AbstractMedical students and residents often seek advice on a variety of topics from more senior physicians. Herein, I share the collected wisdom of 40 practicing physicians on topics of general interest to undergraduate and graduate medical trainees. Much of this advice is applicable to physicians already in practice.
Every year, second year Internal Medicine residents at the University of Toronto are given a weekend reprieve from clinical responsibilities. They travel, many with partners and children in tow, to Niagara-on-the-Lake, a quiet town 90 minutes from Toronto. Here they unwind, socialize and sleep without fear of being paged. Organized by the chief residents and funded by the Department of Medicine, the annual “PGY-2 retreat” has grown into an eagerly anticipated tradition.
The weekend is not all revelry and bacchanalia. The residents spend time in interactive educational sessions facilitated by a small group of invited faculty. These are meant to help the residents mature as physicians, develop leadership skills and facilitate career planning.
In late 2013, I was invited to deliver the keynote address on a topic of my choosing. Slightly intimidated, I searched for a topic that would both hold their interest and be of some practical use. Following a superficial needs assessment (I asked my senior resident what he thought I should talk about), and after reflecting on what I might have wanted from such a lecture as a PGY-2, I settled on the dispensing of advice.
Now not all advice is good, even when dispensed by smart, well-meaning people. On important matters there is often merit in seeking advice from multiple sources. In an effort to make my address more useful, I solicited input from friends and colleagues, as well as from experienced physicians who have previously published reflections of a similar nature. (Spence 2010, Sackett 2001, Krumholz 2012, Smith 2003) I received advice from clinicians, teachers, administrators and researchers of varying ages and backgrounds, including general practice, internal medicine, pediatrics, emergency medicine, critical care, nephrology, cardiology, infectious disease, clinical pharmacology and rheumatology. What follows is a distillation of the advice and wisdom they shared.
Advice for Physicians in Training
On Being a Doctor
- You can be an excellent physician without a stethoscope or a prescription pad, but not without good communication skills. Communication is your most important tool. Tailor your words to the patient, and listen more than you speak. Remember that the physicians who most often run afoul of patients and families (and their lawyers) are those who communicate poorly or not at all.
- A thorough history almost always trumps a thorough physical examination. Osler said “Listen to the patient. He is telling you the diagnosis.” He was right.
- Awareness of what you don’t know - and in particular how you deal with not knowing - will define the sort of physician you are perhaps more than anything else.
- No one expects you to have all the answers, not even your patients. The three most valuable words in your vocabulary are “I don’t know.” Using these words with colleagues and patients demonstrates honesty and awareness of your limitations.
- Project confidence to your patients. It’s therapeutic. But don’t be overconfident, and be wary of colleagues who are. Overconfidence is a dangerous quality in a physician.
- Don’t underestimate the ability of drugs to cause harm. They will be responsible for some of the most common problems you will see in practice. Sometimes this harm will be obvious, but often it will not.
- There are only two good reasons to do something to a patient (or more correctly, for a patient): to make them feel better or to help them live longer. If an intervention – a drug, a device or a procedure – carries no realistic prospect of either, it’s not worth doing.
- Read guidelines, but remember: They’re guidelines, not instructions. It’s difficult to overstate the importance of this point.
On Uncertainty and Error
- Being wrong is unpleasant, but it’s part of the job. Expecting perfection of yourself or your colleagues is a recipe for unhappiness.
- When you make a mistake (and you will), own up to it. Nothing good ever comes from covering it up.
- Uncertainty is everywhere in medicine - in diagnosis, prognosis and therapeutics. Be thankful for that, because without it, medicine would be algorithmic and boring. Uncertainty is where the science of medicine ends and the art of medicine begins.
- Some of what you have been taught is wrong. The problem is that no one can tell you what those things are just yet. Retain a measure of healthy skepticism, particularly about things that seem surprising, counterintuitive, or too good be true.
- Don't rush to fit a patient into a diagnostic category just because it's the one you're most comfortable with. Realize that your initial diagnosis is often wrong. Let time be a test if you can let it.
On Career Choices
- When choosing a career path, remember that the best job has you spending most of your time doing things that get you excited about coming to work each day. Don’t choose a career path based primarily upon “where the jobs are,” and certainly not based upon money.
- Don’t over-plan your career. Do have a sense of what type of medicine you want to practice and where, but these things can change in short order. If you are good at what you do and people like working with you, opportunities will arise.
- Don’t be in a rush to complete your training, especially if you are uncertain about the sort of career you want. Extending your training buys you time to mature as a physician and as a person, and might open doors that would otherwise be closed.
- Competitive specialty programs value content expertise, but generally prefer residents who are hardworking, reliable and good-natured to those whose primary attribute is knowledge.
- If you don’t gain acceptance into your training program or job of choice, recall the words of the 14th Dalai Lama: "Remember that sometimes not getting what you want is a wonderful stroke of luck." Great things can happen when plans go awry.
