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

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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

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

Giving advice to medical students makes doctors think about what is important in what they do

Earlier this year I had the privilege of speaking to new medical students at a new medical school—the Hull York Medical School. What should I say? I felt almost overawed. It seemed a major responsibility, although I knew that most of what I said would—thankfully—be forgotten or ignored as the ramblings of yet another "old fart." Needing help and a method, I started by asking members of our editorial board, doctors from all over the world, what I should say. They responded with enthusiasm, giving me the thought that it might be a good idea to broaden the debate. That's the main reason for this article: it's a preliminary statement in what I hope might be a rich debate. In thinking what we want to say to new entrants to the profession we have to think of what is important about what we do.
What follows is a mixture of my own ideas and those I selected from the responses of the members of the editorial board. Box 1 summarises responses from the BMJ's editorial board, and box 2 gives the full advice of Dave Sackett, the "father of evidence based medicine" (and a member of the board). I also spent some time exploring advice from literature to young people, not specifically medical students (see boxes 3, 4, 5, 7).

"To thine own self be true"

Perhaps the most famous advice to young people in the English language is the speech of Polonius—a tiresome old windbag—to his departing son Laertes in Shakespeare's Hamlet (box 3). The speech contains much excellent advice, but perhaps the quintessence is, "To thine own self be true." Everybody—but perhaps especially medical students—experiences pressure to be somebody else. In the competitive world of medicine there is strong tendency to try to be "the best." But the simplest mathematics shows that everybody cannot be the best: there is only one best.
I asked the students when I spoke to them, "What was the greatest invention of the 20th century?" Was it quantum mechanics, aircraft, penicillin, 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 was jazz.) The attempt to be the best mother in the world, the best neurosurgeon, or the best medical editor will end in tears. Being a good enough mother is to be a good mother, whereas the attempt to be the best will guarantee that you won't be (indeed, you may be a highly damaging mother). Similarly, you should aim to be a good enough medical student and doctor.
One of the curses of doctors is that they have such strong stereotypes. Doctors are upstanding, trustworthy, clever, straitlaced, conservative, authoritarian, inhibited, wealthy, right wing, and—often—dull. Many doctors are none of these things, but as a medical student you may feel a pressure to conform to the stereotype. Don't. A lifetime spent trying to be something you are not will destroy you.

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

Learn to cope with uncertainty

Challenge what you are taught, especially if it seems inconsistent or incoherent

Regard your knowledge with humility

Be yourself at all times

Enjoy yourself

Try to practise medicine with the same ethics and principles you believed in when you started medical school

Never be afraid to admit your ignorance

Medicine is not only clinical work but is also concerned with relationships, team work, systems, communication skills, research, publishing, and critical appraisal

Treat your patients with the same care and respect as if they were your loved friends or family

Cure is not what everyone is expecting from you: your patients and their families may be just seeking support, a friendly hand, a caring soul

Outside the family there are no closer ties than between doctors and patients

Don't believe what you read in medical journals and newspapers

Aim at knowing how to learn, how to get useful medical information, and how to critically assess information

The first 10 times you do anything—present a patient, put in an intravenous catheter, sew up a laceration—will be difficult, so get through the first 10 times as quickly as possible

Although you should not be afraid to say "I don't know" when appropriate, also do not be afraid to be wrong

Cherish every rotation during your training, even if you do not intend to pursue that specialty, because you are getting to do things and share experiences that are special

When you have a bad day because you are tired, stressed, overworked, and underappreciated, never forget that things are much worse for the person on the cold end of the stethoscope. Your day may be lousy, but you don't have pancreatic cancer

More advice can be found on bmj.com

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

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

The most powerful therapeutic tool you'll ever have is your own personality

Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half—so the most important thing to learn is how to learn on your own

Remember that your teachers are as full of bullshit as your parents

You are in for more fun than you can possibly imagine

I've called this the "bogus contract" between doctors and patients, and I believe that it's a cause of the unhappiness of doctors and the infantilisation of patients.1 I favour a stoical philosophy of "life is tough, we have few if any solutions"—but that's me being true to myself. Students and young doctors will find it difficult to avoid entering into the bogus contract, but I advise trying to adopt as dilute a form as possible.
In particular, avoid the trap of thinking you need to know everything. Even if you knew everything at 6 o'clock this morning (which of course you never could), you won't by midday—because a thousand new studies will have been published. "Medicine," says John Fox, head of the Advanced Computing Laboratory, "is an inhuman activity." We need the help of machines. Ask travel agents the time of planes from Shanghai to Hong Kong, and they will not quote from their heads. They will use information tools. Doctors must learn to do the same.

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 medical students. He asks them questions of increasing difficulty. Eventually—and it may take a while—a student will say: "I don't know." Pencheon then gives the student a box of Smarties and tells the students that these are the three most important words in medical education.
T S Eliot thought the same, saying that in order to arrive at what you do not know, you must go by a way which is the "way of ignorance." Ignorance may not be bliss, but it is the beginning of all learning. Those who want to be even good enough doctors must commit to a lifetime of learning—which means displaying, not hiding, our ignorance.

Box 3: Advice from Polonius to his son Laertes
Give every man thy ear, but few thy voice;
Take each man's censure, but reserve thy judgement.
Costly thy habit as thy purse can buy,
But not express'd in fancy; rich, not gaudy;
For the apparel oft proclaims the man,
And they in France of the best rank and station
Are of a most select and generous chief in that.
Neither a borrower nor a lender be;
For loan oft loses both itself and friend,
And borrowing dulls the edge of husbandry.
This above all: to thine own self be true,
And it must follow, as the night the day,
Thou canst not then be false to any man.

