An old fart attempts to impart wisdom to bright young things

1. An old fart attempts to impart wisdom to bright young things Richard Smith Editor, BMJ www.bmj.com/talks

2. 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 • (It’s all on bmj.com/talks)

3. 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

4. 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 Half of what you'll learn in medical school will be shown to be either dead wrong or out-of-date within 5 years of your graduation; the trouble is that nobody can tell you which half • 3.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.

5. 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.

6. “To thine own self be true” • Excellent advice • There’s a great tendency to try and be somebody else--to be the best, when by definition most of us can’t be • To be ashamed of some of your characteristics • Try and be somebody you are not and you’ll go crazy • Don’t try and be infallible • My greatest learning moment in my whole career: “You don’t have to pretend you know everything”

7. The greatest invention of the 20th century? • Quantum mechanics? • Aircraft? • Penicillin? • Atomic bomb? • Randomised controlled trial? • No: It was“Good enough mother”: D W Winnicott • Actually it was jazz

8. The good enough anything • Trying to be the greatest mother in the world drives you crazy--and guarantees that you won’t be • “Good enough doctor” • “Good enough medical student” • “Good enough editor” • “Good enough dean” • “Good enough president of the RCP”

9. 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. "

10. Old and new ideas of learning • Knowing what you should know • Knowing what you don’t 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)

11. 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

12. “There is no question too stupid to ask”

13. Lessons from Stanford • “There is no question too stupid to ask” • You may be suffering from “the imposter syndrome”: “There’s been a dreadful mistake. They are going to find me out.” • I have it regularly • Muir Gray: “If you don’t doubt what you are doing once a week you’re probably doing the wrong thing.”

14. “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

15. Another literary interlude: Ruyard 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;

16. 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”

17. 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

18. “Medicine will change more in the next 20 years than it has in the past 2000” Lord Turnberg, former president of the RCP

19. 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

20. 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

21. 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

22. But…. • Predictions are likely to be wrong • It’s better not to think of one future but several • A process called scenario planning • Create several plausible futures that don’t overlap too much

23. Examples of future scenarios for information and health

24. 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

25. 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

26. 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

27. 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

28. Literary interlude: Henry James • Ralph Touchett, who is close to death, advises Isabel Archer • “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.”

29. 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

30. 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 don’t listen

31. Advice to a young doctor • Integrity is a destination not a state • It’s not something that you have and keep so long as you don’t take a false step • Everyday, every hour you are presented with choices, options for behaving with reduced integrity • I didn’t realise this until I was 51

32. 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

33. 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

34. 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

35. 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

36. My new political party: “Life is tough, we have no solutions” First line of our manifesto: Death is inevitable, prepare for it

37. 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”

38. 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”

39. Final comment • “If you aren’t confused you don’t know what’s going on.” • Jack Welch, former CEO General Electric