Sir Kenneth Calman 

Sir Kenneth Calman 

SOM White Coat Ceremony
Keynote Speaker

August 2009

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Sir Kenneth Calman is Chancellor of the University of Glasgow.  He was born on Christmas Day 1941 and educated at Allan Glen’s School in Glasgow.  He entered medical school in 1959 and took two years out during this course to gain an Honours Degree in Biochemistry.  He graduated in medicine (with commendation) in 1967 having obtained a number of distinctions and prizes throughout this course.  During the latter part of his undergraduate medical career he developed an interest in dermatology and graduated PhD in 1970.  Following his house jobs he moved into the Department of Surgery in Glasgow and proceeded to the Fellowship of the Royal College of Surgeons and an MD Thesis with Honours on Organ Preservation.  His clinical interests at this time were in General Surgery, Vascular Surgery and Transplantation.  In 1972, he was the MRC Clinical Research Fellow at the Chester Beatty Research Institute in London and returned to Glasgow in 1974 as Professor of Oncology.  He remained in that post for 10 years developing particular interests in nutrition, chemotherapy, cancer education, counselling, and patient support groups.

In 1984 he became Dean of Postgraduate Medicine and Professor of Postgraduate Medical Education at the University of Glasgow and Consultant Physician with an interest in palliative care at Victoria Infirmary, Glasgow.  During this time he was involved in developing medical education projects and in the supervising of medical education for those in training in the West of Scotland. 

In 1989 he was appointed Chief Medical Officer at the Scottish Home and Health Department and in September 1991 he became Chief Medical Officer in the Department of Health in London.  He was a member of the Executive Board of the World Health Organisation, and its Chairman from 1998-9.  He was Chairman of the European Environment and Health Committee from 1993-8. He was Vice Chancellor and Warden at the University of Durham from 1998 until 2007. He was a member of the Nuffield Council on Bioethics and the Statistics Commission until 2007. He Chaired the NHS Genetics Education Steering Group.
 
He is currently a member of the Board of the British Library and Chairs the National Cancer Research Institute. He is President of the British Medical Association and a member of the Board of Cancer Research UK.  He is a Fellow of numerous Royal Colleges and Faculties and in 1979 was elected a Fellow of the Royal Society of Edinburgh.  He has written 7 books and over 100 scientific papers.  His current academic interests are in risk, storytelling, ethics and education.  Sir Kenneth has a number of outside interests including the History of Medicine, Scottish Literature, Cartoons and Gardening. His most recent books include “A study of story telling, humour and learning in Medicine” and “A history of medical education”  He lives in Glasgow and the Island of Arran and is married with 3 grown up children and a large dog.

WHITE COAT CEREMONY GRENADA AUGUST 2009

Introduction
Thanks, it is a pleasure to be here to share this day with you. This is not my first visit to St Georges and I have kept in touch with the progress and development of the Medical School for over a decade.

Congratulations on your achievements so far. Well done.

This is an important day for you, and your family and friends.
An unforgettable day-a day on which you will make an important promise, and one which you will need to live up to for the rest of your professional lives.

The white coat ceremony
This ceremony is not just about putting on a white coat
But about putting on an ethos, a philosophy, a method of working
About putting on a set of values
Developing an ethical base to guide you in the future

Not just about you, of course but about me, and your teachers, whose values are also reaffirmed and for whom this is also a special day.

The public nature of the ceremony is also critical.
You will have to stand up and be counted in front of those you love, respect and care for.
This is not a trivial matter

My own medical school in Glasgow did not have a white coat ceremony signifying the transition, but we took an oath at graduation-a modification of the Hippocratic Oath. I was at the ceremony this year, just a few weeks ago, as the new graduates stood up publicly and together repeated aloud the oath. Young men and women, like you, ready to move onto the next stage of their careers. What a wonderful moment for them and for their teachers,

Looking ahead.
It is also an opportunity to look ahead.
It is the beginning of a new phase of your career and your future, and an opportunity for me to reflect on my career and how it has changed.

There are three themes which came through for me as I considered what to say; being part of a profession, the values of medicine, and the crucial importance of life long learning.

To illustrate these points let me give you a few examples of the changes in my career over the last 40 years to make the points more clearly.

