Thoughts for new medical students at a new medical = school -- Smith 327 (7429): 1430 -- BMJ

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Home > Comment > BMJ=20 2003;327(7429):1430 (20 December), = doi:10.1136/bmj.327.7429.1430

BMJ 2003;327:1430-1433 (20 December), = doi:10.1136/bmj.327.7429.1430

It's good to talk

Thoughts for new medical students at a new medical school

Richard Smith, editor¹=20

¹ BMJ, London WC1H 9JR rsmith{at}bmj.com

Giving advice to medical students makes doctors = think=20 aboutwhat is important in what they do

Earlier this year I had the privilege of speaking to new medical⁼students at a new medical school=E2=80=94the Hull York = MedicalSchool.=20 What should I say? I felt almost overawed. It seemeda major=20 responsibility, although I knew that most of what Isaid=20 would=E2=80=94thankfully=E2=80=94be forgotten or ignored as⁼the ramblings of yet=20 another "old fart." Needing help and amethod, I started by = asking=20 members of our editorial board,doctors from all over the = world, what=20 I should say. They respondedwith enthusiasm, giving me the = thought=20 that it might be a goodidea to broaden the debate. That's = the main=20 reason for thisarticle: it's a preliminary statement in what = I hope=20 might bea rich debate. In thinking what we want to say to = new=20 entrantsto the profession we have to think of what is = important=20 aboutwhat we do.

What follows is a mixture of my own ideas and those I selected⁼²⁰from the responses of the members of the editorial board. Box⁼1=20 summarises responses from the BMJ's editorial board, and box⁼2=20 gives the full advice of Dave Sackett, the "father of evidence⁼based=20 medicine" (and a member of the board). I also spent sometime = exploring advice from literature to young people, not specifically⁼²⁰medical students (see boxes 3, 4, 5, 7).

"To thine own self be true"

Perhaps the most famous advice to young people in the English⁼²⁰language is the speech of Polonius=E2=80=94a tiresome old = windbag=E2=80=94to⁼²⁰his departing son Laertes in Shakespeare's Hamlet (box 3). = The⁼²⁰speech contains much excellent advice, but perhaps the = quintessence⁼²⁰is, "To thine own self be true." Everybody=E2=80=94but = perhaps⁼²⁰especially medical students=E2=80=94experiences pressure to = besomebody=20 else. In the competitive world of medicine there isstrong = tendency=20 to try to be "the best." But the simplest mathematicsshows = that=20 everybody cannot be the best: there is only one best.

I asked the students when I spoke to them, "What was the = greatest⁼²⁰invention of the 20th century?" Was it quantum mechanics, = aircraft,⁼²⁰penicillin, the atomic bomb, the double helix, the randomised⁼controlled trial? I suggested (slightly tongue in cheek) that⁼it was D W Winnicott's "the good enough mother." (Actually,⁼it=20 was jazz.) The attempt to be the best mother in the world,⁼the best=20 neurosurgeon, or the best medical editor will end intears. = Being a=20 good enough mother is to be a good mother, whereasthe = attempt to be=20 the best will guarantee that you won't be(indeed, you may be = a=20 highly damaging mother). Similarly, youshould aim to be a = good=20 enough medical student and doctor.

One of the curses of doctors is that they have such strong = stereotypes.⁼²⁰Doctors are upstanding, trustworthy, clever, straitlaced,=20 conservative,authoritarian, inhibited, wealthy, right wing,=20 and=E2=80=94often=E2=80=94dull.Many doctors are none of = these things, but as a=20 medical studentyou may feel a pressure to conform to the = stereotype.=20 Don't.A lifetime spent trying to be something you are not = will=20 destroyyou.