The old way of learning, says Pencheon, was knowing what you should know. Now the way of learning is knowing what you don't know, not feeling bad about it, and knowing how to find out. Uncertainty was discouraged and ignorance avoided. Now, uncertainty is legitimised and questioning encouraged. Medical education was learning by humiliation, with naming, shaming, and blaming. Now, students are encouraged to question received wisdom.
I spent a year at the Stanford Business School, and the most useful thing I learnt for the BMA's $30 000 (£17 000; 25 000) was that "there is no question too stupid to ask." Somebody else in the room will be glad that you've asked it.
I learnt as well about "the impostor syndrome," which is common among medical students and all normal people. You think: "There's been a dreadful mistake. I should never have been admitted. They are going to find me out." I have it regularly, and I also learnt from my friend Muir Gray, another public health doctor, that "If you don't doubt what you are doing once a week you're probably doing the wrong thing."

Credit: TOPFOTO

Box 4: Advice from Rudyard Kipling's If
If you can dream—and not make dreams your master,
If you can think—and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two impostors just the same

And shouldn't doctors also share their ignorance with patients? As somebody who now is more an informed patient than a proper doctor, I believe they should. It may seem wrong and conceited to share uncertainty with patients, but the alternative is not knowledge but false certainty. And another word for false certainty may be "lie."
Sometime back the Lancet asked me some questions for a short article and one was about my greatest moment of learning. I thought back on being a casualty officer in New Zealand and being regularly perplexed about problems like whether patients had 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 that I did? What stunning foolishness."

Box 5: Ralph Touchett, who is close to death, advises Isabel Archer in Henry James's Portrait of a Lady
Take things more easily. Don't ask yourself so much whether this or that is good for you. Don't question your conscience so much—it will get out of tune, like a strummed piano. Keep it for great occasions. Don't try so much to form your character—it's like trying to pull open a rosebud. Live as you like best, and your character will form itself. Most things are good for you; the exceptions are very rare. Spread your wings; rise above the ground. It's never 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, predicted some years back: "Medicine will change more in the next 20 years than it has in the past 2000." This seems likely. We are changing from the industrial age to the information age, and I believe that we are closer to the beginning of that change than to the end of it. We can see some glimmerings of the future world, 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 reason why futurologists developed "scenario planning," a process of imagining not one future but several distinct yet plausible futures. I was chair of a government working party on information and health in 2020, and we imagined three futures. In the titanium world everybody would have access to unlimited sources of information through the internet and its successors. Nobody would trust institutions like the NHS, and "experts" would be suspect. In this postmodern world there would be many versions of the truth. In contrast, in the iron world people would feel overwhelmed by information and look to a reliable and trusted source—like NHS Direct, perhaps. The community would be as important as individuals, and evidence based medicine would flourish. People in the wood world would turn away from technology (as people in Britain have rejected genetically modified foods) and adopt older community values. Concerns about privacy and technology would stop the use of 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 see what that world will look like. Students must thus be willing to adapt, but some things—like a clear set of values and an enthusiasm for learning—must be kept if medicine is to mean anything (box 6).

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

Clear ethical values

Being clear about the purpose of your organisation

Putting patients first

Constantly trying to improve

Basing what we do 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 ample evidence shows that it often doesn't feel that way to patients. They regularly feel like cases rather than people, and what is important to patients is often different from what is important to doctors. Mary Baker, the patient editor of the BMJ and former chief executive of the Parkinson's Disease Association, puts it like this: "For doctors Parkinson's disease is mostly above the neck, something to do with the substantia nigra. For patients it's mostly below the waist: Can I get my knickers on? Will I be continent?" This difference of view is to be expected, but the best doctors are those who can begin to see the world as the patient sees it.
Such a state is achieved mostly by active listening. It's one of the maxims of medicine that "listen to the patient and he or she will tell you the diagnosis." But the maxim is often ignored. Similarly the fashion is to take decisions with the patient, not for the patient, but again this is not the reality of everyday practice in most countries. Evidence shows that genuine partnership with patients produces better outcomes and greater satisfaction for both patient and doctor, but this may be hard to achieve in the middle of an exhausting night with a sick patient who doesn't speak your language and doesn't even seem "grateful."

Recognise that integrity is a destination not a state

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

Box 7: Advice on the importance of learning from T H White in The Once and Future King
The best thing for being sad is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins, you may miss your only love, you may see the world about you devastated by evil lunatics, or know your honour trampled in the sewers of baser minds. There is only one thing for it then—to learn. Learn why the world wags and what wags it. This is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting.

Simple examples are hearing an older doctor be less than honest to a patient, or hearing a colleague make a discriminatory comment. Many examples are much subtler and may arise because you are the member of a group that has made a poor choice: the important and comfortable value of companionship is pitched against honesty.
My message is less that integrity must always come first (although perhaps 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, but the world was created just for you"
Credit: AFP/GETTY IMAGES

If I had been writing this article a century ago then most of my advice would have been religious. Now it isn't, but I am very taken by the wisdom of what I think is a Texan prayer: "In one pocket keep a message that says: `You are just dust and ashes.' In the other pocket keep a message that says: `The world was created just for you." Both messages are, I suggest, equally true.
My final advice is never to forget the value of learning not only for chasing after wisdom but also because it may be the ultimate balm. The author T H White expresses it beautifully in box 7, and I make no apologies for repeating his words: learning "is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting."

More advice can be found on bmj.com
Please tell us through rapid responses to this article what advice you would offer to new medical students. We will then later run a vote to decide on what is most important.
The Powerpoint presentation of this talk is available at www.bmj.com/talks.
Competing interests: RS is the editor of the BMJ and accountable for all it contains. He had his expenses paid to travel to York to deliver the talk but was not paid a fee.

References

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

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