Some dates
In 1964 I completed a BSc in Biochemistry which included a course on statistics-we used hand turning calculator. No computers, no internet, no web, no cloud.
In 1967, July, I graduated in medicine. In Dec 1967 first heart transplant was performed by Christian Barnard
In 1972 palliative care was in its infancy and I got to know Dame Cicely Saunders at this time. She had been a pioneer in this area, and it was not really covered in my medical school curriculum
In 1974 I was a Professor of Oncology, and we had difficulty in treating patients with testicular cancer, until by 1978 platinum based drugs became available, with a complete possibility of cure
In 1981, HIV described, and the virus identified in 1983-4 and I became the CMO Scotland in 1988 with a whole new problem to deal with.
In 1996 BSE and CJD were described when I was CMO England. An entirely new problem
From 2000 onwards stem cell treatments, and cloning adding totally new ethical dimensions to the practice of medicine.

What do these simple facts tell us?

  1. Very little of what I learned in medical school in factual terms, stood the test of time. The whole knowledge base had changed
  2. Learning to learn, something which I saw as being increasingly important, is at the heart of managing change
  3. The values which I learned, the ethical base, and being part of a learning community-the profession of medicine, were crucial to the last 40 years, and have stayed with me since.

My medical school, an ancient and distinguished one, did not provide me with future knowledge, how could it, but they did instil in me the importance of learning, and the values of the profession. Some of this was done in formal class settings, but much of it was by watching and learning from my teachers. They were wonderful role models and I owe them a huge debt, as indeed you will do. As your career advances you too will become such role models for those who come after you. That will be one of your responsibilities.

Hippocrates said
“Life is short, and the Art long; the occasion fleeting, experience fallacious and judgement difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals co-operate.”    The Aphorisms of Hippocrates, Aphorism 1, Trans. Francis Adams

THE AIM OF MEDICINE. Let me first try to set out what I consider to be the aims for medicine and the roles of the doctor.
It is suggested that,

The aim of medicine is to assist in the process of healing in its broadest sense and it can apply to both individuals and communities. This is the primary function of the doctor. Doctors do this by improving quality of life, providing care, relieving suffering, promoting health, and preventing illness and disease. This aim is grounded in the understanding of health and the mechanisms of illness and disease and from this to provide effective and appropriate treatment. Finally doctors must do this in full co-operation with the patient, public and other providers of health care-the health care team.

The roles of the doctor. Three roles thus follow from the aim set out above

  • to be a healer, to  understand the processes of care and to intervene when appropriate. To wish to help others and see medicine as a vocation.
  • to understand people, and use this to provide better care, with co-operation and involvement of patient and the public, should they wish. To communicate as effectively as possible. To be an advocate for health.
  • to understand the reasons for illness and disease and to use this knowledge to improve health, health care, quality of life and well being.

The kind of doctor required is one whose qualities fit these roles; that of healer, people centred, and curious about health and illness. By defining the qualities required, not the type of doctor, it becomes easier to see a way forward.

THE PROFESSION OF MEDICINE. Over the last few decades much has been written about professions, professionalism and the competence of doctors.

Defining quality.
Much of this discussion will relate to the concept of “quality” a term which is particularly difficult to define.

R Pirsig in Zen and the Art of Motorcycle maintenance.Says
“I know there is such a thing as quality, but as soon as you try to define it, it goes haywire and you can’t do it.”

DEFINING A PROFESSION: A SUMMARY. One way of defining a profession is to set out the characteristics which seem to be most appropriate.

  • Medicine is a vocation or calling and implies service to others. This remains an important part of being a doctor. The wish to be a doctor and to help others may seem old fashioned but it matters.
  • Trust and respect are two key aspects of a profession. The patient and the public must trust the doctor, and there should be mutual respect. These two factors (trust and respect) can be difficult to establish and require considerable care and hard work. They can be easily lost, and in the words of the proverb “Trust come on foot and goes on horseback.”
  • Medicine is an art as well as a science and requires judgement and wisdom to make decisions with patients in the face of uncertainty.    
  • Respecting the value of human life. This is an important value.
  • Maintaining privacy and confidentiality. Those who consult a doctor expect to have their privacy protected and that their health information will remain confidential.
  • Acting as an advocate for the patient and the public in health related matters.  It recognises that the doctor has a role as advocate, supporter, agent of change and educator.  
  • Medicine has a distinctive knowledge base which is kept up to date. The knowledge base comes from the sciences, arts and social sciences. It is broad and constantly changing.
  • Medicine has a special relationship with those it serves, patients or clients, including the importance of trust.
  • It has particular ethical principles-the ethical base. This is of fundamental importance, and has been central to clinical practice for generations. These are set out in various ways through codes, oaths and sets of principles.  
  • Setting standards and examinations. This has been a part of professional practice for centuries, set by the profession, assessed by the profession.
  • Self regulating and accountable to patients, clients and the profession itself. This is perhaps the issue most debated at the present time. How far can the profession continue to be accountable to itself, and how much can it relinquish this to those not part of the profession? There is nothing to hide or be afraid of.
  • Works closely with other professional groups. The important of teamwork and of recognising the skills and expertise of others is very much part of being a profession and will be discussed in more detail later.
  • Ability to lead and determine direction of the clinical team. This must be earned by the demonstration of many of the qualities listed above.