Box 1: = Advice to young=20 doctors from members of the BMJ's editorial⁼²⁰board

Learn to cope with uncertainty
Challenge what you aretaught, especially = if it=20 seems inconsistent or incoherent
Regardyour knowledge with humility
Be yourself at all times
Enjoyyourself
Try to practise medicine with the same ethics and⁼principles you believed in when you started medical=20 school
Neverbe afraid to admit your ignorance
Medicine is not only clinicalwork but is = also=20 concerned with relationships, team work, systems,⁼²⁰communication skills, research, publishing, and = critical=20 appraisal
Treatyour patients with the same care and = respect=20 as if they wereyour loved friends or = family
Cure is not what everyone is expectingfrom = you:=20 your patients and their families may be just seeking⁼²⁰support, a friendly hand, a caring soul
Outside the familythere are no closer ties = than=20 between doctors and patients
Don'tbelieve what you read in medical = journals and=20 newspapers
Aimat knowing how to learn, how to get = useful=20 medical information,and how to critically = assess=20 information
The first 10 timesyou do = anything=E2=80=94present a=20 patient, put in an intravenouscatheter, sew up = a=20 laceration=E2=80=94will be difficult, so get⁼through the first=20 10 times as quickly as possible
Althoughyou should not be afraid to say "I = don't=20 know" when appropriate,also do not be afraid = to be=20 wrong
Cherish every rotation duringyour = training, even=20 if you do not intend to pursue that specialty,⁼because=20 you are getting to do things and share experiences = that⁼²⁰are special
When you have a bad day because you are tired,⁼²⁰stressed, overworked, and underappreciated, never = forget=20 thatthings are much worse for the person on = the cold=20 end of thestethoscope. Your day may be lousy, = but you=20 don't have pancreaticcancer

More advice can be found on bmj.com =

The greatest curse of doctors is one they share with Il=20 Papa=E2=80=94infallibility.The public=E2=80=94forced fed = programmes like=20 Tomorrow's World=E2=80=94hasa greatly exaggerated = idea of the power=20 of modern medicine.Even smart people imagine that doctors = can=20 quickly tell what'swrong with them after a few questions, a = cursory=20 examination,and perhaps a blood test. Patients also have a = misplaced=20 confidencein the ability of doctors to fix their problems, = even=20 thoserooted in family and social disorder. Doctors, in=20 contrast,are painfully aware of the limitations and = complexities of=20 modernmedicine, the limited power and dangers of their=20 treatments,and their own profound fallibility. Nevertheless, = they=20 are inclinedto keep this to themselves=E2=80=94partly for = noble (if=20 misplaced)reasons like wanting to maintain the confidence of = patientsand partly for less noble reasons to do with money = and=20 status.

Box 2: = Advice from Dave=20 Sackett, the father of evidence based⁼medicine

The most powerful therapeutic tool you'll ever = have⁼²⁰is your own personality
Half of what you'll learn in medicalschool = will be=20 shown to be either dead wrong or out of date⁼within=20 five years of your graduation; the trouble is that = nobody⁼²⁰can tell you which half=E2=80=94so the most = important thing to⁼²⁰learn is how to learn on your own
Remember that your teachersare as full of = bullshit=20 as your parents
You are in for morefun than you can = possibly=20 imagine

I've called this the "bogus contract" between doctors and = patients,⁼²⁰and I believe that it's a cause of the unhappiness of doctors⁼and the infantilisation of patients.^{1 I=20
favour a stoical philosophyof "life is tough, we have few if =
any=20
solutions"=E2=80=94but that'sme being true to myself. =
Students and young=20
doctors will findit difficult to avoid entering into the =
bogus=20
contract, butI advise trying to adopt as dilute a form as=20
possible.}

In particular, avoid the trap of thinking you need to know = everything.⁼²⁰Even if you knew everything at 6 o'clock this morning (which⁼of=20 course you never could), you won't by midday=E2=80=94because⁼a thousand new=20 studies will have been published. "Medicine,"says John Fox, = head of=20 the Advanced Computing Laboratory, "isan inhuman activity." = We need=20 the help of machines. Ask travelagents the time of planes = from=20 Shanghai to Hong Kong, and theywill not quote from their = heads. They=20 will use information tools.Doctors must learn to do the = same.⁼²⁰

The three most important words

⁼

Good advice from a windbag, via⁼Shakespeare

Credit: MEPL

David Pencheon, a public health doctor, plays a game with new⁼²⁰medical students. He asks them questions of increasing = difficulty.⁼²⁰Eventually=E2=80=94and it may take a while=E2=80=94a student = willsay: "I don't=20 know." Pencheon then gives the student a box ofSmarties and = tells=20 the students that these are the three mostimportant words in = medical=20 education.

