Practice

Five things I wish I had known as a young doctor

Dr Robin Youngson offers advice to his younger self, after more than thirty years of medical practice.

When beginning my medical career, I guess there were three main things I wanted: To provide the best possible care to individual patients; to make a difference in the world beyond caring for my own patients; and to have a happy and satisfying career. Now, at sixty-two, I can look back at a varied career and ask myself, did I achieve those goals? Are there things I know now, that I wish I had known when I was starting out?

Before I go further I want to acknowledge a debt of gratitude to my wife Meredith, who partners with me in our Hearts in Healthcare work. I originally titled this article, ‘Advice to a young doctor‘, after the famous book by Peter Medawar, ‘Advice to a Young Scientist‘. Meredith asked me a question: ‘Wouldn’t it be so much more meaningful and touching if you wrote the advice to your younger self?’ She has a gift for great questions. When I reflect on the lessons I share in my advice to the young Dr Robin, I see so much of her wisdom and guidance.

Looking back on my career, I can say I chose the right profession. To work as a doctor is a great privilege. Each and every day I get deep satisfaction from my work, I take joy from my practice, I enjoy interesting and engaging challenges, and I have made a difference in the world: I have no regrets. Yet had I known in the beginning, what I know now, my career would have taken a very different trajectory. What changed?

I answer that question from a broad perspective. I came into medicine late, having first begun a career in engineering and oil exploration, where I survived many hair-raising adventures in different parts of the world. My medical career has been wide in scope. I trained as an anesthesiologist and I’ve done highly specialised practice in the biggest teaching hospital in New Zealand and a broad range of care in smaller hospitals.

I have enjoyed many health leadership roles: on hospital executive teams, as an advisor to the NZ government, and working with the World Health Organisation on strategies for people-centred health care and patient safety. For more than a decade, I have led an international movement for the humanisation of healthcare and I’m a published author and well-known speaker. I still practice half-time clinical anesthesia, which keeps me honest and grounded.

The things I have learned in later years will be surprising to most young doctors. Although they make an astonishing difference to patient care, and to the satisfaction and wellbeing of doctors, they are rarely taught at medical school, and they are largely absent from medical journals or textbooks.

Here are the five things I could share with the young Dr Robin:

 

Real patients are nothing like the mechanistic models suggested by your studies in anatomy, physiology and pathology!

With each new patient I met as a young doctor, my finely honed instinct was to focus rapidly on the clinical problems and the underlying pathology. At medical school, we are taught a mechanistic view of the human being. We are steeped in anatomy and physiology, right down to a molecular level. What’s missing from all the literature is that our patient are conscious – they are highly dynamic, mind-body beings utterly unlike the materialistic version of the science we are all taught. Here’s some random illustrations:

I now know that one episode of exercise changes our gene expression; that nine weeks of mind-body training for patients with inflammatory bowel disease not only improves symptoms but also changes the expression of more than a thousand genes associated with cell reproduction, immune function and inflammatory responses. Psychotherapy can change gene expression, increase levels of brain growth factors, structurally change the brain and cure mental illness. Pessimists are three times more likely than optimists to develop clinical influenza when exposed to live influenza virus. Trauma patients who rate their surgeon as ‘high empathy’ have better outcomes of surgery.

In contrast to the ideal of clinical detachment I was taught at medical school, I discover that human beings are intimately connected. Mirror neurones give us the basis of empathy, which allow us to intuitively understand other peoples’ feelings and intentions. When two humans stand close together, their hearts and brains are literally coupled together by the electromagnetic field of the heartbeat. Some of my patient’s neurones fire in synchrony with my heart beat, and visa versa – truly a ‘heart-felt’ connection.

If the physician is calm and centred, it directly affects the physiology of the patient and reduces their heart rate, blood pressure, and cortisol. These connections allow our compassionate care to deeply touch our patients and to improve their clinical outcomes in very important ways.

As an anesthesiologist I was astounded to discover some randomised, controlled trials showing that patients who have a warm, empathetic, and supportive pre-operative consultation (compared to those simply offered standard information) need only half the dose of morphine after surgery, have better objective wound healing, better surgical outcomes, they mobilise earlier, have fewer side effects, and have shorter hospital stays.

Many studies show striking results for empathetic and compassionate care. The effect size on clinical outcomes is of a similar magnitude to many of the drugs we use. Compassionate caring improves patients outcomes, reduces patient demand, dramatically reduces interventions and costs, and prolongs survival time in cancer patients. It’s great medicine, yet is rarely taught.

I would teach all this to the young Dr Robin. I would say that even though you struggle with feelings of incompetence and inexperience, you have a fully formed heart. Even if you are lacking in medical knowledge and technical skills, your compassion and caring can make a powerful difference to the outcomes of your patients. It will also give you the joy of human connection, a warm feeling in your heart, and it will protect you from burnout.

