Given the chance I'd start all over again

BMJ 2006; 333 doi: (Published 21 December 2006) Cite this as: BMJ 2006;333:1322
  1. Robert Souhami, emeritus professor of medicine (robert.souhami{at}
  1. 1University College London, WC1E 6BE

    Medicine is based on altruism, science, and human interest. Like most medical students, this is what attracted me and it still does. The aim is to preserve the good health of individuals and the general population. The aspirations are of excellent care, progress, and change. I find the continuing movement, and certainty that we will know more, inspirational and energising. Medicine is remarkable in its clinical and scientific breadth and its fusion with other disciplines and interests. Much of medicine grows from basic biology, but medical research and practice is also linked to physics, chemistry, statistics, population science, sociology, and politics. It's remarkable, for example, that new technical platforms allow quick identification of genetic patterns that in future may influence treatment given to individual patients and that this, in turn, will raise ethical and political issues for society at large.

    Whatever interests and personality you have, there is probably an aspect of medicine to suit you. The diversity can be confusing for a student and young doctor thinking about a career. When I qualified I didn't know what would be the best path to choose. I quickly found that I would get most satisfaction from clinical medicine.

    Throughout my career I have met clinicians and scientists who have set the standards that I wanted to achieve. I trained for eight years in internal medicine, much of it at University College Hospital London, where I came across outstanding clinicians and clinical investigators. The process of diagnosis, lacking modern imaging and molecular techniques, was much less certain then. The therapeutic options were also much more restricted, but the process of making decisions that were in the patient's interest was the same then as now. This clinical approach, based on experience and judgment, has been my main inspiration and has greatly influenced my academic career, both in teaching and in research.

    As a student, I was sometimes defeated by explanations of signs, symptoms, and mechanisms of disease that didn't seem to make sense—at least to me. Later, I realised that words like “idiopathic” or “functional,” often used as if they meant something other than ignorance, were useless. It seemed to me that good teaching would own up to, and demystify, lack of understanding. I think that a good teacher knows in advance what a student might find difficult and takes care to make things clear. We are lucky in the quality of our medical students in the United Kingdom. I enjoy teaching clinical medicine and this has led to writing textbooks, with others, aimed largely at undergraduates. I can't say that I find writing enjoyable or inspirational, but having to express difficult concepts with clarity sharpens up your thinking. Teaching and training are essential components of medicine. Brilliant lectures and articles and new discoveries and ideas are great rejuvenators.

    I came to my specialty, medical oncology, as part of internal medicine. Cancer medicine has been a constant source of inspiration. Few areas of medicine demand the same degree of technical expertise and human understanding. Treatment of cancer by medical means was only just beginning 35 years ago. Over the years, increasing intensity of treatment and more accurate diagnosis have meant that clinical judgment remains just as important, but the emphasis has changed towards the understanding and exploitation of new diagnostic and therapeutic methods. Advances in understanding the process of cancer development have been astonishing, and have come from the technical virtuosity of modern molecular biology. The conceptual framework has been transformed and with it the possibilities of new treatments that are now emerging.

    The constant development of new approaches is engrossing. In cancer medicine how far should new pathological classification and precision change practice? Who will benefit from new treatments and who might be harmed by them? How will an early diagnosis through screening change the advice you give to the patient in front of you? The rapid increase in knowledge necessitates continued learning through specialist publications, meetings, and congresses. Like everyone else, I had to abandon the breadth of the generalist to become specialised in a much narrower area of medicine. I regretted this, and I still do. You become technically expert in the area you know about, but you risk losing the balance and judgment that a wider interest brings.

    This leads me to the last main source of inspiration and that is medical science. My academic work has had two components. The first has been therapeutic research, especially in lung cancer and sarcoma, largely based on large scale randomised therapeutic trials. The trials have brought together investigators in different countries, statisticians, clinicians, nursing specialists, and pharmacists. They have raised issues in medical ethics, data interpretation, and monitoring and have greatly improved the standard of what can be considered to be reliable evidence. The results of some of these trials have changed clinical practice and improved management. The second component has been laboratory work. Here I have had the benefit of working with exceptionally able scientists. As an academic clinician I don't expect to be working at the bench for many years or much of the time. Of course, you need to understand the techniques and their limitations. The partnership comes in the direction and focus of the work and its relevance to cancer. Knowledgeable clinical scientists have much to contribute in this respect. Conversely, knowledge of the limitations of the laboratory science prevents naive or over-optimistic interpretation of new findings in clinical research—a recurring problem in cancer management. It's a great career. Given the chance I'd start all over again.


    Robert Souhami was appointed physician and senior lecturer in medical oncology at University College London in 1975. In 1987 he was appointed to the Kathleen Ferrier chair of cancer medicine at University College London. Ten years later he became dean of University College and Middlesex Medical School and subsequently principal of the newly formed Royal Free and University College Medical School. In 2001 he became director of clinical research at Cancer Research UK.

    He created the first unit in the United Kingdom for the specialised care of adolescents with cancer and co-founded the London Lung Cancer Group. He chaired the cancer therapy committee of the Medical Research Council. His laboratory research has been into how drugs bind to DNA. He has edited or coauthored Tutorials in Differential Diagnosis, Textbook of Medicine, Textbook of Oncology, and Cancer and Its Management.

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