Are you ready to live up to the unspoken expectations?
One of my favourite things to do is engaging medical students and new doctors.
It’s partly because I remember myself like that, from over a decade ago. I was months from completing medical school and struggling to articulate a feeling that was completely new to me. I described it then as something like the emotional equivalent of what a baby might experience when it is expelled from the warm comfort of its mother’s insides.
Education, my primary pursuit for most of my life, had been a safe cocoon. It had offered, at every level, structure, a sense of destination, and a community of like minds all engaged in the same pursuit of grades. At each point, the goal was clear, the next level sharply defined.
But it was all about to end.
This experience isn’t unique to medical students, of course. Nor is it the point of this article. I only mention it to say that, having gone through it as a medical student, I get it. I understand the apprehension, the confusion about what next, the niggling anxiety that you’ve maybe spent years on a wrong choice of profession, the fear that one is graduating without knowing nearly enough.
More important, I understand something else: that you’re right about not knowing nearly enough. Just not in the way you’re probably thinking.
No, this isn’t another doctor-bashing piece. God knows we have more than enough of those. This is an attempt to document, for the benefit of medical students and new doctors (and the interest of older ones and the general public), what the real world expects (and honestly, deserves) from you that you most likely didn’t learn in school.
In one sense, that’s not entirely the fault of medical education, with its already bloated curriculum. (The far smaller size of old texts compared to their modern editions is proof enough of how much medical school curriculums have exploded.) It does call for a rethinking of what the necessary skills for a doctor are, and how they are delivered.
But that’s a topic for another day. For now, let’s get to it. I’m grouping the skills into two: clinical (or back end) skills and communication (or front end) skills. I’ll explain both as I go on.
Back End: Clinical Skills
These have to do with your work as simply a doctor. They’re your back end skills, the ones that make you good at what you do. If you were in the restaurant business, this is the kitchen part, and how amazing your food is.
This might be your number one job as a doctor: to be the maker of final decisions. It’s obvious enough, when you think about it, but if you’re like me, you probably never heard anyone say it in so many words back in school. But make no mistake, this is, above all, what you get paid for.
Everyone else on the medical team makes decisions, of course — nurses do all the time—but yours is final. As it should be: there has to be a table for the buck to stop at. And realise it or not, the entire point of your training was to prepare you to be the last bus stop for decisions. (Now you probably see why you had to do all those courses.)
As soon as you understand this, a few things become more obvious, like why this is the one role you really should not delegate. Or why you should avoid making decisions when you’re tired (except it’s an emergency), becasue you’ll almost certainly make bad ones. It’s also why you, and not a nurse, will get sued if something goes wrong.
And why good doctors make bad decisions: medical knowledge does not poor decision-making skills replace.
If your experience was anything like mine, this is the one you you heard most in school. “The doctor is the leader of the medical team,” goes the mantra. Except, there’s precious little actual training on leadership. Now, on one hand, I do think leadership is something you’re more likely to learn on the job than in a class. But on the other, I feel like having it codified into some basic principles followed by structured practice would be helpful. And by “structured practice,” I mean having graded leadership experience built it.
Barring that, though, your only choice is to take up leadership positions on your own initiative and try to get as much feedback as you can. My first leadership experience was as a group rep in my final year and it was super instructive. Also I was lucky to have some really great examples, for which I’m grateful.
Not that kind of partner o. I mean “partner” as in health partner. This is a more modern role. Basically this is about seeing yourself not simply as an expert who gives “doctor’s orders,” but as a partner who offers insight and knowledge. Patient autonomy really is a thing, but it doesn’t mean, “tell the patient what you know and let them decide by themselves what to do, before you get sued.” (Okay, for some docs in the U.S. it might actually mean that.)
Think of this role, and patient autonomy as a whole, as something more like helping your partner by offering not just your knowledge, but also your recommendations, but still leaving the ultimate choice to them. (Remember what I said earlier about having the final say? Well, that was only part right: you have the final say in what recommedation to make, but the patient has the final final say.)
Quick, before you read the next sentence: can you close your eyes and guess what this one is about?
It’s about recognising patterns. (Did you close your eyes?) Like leadership, this is another skill you already intuitively know, but the analogy is fun, and maybe even useful. So here’s the thing: someone sitting on the other side of your table presents with their symptoms: problems that to them might seem random, or might be connected wrongly in their minds.
Your job is to look at all that randomness, and after asking clarifying questions (your interview), you compare it with the database of patterns in your head (from medical school and all your subsequent experience) and find the closest pattern that fits. That’s your diagnosis. Of course, you should have learned in school to always identify alternative patterns that could explain the clues you have (differentials).