These then are some of the characteristics of a profession though there are some who would argue that in the 21st century medicine is no more than a trade, a series of skills which can be easily mastered and bought at a price. This is not what a profession should be. It has at its core the commitment to people and has a strong vocational aspect without which it would just be another job.

THE BOUNDARIES OF MEDICINE.  If the aim of medicine is primarily to heal, and the role of the doctor to implement this, how does this relate to other branches of knowledge and other professional groups?  What is it that is distinctive about being a doctor? How does medicine fit into the wide range of interests in the arena of health?

Perhaps the first, and to some extent the easiest aspect, is the relationship between the science base in medicine and other areas of knowledge. Medicine is not a discreet science and indeed it could be said that there is no such thing as “medical research” only research into medical and health problems. To enhance our understanding of disease and its control requires a very wide range of scientific interests and there should be no boundaries in this regard. Perhaps of more relevance is the role of the doctor in posing the question and in setting out what needs to be done to influence care.

In a similar way the social sciences have a huge amount to contribute to our understanding of illness, how people respond and react to bad news and how we can improve the ways in which we can assist the healing process. Finally the arts. Here there is an increasing interest in the ways in which the quality of life can be modified and improved through music, literature and the visual arts.  The humanities allow us to think with a philosophical perspective on ethical issues, the value of life and the nature of human existence.

The second, and more complex area, is the relationship between doctors and other health professionals. The first and most obvious point is that working as a team is taken as a given. Modern care requires the skills and expertise of many professionals. But what are the distinctive and specific roles of the doctor in the multi-disciplinary team?

  1.  The specialty training programmes are comprehensive, organised and associated with regular assessment. Continuing professional development is an integral part of this and re-validation is an accepted part of professional practice.  Life long learning should be recognised from the very beginning as part of professional practice and it should not be an add-on.
  1. The wish to be a doctor and not another type of health professional. This may seem obvious, but it is highly relevant. People choose to be a particular type of health professional.  
  1. Certainly doctors do not have a monopoly of caring and compassion. Nor do they have all the skills of other professional groups, speech therapists, physiotherapists, pharmacists, nurses, midwives, psychologists, and all of the other wide range of expertise available. While they have a special role in treatment, particularly in interventional management such as surgery, other groups have an increasing role, and even in surgery this is not strictly true any more.  
  1. Doctors however have a particular role in diagnosis, and especially in the implications for, and consequences of, whatever label is placed on the on the problem presented. These labels may change with time and from an historical perspective it could be said that “the history of medicine is the re-classification of disease.” The key issue is the range of uncertainty surrounding a diagnosis. Once the diagnosis is made then intervention protocols can be set in motion and it is possible that other members of the team will deal with these aspects of care.
  1. Understanding disease and rational treatment. It is not sufficient to treat illness without having some form of rational or paradigm on which to base such interventions. An historical review has shown that over the centuries the understanding of health and illness has continually changed, and is likely to do so again. Treatments which we currently consider sophisticated and avant guarde will in a few years seem crude and old fashioned. The key is that medicine is always changing and it is imperative that doctors are involved in leading such changes.
  1.  There has been, over the generations, a debate on whether medicine is a science or an art. In truth it is both. The scientific method allows the maximum to be gained by investigation and examination. The art comes in synthesising this information in the context of the individual, a patient, their wants and needs, and coming to a judgement, shared with the patient, as to the best way forward. Patients with identical “diagnoses” may have different “interventions” based on the judgement at the time.

THE ROLE OF THE DOCTOR IN SOCIETY. This is a subset of the general aim of medicine and the role of the doctor. The doctor is a citizen as well as a doctor and therefore has an important role in society.

The doctor as an advocate. In this role the doctor has a responsibility to put the case for the patient or the public, to stand up for them and support their needs. This has been a long standing role and over the generations doctors in various ways have supported the case for better public health, treatment facilities, the needs of patients in particular groups or with particular diseases.    Those who have read Ibsen’s “Enemy of the People” will know what this means. Here is a doctor who recognises that there is a problem with the water in the public baths and tries to change things by speaking out. He is derided and abused and eventually has to leave the town, such is the opposition by the town council to his views. The doctor utters the rallying cry of all those in such positions who might be having dirt thrown at them. “You should never have your best trousers on when you turn out to fight for freedom and truth” (Act 5).