 

 You don’t have to be the hero

As a young doctor, I hid my feelings of insecurity and put on a brave front of cool clinical detachment. I pretended to be competent many times when I felt out of my depth. I believed I had to always be the expert in front of my patients, I never admitted ignorance. I wish now that I had been more honest with my patients.

What I know now is that patients have no way to judge your clinical competence. What they do judge is whether you care. When you show kindness, compassion, and an honest desire to help your patients, they will forgive almost anything. I have learned now to be the patients’ friend and advocate. I do many things to help patients that are nothing to do with my technical role as an anesthesiologist.

If I am uncertain about how to manage a condition or perform a procedure, I tell my patient. I explain that I will seek help from a colleague or look up the information I need. If I’m on the learning curve for a procedure, at least I will do it in a way that is safe and kind to the patient, checking as I go along that the patient is doing OK. I will explain the end result that I’m aiming for and how I know it has been a success. I will have a back-up plan. All these things build the patient’s confidence and trust, even if I am not the expert.

It’s easy for me to say this from a position of seniority and experience – I now have a lot of confidence. But I also commend the strategy to the young Dr Robin.

Several years ago, I recall watching a television documentary about first-year doctors working in a major hospital. It was a very candid portrayal, plainly exposing the fears and challenges of being a new doctor. One doctor stood out. He had a wonderful way of empathising with patient and showed especial kindness and consideration. He was much more honest than his colleagues in admitting to patients his lack of experience. He simply promised each patient he would do the best he could, and call for help if he was struggling. All his patient loved him. His intention to be kind and caring, his integrity, and lack of pretence actually heightened his success rate in procedures.

I’d say to the young Dr Robin that I learned that patients also care for their doctors, as much as we care for our patients. A compassionate relationship is a two-way street. I learned that patients were forgiving when I was honest about mistakes. Some of my patients became my greatest teachers.

I’d say to the young Dr Robin, you don’t have to be the hero to your colleagues either. Hiding our feelings and never admitting to vulnerability perpetuates a culture in which doctors never seek help, battle on alone, and suffer high rates of depression, stress, burnout, and suicide.

I now choose to expose my vulnerabilities to my colleagues and to talk openly about cases that upset me or frighten me. I reach out to support other doctors. I try to role-model a healthy approach to my own emotional and psychological wellbeing. Some years ago, when confronted by the sudden death of a young mother in my care, I took two weeks of stress leave. I admitted to myself and to my colleagues that I wasn’t in a fit state to be caring for patients and I took time to work through my own grief and loss. I’m deeply grateful to my wife Meredith for showing me it was safe to be vulnerable.

I now seek professional supervision and counselling to help me deal with the challenges of patient care and my own emotional vulnerabilities. My marriage has benefited greatly. As a doctor, I am more balanced, grounded, mindful and compassionate. I am also a better husband. Acknowledging my own struggles allows me to understand my patients better.

A few weeks ago, the World Medical Association voted to amend the Declaration of Geneva, which lays out the professional and ethical duties of doctors. There is a new duty of doctors – to look after their own health. I didn’t begin to attend to these issues until I was in my fifties.

If I was a mentor to the young Dr Robin, I would be saying, ‘Start now.’ Your first duty of patient care is self care.

 

Patients heal themselves

I always thought that it was my treatment that made patients better, or not. I placed great store on the success of my care. I felt myself responsible for each problem the patient brought to my door and soon began to feel overwhelmed.

In modern times, health services are overwhelmed by the endless demands for patient care. We simply don’t have enough doctors, nurses, clinic appointments, hospital beds, and procedure lists to cope with the tsunami of patient demand. The endless demand leads to overwork and fatigue. Fifty percent of young doctors have symptoms of burnout: emotional exhaustion, cynicism, depersonalisation, and a lack of job satisfaction. With the rise of consumerism, it seems that every patient expects an instant cure or a pill to make them feel better.

The reality is that patients have remarkable capacity for self-healing and that our medical treatments often do little more than support the natural process of recovery. We forget that broken bones heal themselves, that a lung rendered solid with pneumonia restores its own normal anatomy, that our immune system takes care of hundreds of potential infections and cancers. We forget that conditions like hypertension, depression, diabetes, heart disease and most cancers are almost unknown among some ‘primitive’ cultures – they are not part of the natural human condition.

As I have gotten older I have become more humble about my medical practice. I have witnessed miracles completely unexplainable by medical science. There is mystery and awe in medical practice. It’s well documented that patients can have ‘spontaneous remission’ and cure themselves of terminal cancer. I’ve seen elderly patients fully recover a day after prolonged cardiac arrest, when they should be brain dead. Other patients have turned their face to the wall and died within days, through sheer force of will.

