21 Oct, 13 | by BMJ
How when you are a 20 year old medical student with almost no clinical experience and no experience at all of death do you talk to a dying patient? What do you say? Do you avoid the topic of death altogether or do you put it top of the agenda? Should you look sad? Can you make a joke? I had no idea, and somehow at first it didn’t matter. I was a medical student in Edinburgh in the early 70s, and we avoided such conversations. We might know that patients were dying, but did they? Sometimes oblique references were made to “one for the professor of pathology’s wards,” but I didn’t in my initial attachments have to talk to dying patients about the fact they were dying. I might instead talk about their blood tests, their family, or the weather.
Then I was taught by John Munro, a physician at the Eastern General, and days after I arrived he had us talking to dying people. He did it with ease. He was sympathetic, he cared, that was obvious. But he was honest, answering all their questions, spelling out what might happen. He showed us how it wasn’t so hard. It wasn’t different from talking to any patient. And you could joke, although it needed more confidence and better timing than I possessed.
On another occasion he asked a group of us if anybody smoked. One student did. “If I can stop you smoking,” he said, “I’ll do more good than in my whole week of treating patients.” This made a big impression. He was so skilled and caring and worked so hard. The amount of good he did in a week must have been huge. Yet stopping one medical student smoking would do more good. Coming from a clinician we all respected, his saying was a very powerful way to teach us the value of prevention.
Then I remember him teaching us how to take an alcohol history. “People around here,” he said, “drink a lot. Ask them how many pints they drink a night and they’ll tell you ‘two, maybe three.’ But ask them ‘What do you drink, ten pints a night?’ and they’ll tell you ‘Well not every night.’ And if they drink only a couple they’ll just laugh.”
Munro was a hero to Edinburgh medical students. Everybody wanted an attachment to the old hospital by the sewage works rather than the grand Royal Infirmary, where the doctors seemed more interested in publishing papers or giving talks in New York than caring for patients.
But Munro could be scary. He would never humiliate you, as happened elsewhere, but he demanded high standards and respect for patients. One student who examined a patient and left oil on her stomach because he’d been working on his motorbike didn’t ever make the mistake again after Munro had made clear what a serious error he’d made. But Munro was also fun. His suits were bashed, his hair dishevelled, his statements sometimes outlandish, and his laugh loud and infectious. And students were greatly impressed that he sometimes wore not just odd socks but odd shoes: his mind was on his patients and his work not his personal elegance.
We all wanted to work for him, and I had an interview to be his houseman. These sorts of interviews were usually not memorable, but I still remember a question from my interview with him. “Should we,” he asked, “take the best students we can get or should we take some students with problems, perhaps mental health problems?” That was an interesting question. On paper (although not probably in reality) I was a good student, so answering yes could work against me. But clearly good units should take some weaker students or students with problems. Indeed, it would probably be logical for the better units to take a higher proportion of weak or troubled students.
Munro died earlier this year, but I was delighted that I saw him again last December—in happy circumstances. I didn’t know it in the 70s but he had a passionate and informed interest in contemporary art. My wife is an artist, and this fact emerged in some correspondence I had with Munro prompted by a friend who had been looking after him. He invited my wife to exhibit at the Royal College of Physicians of Edinburgh in their Christmas show, which he had been organising for years.
My wife took five paintings, and Munro helped them hang them. He had the same energy, decisiveness, and mad laugh as ever despite all sorts of health problems. My wife, as you’d expect has a great eye, but she conceded that Munro’s proposal of how she hang her pictures was superior to her own. And she liked him. She’d never met him until then, but she’s an accurate and immediate judge of character. (I was her one—big—mistake.)
During our lives we encounter just a few people who leave a lasting impression, who teach us something important. John Munro was one of those people for me.
Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.