T S Eliot thought the same, saying that in order to arrive at⁼what=20 you do not know, you must go by a way which is the "wayof=20 ignorance." Ignorance may not be bliss, but it is the beginning⁼of=20 all learning. Those who want to be even good enough doctors⁼must=20 commit to a lifetime of learning=E2=80=94which means displaying,⁼not hiding,=20 our ignorance.

Box 3: = Advice from=20 Polonius to his son Laertes

Give every manthy ear, but few thy voice;

Take each man's censure, but reservethy = judgement.

Costly thy habit as thy purse can buy,

Butnot express'd in fancy; rich, not gaudy;

For the apparel oftproclaims the man,

And they in France of the best rank and⁼station

Are of a most select and generous chief in that.

Neithera borrower nor a lender be;

For loan oft loses both itselfand friend,

And borrowing dulls the edge of husbandry.

Thisabove all: to thine own self be true,

And it must follow, asthe night the day,

Thou canst not then be false to any man. =

The old way of learning, says Pencheon, was knowing what you⁼²⁰should know. Now the way of learning is knowing what you = don't⁼²⁰know, not feeling bad about it, and knowing how to find out.⁼²⁰Uncertainty was discouraged and ignorance avoided. Now, = uncertainty⁼²⁰is legitimised and questioning encouraged. Medical education⁼²⁰was learning by humiliation, with naming, shaming, and = blaming.⁼²⁰Now, students are encouraged to question received wisdom.⁼

I spent a year at the Stanford Business School, and the most⁼²⁰useful thing I learnt for the BMA's $30 000 (=C2=A317 000;⁼ 25 = 000) was that "there=20 is no question too stupid to ask."Somebody else in the room = will be=20 glad that you've asked it.

I learnt as well about "the impostor syndrome," which is common⁼²⁰among medical students and all normal people. You think: = "There's⁼²⁰been a dreadful mistake. I should never have been admitted.⁼²⁰They are going to find me out." I have it regularly, and I = also⁼²⁰learnt from my friend Muir Gray, another public health = doctor,⁼²⁰that "If you don't doubt what you are doing once a week = you're⁼²⁰probably doing the wrong thing."⁼

Credit: TOPFOTO

Box 4: = Advice from=20 Rudyard Kipling's If

If you can dream=E2=80=94andnot make dreams = your master,

If you can think=E2=80=94and notmake thoughts = your aim;

If you can meet with Triumph and Disaster

Andtreat those two impostors just the same =

And shouldn't doctors also share their ignorance with patients?⁼As=20 somebody who now is more an informed patient than a proper⁼doctor, I=20 believe they should. It may seem wrong and conceitedto share = uncertainty with patients, but the alternative is not⁼knowledge but=20 false certainty. And another word for false certaintymay be=20 "lie."

Sometime back the Lancet asked me some questions for a = short⁼²⁰article and one was about my greatest moment of learning. I⁼²⁰thought back on being a casualty officer in New Zealand and⁼²⁰being regularly perplexed about problems like whether = patients⁼²⁰had twisted or fractured their ankles. The moment of learning⁼came when Phil Gaskell, a fellow casualty officer, said: "You⁼don't have to pretend you know everything." This was like the⁼word of God, a shattering revelation. "Of course," I thought,⁼"but how did I ever get into the absurd state of pretending⁼²⁰that I did? What stunning foolishness."

Box 5: = Ralph Touchett,=20 who is close to death, advises IsabelArcher in = Henry=20 James's Portrait of a Lady

Take things moreeasily. Don't ask yourself so = much=20 whether this or that is goodfor you. Don't = question your=20 conscience so much=E2=80=94it willget out of = tune, like a=20 strummed piano. Keep it for great occasions.⁼Don't try so=20 much to form your character=E2=80=94it's like trying⁼to pull open=20 a rosebud. Live as you like best, and your character⁼will=20 form itself. Most things are good for you; the = exceptions⁼²⁰are very rare. Spread your wings; rise above the = ground.=20 It'snever wrong to do that. =

The world will change but some things must not change

Lord Turnberg, a former president of the Royal College of = Physicians,⁼²⁰predicted some years back: "Medicine will change more in the⁼²⁰next 20 years than it has in the past 2000." This seems = likely.⁼²⁰We are changing from the industrial age to the information = age,⁼²⁰and I believe that we are closer to the beginning of that = change⁼²⁰than to the end of it. We can see some glimmerings of the = future⁼²⁰world, but it's the nature of what the philosopher of science⁼Thomas Kuhn called a "paradigm shift" that those stuck in the⁼old paradigm cannot envisage the new.

