In 2002 the British Medical Journal published an article on 'Unhappy Doctors'. (1) The authors noted declining morale among doctors worldwide, investigated this, and found it was not to do with workload or pay (important though these were). Rather the key factor appeared to be change in the 'psychological compact' between the profession and employers, patients and society. The job the doctor is now expected to do is radically different from the one they had expected on graduation – the 'unspoken agreement' between doctors and society has been changed.

In the 'old compact' doctors sacrificed early earning, studied and worked hard as trainees, saw lots of patients, and provided good patient care (as defined by the doctor). In return they got reasonable remuneration, reasonable work/life balance after training, autonomy, job security, deference and respect. But society has a new set of imperatives which cut across the doctor's expectations. These include greater accountability, working to guidelines and protocols, patients who have become consumers and want care at their convenience, more external scrutiny, and a growing blame culture.

The authors advocated a 'new compact', explicitly agreeing what the doctor gave to patients and society and what they could expect in return. However, as Christian doctors we don't simply have a contract with our employers or a compact with society – we also have a covenant relationship with the Living God.

Historic views of work

So what difference does this covenant make to our work? How does God view our work, and what are the implications for our behaviour and relationships there? Unfortunately biblical teaching can be in short supply, so for many Christians it is society's view of work rather than God's that colours their thinking. Ryken2 helpfully sets out a historical perspective.

Do any of these sound familiar?
• The Classical (Greek and Roman) view was of work as a curse, an obstacle to leisure, and the province of slaves. This view still shapes thinking: work is seen as an unpleasant necessity. 'If only I could win the lottery I could give up work and enjoy myself.'
• In the Middle Ages a dichotomy developed between secular and spiritual work. The only true vocation was priest or nun – anything else made you a second-class Christian. This attitude dangerously suggests God is not interested in our secular work and so does not care how we carry it out. Nothing could be further from the truth.
• A sea-change came with the Reformation, the Puritans, and the now much misunderstood 'Protestant work ethic'. The reformers fought to break down barriers of sacred and secular, believing God was sovereign in all areas. They taught that all work should be done to the glory of God and was thus sacred, and developed the doctrine of calling or vocation.
• However, the (so-called) Enlightenment perverted the Protestant work ethic. The spirit of humanism replaced the Spirit of God. Work became man-centred not God-centred; a means to the end of personal success and money. Work was removed from the idea of partnership with God in stewarding his world, and exclusively understood as self-interest. Adam Smith, an architect of capitalism, said: 'It is not from the benevolence of the butcher, the brewer or the baker that we expect our dinner, but from theirregard to their own interest. We address ourselves not to their humanity but to their self-love.'
• In the 19th and 20th centuries two opposing views competed: unrestrained capitalism and Marxism. But as Brian Griffiths aptly states in Morality in the Marketplace: 'The trouble with capitalism is that there is no limit to man's greed and the trouble with socialism is that there is no limit to man's desire to control'.

Do you recognise your views above? Let's be honest: for many of us it is the Enlightenment view. We work hard for maximum gain and to fulfil our personal ambitions, and if thwarted can all too easily react with cynicism, despair or anger.

The theology of work

First, God is a worker: 'By the seventh day God had finished the work he had been doing; so on the seventh day he rested from all his work'. (3) Jesus confirms that God continues to work: 'My father is always at his work to this very day, and I, too, am working'. 4We are created in the image of God and work is part of God's perfect plan for us.

Secondly, work is a creation ordinance: 'The Lord God took the man and put him in the Garden of Eden to work it and take care of it'. (5) Work is part of stewardship and partnership with God, expressing an aspect of the divine character within us. God works through us to achieve his purposes.

However, work has been marred by the Fall. (6) Work becomes toil, often appearing futile and senseless. (7) It becomes subject to abuse: idleness, unemployment, and exploitation. Many find work burdensome, boring, and apparently pointless and count the days until retirement. For others, including doctors, work becomes an idol. We define ourselves by it and draw all our self worth from it. If we lose it or it goes wrong, we despair.

But the good news is that work can be redeemed! Let's look at three perspectives:
• Jesus' work on the cross. Jesus is the creator, sustainer and reconciler of all things. (8) All life is God's. He created it, sustains it and redeemed it. God is interested in whatever we do and can be glorified by it: 'So whether you eat or drink or whatever you do, do it all for the glory of God'. (9)
• The worker is a steward for God. One of the most significant passages about work is Jesus' parable of the talents. (10) It teaches us that God provides us with talents, opportunities and materials. He expects our service (laziness is harshly judged). Furthermore, as stewards we exercise choice and responsibility. Our faithful work is rewarded, often with more responsibility!
• The worker is called by God. The reformers talked about two callings: the first was to salvation, godliness and discipleship; the second to work for God. Prior to the Reformation this was seen simply as a call to 'religious' work; Luther and Calvin extended the concept of vocation to every legitimate form of work. They based this on both Old and New Testament Scripture. God called Bezalel and Oholiab as craftsmen and teachers. (11) We are called to do good works, prepared in advance for us. (12) Paul teaches that 'each one should retain the place in life that the Lord assigned to him and to which God has called him'. (13)
  If work, in our case medicine, is a vocation or calling from God, important implications arise:
• Contentment. Paul talks in Philippians 4 about being content in every situation. If God has called us then knowing we are serving him makes even difficult or dull work special.
• Persistence. This is particularly relevant given the high medical 'delinquency' rate. If God has called us to medicine, we should not readily give it up unless he calls us elsewhere.
• Service. If work is a calling from God then it is not just an arena in which to serve, but part of our service to God.