Here’s what I’d like to tell the young Dr Robin:

Do your best for each patient but have less attachment to the outcomes; whether your patient lives, or dies, has causes far beyond the limited influence of your medical care. Care deeply about your patients, bring your heart to work, but let go of striving to save everyone.

Don’t see patients as a burden of demand, try to see each patient as the most abundant resource of health, healing and wellbeing. Have faith in your patients, explore their strengths, be positive and encouraging, expect miracles. Admire your patient’s courage, resilience, wisdom and good humour in the face of serious illness or injury. Be grateful for every patient you meet – it’s a privilege to journey alongside them.

 

Even doctors make mistakes

Did I tell you about the time I did an arm block in the wrong arm of a patient so he ended up with one painful arm in a plaster cast and the other arm numb and useless? Or the time I gave another dose of muscle paralysing drug at the end of an anaesthetic, instead of the reversal drug? Or the time I took a blood sample from completely the wrong patient – who had the same name, the same diagnosis and was on the same ward as the correct patient? Or the time I shocked a patient in Ventricular Tachycardia (VT) without first synchronising the defibrillator, so the patient went into VF?

The last accident didn’t happen to a real patient – it was a high-fidelity emergency simulation demonstrating that all human beings make mistakes when stressed, and that outcomes depend much more on teamwork, situational awareness, and good communication, than your skill as an individual.

It’s a sobering experience to watch the video replay of your actions in the simulation. In that scenario, we were caring for a patient with multiple medical problems having a major abdominal procedure, when complications started to develop. The simulation involved three very senior and experienced anesthesiologists all trying to solve the problem as the patient rapidly deteriorated. In the confusion of the emergency, not one of us remembered to synchronise the defibrillator, even though we have all done it before many times before.

Every single doctor put on the simulator makes mistakes – everyone! The science of ‘human factors’ says the mistakes are predictable: the result of intense stress, information overload, task overload, and extreme urgency. The only way to avoid such errors is to train as a team, in high-fidelity simulation, and to learn and rehearse carefully-designed emergency responses that keep you out of trouble. That’s what airline pilots do.

So here’s what I’d like to tell the young Dr Robin:

No matter how careful and skilful you are, you will make mistakes and some of them will harm your patients. My advice is that you should always be honest with your patient. Sincerely apologise, explain how the error occurred and what the consequences are. Demonstrate to the patient that you care for them very much and that you will do everything in your power to help them recover. Also that you have learned from your mistake and that you will take steps to prevent the same error from happening to others.

If you do all these things, the patient will likely forgive you. Their forgiveness is truly humbling. If you do all these things you dramatically reduce the risk of being sued or having a formal complaint registered against you. I have not received a formal patient complaint since 1990, when I was a resident, and I seriously mishandled the relationship with a patient and her husband at a time of great stress.

Early in your career, learn about human factors. Become aware of the circumstance when you are likely to make errors and invite others to warn you of a potential mistake – regardless of their rank or title. One month ago, a nurse in the OR saved me from a potentially life-threatening mistake because I made it safe in my team for anyone to speak up. Anytime I make a mistake, I tell everyone in the team. If an unexpected complication or emergency starts to develop, I alert my teammates and call for help early. Take the opportunity to train on the simulator; you will be shocked at the mistakes you make and you will learn skills that will save a life.

 

You have great power to change the world

As a medical student or junior doctor, it’s easy to feel powerless especially in a hierarchical medical system that too often teaches by humiliation, punishes those who question the status quo, and grinds people down through overwork and inhuman working conditions.

Our sense of powerlessness stems from accepting our perception of the harsh world, which we see as a concrete reality ‘out there’. What I have learned is that much of the reality ‘out there’ is actually our own creation and we therefore have great power to change the world.

Here’s an example: Early in my hospital career, I made a curious observation. One of the nurses working in the OR had a very bubbly, affectionate and flirty character. She gave lots of people hugs and always had a cheery smile. Especially at that time, I was personally very reserved and socially awkward. But with this nurse, I was outgoing and even flirtatious!

I began to watch her interactions and every single person she met was cheerful and outgoing – even the workers who were normally grumpy. I began to imagine what it must be like to live in her world. Conversely, another nurse was always gloomy and complaining; her attitude was contagious too. I realised that these two nurses had radically different experiences of the same workplace.

When I began to change my attitude, I noticed the world changing around me. I tried experiments. One day I decided to make the assumption that ‘difficult’ patients don’t exist, that if a consultation was going badly the problem was a ‘difficult’ doctor, not a difficult patient. My job was to listen better and to try to understand the patient’s perspective. I guess I dropped my judgmental attitude to challenging patients, and they sensed a difference. The result was a near miracle: most of my ‘difficult’ patients melted away and I began to enjoy my consultations much more.