Furthermore, predictions are almost always wrong, which is one⁼²⁰reason why futurologists developed "scenario planning," a = process⁼²⁰of imagining not one future but several distinct yet = plausible⁼²⁰futures. I was chair of a government working party on = information⁼²⁰and health in 2020, and we imagined three futures. In the = titanium⁼²⁰world everybody would have access to unlimited sources of = information⁼²⁰through the internet and its successors. Nobody would trust⁼²⁰institutions like the NHS, and "experts" would be suspect. In⁼this postmodern world there would be many versions of the = truth.⁼²⁰In contrast, in the iron world people would feel overwhelmed⁼by=20 information and look to a reliable and trusted source=E2=80=94like⁼NHS=20 Direct, perhaps. The community would be as important as⁼individuals,=20 and evidence based medicine would flourish. Peoplein the = wood world=20 would turn away from technology (as peoplein Britain have = rejected=20 genetically modified foods) and adoptolder community values. = Concerns about privacy and technologywould stop the use of=20 electronic patient records.

The point is that medical students are likely to find themselves⁼practising in worlds very different from now, but it's hard⁼to=20 see what that world will look like. Students must thus be⁼willing to=20 adapt, but some things=E2=80=94like a clear set ofvalues and = an enthusiasm=20 for learning=E2=80=94must be kept ifmedicine is to mean = anything (box=20 6).

Box 6: As = the world=20 changes, what should persist?

Clear ethicalvalues
Being clear about the purpose of your organisation
Puttingpatients first
Constantly trying to improve
Basing what wedo on evidence
Leadership
Education and learning

Put patients first, listen to them, and work with them as = partners

All doctors and health systems purport to put patients first,⁼but=20 ample evidence shows that it often doesn't feel that wayto = patients.=20 They regularly feel like cases rather than people,and what = is=20 important to patients is often different from whatis = important to=20 doctors. Mary Baker, the patient editor of theBMJ and = former=20 chief executive of the Parkinson's Disease Association,puts = it like=20 this: "For doctors Parkinson's disease is mostlyabove the = neck,=20 something to do with the substantia nigra. Forpatients it's = mostly=20 below the waist: Can I get my knickerson? Will I be = continent?" This=20 difference of view is to be expected,but the best doctors = are those=20 who can begin to see the worldas the patient sees it.⁼

Such a state is achieved mostly by active listening. It's one⁼of=20 the maxims of medicine that "listen to the patient and heor = she will=20 tell you the diagnosis." But the maxim is oftenignored. = Similarly=20 the fashion is to take decisions with thepatient, not for = the=20 patient, but again this is not the realityof everyday = practice in=20 most countries. Evidence shows thatgenuine partnership with = patients=20 produces better outcomes andgreater satisfaction for both = patient=20 and doctor, but this maybe hard to achieve in the middle of = an=20 exhausting night witha sick patient who doesn't speak your = language=20 and doesn't evenseem "grateful."

Recognise that integrity is a destination not a state

Until I was 51 (the age I am now) I thought that integrity was⁼²⁰something you had and continued to have unless you took a = dishonest⁼²⁰step. Now I recognise that every day we are presented with = choices⁼²⁰where it may be easiest to take an action that diminishes our⁼integrity. (I'm not sure why it took me 51 years to realise⁼²⁰what may seem obvious to many. Stupidity probably.) We often⁼²⁰take those choices not only because they make life easier but⁼also because we haven't time to think through the choices=20 or=E2=80=94worse=E2=80=94becausewe simply don't recognise = that the choice we are=20 making erodesour integrity.

