The speaker had finished, it was my task to respond and deliver the vote of thanks. I disagreed with much of what had been said and I wanted a framework for my response. I looked at my notes from the talk and found his critique of the education system classified into “History”, “Examination”, “Investigations” and “Treatment”. I thought the history and examination had been insightful, the investigations inappropriate, and the treatment likely to deliver the wrong outcome.
I am clearly a prisoner of my early academic exposure and fall back on the skills I acquired as a clinical medical student. Learning to take a proper history from a patient, examine them thoroughly, then using the finding to formulate a hypothesis which is tested by further history taking, more detailed examination and appropriate has been one of the most interesting and exacting things I have done. My companions were MH Pappworth’s Primer of Medicine and Macleod’s Clinical Examination.
Both books set out the basics of systematic history taking, systems for ensuring thoroughness and how to use the clues in the narrative to guide further inquiry, examination and investigation. Chest pain – does it happen on exercise and go down the left arm, think heart; no, is it worse on lying down and central, think reflux ... I realise now how often I fall back upon those skills, sometimes unconsciously, but often deliberately. What am I being told, and what should it lead me to ask? I can formulate a hypothesis about the health of the organisation, how can I test the hypothesis, what are the best investigations to use before setting out the treatment plan (I mean strategy ... getting carried away!). I realise now that basic clinical training was a good foundation for management and leadership. Decisions should be based on evidence however one also has to be prepared to act, sometimes on inadequate information. A sick person in the middle of the night or in a developing country where the facilities are limited is reliant on your best judgement. So you also have to be prepared to go back, look again, and be prepared to accept that you were wrong in your diagnosis and change your mind if things are not going as you had expected.
However there was more to learn than clinical acumen. Maurice Pappworth was the author of Human Guinea Pigs, which had exposed the unethical dimensions of some medical research. Pappworth had been an outsider, un-liked by much of the medical establishment. He had established himself as an independent consultant, and was one of the most successful teachers of postgraduate students. His book was influential in changing the codes of practice for human experimentation. Becoming a Doctor was not just about learning a set of skills, but also values, both Pappworth and McLeod tried, in their books, to inculcate a sense of service to the patient in the aspiring clinician.
Then I encountered Sackett’s Clinical Epidemiology: A Basic Science for Clinical Medicine. Sackett, puts science into the art of medicine; asking clinicians to be critical about what they thought they knew. To apply epidemiological (and statistical) principles to the judgements, and intuitions that made up clinical decision making. Many of the examination techniques described in the Primer of Medicine, or Clinical Examination had been hallowed by tradition, and never rigorously tested. The book was influential in the “Evidence Based Medicine” movement. Somehow we need to make information available from a range of sources such as clinical trials relevant to the individual being treated. The value of an investigation is enhanced by knowing the sensitivity and specificity, the likelihood of a false positive (or negative) and the attitude of the patient to the result.
Clinical Epidemiology also raised the importance and responsibility of keeping up to date with the literature, but more than that, the need to be able to interrogate the literature efficiently and effectively. How do you know that what you are reading is well founded – the authority of the author is probably the least good guide. My second edition (1991) was written as the information explosion was beginning and as the world’s literature became more available. The guidance set out on how to identify the highest quality literature remains pertinent today. As I have moved from medicine to doing degrees in education and now the humanities I still rely upon the tools.
Clinical training, particularly the basics, listening, examining, investigating and thinking critically about the strength of the evidence upon which a decision has been made has undoubtedly influenced my approach to leadership. Perhaps I should finish with a quote from Clinical Epidemiology: “It ain’t what we don’t know that gets us into trouble, it’s what we do (know, but) that ain’t so”.
Professor Julius Weinberg is the vice-chancellor of Kingston University. Prior to this he was deputy vice-chancellor at City University London (from 2007). He joined City University London in 1999 as pro vice-chancellor for Research and also became director of the Institute of Health Sciences in 2001.
Outside the University Julius Weinberg is a Board member of Ofqual, the regulator of qualifications, examinations and assessments in England and vocational qualifications in Northern Ireland; St Georges University of London; London Higher and a School Governor.
Julius qualified in medicine from the University of Oxford in 1979. He has completed specialist training as a physician in infectious diseases, general medicine and public health medicine. He worked within the NHS, as a consultant/lecturer in Zimbabwe, for the World Health Organisation in Bosnia during the war and was a consultant and the head of epidemiology programmes for the UK Public Health Laboratory Service (now the HPA), with particular interest in developing international infection surveillance programmes.
Julius has published over 100 peer reviewed publications, books, book chapters and conference papers in subjects ranging from cell biology and physiology to mathematical modelling and computer games in education.
My Inspiring Leader is Daniel Dennett the philosopher – one of the clearest thinking, best writers, on evolution, consciousness and religion.