Speech to UP-PGH graduating class of medical residents and fellows
February 11, 2007
by Dr. Antonio Dans
I would like to thank the graduating class of residents and fellows for inviting me to speak to you today. I speak to you so often and I am surprised you haven't had enough. The difficulty for me was looking for something to say, that you had not heard before. So for tonight, I chose to give a message, not from myself, but from my generation. I did a survey!
The research Q was this: What do former residents and fellows of PGH know now, that they wish they knew when they graduated?
Methodology: This was a survey sent by SMS.
Inclusion Criteria: 1) former student, resident or fellow 2) graduated shortly before or after me and 3) must be listed in my cell phone.
Results: There were 72 text messages were sent out, and 68 responses were received - a surprisingly high 94% response rate. Of these however, only 56 were analyzable - a dismal 78%. "Sana nag nursing na lang ako" for example, does not refer to something I wish I knew. Or "Sana di ko na binoto si GMA" - falsely implying he only graduated at the time GMA ran. Or, the most common impertinent answer, "Hus dis pls", as if it mattered who was asking.
Of the analyzable responses, there were 5 main categories. Let me get rid of the miscellaneous ones first. From Dr. Hilda Alava - "I wish I knew you had to buy stocks to practice in some hospitals." Now be aware. From Leny Fernandez - I wish I knew how to charge patients. (Yup, important)
I wish I knew who my real friends were - from Dr. Boying dela Paz. (Look beside you now and think hard). From Shelley dela Vega: I wish I knew that I should wear sun block. (Someday she might explain this to me)
From Dr. Edward Wang just a few minutes ago - I'm sorry Tony; I haven't learned anything since fellowship. And a similar reply from Raymond Alonzo - "Nothing. I already knew everything even then". Other than these, responses fell into 4 general categories, which I would like to share with you. General category # 1. We wish we knew then, that we knew so little.
Beta-blockers are bad for CHF, Vitamin C improves immunity, and all enlarged tonsils should be removed. Not many years ago, these were non-debatable bits of "knowledge". Today, they are nothing more than somber testimony to the fallibility of the human mind. Here's a sobering thought, which most of us have discovered by now - "Half of what we learn in medical school is wrong. We just don't know which half" (from Dr. Dave Sackett, one of the pioneers of Clinical Epidemiology).
If ONLY we knew this, then we wouldn't have bothered to memorize many of the things we were asked to. We wouldn't have focused on accumulating knowledge per se, but on developing skills to keep up with information. How to track, how to appraise, how to apply the medical literature, which, after all, represents the collective experience of the medical profession.
If ONLY we knew this, then we would have paid less attention to knowledge per se, cultivating instead, our creativity. Einstein said, "Imagination is more important than knowledge". No he didn't text me. But I agree with him. With knowledge alone you become outdated like an old book. With creativity, you can actually discover new knowledge, and rewrite the books yourself! True, you need knowledge to understand problems, but remember, you need creativity to solve it.
For sure, the medical curriculum, and indeed our residency training program, must think of ways to de-emphasize absolute knowledge. We must spend as much time cultivating self-learning, creativity, and problem-solving skills. This is easier said than done. It requires not just a change in content, but also a change in teaching style. The "all-knowing consultant" of the past, must abandon the impossible image of omniscience. Instead we must role model humility, intellectual curiosity, information- seeking behavior, creativity and problem-solving skills. If we agree on this, admitting, "I'm not sure what to do, let's look it up" - would have far better pedagogical value than an authoritarian approach: "there is only one way to mange this case".
The 2nd general category - We wish we knew then, that there were many things more important than hard work.
So, knowledge isn't important, and now, hard work isn't important. This tells you a lot about my generation. Think about it though. Hard work is great - but it makes life sound like a prison sentence: 75 years of hard work! Surely, even doctors are human. Faced with the prospect of hard labor, many will burn out. Others will avert this by migrating to greener pastures, or even shifting careers. One reason for this is that perhaps, our model has been wrong all along. Instead of modeling hard work, shouldn't we be modeling zest? There's big difference. Hard workers do things because they have to. People with zest do things because they love to do it. Students easily sense this. When arranging for preceptorials, they see the difference between "OSCE nanaman, kakatapos lang natin a!" as opposed to "Uy enjoy ako dun a, lets do it again next year!"
If we had known this before, many of us would have nurtured our zest. We would have protected time for activities that revive our energy. Unfortunately, our training places a premium on pure hard work - staying in the hospital long after office hours, coming in early before shifts, giving up weekends and holidays, working through meal times. To live up to such expectations, we have given up things that maintain our zest - time with our family and our friends, and time on leisure activities that revive us physically, spiritually, and emotionally. Except for the strongest, this leaves most of us tired, and drained - and ready to leave for good.
