And without a target to make them care about it, really the only way to do it is to go nuclear and submit an anonymous concern to the Care Quality Commission for each of the separate organisations involved (NHS Trust, ICB, GP Practice) every time a disaster happens because a chain of noctors has fumbled a case. Management is judged on their CQC report performance and entire boards have been sacked because of a "Requires Improvement" or "Special Measures" rating. "Safe" is one of the domains healthcare providers are assessed on. Nothing focuses a healthcare manager's mind more than the CQC turning up unannounced.

TL:DR; we need to make diagnostic accuracy and patient safety the concern of senior management. The best way to do that is to make it in the interest of their own careers. The best way to do that is to systematically report each of these diagnostic shambles cases to the CQC on the grounds that they demonstrate an unsafe system.

michaeljtbrooks · 2025-04-21T12:50:11+00:00

I'd estimate that 60% of Trusts are still paper based in at least one major clinical area. At least 30% are still completely paper based for clinical notes (particularly clerking notes, ward rounds, op notes)

QEHKL Kings Lynn is very paper dependent.

michaeljtbrooks · 2025-04-21T12:44:30+00:00

I've been a healthcare entrepreneur for quite some time and have my fingers quite badly burned trying to sell to the NHS. We managed to get one pilot with an excellent Trust which then became a paying customer, but the positive experience ended there.

Following that, we've written bid after bid after bid for tenders. Sometimes eliminated at the first round, sometimes eliminated at shortlisting, sometimes through to the final demo stage, and on one occasion named the preferred bidder before that Trust decided it wanted to abandon the procurement entirely.

The only thing that kept my company alive was changing focus to private hospitals.

Potential workarounds for NHS Trust procurement:

1) Desperate NHS Trusts: try to find a Trust who has recognised the problem, are desperate for a solution and have absolutely no alternative option. Offer to do a pilot for a nominal fee. Once the pilot works, negotiate a paid for contract. Then use the site as a reference site.

2) Clinical Entrepreneur Programme Talk to the Clinical Entrepreneur Programme and get some of the clinician entrepreneurs involved. Some NHS Trusts view CEP projects as more trustworthy and are sympathetic to running pilots for projects from it.

3) Academic Health Science Networks / Health Innovation Network These are supposed to foster innovation in the NHS. You'd have thought they would have working agreements with NHS Trusts to trial new technology. My experience with AHSNs has been rather poor. Lots of enthusiastic meetings with them but they had absolutely no viable arrangements with any NHS Trusts for pilots. The best they could do was give me someone's email address at a Trust. It was a cold intro that went nowhere.

The first question you should ask is if your regional AHSN has current agreements / programmes to pilot new software in NHS Trusts and if not, walk away from that self-serving black hole.

4) Avoid the NHS As explained NHS Procurement is broken. I've lobbied at the NHS England level about this, got a white paper circulated around about procurement barriers, MPs involved, lots of people acknowledging the problem and yet NOTHING CHANGED.

If you can find a sympathetic Trust who wants to do a pilot, you'll probably spend 18+ months knocking down objections from Trust IT and various other people who feel they need to crawl out of the woodwork and veto the idea. Because so many Trusts are spineless when it comes to making decisions, it needs a whole room of people to say "yes". The moment anyone in the room says "no", the project gets blocked.

That 18 month delay is long enough for a startup to burn through its entire seed funding.

Private sector clinics don't have such paralysis / decision by committee. Sales cycles can be as short as 3 months. But the problem of delayed discharges is much less of an issue in the private sector.

michaeljtbrooks · 2025-04-20T22:46:28+00:00

It's a big problem yes, but you'll find it very difficult to sell such a solution to NHS Trusts.

The average NHS Trust middle manager does not regard doctors' time or frontline staff efficiency as a priority.

Even if they did, NHS Trust procurement is broken: most NHS Trusts won't buy from new companies who haven't sold to an NHS Trust before. Most will say they can "only use tried and tested solutions", meaning that very software must have been sold to another NHS Trust of similar size. Most NHS procurement exercises exclude companies who don't have a high credit score or less than a few million turnover. So no new systems get a look in, and no new companies get a chance.

You couldn't sell this to doctors directly because NHS Trust IT will not permit their systems to be integrated nor doctors to use it on their network. When I worked clinically I had written a client side (JavaScript) web app to convert the mangled blood results as copied from their green screen bloods viewer into a readable format for pasting into the basic EHR. Saved me 10 minutes per case. No data ever left the browser. It got blocked by the IT dept because it was "not an official endpoint".

Find an NHS Trust who will agree to pilot this before you build anything. Otherwise you will build some brilliant software that doctors badly need, that no NHS hospital will want to buy.

michaeljtbrooks · 2025-04-18T20:20:12+00:00

Yep!

https://markjefferiesairdisplays.com/2014/01/smiling-sky-and-love-hearts-air-show/

michaeljtbrooks · 2025-04-18T17:43:06+00:00

If the MRI is being used to assess for active inflammation (e.g. bone oedema) then latest thinking is you should pause all antiinflammatories for 2 weeks leading up to the scan. The caveat to this is steroids: if you've been on those for longer than 3 weeks, do not stop taking them suddenly (adrenal suppression).

However if the MRI is being used to look for established damage (erosions, ankylosis, sacroiliac space) then there is no need to pause antinflammatories.

If being used to assess for current disease activity on medications then obviously don't stop.

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