- When choosing your first “real job”, don’t underestimate the value of living close to where you work. And take note of the personalities of your prospective colleagues; you will spend a lot of time with them. Medicine is full of smart people. Gravitate toward the nicer ones.
- Some trainees harbor the idea that great medicine is limited to academic centers. This is wrong. Community-based medicine is full of outstanding physicians who have fulfilling careers and are loved by their patients.
- Time is your most precious resource. It’s nonrenewable, and it’s important to protect it. Do not be afraid to say “no” when asked to assume new responsibilities, particularly in the early stages of your career. There is no shortage of work to be done, and senior colleagues will often turn to younger, more energetic people to do it.
- Do say “yes” to some requests, particularly those that present opportunities for learning or other personal betterment. You didn’t get to where you are by shirking responsibility or by avoiding challenges. Say yes and no in good measure.
- Spend less than you earn. There will be temptation to live beyond your means, particularly in the early years of practice. Pay off debt as quickly as possible.
- Buy disability and, particularly if you have dependents, life insurance. (This is a dull but essential point.)
On Professional Relationships
- During residency, your work relationships are fleeting. When you enter practice, they immediately become long-term. Be kind to the nurses, the physiotherapists and the pharmacists, the ward clerks and porters. We are all in this together.
- “Drug reps” are not your friends. They have a job to do, and their objectives are often at odds with your obligations to your patients. Drug reps tend to exaggerate a drug’s benefits and minimize its harms. Decline free samples, which are nothing more than marketing devices, and skip the fancy “educational” dinners, which will only make you feel cheap. (And if they don’t, you might want to think about that.)
- Helping patients and families deal with death is one of the most rewarding aspects of practicing medicine. Becoming comfortable talking about death, however, is not easy, and physicians who are good at it didn’t get that way overnight. When you find one who is, observe and emulate them.
On Personal Wellbeing
- Have a personal physician who isn’t you. You’re just not that objective.
- Medicine is busy, tiring work, and it’s easy to neglect your physical fitness. Find an enjoyable way to exercise several times each week. This will have secondary benefits for your mental wellbeing.
- Don’t sacrifice family events for work if you can avoid it, but do choose a partner who understands your commitment to your work. This will make it easier when you’re late for dinner or working on evenings or weekends, as will sometimes be the case.
- Medicine is your major. Try to have a “minor” – at least one other important activity in your life. This could be an interest of a medical nature (advocacy, volunteerism, blogging etc.) or not (a musical instrument, sport, travel or other hobby pursuit.) Having a minor offers balance and enrichment, and will make you a better doctor.
On Mentorship and Guidance
- Mentorship is critical, particularly during subspecialty training and the first five to ten years of your career. Recognize that mentors are not the same as role models, who are simply people you wish to emulate.
- True mentors want you to succeed and are guided by your interests rather than theirs. A good mentor has “been around” and knows things you don’t, including which rules can be broken and which ones cannot. The best mentors will sometimes tell you things you don't want to hear. Time often proves them right.
- You can have several mentors - a clinical mentor, a teaching mentor, a research mentor, even ‘a work-life balance’ mentor. The mentor-mentee relationship can be formal or informal, and the only unacceptable number of mentors is zero.
- Most of the fun in medicine is at the bedside. Try to get out from behind the computer as much as possible (there is little fun to be had there) and spend more time with the patients.
- Keep every letter and card of thanks from patients and their families. If you are acknowledged in an obituary, clip and save it. Read these things periodically. They are affirmations that you are making a difference in the lives of others.
- When you think you’re having difficult day, remember: your patients have it worse. You weren’t just diagnosed with leukemia, you aren’t eating hospital food, and you’re going home to sleep in your own bed.
- Don't wait until your mother, father, spouse or child is sick to understand what a drag it is to be a patient. The waiting, the uncertainty, the pain, the misery, the lack of information or time for questions. Try to put yourself in each patient’s shoes every day, even if just for a moment. With practice this will help you see every case as interesting in its way. Thinking otherwise is a betrayal to the person in front of you.
- Never lose sight of how fortunate you are. You get to decide what you will do for a living, where you will work, and with whom. You have smart, like-minded colleagues, you get to use your brain to solve problems for the whole of your career, and your occupation affords you the respect of people you don’t even know.
- Remember how much your work matters, because health is important to everyone. You get to cure disease sometimes and offer comfort when you cannot. What you do makes a real difference in the lives of others, allowing you to leave the world a better place than you found it. And as if all that wasn’t enough, you actually get paid to do these things.
Was this an unbiased, scientific process? Not even close. Was all of the advice received good? No. (“Don’t have more than two children” did not appear in my keynote address.) Will everyone agree with all of the advice on offer? No, although a good bit of it is irrefutable. What struck me most from this process was that so many physicians – women and men, young and old, clinicians, teachers, researchers and administrators from diverse fields of medicine – could offer such a variety of positive, reaffirming and hope-filled reflections to young doctors in training. Hopefully some of it resonates. If nothing else sticks, remember the final bit of advice. None of us should lose sight of how fortunate we are – and what a privilege it is – to do what we do.