We must rethink expectations made of residents and fellows. In recent years, many training programs in medicine have paid closer attention to institutionalize measures to prevent compassion fatigue. This will take some introspection and planning from the point of view of the department. Meanwhile, there are things you can do. Diagnose yourself. If you don't wake up in the morning excited and raring to go, at least now and then, then something is wrong. Rest. Organize your schedule. Pray. Do something new. You have to revive your zest.
General category # 3. We wish we knew then, that the practice of medicine was more an art than a science. Dr. Greg Rogelio of SLMC texted me: "I wish I knew that medicine was more than a science. A lot of it is art and personal touch. Graduates of government training, like myself, aren't made to realize that." I agree with Greg. We were required to read tons of material, but we were taught nothing about how to relate with people. Have we helped you relate well with your patients and with your peers, with people of different social classes and levels of education? How much do your patients like you? Do they look forward to visiting you again? We're so used to evaluating patients that we forget we are being evaluated too. And between the two, their evaluation of you is more important than the one you make of them. There is this saying - patients don't care what you know, unless they know that you care! How much you read - that determines success in medical training. How well you relate to people - that determines success in your medical career.
If we knew that then, we would have done more than just listen to what our consultants say. We would have paid more attention to how they say things. Perhaps we should program communication skills into residency training, and increase its importance in the instruments we use to evaluate you. We have workshops on all sorts of things, but I haven't heard of any on patient communication and bedside manners.
And finally, general category # 4. We wish we knew then, that there was a lot of room for change. We wanted to be accepted by our profession so much, that we didn't see that so many things needed change. Eugene Ramos texted me: I should have had more confidence to follow my own lead. People who I thought knew more turned out to be no better than me. And from Miriam Timonera in Iligan: Ang dami palang bisyo ng doctor. Many more made subtle criticisms of the medical profession, that we did not realize when we graduated. Recognizing the need for change is important, but it isn't always easy. Our educational system breeds conformity. We try to turn all of our students into realists. "Don't try to change how we do things - it has been tried and tested for many years!" Sound familiar? I wonder, how hard have we tried to nurture your other half - the idealist? The one that wants to rebel against society, change the status quo, and fight for a better world? We honor conformists in school because they have discipline and they don't rock the boat - but after school, it's the rebel we honor - the people who saw what is, and tried to change it into what ought to be - people like Mahatma Gandhi, Martin Luther King and Ninoy Aquino.
I am proud of my generation of doctors from PGH. And I am proud of being part of the faculty. While we have no national heroes or martyrs, many of us have rebelled against the status quo in some small way, and have been able to implement some improvements in how we teach, how we practice, and how we do research.
Summary and conclusion: There are 4 things people from my generation want to convey, at least those who were in my cell phone. In one way these 4 messages represent deficiencies in how our generation learned medicine. In another way, understanding these 4 messages may help you prepare for the real world.
1) Knowledge isn't important 2) Hard work is overrated 3) Medicine isn't just a science 4) Do not conform to society. Further studies: It would be interesting to do a cohort study after this survey. My hypothesis is that these characteristics will predict success in your medical career. The hard workers will probably burn out, and those with zest will run circles around them. The knowledgeable ones will probably land decent jobs earlier, because of their excellent grades, but the creative ones will soon fly past them in the rank and file. The conformists will stagnate in the past; the idealists will create the future. Encyclopedic ones will have silent careers, but those who relate and communicate well - they will be heard by their patients and peers.
I am no longer sure how to end this talk. My speech teacher told me once, if you don't have one message when you speak, then you have none. Now that's a hard one, given the cacophony of responses I received. I did marvel at one thing though - how quickly people answered, and how passionate their answers were. Looking back, I think THAT is the singular message from my generation to yours - nurture passion for your work. Not fashion with an F. I know many of you think that is the formula for success. Passion with a P. Passion drives all 4 categories of messages. Passion for what you do will fuel your curiosity and creativity, so that knowledge does not stagnate. Passion will add zest to your life, so that what you do does not seem like work at all. Passion will add meaning to how you deal with patients and peers - because passion is contagious, and many times more effective than words. Finally passion will lead you to a cause, and will drive the rebel in you to change things. Now for me, THAT's worth remembering.
I have truly learned so much preparing for this talk. To the graduating class of 2007, you are amply prepared and we are all TRULY proud of you. Now go out and change the world... because you can. Whatever you do. Do it with passion.
Congratulations, thank you, and good night!