The doctor as an educator. In addition to having a role as an educator (teacher) of students and doctors, there is also a responsibility for the education of patients, the public and politicians. This is a most important role as without knowledge and the skills to act on this knowledge patients and the public will have increasing difficulty in making choices. Sources of information of illness and disease have never been easier to get; books, the media including television and the internet. There is a need for dispassionate advice built on experience.
 
The doctor as an agent of change. This requires the doctor to produce the evidence and present it effectively to those who matter. It can be a lonely and a long term task to change the health of the public. However it is part of professional practice and whether it is changing the service, improving the quality of care, developing new treatments, or improving the health of the public.

The doctor in society.  As a part of society is it possible to separate out the doctor as a citizen from that of the professional? For example do the standards of behaviour of doctors in their professional role differ from that of their private role? Do we expect standards of behaviour of doctors, as people, to be greater than that which we would expect from the public generally? Should doctors not smoke, eat too much, or be violent to others just because they are doctors?

Doctors as leaders.  In many instances doctors are expected to assume positions of leadership and some preparation for this is essential. This may come by working with those who are effective leaders, by learning through experience, or by relevant courses. The key issue is that leadership needs to be earned and cannot be assumed. To retain the position as the leader of a particular team will require more than the title “doctor”.  

Medical practitioners sometimes suffer from the disease mural dyslexia, the inability to see the writing on the wall. They cannot see that this is no time for complacency, but for vigorous and positive action. The profession must return to its roots and embrace public involvement as a signal of the determination to act as healers and assist people in need.

For me the secret is in a passion for learning, and as a corollary, a passion for teaching; teaching not just students or young graduates, but patients, the public, and politicians. One of my major roles was as Chief Medical Officer in England, the equivalent of the Surgeon General in the USA.  This involved me in helping government ministers to understand some of the most complex aspects of science and medicine.

As another example, as an oncologist I set up a series of cancer support groups for my patients. I hope patients benefited from this, but I am equally sure that I did too. It was a huge learning experience for me and the staff who worked with me. Patients are a remarkable source of experience and knowledge.

The first time you realise that lives can be changed and health improved, not by drugs or surgical procedures, but by what you say, you will realise how wonderful it is to be a doctor.
A word on smoking
Bringing up a child
Advice on anxiety
Comforting the bereaved

These are things you might not have considered in your training, but they mean so much.

Summary.
Let me tell you three short stories to finish

First a poem from a New Zealand physician, Glenn Colquhoun

“She asked me if she took one pill for her heart and one pill for her hips and one pill for her chest and one pill for her blood how come they would all know which part of her body they should go to.

I explained to her that active metabolites in each pharmaceutical would adopt a spatial configuration leading to an exact interface with receptor molecules on the cellular surfaces of the target structures involved.

She told me not to bullshit her

I told her that each pill had a different shape and that each part of her body had a different shape and that her pills could only work when both these shapes could fit together.

She said I had no right to talk about the shape of her body.

I said that each pill was a key and that her body was ten thousand locks.

She said she was not going to swallow that

I told her that they worked by magic.

She asked me why I didn’t say that in the first place.”

Glenn Colquhoun, in “Playing God” Steele Roberts, Aotearoa, New Zealand, 2002

Second, the importance of change. You have be familiar with the “Light bulb Jokes” which were common a few years back. My favourite is
“How many psychiatrists does it take to change a light bulb. None, but the light bulb really has to want to change.”

You will need a passion to change and maintain your professional standards.

Third. The wish and the commitment to make things better.

I used to compare my golf with that of Jack Nicklaus. He is 6 foot two and blond, and I have always imagined myself to be the same. But compare his golf with mine. First he plays golf regularly, and I don’t. Second he has a full set of clubs and can get out of bunkers easily. Third he is better that I am. But the most important difference is that when he plays golf he plays to win, and when I play I am just glad to get on the course, never mind win.

The lesson is clear for our patients, their relatives and friends and the wider public. We must continue to want to win, and get out of bunkers even when it means we have to change.

I live for part of the year on a small Scottish Island. There is a cave on the island where it is said that Robert the Bruce, a great Scottish King was lying depressed and not sure what to do. He watched a spider on the roof of the cave trying to reach the top but couldn’t, but it tried and tried and tried again, and eventually got to the top. The lesson for him was also clear. That he had to get up and keep trying until he managed to achieve his goals.

We need to keep trying and practicing to get better for the benefit of our patients and to provide them, not only with the best treatment, but with compassion and care.

It is my privilege to give you every good wish for your future careers.

Kenneth C Calman, August 2009.