As he hung up his coat at the end of the morning, he stunned his nursing and junior colleagues: “I will be glad when I don’t have to do that clinic anymore.” It was a cancer clinic in a non cancer speciality. Everyone in outpatients thought he was wonderful; a caring clinician, a good listener with time for everyone, and great with patients in many difficult circumstances.  He seemed to take it in his stride, everyone enjoyed working with him, a superb role model, and no one ever noticed that he found it difficult. He never said anything.

Relentless, draining, wearing. The daily, weekly, yearly ebb and flow of ill health through the surgery door. A job where every day is different means that every day is a challenge.  In specialist medicine the pressures are easier to see—in general practice, trivialities deceive, but every cough could be cancer, and every minor complaint the undifferentiated prelude to significant illness. Hidden among the minor and self limiting are the serious and life ending. Everyone dies, and almost everyone sees their doctor first.

In palliative care there are no happy endings. Those committed will tell you there is no job more rewarding than sharing someone’s last illness. But, aspiring to ease patients on life’s last journey, the rewards must always be relative. No problems solved, treated, or cured. A good death. I admire my palliative care colleagues and appreciate their tough role. But, no one can give forever. Every day testing the ability to recover.  Endlessly draining, they must eventually come to the bottom of the tank.

The better the doctor—the more caring, compassionate, empathetic, and generous—the greater the price. Just three examples from different parts of healthcare. Maybe medicine should begin to talk about this.

Domhnall MacAuley is primary care editor, BMJ.