Eccentricity and conformityBMJ 1999; 319 doi: http://dx.doi.org/10.1136/bmj.319.7220.2 (Published 13 November 1999) Cite this as: BMJ 1999;319:S2-7220
- Carl Gray, consultant histopathologist ()
Eccentric conformist Carl Gray analyses diversity in medical style
Medical teachers are understandably concerned to equip their students with the necessary skills, attitudes, and knowledge for work in the profession. There used to be traditional assumptions of style in appearance, clothing, and manners. This was exemplified by Trevor Howard's character in Brief Encounter: a well-scrubbed doctor in fustian gents” outfitting with mild manners and understated passion. Teachers at medical school said, ‘Look smart, get your hair cut, and keep your finger nails short: the patients, especially elderly patients, want their doctors, and therefore you students, to look like doctors.” The message was a little spoilt by their embroidered Afghan goatskin coat and flares, but we listened in kindly disbelief. Conventional manners and style were part of civilisation, part of the contract between strangers that enabled them to interact with predictable success.
Alas, the world has changed, and the question of style v quality has returned with a vengeance. British reserve is increasingly replaced by transatlantic style, pan-European chic, or Australasian informality. The world is asking for accountable standards of performance from doctors. How far should professionalism determine style and conformity in a medical career? Can medical eccentrics survive the new quality environment?
Doctors are as delightfully varied as humankind. We can all bring to mind the traditional medical stereotypes: bombastic surgeons, sinister physicians, jolly general practitioners, baffled pathologists, and the rest. And we know that in most cases such types are false. In our evidence base of acquaintances, we can perhaps find contrary examples of baffled surgeons, jolly physicians, sinister general practitioners, and bombastic pathologists. Real doctors differ from typecasting by miles, and if you compute the infinite parameters of individuality you rapidly become the unique example of your kind of doctor, and number one in your class.
Medical students are amazed by discordance between appearances and reality. Hippies of the 1970s have become professors of surgery, Gilbert and George lookalikes have turned into trendy psychiatrists, and medical directors everywhere can have beards, pony tails, sandals, and short skirts (and that's just the men).Despite the initially normative valve of medical education, doctors will naturally diverge thereafter along their individual career paths: into hospital or general practice, into different specialties, into rapid or postponed success, into international travel, into family commitments, into programmatic life satisfaction or mere medical existence. Individual peculiarities flourish in medicine, where most doctors are their own boss and, up to a point, have been able to run their lives as they wish.
Teenagers converge towards the norm; it's just that their parents do not like the normal teenager. Nowadays, doctors also are having to converge into conformity, but under the influence of external forces. There soon will be guidelines for everything, and a substantial degree of standardisation is inevitable in all parts of practice. We may not like it, but nice men and women in suits will say what we should do and cute chimps in police helmets will check that we are doing it. Comfortable conformity removes exploration and innovation. Conformity is comfortable for those who make rules, enforce rules, and accept rules, but not, alas, for eccentrics.
Eccentricity is part of the British way of life. Whether you look odd, act odd, or really are odd, you will fit in somewhere. We enjoy diversity and combine it with tolerance and ridicule, but we don't mind at all. Mild eccentricity is the basis of much loved situation comedies. Mavericks, non-conformists, and the person who disagrees (there is always at least one) are secretly valued. The late Screaming Lord Such and his Monster Raving Loony Party were much admired—not much voted for—but admired and necessary.
