When I was a medical student, a professor lowered his glasses and bellowed at me: “if you want to be popular then get a dog.” His point, presumably, was that I had entered a profession of high standards and tough truths. Later, he thundered that “well done matters more than well said” and that “ten percent more effort makes you fifty percent better.” He was right, he was almost always right, and always at the top of his voice. Back then, I took it all with a mixture of bewilderment and shame and gratitude. Over time I likely absorbed both the terrific advice and the terrible delivery style. Fast forward two decades and just imagine me giving similarly “forthright feedback” to modern learners. Well, you needn’t imagine it because this is exactly what I did.
Clearly, the world has changed. I know this because in the same year that I was pulled up for an outburst with trainees I also expected to face my first formal complaint from a patient. I braced for a one-two existential punch, and in both cases the subtext would be that I was “unprofessional.” I was prepared to be contrite, but was also confused about whether the world in which I was raised still resembled the one in which I work. I believe that sincere apologies help us all move on, but worry that I inhabit a world where it is safest to stay quiet, or launch counter accusations. While some businesses face complaints dispassionately, for us doctors, it can feel profoundly personal. Moreover, that word “unprofessional” can truly hurt. We are resilient, but empathy opens us up to injury. This job is not just what we do, but who we are.
If the last few years have taught me anything it is that communication is likely the most important “procedure” in modern life. Moreover, it doesn’t hurt to remember that we have two ears and one mouth because we should use them in that proportion. Healthcare workers don’t need, nor usually deserve, fawning praise. However, my sense is that when there is a communication breakdown the punitive route increases the likelihood that nobody really wins. For example, the doctor, even if admonished, suffers reputational damage and may be less likely to re-engage. The family, even if validated, will likely have lost time that could have been used for grieving or attempting to move on.
When it comes to my self-righteous outburst with the trainees, I am genuinely sorry for losing my cool. I am working hard to be a kinder and gentler me. However, I would be disingenuous if I didn’t admit that I worry that teaching may become as much a popularity contest as a search for epistemological truth. I don’t want to believe that buying cookies will get me farther than asking my students questions (in the way of the Socratic method), but there is evidence that this is the case.  I also fear that this brave new world expects every learner’s evaluation to be above average, even if this is mathematically impossible. In short, I am confused even if I am contrite. I don’t want to believe the solution is just to keep my head down and my trap shut.
I still love this job and have helped many patients. However, doctoring means living with the likelihood that you will make mistakes and will cause some harm. Doing good means risking bad. Moreover, the desire to do ever better is why I read and write, and teach and debate. I don’t need you to accuse me of imperfection: I can do that all on my own. Canada’s always quotable, William Osler stated that “more mistakes are made by not looking than by not knowing.”  Perhaps we should humbly update the great man. In our more litigious and sensitive world “more accusations are made by not communicating than by not knowing.” Perception is reality, and the reality of modern medicine is that verbal dexterity matters as much as big brains or nimble hands.
Communication is how we interact socially and how we show people whether they are safe or unsafe. Sometimes this means talking, but just as often it means listening or simply being present. To quote a more enlightened colleague, we often need to simply sit with our patients in the rubble.  My grumpy professors never told me anything about giving feedback, the importance of feelings over facts, or how to say sorry. Now that I am the professor I need to encourage a just system where we learn from mistakes and minimize finger pointing. Please excuse this old dog as he tries to learn new tricks. I will start by controlling my bark.
Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb
Competing interests: None declared.
- SMACC conference 2019- Liz Crowe