Box 7: = Advice on the=20 importance of learning from T H White inThe = Once and=20 Future King

The best thing for being sad is tolearn = something.=20 That is the only thing that never fails. Youmay = grow old=20 and trembling in your anatomies, you may lie awake⁼at=20 night listening to the disorder of your veins, you may = miss⁼²⁰your only love, you may see the world about you = devastated=20 byevil lunatics, or know your honour trampled in = the=20 sewers ofbaser minds. There is only one thing = for it=20 then=E2=80=94to learn.Learn why the world wags = and what wags it.=20 This is the onlything which the mind can never = exhaust,=20 never alienate, neverbe tortured by, never fear = or=20 distrust, and never dream of regretting. =

Simple examples are hearing an older doctor be less than honest⁼to=20 a patient, or hearing a colleague make a discriminatory comment.⁼Many=20 examples are much subtler and may arise because you arethe = member of=20 a group that has made a poor choice: the importantand = comfortable=20 value of companionship is pitched against honesty.

My message is less that integrity must always come first = (although⁼²⁰perhaps it should) and more that we should recognise our need⁼to struggle constantly to be honest.

Final thoughts: a prayer and a word on the importance of = learning

⁼

"You are only dust and ashes, butthe = world=20 was created just for you"

Credit: AFP/GETTY IMAGES

If I had been writing this article a century ago then most of⁼my=20 advice would have been religious. Now it isn't, but I amvery = taken=20 by the wisdom of what I think is a Texan prayer:"In one = pocket keep=20 a message that says: `You are just dustand ashes.' In the = other=20 pocket keep a message that says: `Theworld was created just = for=20 you." Both messages are, I suggest,equally true.

My final advice is never to forget the value of learning not⁼only=20 for chasing after wisdom but also because it may be the⁼ultimate=20 balm. The author T H White expresses it beautifullyin box 7, = and I=20 make no apologies for repeating his words: learning"is the = only=20 thing which the mind can never exhaust, never alienate,never = be=20 tortured by, never fear or distrust, and never dreamof=20 regretting."

More advice can be found on bmj.com⁼

Please tell us through rapid = responses to this=20 article whatadvice you would offer to new medical students. = We will=20 thenlater run a vote to decide on what is most = important.⁼²⁰

The Powerpoint presentation of this = talk is=20 available at www.bmj.com/talks.⁼²⁰

Competing interests: RS is the editor = of the=20 BMJ and accountablefor all it contains. He had his = expenses=20 paid to travel to Yorkto deliver the talk but was not paid a = fee.

References

Smith R. Why are doctors so unhappy? = BMJ=20 2001;322: 1073-4.[Free Full Text]⁼²⁰

This article has been cited by other articles:

(Search Google Scholar for Other Citing Articles)=20

Humphrey, C. (2006). Ways of seeing: Biomedical perspectives on = the social=20 world. J. R. Soc. Med. 99: 602-606 [Full = text]=20 =20
Lindsay, M. (2005). Good enough general practice. BMJ = 330:=20 236-236 [Full=20 text] =20
Smith, R. (2004). Self pity will destroy you. BMJ 328: - = [Full = text]=20

Rapid Responses:

