British Medical Journal Medical teachers are understand- ably concerned to equip their stu- dents with the necessary skills, attitudes, and knowledge for work in the profession. There used to be traditional assumptions of style in appearance, clothing, and manners. This was exemplified by Trevor Howard’s character in Brief Encounter: a well-scrubbed doctor in fustian gents’ outfitting with mild manners and under- stated passion. Teachers at med- ical school said, ‘Look smart, get your hair cut, and keep your fin- ger nails short: the patients, espe- cially elderly patients, want their doctors, and therefore you stu- dents, to look like doctors.’ The message was a little spoilt by their embroidered Afghan goatskin coat and flares, but we listened in kindly disbelief. Conventional manners and style were part of civilisation, part of the contract between strangers that enabled them to interact with predictable success. Alas, the world has changed, and the question of style v quality has returned with a vengeance. British reserve is increasingly replaced by transatlantic style, pan-European chic, or Aus- tralasian informality. The world is asking for accountable standards of performance from doctors. How far should professionalism determine style and conformity in a medical career? Can medical eccentrics survive the new quality environment? Diversity Doctors are as delightfully varied as humankind. We can all bring to mind the traditional medical stereotypes: bombastic surgeons, sinister physicians, jolly general practitioners, baffled pathologists, and the rest. And we know that in most cases such types are false. In our evidence base of acquain- tances, we can perhaps find con- trary examples of baffled surgeons, jolly physicians, sinister general practitioners, and bom- bastic pathologists. Real doctors differ from typecasting by miles, and if you compute the infinite parameters of individuality you rapidly become the unique exam- ple of your kind of doctor, and number one in your class. Medical students are amazed by discordance between appear- ances and reality. Hippies of the 1970s have become professors of surgery, Gilbert and George lookalikes have turned into trendy psychiatrists, and medical directors everywhere can have beards, pony tails, sandals, and short skirts (and that’s just the men). Despite the initially normative valve of medical education, doc- tors will naturally diverge there- after along their individual career paths: into hospital or general practice, into different specialties, into rapid or postponed success, into international travel, into fam- ily commitments, into program- matic life satisfaction or mere medical existence. Individual peculiarities flourish in medicine, where most doctors are their own boss and, up to a point, have been able to run their lives as they wish. Conformity Teenagers converge towards the norm; it’s just that their parents do not like the normal teenager. Nowadays, doctors also are hav- ing to converge into conformity, but under the influence of exter- nal forces. There soon will be guidelines for everything, and a substantial degree of standardisa- tion is inevitable in all parts of practice. We may not like it, but nice men and women in suits will say what we should do and cute chimps in police helmets will check that we are doing it. Com- fortable conformity removes exploration and innovation. Con- formity is comfortable for those who make rules, enforce rules, and accept rules, but not, alas, for eccentrics. Eccentricity Eccentricity is part of the British way of life. Whether you look odd, act odd, or really are odd, you will fit in somewhere. We enjoy diversity and combine it with tolerance and ridicule, but we don’t mind at all. Mild eccen- tricity is the basis of much loved situation comedies. Mavericks, non-conformists, and the person who disagrees (there is always at least one) are secretly valued. The late Screaming Lord Such and his Monster Raving Loony Party were much admired—not much voted for—but admired and nec- essary. Eccentricity varies by degrees: you are eccentric, she is bizarre, I am creative. One person’s weird- ness is another’s weekend hobby or even way of life. There are dif- ferences between being eccentric and acting eccentrically: showing lack of insight or consciously cul- tivating behaviour. The real eccentric thinks he’s normal; he is blind to the rules and is naively surprised at the response he engenders everywhere. The nor- mal reference ranges for humans are indeed very wide. Humans are also subject to peer group pressure and fashion. Most suc- cumb to some extent. In British professional life we have had the unspoken doctrine of maximum permissible oddity: that one major oddity, or two minor oddities, as long as every- thing