Developing the medical mindBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7159.2 (Published 05 September 1998) Cite this as: BMJ 1998;317:S2-7159
The medical mind has plenty of reserve capacity: Carl Gray explores using it to the full for career and life satisfaction
Lifelong learning should include doctors too. Happily, “The evidence suggests that humans everywhere on the planet see, talk and think about objects and people the same basic way.”(1) Reassuringly, this must apply to doctors also. And excitingly, the neurobiology of the mind has leapt forwards lately. Pinker's superb book tells all in a racy style. The medical mind is merely a special case and its owner rather ordinary in human terms. But, as humans, there is great scope for development. Are you sitting comfortably?
“Feather-footed through the plashy fens passes the questing vole.”(2) All questing creatures have brains made of nervous tissues acting as Turing machines. Even tiny insect and bird brains can navigate and can transfer information. Larger brains, such as those of us mighty mammals, are universes of billions of smaller computational units: “demons” in the jargon. These operate on bits of data received from sense organs, held in various memory files, and shared to different extents. There is no single homunculus watching a screen within - rather, there is a jostling bazaar of mental organs, modules, and demons competing for data and attention. The awesome features of the human brain are its powerful visual interpretation, enormous memory, and symbolic coding for thought and language. Think on this as you stroll into your next postgraduate examination. Its weaknesses are the tiny focus of attention and the episodic spurts of consciousness.
The mind is explained by natural selection. We evolved to meet the challenges of the African savannahs: long grass, large animals, and competing tribes. Mental mechanisms which conveyed advantage survived, which means the modern medical mind is strong on detecting fierce animals, recognising friends and relations, and defending its own territory: all are used in the clinical jungle.
We are apes with attitude because primates happened to have the bases for the evolution of intelligence: binocular vision and the manipulative hand, group living, and hunting for lunch. Doctors inherited their mental functions from three wise monkeys: looker, grasper, and hunter; and they still have to hunt for resources.
Common medical mental failings
Fashionable views and phrases
Reverence for dogma
Obedience to authority
Resistance to change
Lack of empathy
Numbers and statistics
Culture and literature
Lack of ideas
Lack of opportunity
Philosophy and meaning
The central puzzles of the meaning of life, the location of my car keys, and the physical bases of qualia and consciousness are not to be solved in terms of neurobiology. Society's judgments on morality and doctors' grip on medical ethics are in different domains from neuroscience: the content of the software is different from the wiring of the hardware. So watch your floppy and avoid corruption.
Not just romancing but Romanticism is back in vogue. Not since the 19th century has it been so fashionable to value raw natural feeling over reason. Nothing is real unless it induces strong feelings in someone somewhere. Although annoying at times, emotions are “well-engineered adaptive mechanisms,”(1) concentrating the mind wonderfully. Emotions steer the whole person in safer directions at times of crisis, such as seeing a predator on the ward, taking exams and attending job interviews, and losing your nuts. Emotion and intuition are sometimes telling us something valuable, using other streams of information. If you are miserable, there are probably reasons why.
Put monkeys in white coats and they lose their bananas. Traditional medical thinking follows the chimps: breast beating, head scratching, grooming of the dominant male, and using rudimentary tools. Despite centuries of medical science and epidemiology, we itch to name things, to define discrete categories, and to treat syndromes as entities. We automatically regard association as causation and overvalue repetition in chance events. Even clever doctors make the usual errors in probability calculations.
Applications of different forms of logic in medicine have been well explained in popular books(3)(4); but little is ever applied in the hurly burly of medical practice. Most of us get by on pattern recognition, regular routines, and lists of things to do - techniques that do at least work but are rather less than our sporting best. The pressing difficulty is clinical quality: to achieve consistency, reducing variation in practice and lapses into mediocrity, while allowing flexibility in the face of the changing world. These ideals are antithetical: creative people are not necessarily reliable, and predictable chaps are not creative. But doctors are supposed to be both safe and adaptable.