Spence D. “A letter to me at 23.” BMJ 2010; 340:c180 doi: 10.1136/bmj.c180
Sackett DL. “On the determinants of academic success as a clinician-scientist.” Clin Invest Med 2001; 24(2):94-100 PMID: 11368152
Krumholz HM. “A note to my younger colleagues. . . be brave.” Circ Cardiovasc Qual Outcomes 2012;5(3):245-246 doi: 10.1161/CIRCOUTCOMES.112.966473
Smith R. “Thoughts for new medical students at a new medical school.” BMJ 2003; 327(7429):1430-1433. PMID: 14684637
I am indebted to the following physicians for suggestions and advice:
Toronto: Nadine Abdullah, Michael Baker, Allan Detsky, Shelly Dev, Irfan A. Dhalla, James Downey, Edward E. Etchells, Wayne L. Gold, Gillian A. Hawker, Moira K. Kapral, Andreas Laupacis, Lauren Lapointe-Shaw, Heather MacDonald-Blumer, Jeffrey Powis, Joel Ray, Donald A. Redelmeier, Robert Sargeant, Steven L. Shumak, Joo-Meng Soh, Lynfa Stroud, Jill Tinmouth Hamilton: David L. Sackett Kingston: Marco L.A. Sivilotti Ottawa: Carl van Walraven Vancouver: Anita Palepu Edmonton: Finlay McAlister Winnipeg: Milton Tenenbein Amos: Bert Govig Charlottetown: Patrick Bergin
Boston: David W. Bates Cincinnati: G. Randall Bond New York: David S. Goldfarb, Robert S. Hoffman New Haven: Harlan Krumholz, Joseph S. Ross
Edinburgh: Nick Bateman, Michael Eddleston Glasgow: Desmond Spence London: Richard Smith Oxfordshire: Richard Lehman
Sydney: Nick Buckley
Showing 19 Reviews
Thanks for the work that you've done on this paper! Medical students and residents have a lot of advice available to them but rarely has it been compiled in this fashion. I think you have produced a valuable resource and I will be referring medical students to it in the future.
-I believe the standard formatting does not include indentations for each paragraph. Could these be removed from the introduction and conclusion?
-For the purposes of reproducibility and clarity, I think it the inclusion of a brief Methods section describing how this advice was solicited and distilled would help to contextualize the article. Would it be possible to provide the number of individuals approached for advice, the criteria for deciding who should be asked, how the advice was solicited and provided, any distillation or modification of the advice that occurred to get it into its final form, was all advice included, etc. I expect that much of this was informal, but the details are still of value to help the reader understand where this advice came from.
-I believe the advice that was provided warrants the title of 'Results' with the rest of the other headings becoming subheadings.
-Would it be possible to provide the demographic information of those that solicited advice? e.g. age, gender, specialty, number of years since residency.
I would suggest revising and expanding this section. It may also be appropriate to retitle it as a 'Discussion.' This would allow further reflection upon the process. Some possible topics of discussion would include: 1) the reception of the talk that was alluded to in the introduction, 2) the limitations and benefits of the informal methodology, 3) the underlying positive, hopeful tone of the advice, 4) the need to better consolidate advice like this in the future.
Grammar and Writing
-I am unsure if PGY2 is a term that is internationally understood. I would suggest using "Second year residents" whenever possible to assist in the interpretation of the article for international readers.
-The introduction are written in a comprehensible and entertaining style.
-Paragraph 1 Sentence 2 would better read: They travel to Niagara-on-the-Lake, a quiet town 90 minutes from Toronto, with their partners and children in tow.
-Paragraph 2 Sentence 2/3 would better read: The residents spend time in interactive educational sessions facilitated by a small intended to help them mature as physicians, develop leadership skills, and facilitate career planning.
-Paragraph 3 Sentence 1: "This past year, I was" is less clear than "In 20xx I was." In subsequent years this change will allow readers to know when this occurred without checking the year of publication.
-Paragraph 3 Sentence 3: "Following a superficial needs assessment (I asked my senior resident what he thought I should talk about) and reflection upon my circumstances as a PGY2, I decided to offer them advice.
-I think this paper contains valuable advice for medical students that is worthy of being disseminated in published form.
-The data from this paper supports its conclusions as it acknowledges the limitations inherent in the process used to gather the presented data. However, I think the paper would benefit from further description of these methods and a more expansive discussion.
-I have no competing interests.
In closing, thank you for publishing this paper in an open format as the advice it contains will be valuable to medical learners. I hope my suggestions help you to improve this paper prior to submission for formal publication.
Brent Thoma, MD, MA
University of Saskatchewan
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