Title: An old fart attempts to impart wisdom to bright young things
1An old fart attempts to impart wisdom to bright
young things
- Richard Smith
- Editor, BMJ
- www.bmj.com/talks
2What I want to talk about
- Thoughts/ advice on being a medical student
- Something on what medicine might look like in 20
years - Thoughts/ advice on being a doctor
- (Its all on bmj.com/talks)
3My methods
- Asked our editorial board--30 zappy doctors and
others from every part of the globe - Big response
- Added my own ideas
- Took extracts from literature
- Trimmed them down--to what follows
- Article in the Christmas BMJ plus ask all our
readers--please join in
4Dave Sackett Old fart from the frozen north
Father of EBM
- 1. The most powerful therapeutic tool you'll ever
have is your own personality. The idea of doctor
as drug. May seem very strange. - 2. Half of what you'll learn in medical school
will be shown to be either dead wrong or
out-of-date within 5 years of your graduation
the trouble is that nobody can tell you which
half - 3. So the most important thing to learn is how to
learn on your own. - 4. Remember that your teachers are as full of
bullshit as your parents. - 5. You are in for more fun than you can possibly
imagine.
5A literary interlude Polonius to Laertes.
Polonius was the ultimate literary old fart A
greybeard loon
- 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 ownself be true,
- And it must follow, as the night the day,
- Thou canst not then be false to any man.
6To thine own self be true
- Excellent advice
- Theres a great tendency to try and be somebody
else--to be the best, when by definition most of
us cant be - To be ashamed of some of your characteristics
- Try and be somebody you are not and youll go
crazy - Dont try and be infallible
- My greatest learning moment in my whole career
You dont have to pretend you know everything
7The greatest invention of the 20th century?
- Quantum mechanics?
- Aircraft?
- Penicillin?
- Atomic bomb?
- Randomised controlled trial?
- No It wasGood enough mother D W Winnicott
- Actually it was jazz
8The good enough anything
- Trying to be the greatest mother in the world
drives you crazy--and guarantees that you wont
be - Good enough doctor
- Good enough medical student
- Good enough editor
- Good enough dean
- Good enough president of the RCP
9What are the three most important words in
medical education?
- David Pencheon plays a game with medical
students. - He asks them increasingly difficult questions,
which they usually keep trying to answer,
guessing as they go. - Eventually a student will say, "I don't know."
- Pencheon awards that student a tube of Smarties.
- "Those three words," he says, "are the most
important words in education. "
10Old and new ideas of learning
- Knowing what you should know
- Knowing what you dont know (not feeling bad
about it) and knowing how to find out (and help
others to) - Much learning "complete" at the end of formal
training - Learning from cradle to grave (lifelong learner)
11Old and new ideas of learning
- Uncertainty discouraged and ignorance avoided
- (Mindless, rote learning A salt and water losing
crisis? What is it? Why do you have an
antecubital fossa? - Legitimising uncertainty, learning by questioning
- Learning by humiliation name, shame, and blame
- Able to question received wisdom
12There is no question too stupid to ask
13Lessons from Stanford
- There is no question too stupid to ask
- You may be suffering from the imposter
syndrome Theres been a dreadful mistake. They
are going to find me out. - I have it regularly
- Muir Gray If you dont doubt what you are doing
once a week youre probably doing the wrong
thing.
14Medicine is an inhuman activity
- John Fox, head of the Advanced Computation
Laboratory - Nobody goes to a travel agent and expects them to
know the times of all trains from Shanghai to
Beijing - Doctors need information aids
15Another literary interlude Ruyard Kiplings 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
16Dangers of looking to the future
- I never make predictions, especially about the
future. Sam Goldwyn Mayer - Predictions of Lord Kelvin, president of the
Royal Society - "Radio has no future"
- "Heavier than air flying machines are impossible"
- "X rays will prove to be a hoax
17Dangers of looking to the future
- The telephone has too many shortcomings to be
seriously considered as a means of
communication. Western Union internal memo, 1876 - Who the hell wants to hear actors talk? Henry M
Warner, 1927 - Everything that can be invented has been
invented. Charles H Duell, Commission US Office
of Patents, 1899 - A woman has just rung in to ask if a hurricane
is on its way. Well I can reassure her Michael
Fish, weatherman, 1987, cut to pictures of roofs
being blown off and trees being blow down
18Medicine will change more in the next 20 years
than it has in the past 2000
- Lord Turnberg, former president of the RCP
19Selections from Healthcare 2020, a Foresight
report
- From industrial age healthcare to information
healthcare - Chronic not acute illness
- Patients and the public will come to the heart of
healthcare - Regeneration medicine will become a major
component of healthcare--use of stem cells,
xenotransplantation, tissue engineering, induced
regeneration, modulation of the ageing process
20Selections from Healthcare 2020, a Foresight
report
- We have done badly with neuropsychiatric illness,
but it will become steadily higher profile with
rising prevalence and a sharp increase in
diagnostic and therapeutic possibilities.
