/ MEDICINE

Medicine from Fifty Thousand Feet: Perspective, Targets and Limits

Welcome to medicine, a fascinating field with endless amounts of knowledge that can be obtained. Someone could, and many do, spend an entire life striving to learn as much medical knowledge as possible yet, like someone travelling the world, so much will always remain unexplored.

It can be a satisfying feeling to go from ignorance to relative expertise in certain topics. There are other incentives to work hard to obtain this knowledge too, such as admiration from your peers, praise from your parents and points for your CV.

However, this leads to a common pitfall: working too hard. You may have heard this before a million times, but let me use a personal example to demonstrate a point.

In my first year of medical school I was aiming high. At the end of the year, I was disappointed with my result so I resolved to do better the following year. I made a lot of sacrifices; I skipped social events, spent less time with my friends and spent many late nights in the library. Half-way through the year, we had a full ‘mock’ exam and the hard work paid off; I achieved a mark that, based on projections from previous mock and actual marks, predicted I’d finish in the top 10 of our 400-person cohort. However, my approach wasn’t sustainable; before the end of the year I became apathetic, burnt out and achieved a good but, compared to my personal target, disappointing result once again.

The following summer I spend a lot of time reflecting. My approach that year contributed to me breaking up with my girlfriend, feeling more distant from my friends and family and ultimately feeling less happy. I had sacrificed so much – what had it all been for?

I began to assess my motives. For a long time, I had been telling myself “I need to study hard so that I can be the best doctor I can be” but I realised this didn’t hold up to scrutiny: the difference between a good and a great result wouldn’t make me a much better doctor, yet the reduced life experiences from living in the library may well make me a worse one.

I realised that being the best had become part of my identity during school, causing me to lose perspective on how important it really is relative to other areas of life. I also realised that I cared too much about what other people thought of me and part of my motivation was to prove myself to others and show everyone how smart I was.

I want to stress that I don’t think that working extremely hard is a bad thing. On the contrary, I think it is important and admirable to work hard towards a worthy goal. Most people don’t work hard enough. However, we must be clear about our priorities, honest about our motives and strive to maintain perspective at all times.

I appreciate it is not that simple. If I had told my second-year self that exams aren’t the be-all and end-all, I doubt he would have listened. I needed that tough summer of soul-searching to figure things out. Sometimes you just have to make your own mistakes and learn from your own experiences.

Different people will come to appreciate their priorities and motives in different ways. Two techniques which, if undertaken with an open mind and honest approach, can help provide this clarity are ‘Following the Trail of Whys’ and ‘Attending Your Own Funeral’.

Follow the Trail of Whys

It is easy to ask ‘why’ and accept the response, even when it doesn’t really answer the question. For example:

Q: Why was the patient’s intravenous fluid run at the wrong rate?A: Because the previous nurse didn’t change the run rate.

If we accept this answer without probing further, we will assume that this was the nurse’s fault and that she should be blamed or held accountable in some way. However, this doesn’t get to the bottom of the problem and is not a solution.

The founder of Toyota, Sakichi Toyoda, is credited with advising people to “Ask why five times.” The exact number is not important, but continually asking why can be effective at finding new answers and uncovering flaws in previous assumptions.

Let me demonstrate with the above example:

  1. Why was the patient’s intravenous fluid run at the wrong rate?

The previous nurse didn’t change the run rate.

  1. Why didn’t the previous nurse change the rate?

The doctor’s order had gone to the pharmacy and the medication administration record (MAR) was not updated.

  1. Why wasn’t the MAR updated?

The MAR is updated only once per day.

  1. Why is the MAR updated only once per day?

The hospital has chosen to use oral instructions for updates that happen more frequently.

  1. Why are oral instructions used?

The process was constructed a decade ago, when medication orders changed less frequently due to longer lengths of stay. Upon further study, the hospital determines that 40 to 50 percent of its medications change every day.

It isn’t until the fifth why that the actual answer to the question is found. This technique can be applied to any situation, including understanding why you think or act in a certain way.

If I had been honest and objective with myself during my first two years of university, the Trail of Whys may have produced something like this:

Why do you study so hard?

Because I want to get one of the highest marks.

Why do you want to get one of the highest marks?

Because I want to show everyone that I’m the best.

Why do you want to show everyone that you’re the best?

Because I derive some of my sense of self-worth from what others think of me.

Why do you derive your sense of self-worth from what others think of you?

Because my upbringing taught me to seek the approval of others. This was an adaptive response to my environment but is not serving me well while studying a competitive course at a competitive university.

Therefore, the solution is to deliberately re-appraise how I evaluate myself, rather than to focus on how hard I am studying or working.

As you can see, this technique can get deep and personal pretty quickly. This is why absolute self-honesty is so important.

