An old fart attempts to impart wisdom to bright young things

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An old fart attempts to impart wisdom to bright
young things

• Richard Smith
• Editor, BMJ
• www.bmj.com/talks

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What 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)

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My 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

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Dave 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  out-of-date within 5 years of your graduation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.

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A 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.

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To 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

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The 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

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The 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

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What 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. "

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Old 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)

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Old 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

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There is no question too stupid to ask
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Lessons 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.

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Medicine 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

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Another 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

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Dangers 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

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Dangers 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

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Medicine will change more in the next 20 years
than it has in the past 2000

• Lord Turnberg, former president of the RCP

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Selections 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

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Selections 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

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Information 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

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But.

• 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

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Examples of future scenarios for information and
health
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Three 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

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Three 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

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Three 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

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What 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

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Literary 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.

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Advice 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

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Advice 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

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Advice 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

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Advice 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

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The 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

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The 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

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The 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

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My new political party Life is tough, we have
no solutions

• First line of our manifesto Death is inevitable,
  prepare for it

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Almost 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

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Final 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

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Final comment

• If you arent confused you dont know whats
  going on.
• Jack Welch, former CEO General Electric