Dementia may eventually strike 85 of the
population
21Information and health 2020
- Think for itself hardware and self-generating
software by 2020 - Wearable computers intelligent clothing
- Personal agents-- digital butlers smart
sensing - Electronic circuitry can be connected to nerves
and tissues
22But.
- Predictions are likely to be wrong
- Its better not to think of one future but
several - A process called scenario planning
- Create several plausible futures that dont
overlap too much
23Examples of future scenarios for information and
health
24Three possible futures titanium
- Information technology develops fast in a global
market - Governments have minimal control
- People have a huge choice of technologies and
information sources - People are suspicious of government sponsored
services like the NHS - There are many truths. Doctors have no monopoly
on truth
25Three possible futures iron
- A top down, regulated world
- People are overwhelmed by information so turn to
trusted institutions--like the NHS - Experts are important
- Information is standardised
- Public interest is more important than privacy
26Three possible futures wood
- People react against technology as against
genetically modified foods - Legislation restricts technological innovation
- Privacy is highly valued
- Internet access is a community not an individual
resource - There are no mobile phones
27What will survive as the world changes
completely
- 1. Clear ethical values
- 2. Being clear about the purpose of your
organisation - 3. Putting patients first
- 4. Constantly trying to improve
- 5. Basing what we do on evidence
- 6. Leadership
- 7. Education/learning
28Literary interlude Henry James
- Ralph Touchett, who is close to death, advises
Isabel Archer - Take things more easily. Dont ask yourself so
much whether this or that is good for you. Dont
question your conscience so muchit will get out
of tune, like a strummed piano. Keep it for great
occasions. Dont try so much to form your
characterits 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. Its never
wrong to do that.
29Advice to a young doctor
- Put patients first
- a cliché, but is it meant?
- Having my hernia fixed as an outpatient under
local anaesthetic - Patients before family, really?
- Patients as partners
- doctor decides
- doctor consults patient and decides
- doctor and patient describe together
- patient decides
30Advice to a young doctor
- Listen--active listening, hearing, thinking,
understanding - Do as I do, not as I say my wife, my daughter,
my staff all tell me that I dont listen
31Advice to a young doctor
- Integrity is a destination not a state
- Its not something that you have and keep so long
as you dont take a false step - Everyday, every hour you are presented with
choices, options for behaving with reduced
integrity - I didnt realise this until I was 51
32Advice to a young doctor
- Returning to To thine ownself be true
- Are doctors true to themselves?
- Is there something bogus in the contract between
doctors and patients? - I believe that there is
33The bogus contract the patient's view
- Modern medicine can do remarkable things it can
solve many of my problems - You, the doctor, can see inside me and know
what's wrong - You know everything it's necessary to know
- You can solve my problems, even my social
problems - So we give you high status and a good salary
34The bogus contract the doctor's view
- Modern medicine has limited powers
- Worse, it's dangerous
- We can't begin to solve all problems, especially
social ones - I don't know everything, but I do know how
difficult many things are - The balance between doing good and harm is very
fine - I'd better keep quiet about all this so as not to
disappoint my patients and lose my status
35The new contract both patients and doctors know
- Death, sickness, and pain are part of life
- Medicine has limited powers, particularly to
solve social problems, and is risky - Doctors don't know everything they need decision
making and psychological support
36My new political party Life is tough, we have
no solutions
- First line of our manifesto Death is inevitable,
prepare for it
37Almost at the end something religious
- In one pocket keep a message that says You are
just dust and ashes-- hungry dust, as I read
the other day - In the other pocket keep a message that says
The world was created just for you
38Final literary interlude
- 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. - T H White, The once and future king
39Final comment
- If you arent confused you dont know whats
going on. - Jack Welch, former CEO General Electric