(This technique can also be applied to academic learning. I shall discuss learning by understanding in Chapter 2.)

Attend your own funeral

This technique involves visualising your own funeral, imagining how it could go and how you want it to go. The aim is that, by doing so, you will appreciate what really matters and is most important to you. There is a wider philosophy termed ‘memento mori’, meaning ‘remember that you have to die’, which believes meditating on our death can bring profound insights about ourselves.

A palliative care nurse called Bronnie Ware revealed the five most common regrets that people have at the end of their lives:

  1. I wish I’d had the courage to live a life true to myself, not the life others expected of me.
  2. I wish I hadn’t worked so hard.
  3. I wish I’d had the courage to express my feelings.
  4. I wish I had stayed in touch with my friends.
  5. I wish that I had let myself be happier.

Below is an abridged description of the technique - see ‘The Charisma Myth’ by Olivia Fox Cabane for the full version or for an audio recording, visit here. It can stir up emotions, so you are encouraged to do it in an environment where you feel comfortable being emotional and with time to process things after the exercise.

Set the scene and involve your senses:

  • Sit or lie down, close your eyes, and set the scene.
  • See the building where the ceremony is being held. See people arriving. Who’s coming? What are they wearing?
  • See people coming through the door. What are they thinking?

Watch your funeral:

  • Think of the people whose opinions matter most to you. What are they thinking?
  • See them stepping up to deliver their eulogy. What are they saying? What regrets do they have for you?
  • What would you like them to have said? What regrets do you have?

Other techniques

List different elements of your life (spending time with your family, studying to achieve exam success, going to parties, etc.) and then give relative scores for how important each one is to you (such as a mark out of 10). Consider how much time you actually spend doing each activity and ask whether you would like to change this.

Talk to a friend about what they think is important. Reflect on the similarities and differences in your priorities and the reasons for them.

A Canadian psychologist called Jordan Peterson founded the “Self Authoring” suite which encourages people to use writing to understand past events and plan for your ideal future. One exercise is as follows:

Think about your life in the future. Imagine that everything has gone as well as it possibly could. You have worked hard and succeeded at accomplishing all of your life goals. Think of this as the realization of all of your life dreams. Now, write about what you have imagined.

A medical student colleague of mine wrote a great article about how he approaches exams by viewing them as a game.

Set limits, not just targets

Medicine can consume your life. With clearer understanding of your priorities, you can set not only more appropriate targets but you can also set limits.

It may be that you still want to aim to finish top in your medical school, and that’s fine. However, you may be content with a more modest target. For example, after my summer of reflection I set my target as finishing in the top 25% of all exams alongside enjoying life, spending time with friends and family and investing time and energy into other pursuits.

This limited the amount of time I spent studying and gave me more stress- and guilt-free time to enjoy. It also helped guide my studying. Whenever I came across new content, I would ask myself “would someone in the top 25% know this?” In some cases, the answer was “definitely yes”, in which case I would work hard to learn it as efficiently as possible, using techniques I shall outline in Chapter 2. In other cases, the answer was “probably not”, in which case I decidedly did not learn it. As well as saving time, I found my studying was more consistent, as were my results.

Don’t get me wrong, I still work hard. But now I vent that same energy and determination into goals that I consider more worthwhile and more in-line with my deeper intrinsic values. I will elaborate upon this in Chapter 4.

One fear that some medical students have is that if they don’t study as much as they can, they won’t pass their exams. However, if you are intelligent enough to get into medical school then you are definitely smart enough to pass exams with the right approach. If you feel like this, you will benefit a lot from the principles of learning that I outline in Chapter 2. By taking the approach I outline in this book, I spent less time studying yet achieved better results.

CHAPTER 1 SUMMARY

  • Studying medicine is competitive, there is an endless amount to learn and there are continuous exams. This means that many people sacrifice too much for work.
  • Perspective and clarity can be increased by following the ‘Trail of Whys’ and ‘attending your own funeral’.
  • This enables us to set targets and limits. Limits can increase studying efficiency and help us find a good work-life balance.

Continued in Chapter 2.

This is a chapter from The Modern Medical Student Manual. A full list of chapters are below:

  • Introduction: From That Day To This Book
  • Chapter 1: Medicine from Fifty Thousand Feet: Perspective, Targets and Limits
  • Chapter 2: The Fundamentals of Fast Learning - Part 1 and Part 2
  • Chapter 3: Mastering Clinical Medicine - Part 1 and Part 2
  • Chapter 4: Increasing our Impact (and the power of Self-Education) - Part 1 and Part 2
  • Chapter 5: A Scientific Approach to Research - Part 1 and Part 2
  • Chapter 6: Commanding Clearer Communication - Part 1 and Part 2
  • Conclusion

Plus Bonus Chapters:

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The full book is also available on Amazon as an eBook or Paperback.