Read all Rapid=20 Responses

First impressions=20: Rosemary Aldrich
bmj.com, 19 Dec 2003 [Full = text]=20
What I say to new medical students and young = doctors=20: Sergio Stagnaro
bmj.com, 19 Dec 2003 [Full = text]=20
A Texan prayer from Poland=20: Jacob F. de Wolff
bmj.com, 19 Dec 2003 [Full = text]=20
Good Luck to medical students- enjoy your careers =: susanne mccabe
bmj.com, 19 Dec 2003 [Full = text]=20
Evidence Based Medicine=20: Edward L. McNeil, et al.
bmj.com, 20 Dec 2003 [Full = text]=20
Everyone and everything is important - attitude should be=20 right=20: Anju Aggarwal
bmj.com, 20 Dec 2003 [Full = text]=20
Keep up the Good Work=20: Gerald B Lapinsky
bmj.com, 21 Dec 2003 [Full = text]=20
Offensive comment?=20: Naushad A Junglee
bmj.com, 21 Dec 2003 [Full = text]=20
Learning not an end in itself=20: Neil R Aiton
bmj.com, 21 Dec 2003 [Full = text]=20
Medical sense!=20: Malvinder S. Parmar
bmj.com, 21 Dec 2003 [Full = text]=20
Advice to young doctors and young GPs=20: John Griffiths, et al.
bmj.com, 22 Dec 2003 [Full = text]=20
Thanks for this piece=20: Bie Nio Ong
bmj.com, 22 Dec 2003 [Full = text]=20
My Father's Advice to me=20: James A Cave
bmj.com, 22 Dec 2003 [Full = text]=20
Thoughts for new medical students=20: Morris P. Doublet-Stewart
bmj.com, 23 Dec 2003 [Full = text]=20
Teamwork and independence=20: A Clark
bmj.com, 23 Dec 2003 [Full = text]=20
There are no pockets in a shroud=20: Des Spence
bmj.com, 24 Dec 2003 [Full = text]=20
Limit your ambition=20: William G Anderson
bmj.com, 24 Dec 2003 [Full = text]=20
Important dialogue=20: Robert A Knuppel, MD,MPH,MBA
bmj.com, 24 Dec 2003 [Full = text]=20
realizing one's full potential=20: Bruce M Gray
bmj.com, 24 Dec 2003 [Full = text]=20
Diagnosis - words of advice for young doctors=20: Fernando Pita
bmj.com, 25 Dec 2003 [Full = text]=20
How to Study Medicine=20: Robert J Morris
bmj.com, 27 Dec 2003 [Full = text]=20
Medical education was...?=20: David F Levine
bmj.com, 28 Dec 2003 [Full = text]=20
Principles and Reality=20: graeme mackenzie
bmj.com, 30 Dec 2003 [Full = text]=20
What i would add as a student.=20: Uriel Trahtemberg
bmj.com, 31 Dec 2003 [Full = text]=20
Medicine is a wide world=20: Irina E Haivas
bmj.com, 31 Dec 2003 [Full = text]=20
Parents and Teacher Written Off?=20: J Larry Reynolds
bmj.com, 31 Dec 2003 [Full = text]=20
My two cents worth=20: Solomon MS Gruber
bmj.com, 31 Dec 2003 [Full = text]=20
Advice for Medical Students=20: Louis B Jacques
bmj.com, 31 Dec 2003 [Full = text]=20
Re: Good Luck to medical students- enjoy your = careers=20: Preshit P Mulay
bmj.com, 31 Dec 2003 [Full = text]=20
Unify your learning=20: Amar Dhand
bmj.com, 31 Dec 2003 [Full = text]=20
Is that Texan prayer really Texan or maybe = Jewish?=20: Gervase Vernon
bmj.com, 1 Jan 2004 [Full = text]=20
Becoming a good doctor is a life long journey=20: S D Salt, et al.
bmj.com, 9 Jan 2004 [Full = text]=20
Re: A Texan prayer from Poland=20: Gervase Vernon
bmj.com, 14 Jan 2004 [Full = text]=20
Students are an essential part of the education of their=20 institutions=20: George J Romanes
bmj.com, 20 Jan 2004 [Full = text]=20
Some further rules/bits of advice for medical = students=20: Narinder Kapur
bmj.com, 26 Jan 2004 [Full = text]=20
Link not missing but unclear: sorry=20: Richard Smith
bmj.com, 2 Feb 2004 [Full = text]=20
Texan Words=20: Jean McKendree
bmj.com, 6 Feb 2004 [Full = text]=20
Two more prayers for medical students=20: Richard Smith
bmj.com, 7 Feb 2004 [Full = text]=20
Words to Medical Students=20: Robert I. Rudolph, MD, FACP
bmj.com, 8 Feb 2004 [Full = text]=20
Source of the Texan prayer=20: A D Lloyd
bmj.com, 10 Feb 2004 [Full = text]=20
To Practise Medicine is a Priveledge=20: Joe W Butchart
bmj.com, 18 Feb 2004 [Full = text]=20
empathic listening (and advice)=20: Luis M. Pinet Peralta
bmj.com, 14 Sep 2004 [Full = text]=20

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It's good to talk

Thoughts for new medical students at a new medical school

"To thine own self be true"

The three most important words

The world will change but some things must not change

Put patients first, listen to them, and work with them as = partners

Recognise that integrity is a destination not a state

Final thoughts: a prayer and a word on the importance of = learning

References

This article has been cited by other articles:

Rapid Responses:

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This week's print = issue

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