I offer these ten points in the hope that you will surpass my generation of physicians, myself included, and learn from our mistakes. God help us all if you do not.
Congratulations on your hard work, academic achievements, and the persistence and sacrifice that brought you to this moment in your medical careers. Good for you. And now, reality.
1. Although you have memorized many facts, you know nothing. Truth does not care about diplomas hanging on walls. Neither do your patients, who just want to get well. Perhaps seventy-five percent of the alleged facts I learned in medical school in the late sixties have been disproven or deemed irrelevant under the onslaught of subsequent discoveries. Most of the treatments and tests we administered back in the day have obsolesced. What you have learned in your own training will suffer a similar fate. Why? Because despite our efforts, good intentions, and discoveries, our society is increasingly sick. We do not have a clue how to cure most illness, let alone prevent it. Be humble, not as a pose, but as a concession to reality. Some of your patients, as they have lived whole lives in their bodies, may actually know better than you what they need. Remain open to their input and be grateful for it.
2. For the same reasons, your instructors know far less than they think they know. Authority does not equal wisdom. Question their claims and their practices. You ably negotiated many years of education and training as obedient pupils. Continued, unquestioning indoctrination in the current pieties of our profession will serve neither you nor your patients well. Wake up. Given the passage of enough time, medical authorities have been proven wrong about almost everything.
Study all research findings with skepticism. Even editors of top journals admit that flawed science and fraud abound in a high percentage of their articles, which do not reflect honest searches for truth. As partial antidotes, scrutinize for corrupt bias the names of the funders of studies. Cultivate expertise in statistics, which will help you spot the kernels of truth gleaming within the piles of published vomitus. Mistrust generalizations about groups of experimental subjects, lumped together as if they are clones because they share a common symptom or diagnostic label. Medical truths, perhaps the most paradigm-disrupting ones, can be found in the idiosyncratic experiences of single individuals, the outliers who contradict general narratives.
3. Medicine is a noble path of service. Be clear whom you are serving. If corporations, large medical groups, HMOs, hospitals, insurers, pharmaceutical companies, or governmental agencies demand that you sacrifice your obligations to patients on the altar of organizational imperatives, consider another job setting before you corrupt your soul. Alternative models of medical practice allow you greater autonomy, though usually with less income and security. Consider why you are here, what is the point of your existence, and act accordingly.
4. As a medical practitioner, you aim to improve the lives of patients. To do that you need to know what they want or need. You must know who they are. If you consider your patients only as cases or as the sum of their laboratory data, you will not see them as unique human beings. Consequently, because we all differ, you will be less likely to determine the best treatments for each of those individuals. If you do not encounter patients as whole beings, treating cases or lab data will get old fast and lead to professional burnout.
5. To understand what your patients need, listen to them. An excellent medical history based upon rapport is your best diagnostic tool. The subjective experiences of human beings are far more sensitive indicators of illness than are lab tests or physical findings. One factor preventing your eventual replacement by AI bots is your ability to establish rapport and elicit a sensitive, observant history.
How best to listen? Begin by asking general, open-ended questions such as, “What do you hope I can assist you with today?” Then remain silent and let them speak freely for the next five to ten minutes with only minimal interruptions such as, “Tell me more about that.” After they have had their say, go ahead and ask your litany of rote diagnostic questions. If instead you lead with those questions, you risk missing essential clues about what is important to patients.
6. Prioritize your self-care. Medical students and physicians face statistically high risks of depression, substance abuse, and suicide. Many of us presume a personal invulnerability, believing that only others need help. That is false. Take care of yourself as if you were your favorite patient; heed your own advice. You cannot ignore your own physical and mental health and function at your best. Healthy diet, exercise, time for meditation, certainly. In addition, if you are a student or resident, advocate for a regular meeting time in which you can gather with a group of your peers to discuss problems and support each other, either with or without a professional therapist to lead it. This is essential. If you are struggling emotionally, seek counseling. You should not do this alone; the stresses can exceed the capacity of one person to handle.
7. The issue most germane to your self-care is your perfectionism, or rather your relationship to it. This trait, if securely harnessed to a sound sense of self-esteem, can function as an able servant. Thus far it has enabled you to perform at a high level. A physician bereft of perfectionism is as oxymoronic as a martial artist without a combative spirit. Beware, for perfectionism can harness you and dominate you as a cruel, even lethal, master. It does so when you confuse the level of perfection in your performance with your self-worth or identity. In such instances, you interpret your mistakes and imperfections as blights upon your personhood rather than as opportunities to learn or spurs to improve. Unhealthy perfectionism leads among physicians to depression, addiction, and suicide.
If you think that a mistake or flaw makes you a lesser person, you need to correct this cognitive distortion as soon as possible. Despite your precautions, you will make mistakes, some of which may even harm patients. Acceptance of your inevitable shortcomings as physicians, even as you try to do better, is essential to your mental health. Those struggling with this issue can find resolution through psychotherapy, most notably, according to research, in cognitive-behavioral therapy, which helps you alter your destructive thinking.
8. What are your patients’ healthy points? Learn not only what is wrong with your patients, but also what is right with them, their strengths—accomplishments, interests, personal virtues, roles in their community. Such knowledge will enable you to view them as people instead of just cases, thereby enriching your experience, building rapport, and revealing clues about treatment strategies.
9. By the same token, beware of our profession’s major blind spot. We spend untold hours trying to understand why people fall ill. That is only half the story, if that. To prevent and cure illnesses that currently defy us, accord equal if not more emphasis to learning how we maintain our health and how we restore ourselves to health after setbacks. Then learn how to support those self-healing resources that reside in us all. By focusing only on the causes of illness, you will always be playing catch-up, waiting for the next shoe to drop, lagging behind the curve.
Mainstream medical education ignores such concepts. Accordingly, supplement that education by exploring alternative forms of health care that focus not on suppressing illness but on strengthening people.
10. Be kind to your subordinates, trainees, and nurses. Despite our flaws, we are in this together, battling private demons while trying to do good and make it through another day. Thank them and solicit their opinions. Respect their different perspectives as they all know things you do not, even about your patients. These practices will reward you and them emotionally, and also determine whether your staff, especially the nurses, support you or make your life difficult. Know the name of the custodian who mops the floor at the end of your workday.
Steven Goldsmith is a psychiatrist.