Medical knowledge is in a marvellously interesting state, yet too many doctors and students are suffering burnout, dissatisfaction, and stress, leading to dropout or early retirement. Conventional training prepares us for a dated and rather idealised world, like an old black and white medical film. We are unprepared for the modern challenges of overwork, rapid change, accountability, and time starvation.
Nowadays medical students are cloned from their motherboards and fed on computer chips. Their selection is ruthless, requiring high grades, social service, positions of responsibility, personal achievements, and tests of motivation and insight. But the education of these superb entrants has too long combined information overload with deficient thinking, lashings of humiliation, and many dismal role models. Unlike the gentlemen scholars of past centuries, few doctors today have been trained in thinking or logic, philosophy or ethics, and culture is usually reserved for a sleep in front of Channel 4. Many bright students have been dismayed by the dumbing down at medical school. Liberal adult education has worked in other professions for the past seven decades; why does medicine remain unliberal and relentlessly anti-intellectual?
Doctors were traditionally wedded to the job and its place, style, and status: a true vocation. Now the work has ratcheted up several orders of gearing; increased pace has outstripped its traditional satisfactions of gently and slowly attending every patient's passage through birth, life, and death.
The modern professional is required to deliver clinical services of the highest quality, with kindness and sympathy, but complying with all national guidelines at all times - and pretty damn fast. Although it's always brisk and sometimes bracing, this is not really a bad deal. In return, doctors can themselves get a life outside the profession. Increasingly, younger doctors want to live like everyone else with family and leisure, not to be tied slavishly to clinical demands around the clock. Giving up alpha status, reverence, and being special will entitle us to balanced lives, better withstanding the pressures of change and meeting the future. And mental performance should also change.
All medicine is just information processing. Data inwards; coded information and actions outwards: an everyday job for neurones in squid and senior house officers, rats and registrars, cobras and consultants. Untangling our axons we can find areas where the demons and little monkeys in our heads could do better. Daily experience shows that doctors of all ages - like all people everywhere - are failing to make best use of their brains (box). Have you seen my slippers anywhere?
Successful doctors of the future will extend their development beyond their short spell of formal specialist or general practitioner training. Clinical and technical proficiency has to be achieved in the time available; but a full medical life will require more in the future and over its full span. The mind of the doctor will have to embrace a wider world.
What to do about it?
Come down from your tree, identify and study the failings in your own mind, and attempt exercises to address them. Other monkeys in your troop are your experts and will be delighted to help list your habitual mental faults. These include absent mindedness, fixed opinions, not listening, repetition of phrases and mannerisms, and utter predictability. Loosen the grip on your ganglia. Develop a new strand of intellectual activity; exercise can be inward as well as outward bound. Learn a new skill: do games or puzzles, learn a new language, attempt an unfashionable or previously disliked genre of films, literature, music, or drama. The medical mind can best be refreshed by activity outside medicine; many areas of life will crossfertilise, infusing professional function with hybrid vigour. Are those my nuts?
There is an abundance of material in books and the media, and on the internet. (A helpful list is provided on the web version of this article.) The modern bookshop is a fabulous treasure house of self help works lapped up by people in all walks of life. Only we poor doctors have too little time to join in. Revelatory advice is available on all subjects from male and female minds to controlling emotional response in all situations. All mental functions - memory, numeracy, word power, analysis, nut recognition - can be sharpened by exercise using techniques that really work.
New minds for old
The medical mind is a classic case of use it or lose it. Nice examples of both results can be seen in hospital corridors and doctors' messes. If we are to keep up with the birds, the bees, the voles, the editor, the chimps, and our new students, a little more mental striving is due. Despite our anthropoid preoccupations with bodily pleasures and sleep, the brain remains our sexiest organ - but only if turned on.
Exercise will develop the mental muscles you want. Inside your head your intranet has more connections than the entire world wide web: there's plenty of space for new development in the lush cerebral green belt and no planning permission is needed. Nature has adapted your brain over millions of years to have unlimited potential for pattern recognition, ideas, memory, and enjoyment. Medical chimps or medical chumps, we humans have the best brains biology can do: so stop scratching, think again, and enjoy opening your mind.