Eccentricity varies by degrees: you are eccentric, she is bizarre, I am creative. One person's weirdness is another's weekend hobby or even way of life. There are differences between being eccentric and acting eccentrically: showing lack of insight or consciously cultivating behaviour. The real eccentric thinks he's normal; he is blind to the rules and is naively surprised at the response he engenders everywhere. The normal reference ranges for humans are indeed very wide. Humans are also subject to peer group pressure and fashion. Most succumb to some extent.In British professional life we have had the unspoken doctrine of maximum permissible oddity: that one major oddity, or two minor oddities, as long as everything else is conventional, is still OK. Selection boards in the armed forces, professions, and civil service have long struggled to deal with the slightly odd chap. Pragmatically, the chap might be permitted a major oddity or two minor oddities so long as everything else was reassuringly conventional. The definitions of oddity have varied through the ages: at one time having a beard or being a female chap, a gay chap, or a foreign chap were major oddities, while wearing bow ties, being drunk, keeping newts, playing the accordion or guitar, ladies wearing trousers, and anyone discussing religion, money, sex, culture, or football were minor oddities. Alas, standards have slipped: these days bearded ladies in trousers discuss whether the football culture is the sexy new religion all over the place.Modern oddities might include smoking a pipe, editing a periodical, studying chafing in cyclists, and not enjoying football. Happily, the increase in cultural diversity in Britain has led to a massive broadening of minds in recent years. Unhappily, racial and sex discrimination may not yet be completely extinct. Dislike of eccentricity is closely related to larger scale xenophobia. Slightly odd chaps everywhere are still wise to cultivate reassuring normality so far as they can manage. Different settings encourage conformity and diversity (see box), and in a working day doctors may fluctuate between convention and eccentricity.
Pros and cons of being odd
The value of diversity—including its extreme form, eccentricity—lies in creativity, adaptability, and the bypassing of the limits of convention. Innovation springs from dissatisfied minds and strives in new directions. Many currently accepted views were once unorthodox, until they were challenged, tried, and finally adopted. The people who ask “Why?” are those who find the answer.
The downside of eccentricity is its potential to cover mediocrity and non-cooperation. Flamboyant weirdness is captivating but also confusing. How is this person performing behind his or her persiflage or camouflage? Strip off the make-up, the mannerisms, the body piercing devices, and the affected Viennese politesse and what is left: anything or nothing? If this is self expression then what is being expressed? Is the chap under the cowboy hat or the girl in the fishnet tights any bloody good? Are mere stylistic choices inappropriately obstructing function?
Professionalism means delivering the same service to the patient whoever you are and however you are feeling or looking today. A paediatrician in a clown costume or one in a white coat should be delivering the same paediatrics to the sick child. One should still wake up whether the anaesthetist looks funny or merely peculiar, whether he has come in through the door or the window. A doctor who cultivates Jane Austen mannerisms or who, like Black Adder's King George, says “penguin” at the end of every sentence should be just as alert to drug interactions or the subtle downward trend in vital signs in the acutely ill.
Acting the doctor
We know how doctors should look and act; we've seen them in films and even some examples on the wards. But medicine is changing, and diverse professional personalities are adapting in different ways. Some retreat into traditionalism and conservatism—indeed, all those young fogeys at medical school now turn out to be perfectly equipped country general practitioners. Others leap into the new ways and language and the fashionable thing, whatever it is this week. Many are wondering, ‘Am I good enough for these challenges?” Which would you rather be: the mountebank or his zany? Trainee doctors must flourish in their chosen styles: it does not matter how you look or seem, it's what you can do that will be evaluated. The patients must understand and value their doctors. Open communication must mean what it says. The days of coded messages, secret societies, and closed conventions are over. What is understood to be understood may be misleading. Spit it out, man!
The answer surely lies in cultivating diversity and doing our own thing while identifying the essentials of good practice and communication and ruthlessly proving we can do them. Confusions between quality, message, and style will continue until quality standards are more fully assessed. This is the direction the profession is taking. Under the new rules, doctors will be legislators, enforcers, conformists, or eccentrics. Politicians will set the aims on behalf of society. Clever doctors will set the rules. Enforcers will implement them gleefully. Conformists will follow them, grumbling. And eccentrics will set about ignoring them, breaking them, or looking odd. But they might at least wonder “Why?“This is the new medicine. Why not ask your consultants or colleagues for permission to change your style, or theirs? You're looking stylish today, Doctor, but how will you fit in?
Locating conformity and diversity
Settings that deserve conformity
Court of law
Settings which encourage diversity
Research and innovation
Learned societies and associations