MANY readers will have heard the old aphorism “those who can, do, and those who can’t, teach”. This saying seriously underestimates the value and skill of teaching, not to mention the Hippocratic obligations in medicine to do both. So, I would like to propose my own version: those who neither do nor teach should be cautious about criticising those who do.

This comes to mind due to a confluence of situations which, in my observation, contribute to the pervasive malaise that affects many parts of the health workforce at the moment.

First, there are well intentioned but poorly executed risk management systems, including that tool of the quality and safety industry known as the root cause analysis. Applied with insight and in situations where there is an identifiable root cause for an incident, the resulting recommendations can assist in prevention of future occurrences. Hopefully, this will occur without causing other sidestream harms worse than the ones being mitigated.

Applied inappropriately, however, as may be done when teams are unskilled or lack insight into the work process, they can be another tool for blame and result in yet even more cumbersome procedures. A health care workforce labouring under conditions of fear and overburdened by “risk management” procedures will not be able to use their skills for optimal patient care. More sophisticated tools for clinical risk management do exist, including the so-called London Protocol.

Next, there is the frequent bombardment of “conventional medicine” by the non-conventional – those providers who hold little responsibility for their advice, products or outcomes, and yet constantly criticise those of us who do. In selling their services or their wares, many “alternative” health care providers use a constant critique of conventional medicine, diminishing its benefits and exaggerating its harms. Ethical providers may be frustrated in finding that those who sell simplistic, magical solutions may be held in higher esteem than those who do their best to convey accurate, evidence-based advice.

Finally, there are those within our own profession who provide expert advice on the performance of others. This may occur in the workplace, in the regulatory system, or for the courts. We all know of a minority of people who are too ready to hold colleagues to standards that they have never met themselves.

The safe and ethical practice of medicine requires constant self-reflection, sharpened by an understanding of cognitive science, medical science and emotional intelligence. The same approach is needed when appraising the work of others.

In my view, the question we should ask ourselves is not just “what would I have done in that situation?”, but also “what HAVE I done in that situation?” If the answer is that we have never directly experienced it, or have never been held to account for the outcome of such a situation, we must be very careful in judging the actions of those who have – especially with the benefit of hindsight.

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.


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Self-reflection is a vital part of any doctor's professional development

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5 thoughts on “Self-reflection, science and emotional intelligence in medicine

  1. Todd Fraser says:

    It will be extremely interesting to see what the results of the poll are.

    I suspect that the result will be be in the affirmative.

    The question then is how we best reflect. Julian Archer (head of the Collaboration for Medical Education Research and Assessment to Plymouth University) spearheaded a report on this for the Medical Board of Australia recently. He believes reflection has most impact when we have concrete data to base that reflection upon. That data set can be comprised of many different metrics, including objective outcome data, self assessment and peer / patient feedback.

    The data needs to be creditable, objective (where possible), quantifiable and relevant to our perceived needs.

    Finally, where possible, it has more impact when facilitated, because as good as we believe we are at self-reflection, we all need a helping hand sometimes.

    How many of us achieve this standard currently?

    There’s a good podcast with Marcus Watson from the Skills Development Centre in Brisbane on this topic too :

  2. Toby Commerford says:

    Thanks Sue. Loving the new aphorism! I’m grateful every day that I am both doing (geri med) and teaching (course coordinator for one uni course). That said, there is an endless supply and stream of critics and snake-oil sellers in life generally, and unless I’m mistaken, it appears to be a universality in any sphere, perhaps even human nature (we seem to love outrage… eg look at the ball tampering reaction recently). Nevertheless, this needn’t mean we have to let ubiquitous handbrakes impede forward progress. Teaching core concepts and enthusiasm to young people may be one antidote to pessimism, and may hopefully get more clinicians to be aware of what is data-free nonsense and what isn’t, all the while maintaining the key humility underpinning science: “we know that we don’t know everything”. We can still be upfront with this, and use it to drive genuine ‘non-magical’ progress.

  3. Anonymous says:

    Good points made through-out; only one I should mention…Hippocrates was a pagan,worshipping all the gods the
    Romans tried to appease,and even today pagan-worship takes place on the Island of Cos !
    Pity he did not know the One,True,Living God….The God of Abraham ,Isaac and Jacob !!…………….rob.the.physician

  4. Ian Hargreaves says:

    An anaesthetist once told me that if he wanted to get out of doing an obstetric epidural, he told the patient there was a 1 in 100,000 risk of paraplegia (which is apparently an appropriate figure.)

    Many of the quacks whom you disparage, Sue, use similar tactics both to dissuade (may cause autism) or seduce (may help immune system support). But I suspect the ‘pervasive malaise’ may be a result of too much self reflection on minutiae. Narcissus didn’t get anything done.

    As Hamlet put it:
    Thus conscience doth make cowards of us all,
    And thus the native hue of resolution
    Is sicklied o’er with the pale cast of thought,
    And enterprises of great pitch and moment
    With this regard their currents turn awry
    And lose the name of action.

    In cases like that of Dr Bawa Garba, she made a diagnosis and instituted treatment, then changed her diagnosis/treatment after receiving updated test results, which arrived too late to save the child. Her reflections on her management were used against her in court. However, the blame process does not help the next doctor in that situation to make a better decision, only to feel more vulnerable. Or worst of all, to consider Hamlet’s ‘bare bodkin’ as a solution.

  5. Stephanie Pommerel says:

    It’s impossible not to make mistakes in medicine – we are human beings, not made with perfection in this realm. As a current medical student, there is also the constant process of reflection on how one has performed in each and every situation. It’s very easy to throw eggs from a position of relative comfort, protected, as we are, from the responsibility that apparently lays with our many teachers and clinicians. But in a few short months, I will be amongst you as one of your colleagues, and long may that self reflection continue. In that light, I cannot see how current student colleagues’ tendency to throw stones will abate upon graduation. There is a long legacy of not taking responsibility for our personal and if not professional actions (“I’m just a student”). We are responsible for our learning, but there must surely be an adjustment for us to learn, en mass, how to step up to the responsibilities delivered to us as human beings doing medicine, with all our imperfections and challenges yet to master, instead of passing the buck up or across the line to criticise others.

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