I’ve found that any problem can be reframed and made easier if you are willing to examine and change your own attitudes, to take responsibility for your side of the interaction. The result can be life-changing. I did a TEDx talk on the subject, showing how a change of attitude transformed my effectiveness as a leader in compassionate healthcare. If you’d like more examples of how this can work in medicine, see my blog, ‘Choose to love your work‘.

So here’s my advice to the young Dr Robin who is, to be honest, something of a righteous troublemaker in challenging the hierarchy: Think about your attitude. What judgments are you making about others and could a different approach work better? If you dropped your need to be right all the time, could you build more collaborative relationships? What mood do you bring to work? Are you relaxed, easy-going, cheerful and appreciative, or grumpy all the time? Could you choose to love your work, rather than dwell on the dissatisfactions?

Go kindly, there is already too much trouble in the world. Be appreciative, kind, generous, and practice gratitude. The world will become more joyful, loving and generous to you.

 

If I began my career again, where would I focus?

It’s hard to predict the future of medicine; all I can say is that it will have changed profoundly before you even finish your training. Advances in artificial intelligence, diagnostic methods, gene therapy and robotics will displace many of the conventional roles of doctors.

In reflecting on all my efforts to change healthcare, I’ve come to realise that we don’t actually have a health system at all, it would be truer to say we have a ‘medicated sickness’ system. It is uncommon for me to meet any patient in their fifties who is not already on life-long medications for high cholesterol, hypertension, diabetes, depression, or gastro-oesophageal reflux. Today I met a 78 year old patient who takes no medication and is in robust good health. Why can’t that be the norm?

Modern medicine is astonishingly good at treating acute illness and injury but is a disaster when it comes to managing chronic illness. Almost all of the patients we treat in hospital have disease that is preventable. However, the pharmaceutical and technology companies have a strong incentive to make money from maintaining chronic illness and there is very little curiosity or research funding to investigate what keeps people well.

If I began my career again, that would be my focus: I’d devote a lifetime of effort to changing our sickness system into a true health system. I’d work in primary care and in community. Many of the determinants of chronic disease are in our society. It’s time for physicians to become community leaders helping to change the way we lead our lives. It’s time for us to be champions of medical research into what keeps us well, rather than investigating yet another new and expensive treatment for illness.

I would take joy in caring for people, not just treating disease. I’d know that even though the challenge of expert medical care can eventually become routine, there is boundless satisfaction and interest in caring for my patients as unique individuals. I would know that every one of the five lessons I shared with the young Dr Robin will be as valid and relevant in another thirty years.

6 Responses to “Five things I wish I had known as a young doctor”

  1. Ann Thornton says:

    This article is very timely for me Robin, as well as being superb advice! Thank you!
    After years in the hospital system I have just started to train as a GP mostly so I can contribute to the prevention of illness. I am inspired by your words and I’m off to buy your book!!

  2. What a refreshing and hope inspiring article. We are at a major turning point in healthcare and medicine. The future looks like offering everyone a great challenge, that includes every patient and every health worker. The two key elements of this challenge are to first recognise that health trumps disease and that medical education and practice has to shift from pathology dominance, curing the sick, towards ethology, promoting health and secondly for everyone of us to realise we are individually responsible for our own health and lifestyles. As intelligent creatures, Homo sapiens, we have the ability to respond to our environment, let us all be more response-able, or responsible!

  3. David Lee says:

    My Dad was a family doc. His success was due to having great bedside manner. As to our healthcare system, far more resources need to be devoted to prevention. We can’t afford the way we do this now.

  4. ALison James says:

    Thank you for this article. I will be printing it out and leaving in coffee rooms everywhere! Its a wonderful reminder of the power of human connection and the ‘art’ of medicine in a world were we seem to be moving away from human relationship even in primary care, where I work. I am fearful of the slow creep of ‘virtual’ consults which I worry will not allow the powerful effect of human empathy to be realised as well as it can be when you are also physically present. That simple dynamic has been present for hundreds of years when one human consults another ‘wise’ person about some health concern and its so complex, beautiful and potentially healing!

  5. Stephanie Barnett says:

    More inspiration for our next generation of health professionals … and an excellent refresher for those who just think they’re too old to change.

    Thank you for this courageous and compassionate piece, dear Robin.

    Love y’all!

  6. Thank you for another genuine thought-provoking and heart-felt article Robin. I am continuing to point people attending my Self-care in Healthcare programme in DHBs to your book and your work. You really are an inspiration!

Leave a Reply

“When all members of an organization are motivated to understand and value the most favourable features of its culture, it can make rapid improvements.”