What I believe about medicine
75 things I believe to be true about people, patient care, and machines
Below are some things that are true to me as a doctor — Some realities, some beliefs, a couple of provocations. These are things I believe. They come from over 30 years in clinical medicine. I had a lot of fun putting these together. And these ideas are in no particular order.
Maybe I’ll make more lists like this, or add to this one … I found it to be an interesting way to frame my ideas.
What do you believe?
Great technology in patient care should be nearly invisible.
You’ll never understand what a patient is going through. You might get close.
The closer you look the harder medicine becomes — John Mandrola
The clinical impression is a dying art. AI can synthesize an impression but not have an impression — Only humans can have an impression.
If we train doctors how to get good satisfactions scores, the scores stop being a valid measure of satisfaction.
Patients should be informed when AI has created a message.
Burnout is a sign, not a disease. It’s the downstream result of upstream problems.
The medical profession has lost its sense of unity.
Great medicine is sense-making. And the best doctors are the best communicators.
What we do is more important than where we came from. Be wary of doctors who self-identify as a “(fancy institution)-trained cardiologist”, or whatever specialist they are.
Credentialism rarely moves the needle in patient care.
Talk to people, you’ll figure it out (h/t to Tony Hsieh, founder of Zappos).
The electronic medical record should be just the medical record.
The most important attribute of a 21st century physician: flexibility (h/t Eric Topol, circa 2015 while visiting Baylor College of Medicine).
You can always make more money somewhere else.
Regarding your appearance: Put the comfort of your patients above your perceived right to look or dress a certain way.
Modern (American) doctoring is marked by a loss of agency.
The trifecta for a great physician culture: 1) Mission (reason you are all there), 2) Tribe (sense of belonging, alignment, and group safety), 3) Agency (the capacity for some control over decisions).
Few things that will get you as far as treating entry-level hospital workers with respect.
Your patient’s experience will improve when procedures and pathology are illustrated with diagrams, arrows, and bullet lists.
Think twice about making yourself always available. Boundaries and rest are part of great patient care.
Clinical medicine is rooted in patterns — understanding the difference between a variation of normal and a red flag is one superpower of a great clinician.
Know what technology to leave out of the exam room.
The most precious thing you can bring to the exam room: presence.
The hardest part of medicine is knowing what not to do.
Most patients won’t tell you why they’re there.
Dignity comes from agency. Physician unions come from lack of agency.
Healthcare strategy should begin outside of the hospital.
The most important question to ask a patient: What do you think is going on?
Medicine begins with storytelling (h/t Sid Mukherjee, The Emperor of All Maladies). I’d add that it also ends with storytelling.
Managing doctors is easy. Leading doctors is hard.
Being smart is less important than being thorough.
Good communication trumps any process or policy crafted by a hospital administrator.
Be careful mixing politics and medicine.
Intentional friction can be constructive in patient care. Some things should be slow by design.
Shaping a patient’s experience should never be framed as a ‘process.
Drink plenty of water when on call.
How to secure your job as a physician: Offer things that are hard to measure and difficult to operationalize.
Every “non-adherent” patient has a story that explains their actions.
Don’t wear scrubs to the airport.
Critical advice for doing anything in a hospital: Make sure the process does not become more important than the product.
What I look for when hiring a doctor: solid knowledge base, clear thinking, great clinical judgment, humility, and integrity.
Every patient encounter involves negotiation.
“If you turn medicine into a culture war, then every new piece of data appears to be a weapon.” — Dr. Ben Mazer on Twitter during COVID
No matter how far technology evolves, your work is will always be grounded in the physical and emotional needs of the patient.
When in doubt get ‘em on the phone.
Be honest about what can be done by message and teleconnection; be passionate and defent what should be done in-person.
Know what not to be wrong about.
The more we optimize in a hospital the harder it becomes to do things any other way.
AI won’t make doctors irrelevant, it only changes where they add value. Figure out how to offer value.
Hospitals are power and communication structures.
Prediction: Death will be the last human experience not mediated by technology.
When it comes to patients, access is not the same as connection. Communication tools only create access, but value comes from connection.
Your defining strength as a healthcare professional may be in handling ambiguity.
All hospitals use the same technology; what defines hospitals is how the technology is used.
Admit that you don’t know what palliative care medicine does.
If you think you know what you want do with your life during medical school, you’re probably mistaken.
Surgeons are clever.
Never be seen with a stethoscope around your neck during a telemedicine encounter.
Know your superpower. Leverage it. And remember that the magic happens when you surround yourself with other who have different superpowers.
When done right clinical medicine is backbreaking work.
Humans are messy, complicated, and exhausting. Relish these weird contours of the human experience.
‘I don’t know’ may be the most important thing you can say during a clinical encounter.
There’s nothing on your phone more important than the team and the patients in front of you.
Adults are just big children.
A good online footprint will never make up for a bad clinical reputation.
The appearance of empathy can be operationalized. Real empathy, not so much.
As machines get smarter, human fallibility and imperfection will confer a unique advantage. Embrace this.
Disease is as predictable as humans.
One of many things I didn’t know in medical school: Rather than ‘curing’ I would spend my career helping patients/families navigate their journey with disease.
Perception trumps reality.
No matter how many times you’ve done a procedure, it’s probably the patient’s first time.
Healthcare is a service industry and doctors are the servant leaders of the clinical space. Medicine becomes a painful career choice for those who don’t embody this mindset.
The healthcare system won’t save you; find pockets of sanity with people you trust.
My core values in patient care, leadership, and life: clarity, equanimity, empathy. They guide everything from how I respond to problems, the way I make powerpoint slides, and how I draft Substack posts.
This should be a curriculum
Taught at the beginning of medical school and the last week of residency (when doctors think they know everything) and then every 10 years as a refresher
Many of these 75 will take years to believe
Thanks for the inspiration. https://johnmandrola.substack.com/p/what-i-believe-in-medicine