What this highlights is that, knowledge-wise, you’re as good as the number of patterns you know (the size of your database), and your skill at calling them up when necessary (the speed of your retrieval). Of course, knowledge-wise is not enough, as I explained earlier: you can still make bad decisions. Your pattern database helps improve your decisions, and if you include some algorithms in there, even better.
[Side note. This is why I chose psychiatry: I felt like it would give the best shot at spending time playing this particular role, and it has. (Surgery felt more like it was about mastering motor memory and internal medicine let you play detective but on a much smaller scale. Feel free to disagree with either opinion.)]
Front End: Communication skills
hese are skills at the “user interface.” Your front end skills, basically. These are what make people call you a good doctor. I’ll be honest, part of why I’m in psychiatry is my interest in this skillset. Back to the restaurant analogy: these skills are about how you serve the food.
Like leadership, this is a skill most medical students and new doctors appreciate. But also like leadership, familiarity and training are two different things. As you probably know, the word “doctor” has its roots in a Latin word for “teach.” (Which, by the way, is also the root word for “doctrine.”)
But you see, this role as teachers is not limited to teaching doctors, which most of us are obviously familiar with, but also of the public. You mostly get a lot of practice teaching colleagues, but you get very little teaching the public.
Which, in a world where social media is a thing and every doctor gets a free platform, you might want to start working on that skill. And make no mistake: educating the public about health is a completely different thing from educating your colleagues. Keep it simple: not because your audience is dumb (they’re not), but because they largely have more interesting options for using their time than to spend it struggling to understand you.
Which brings us to the next skill…
If they taught you about this in school, I’d like to know where you trained. And before you say it was mentioned, allow me to explain myself: I don’t mean translating from one language to another. I mean translating from one worldview to another.
By that I mean, it’s not enough to know that hypertension is translated, “ifunpa giga” in Yoruba. You’ll have to learn to explain high blood pressure to someone uninterested in blood vessels and arteries and more interested in knowing who is “doing” them from the village.
And don’t think choosing to focus on urban or educated people will save you from needing this skill, because then you miss the point. It’s not that people are ignorant, it’s just that the medical language that you spent over half a decade mastering is basically code to them.
Plus, just because you have a computer, should someone pester you to master PHP or Ruby on Rails? Exactly.
Depending where you trained, you may or may not have learned this. No matter where you trained, you don’t know the half of it.
First off, you will do this almost everyday. Don’t assume, like I did at first that “bad news” refers to losing a patient or failing to accomplish a cure. That’s just one tiny part of it. The reality is, almost every diagnosis you make comes to your patient as bad news. (Except they maybe feared something worse and your diagnosis is a relief, but it’s still only the lesser of two evils.)
And if your diagnosis is not bad news, the treatment often is. Many people don’t like tablets or injections, or being admitted or…many people just don’t like medical treatment, period.
One more thing: you’ll never get good enough at giving bad news, and that’s okay. Just don’t stop trying to get better at it.
Wait, one more thing again. There’s something you should remember: you may have delivered the same news a thousand times, but try to always remember the patient in front of you is hearing it the first time.
It’s not easy, I know. But it will be worth it to that person. And to you too, at the end of the day.
8. Customer service person
You’re probably wondering, “What?” And at the same time, it’s maybe dawning on you how real this is.
You’re in the service business, friend. That’s what all healthcare delivery is. And at the root of service businesses is, well…service.
Take it from me: an average doctor with great service skills will trump a brilliant jerk anyday. (No, I’m not saying it’s average is okay: I mean, brilliance is no excuse to be a jerk.)
That said, you’re probably not a jerk (hey, you’ve read this far!). But depending on how things work at whatever you end up in, it’s not that hard to be like one when the heat is on and you’re running on reserve emotional energy. Again though: the patient doesn’t know any of that, and they have their own stresses too. Being in the hospital is a stress in itself.
A tip for you: pay attention to the customer service guys from today. At restaurants, in banks. Note what they do well and try to emulate it. And when they vex you, remember to check that you’re not doing similar to the people you serve.
Above all, offer hope
This should come under the communication skills, but I think it deserves a category of its own. In fact, it deserves an article of its own, but let me just say here that offering hope is more than a skill. It’s your primary value.
You know how I said near the beginning that making decisions is your number one job as a doctor? That’s as a doctor. As far as the patient is concerned, however, your highest value is to offer hope. Everything else should serve that.
I will close with my most memorable favourite saying from a medical textbook, the prayer in the opening pages of Hutchison’s Clinical Methods.
From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense; from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.’ — Sir Robert Hutchison (1871–1960)
And to that I say “Amen.”