An old fart attempts to
impart wisdom to bright
young things
Richard Smith
Editor, BMJ
www.bmj.com/talks
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)
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
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 outof-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.
A literary interlude: Polonius to Laertes.
Polonius was the ultimate literary old fart;
“A greybeard loon”
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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.
“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”
The greatest invention of the
20th century?
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Quantum mechanics?
Aircraft?
Penicillin?
Atomic bomb?
Randomised controlled trial?
No: It was“Good enough mother”: D
W Winnicott
• Actually it was jazz
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”
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. "
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)
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
“There is no
question too
stupid to ask”
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.”
“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
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;
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”
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
“Medicine will change
more in the next 20
years than it has in the
past 2000”
Lord Turnberg, former
president of the RCP
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
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
Information and health
2020
• “Think for itself hardware” and selfgenerating software by 2020
• Wearable computers; “intelligent
clothing”
• Personal agents-- “digital butlers”;
smart sensing
• Electronic circuitry can be
connected to nerves and tissues
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
Examples of future
scenarios for
information and health
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
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
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
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
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.”
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
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doctor decides
doctor consults patient and decides
doctor and patient describe together
patient decides
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
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
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
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
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
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
My new political party:
“Life is tough, we have
no solutions”
First line of our manifesto:
Death is inevitable, prepare
for it
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”
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”
Final comment
• “If you aren’t confused
you don’t know what’s
going on.”
• Jack Welch, former CEO
General Electric