In summary, Christian doctrine starts with God working through us as workers in his image. Initially an entirely good gift, work became marred through the Fall, so it can be difficult and frustrating. Work can be redeemed through knowing we are stewards called by God into work we do for him and with him. As Paul says 'Whatever you do, work at it with all your heart, as working for the Lord, not for men'. (14)

How should we work?

This theology has enormous implications. Some are political. If work is so important, is it right for economics to focus on profit and efficiency without taking into account the impact on the numbers and nature of jobs? Some are personal. Work is not just paid employment or church service. It includes caring for children, housework, and voluntary work: these equally important areas of activity sustain us as communities. However, let's concentrate on how God's view should impact our behaviour as Christian doctors.

1. Work is a moral imperative. Proverbs criticises 'the sluggard'. Paul teaches: 'If a man will not work, he shall not eat'. (15) Skiving is out! Not pulling your weight in a team will destroy your Christian witness.
2. Work must not become an idol. This is a real danger; Christian doctors must not put work before God. (16)
3. Meet human needs. Consider this in choosing your specialty. Puritan Richard Baxter said: 'Choose not that calling in which you may be most rich and honorable in the world, but that in which you may do the most good'.
4. Aspire to excellence. 'Do your best to present yourself to God as one approved, a workman who does not need to be ashamed'. (17) However, excellence must extend beyond the technical or academic to encompass a vision for service.
5. Glorify God. He hates dishonesty; we need to beware of the subtle ways doctors can be dragged into this. Dishonesty ranges from consultants doing too much private work in NHS time to amedical student saying 'The results aren't back from the lab' when they really mean 'I forgot to take the blood'! It can be as serious as forging research results or as trivial as allowing your secretary to say you are out when you're in! We need to work hard to ensure Christian integrity, and that of our organisation.
6. Be enthusiastic, not cynical! One of the most corrosive and debilitating forces in medicine is cynicism. Almost every ward round, management meeting and canteen meal is poisoned with cynical remarks. It prevents excellence and undermines teaching; relationships are reduced to twodimensional caricatures. We will never be salt and light if we are infected by cynicism. The antidote to cynicism is Christian enthusiasm; we have been given our work by a sovereign God and we have the opportunity to show his love to tens or even hundreds of people every week. In the power of the Holy Spirit, we must work enthusiastically – then we will make a real difference to our patients and institutions.
7. Build Christ-centred relationships. The health service is based on relationships between doctors, patients, nurses, health professionals, managers and students. Many of these relationships have become damaged and corrupted by sin. Restoring and rebuilding them is a key way in which we can serve God in our work.

How can we build Christ-centred relationships?

• Be servants. Doctors are not always good at this! Try taking the 'Nescafe Test' – how many cups of coffee do you make for your secretary/receptionist compared with the number they make for you? Being a servant means looking to others' interests rather than our own. (18) We will listen to other disciplines and seek the good of the whole service, not just our specialty. We will seek to serve patients and colleagues.
• Be holy: '...just as he who called you is holy, so be holy in all you do'. (19) In practice this includes avoiding gossip (20) – hospitals are full of it! It means being peacemakers. (21) Finally it means sexual purity. Relationships between staff are often close and emotionally intimate. Sexual temptation can be very strong but '...among you there must not be even a hint of sexual immorality...' (22)
• Be careful with anger. There is such a thing as righteous anger (eg Jesus cleansing the temple). It may be right to be angry when incompetence, laziness or bad management put people at risk. However, I have struggled here. We must be very careful what we do with our anger. Paul says: 'In your anger do not sin' (23) and James writes wisely 'everyone should be quick to listen, slow to speak and slow to become angry, for man's anger does not bring about the righteous life that God desires'. (24)
• Exercise Christian leadership. There is often a vacuum in medical leadership; we have opportunity to fill this. We should be willing to take positions of responsibility but as servants, not for self-aggrandisement. As a medical student, be salt and light in Medsoc or the student council. As a junior doctor, organise the on-call rota, or lead in the BMA. Consultants or GPs, give a Christian lead in managing the hospital, practice, trust or PCT. Whatever our responsibility we need to exercise it with prayer, for 'The Lord gives wisdom, and from his mouth come knowledge and understanding'. (25)
• Bring hope. At work we will find many people in need of love and hope. We should always 'be prepared to give an answer to everyone who asks you to give the reason for the hope that you have...with gentleness and respect'. (26) There is the issue of the patient/doctor power imbalance, but we should pray for opportunities.

We need help

Living out our faith as Christian doctors is not easy, so:
• Develop an accountability relationship. We need another Christian we can trust and develop a close and honest relationship with. They need to know us and the pressures we are under. We need to give them permission to ask searching questions about our behaviour and attitudes at work.
• Develop prayer partnerships. If our work in medicine is part of God's work then we should be praying for it. We should pray for our services, institutions, patients, colleagues, and ourselves. I have had the privilege of a close Christian colleague who has been my prayer partner for 20 years and we can testify that prayer works.
• Seek Christian career guidance. Romans 12:3 exhorts us to have a right view of ourselves. As a trainee think about taking jobs locally to keep in contact with church and Christian friends. Have a realistic view of your skills, response to stress, and ability to withstand sleep deprivation. Do not take a job that is going to stretch you beyond your limits unless God tells you very clearly to do so!
• Spend time with God in Bible study, prayer, worship and meditation. Work is an integral part of our Christian life but it must not take the place of building our relationship with God. Our work will fade and die but our relationship with God will last for all eternity.

further reading

Ryken L. Work and Leisure in Christian Perspective. IVP, 1990 . Greene M. Thank God it's Monday. Scripture Union, 2001