Bob Bury

Importance of self-awareness in medicine

We were chatting with friends recently, and the topic of fear of flying came up. We agreed that it was rational to feel some concern, and that the degree of that concern had something to do with the awareness that you were 30,000 feet in the air in a thin metal tube, totally dependent on the skills of someone you had never met to get you back on the ground safely. It occurred to me that I am only able to fly at all because I just don’t think about it too much.

Then again, I’m just back from a week’s holiday down in Cornwall, and that involved a 350 mile drive each way, mostly on motorways. On the way back, during heavy rain on the M5, I had one of those moments of self-awareness that hit you from time to time (I say ‘one of those’ moments and ‘you’ – but perhaps it’s just me?).

I suddenly became uncomfortably conscious of the fact that I was driving at 70mph in the middle lane, in a relatively thin-walled metal box, surrounded on all sides by other metal boxes under the control of people I had never met, any or all of whom could be tired, drunk, stoned or partially sighted (or arguing with their wife or screaming at the kids to stop whining because no, they weren’t nearly there). My wellbeing and continued existence was entirely dependent on the ability of this miscellaneous cross-section of humanity to avoid doing anything stupid.

I did what I always do in that situation – slow down, move back into the inside lane, and allow plenty of space between me and the car in front. Which lasted for about two minutes, until I found myself behind yet another caravan. And it’s not just flying and driving. In my very early career as a surgeon, or later on as a radiologist undertaking invasive procedures, I wouldn’t have been able to put knife to skin, or needle to groin, if I had been too aware of the enormity of what I was doing. I’d have had to transfer to a specialty where I couldn’t do any damage – dermatology, psychiatry, something like that.

The more I think about it, the more it seems that our ability to function in any sphere of life depends on achieving the right degree of self-awareness. Too much and we become gibbering wrecks, unable to undertake any task for fear of the consequences. Too little, and we become psychopaths. Or politicians. I’d be willing to bet that many of the would-be doctors who don’t make the grade owe their failure to an undue sensitivity to the reality of their situation and the possible consequences of their actions. And while I’m no psychiatrist (I was just joking about psychiatrists and dermatologists by the way), I do wonder how many patients who develop mental illness owe their difficulty in coping with reality to a similar surfeit of self-awareness.

Perhaps that’s what the late, great Douglas Adams was getting at when he invented the Total Perspective Vortex. In case you’ve forgotten, this was the device which gave anyone subjected to it a momentary glimpse of the entire unimaginable infinity of creation, along with a tiny little mark, a microscopic dot on a microscopic dot, which says, ‘You are here’.

Most people either died in the vortex, overwhelmed by their insignificance, or emerged with their brains completely scrambled. The exception was Zaphod Beebelbrox, who interpreted his experience as confirmation of his belief that he was the most important person in the universe. It’s those politicians again. And possibly some surgeons.

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7 Responses to “Importance of self-awareness in medicine”

  1. London Med Student says:

    Very true I think! I’m currently struggling massively with the realisation that in one short year I will be an F1 (if I don’t do anything stupid like fail an exam before then, anyway) and suddenly decisions about patients will be in my hands. I’m so used to clerking a patient and having a vague idea about what could be wrong with them before the doctor puts me right… “some kind of… heart problem?”.
    I’m hoping I can put this realisation to good use and make it spur me through the next year, whipping myself into shape in time!

  2. mlw says:

    The psychology of the perception of risk is fascinating, Bob, as we both know from trying to explain radiation risks to patients. One factor that exacerbates the problem is the widely-believed fallacy that one can lead a risk-free life. It manifests as the “something must be done…” reaction to any newsworthy tragedy, and often results in awful knee-jerkeries such as the dangerous dogs act. I don’t think I’ve ever known a politician have the courage to say, “This is an acceptable level of risk and we couldn’t mitigate it any further, even if we spent silly amounts of money or enacted OTT legislation.” To address this problem, I would propose making it part of the national curriculum to learn the basics of poker: what do I stand to win (the pot) and to lose (my bet) by playing this hand and how does that compare with my chances of success? So, I’ll take the odds on the motorway (made a little more favourable by driving defensively) because of the enhanced quality of life I gain.

  3. Caroline whymark says:

    I used to feel like this a lot when I worked in A+E. I’d be on a roll, x-raying, referring, managing, thinking I had it sussed and growing more and more confident. Then I’d miss a fracture and have to recall a patient ( and live it down amongst peers during our radiology teaching). It was like landing on the big snake at square 99 and going right back to the bottom. I became ultra cautious, checking with seniors, erring on the side of caution. Terrified not to repeat the mistake. Soon my confidence would re-grow and be back to normal, then super confident, then the whole cycle would repeat itself again. I could tell the same story about chest pains I sent home! Now in anaesthesia we know that venflons serve to keep most of us humble at some point.

  4. Dr Death says:

    Why not take up pathology? Better paid than basket-weaving, more fun than doing crosswords while sniffing gases and watching patients being attacked by surgeons, and we are never wrong (even when we have a “difference of opinion” with a colleague – it’s usually the clinician’s fault for giving us inaccurate information). It’s the life for me!

  5. privatepracticeexpert says:

    I think the nature of life itself is that you have to be able to AVOID being able to grasp the true meaning of reality: namely that in a few short years you will surely DIE. Because if any of of us really and truly understood and internalised that we would be completely unable to function in any useful way at all.

    If you genuinely truly understood the imminence and finality of your own mortality would you go to work? Surely you would spend time with your family and tick things off your bucket list?

    Funnily enough, that is precisely what I’m doing. (And I’m very much a glass 1/2 full kind of guy)

    (Pretty philosophical for a surgeon, huh?)

  6. Natasha says:

    Zaphod Beeblebrox survived the Total Perspective Vortex because he experienced it in a virtual world where he in fact was the most significant person in the universe. It confirmed his vastly inflated view of himself and so he came out exactly the same as he went in. Something about that reminds me of certain health professionals I have met, surgeons being at the top of the list unfortunately.

  7. Oldladysurgeon says:

    Wow! Lots of surgeon bashing- especially in the comments! Never mind, I enjoyed the article anyway and one of the important aspects of self awareness is not taking ourselves too seriously and having a sense of humour!

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