Doctors and the Permission to Speak

December 16, 2011

Let’s say you’re a doctor and you have an idea, opinion, or a new way of doing things.  What do you do with it?

It used to be that the only place we could share ideas was in a medical journal or from the podium of a national meeting.  Both require that your idea pass through someone’s filter.  As physicians we’ve been raised to seek approval before approaching the microphone.

This is unfortunate.  When I think about the doctors around me, I think about the remarkable mindshare that exists.  Each is unique in the way they think.  Each sees disease and the human condition differently.  But for many their brilliance and wisdom is stored away deep inside.  They are human silos of unique experience and perspective.  They are of a generation when someone else decided if their ideas were worthy of discussion.  They are of a generation when it was understood that few ideas are worthy of discussion.  They are the medical generation of information isolation.

I spoke with a couple of students recently about medical education reform.  And as I often like to do, we discussed what was needed to prepare doctors for life in 2050.  I picked up on the most remarkable ideas and suggested that they publish their views as a position paper or editorial.  They looked puzzled.  And for good reason.  They believe that the simple expression of their brilliance is not their responsibility or even their right.  It’s that of some national professional body or editor.  You need the keys to the kingdom to be heard.  You need permission.  You need to be invited.

In Poke the Box, Seth Godin calls this the tyranny of the picked:  Waiting and hoping “acknowledges the power of the system and passes responsibility to someone else to initiate.

But the way the world communicates is changing.  The barrier to publish is effectively non-existent.  The democratization of media has given every physician a platform to the world.  But the physicians have yet to speak up.  We’re preoccupied with how our voices will sound.  We pine over what someone might think.  We’re too concerned with how we’ll look and not concerned enough with how our thoughts, ideas and passions could be an instrument for the world.

If the 20th  century was marked by the physician-as-silo, the 21st century will be marked by the dissolution of barriers and the emergence of new ways of collaboration and thinking.  This will be a generation marked by information and networks.  The institutions that existed to organize us will give way to social structures compatible with the way we communicate.  Tools for sharing and drawing from collective intelligence will capture our restrained wisdom.  And I suspect that we’ll see the most amazing things emerge.

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Katherine December 16, 2011 at 8:06 am

Your post offers a great way to open up conversation and dialogue on the development of new and emerging voices within the profession of medicine. I’m hopeful 2050.

AC December 16, 2011 at 8:44 am

Bright students will only speak up if the rewards of doing so outweigh the costs. Right now medical education – at least at the prestigious institutions – is still very bureaucratic and hierarchical. Med students live in an environment where your performance is largely determined by what powerful people subjectively think about you, so naturally even the freethinkers keep their heads down until graduation.

It is all very well for an established physician to chide students for not sharing their ideas (which may be critical of currently powerful and high-status institutions.). But from the perspective of non-suicidal potential young firebrands it simply doesn’t make sense. Academia has no incentive to foster an open atmosphere of criticism. (Though it may create a facsimile by inciting student activism against pre-approved politically correct targets, such as drug reps.

Chris Porter MD December 16, 2011 at 12:22 pm

Professional organizations will need to reassess their roles as attitudes and open communication platforms flatten existing heirarchies (or obviate the need for approval.)

Lisa Fields December 17, 2011 at 8:19 pm

I’m a member of the generation of information isolation. I remember when we only had three television stations we could view and unless we wrote a letter to the editor our voice was simply not heard within our community.

It’s fascinating and frankly sad that even though we teach a very different population of adult students, it’s been our experience that they are not using the social tools that are so widely available to them.

We now have Social Media/New media and we also have the ability to demonstrate extreme radical collaboration so why are so many mute when their voice could be so powerfully amplified?

DrV December 18, 2011 at 8:19 am

Time, issues with transparency, and concerns with liability/risk rule the day. Otherwise a complicated issue. I’ll try to follow up with a post on the issue. Thanks, Lisa.

Jennifer Shine Dyer MD, MPH December 17, 2011 at 8:39 pm

Excellent post. I agree with your observations. A symphony of physicians voices in reforming the system is very needed right now yet hindered by the system itself. It takes courage to speak up but it is the right thing to do. Leading by example, you are teaching students everyday how to do just that. Thanks Bryan! :)

@doctorinsulin December 18, 2011 at 1:58 am

Great post. Wonder if your students published their ideas on a blog.

DrV December 18, 2011 at 8:16 am

Not enough. Interestingly, the younger the trainee the less apt they are to share their opinion on issues that matter.

drdarrellwhite December 18, 2011 at 8:39 am

It’s little different with established, practicing physicians if one speaks against prevailing orthodoxy. Even with the expanded universe of publishing options if your thoughts and views are not “picked up” by the establishment channels the sound of even the “loyal opposition” is roughly equivalent to that of a bucket of water tossed into the surf.

DrV December 18, 2011 at 8:46 am

Fatalistic to some degree but certainly there’s an element of truth there. I’m going to chew on this and come up with a post ….

Gregg Masters December 18, 2011 at 2:36 pm

I love:’the institutions that exist to organize us will give way to social structures compatible with the way we communicate’. N’uff said Bryan.

Dr_som December 18, 2011 at 5:01 pm
DrV December 18, 2011 at 12:40 pm

It sounds similar because 1) Franz and I study Godin and 2) we think dangerously alike. I consider myself in good company.

Dr. Gwenn December 19, 2011 at 7:18 am

Excellent observations. What would help break this cycle that has existed in medical education for much too long is students and residents having mentors willing to step up and help them find their voice. Perhaps in your institution, Bryan, that could be you. You’ve already put the bug in these students’ ears to publish – show them how. Nudge them through a draft and help them submit.

The medical education system uses negative reinforcement, even today, so students and residents become reluctant to pursue dreams for fear of repercussions. They need a champion. If more docs like you step up, we can break the cycle. But, if we don’t step up…we become just another silent voice with a great idea.

Chris Johnson December 19, 2011 at 10:00 am

There are also institutional considerations.

In 1982 I joined the staff of a well-known medical facility whose name resembles a salad dressing. I worked “at pleasure,” without a contract, meaning I could be fired overnight. And I would have been sacked for doing what I do now — write general interest books and blog without getting anybody’s approval in advance.

Since I no longer work there I don’t know if their attitude of top-down management has changed. I doubt it.

Beaver EMS December 19, 2011 at 1:56 pm

Great article! The internet is such a great source for learning and inspiring.

Thanks for sharing!

jason @ cinnamon agency December 20, 2011 at 12:27 pm

Too much bureaucracy in healthcare?

Surely shome mishtake! (sic)

Dr. Kelly Ross December 21, 2011 at 10:10 am

Just reread Steve Jobs speach, then read your post. He said, “Your time is limited, so don’t waste it living someone else’s life. Don’t be trapped by dogma,which is living with the results of other people’s thinking. Don’t let the noise of others’ opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition.” Those of us who work in the Ivory Towers and are wading into social media are following Job’s advice. If we lead by example, the students will follow.

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