else is conventional, is still OK. Selection boards in the armed forces, professions, and civil service have long struggled to deal with the slightly odd chap. Pragmatically, the chap might be permitted a major oddity or two minor oddities so long as every- thing else was reassuringly con- ventional. The definitions of oddity have varied through the Career focus 2 BMJ CLASSIFIED 13 NOVEMBER 1999 Eccentricity and conformity Eccentric conformist Carl Gray analyses diversity in medical style Locating conformity and diversity Settings that deserve conformity ● Consulting room ● Operating theatre ● Laboratory ● Court of law ● Exams ● Interviews ● Media exposure ● Interprofessional liaison ● Audit Settings which encourage diversity ● Research and innovation ● Management ● Medical comedy ● Journalism ● Performing ● Politics ● Travel ● Teaching ● Learned societies and associations Table: Medical types in relation to new rules In authority Legislators Enforcers Eccentrics ConformistsSubject to authority Original thinking No original thinking o n 5 A p ril 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://w w w .b m j.co m / B M J: first p u b lish e d a s 1 0 .1 1 3 6 /b m j.3 1 9 .7 2 2 0 .2 o n 1 3 N o ve m b e r 1 9 9 9 . D o w n lo a d e d fro m http://www.bmj.com/ Career focus 3BMJ CLASSIFIED 13 NOVEMBER 1999 Career focus is edited by Douglas Carnall, BMJ, BMA House, Tavistock Square, London WC1H 9JR Tel: 0171 387 4499 Fax: 0171 383 6418 dcarnall@bmj.com or send the command subscribe career-f to listserv@listserv.bma.org.uk Archived at http://classified.bmj.com ages: at one time having a beard or being a female chap, a gay chap, or a foreign chap were major oddities, while wearing bow ties, being drunk, keeping newts, playing the accordion or guitar, ladies wearing trousers, and anyone discussing religion, money, sex, culture, or football were minor oddities. Alas, stan- dards have slipped: these days bearded ladies in trousers discuss whether the football culture is the sexy new religion all over the place. Modern oddities might include smoking a pipe, editing a periodical, studying chafing in cyclists, and not enjoying football. Happily, the increase in cultural diversity in Britain has led to a massive broadening of minds in recent years. Unhappily, racial and sex discrimination may not yet be completely extinct. Dislike of eccentricity is closely related to larger scale xenophobia. Slightly odd chaps everywhere are still wise to cultivate reassuring nor- mality so far as they can manage. Different settings encourage con- formity and diversity (see box), and in a working day doctors may fluctuate between convention and eccentricity. Pros and cons of being odd The value of diversity—including its extreme form, eccentricity—lies in creativity, adaptability, and the bypassing of the limits of conven- tion. Innovation springs from dissatisfied minds and strives in new directions. Many currently accepted views were once unorthodox, until they were chal- lenged, tried, and finally adopted. The people who ask “Why?” are those who find the answer. The downside of eccentricity is its potential to cover mediocrity and non-cooperation. Flamboy- ant weirdness is captivating but also confusing. How is this per- son performing behind his or her persiflage or camouflage? Strip off the make-up, the mannerisms, the body piercing devices, and the affected Viennese politesse and what is left: anything or noth- ing? If this is self expression then what is being expressed? Is the chap under the cowboy hat or the girl in the fishnet tights any bloody good? Are mere stylistic choices inappropriately obstruct- ing function? Professionalism Professionalism means delivering the same service to the patient whoever you are and however you are feeling or looking today. A paediatrician in a clown cos- tume or one in a white coat should be delivering the same paediatrics to the sick child. One should still wake up whether the anaesthetist looks funny or mere- ly peculiar, whether he has come in through the door or the win- dow. A doctor who cultivates Jane Austen mannerisms or who, like Black Adder’s King George, says “penguin” at the end of every sen- tence should be just as alert to drug interactions or the subtle downward trend in vital signs in the acutely ill. Acting the doctor We know how doctors should look and act; we’ve seen them in films and even some examples on the wards. But medicine is chang- ing, and diverse professional per- sonalities are adapting in different ways. Some retreat into traditionalism and conservatism— indeed, all those young fogeys at medical school now turn out to be perfectly equipped country general practitioners. Others leap into the new ways and language and the fashionable thing, what- ever it is this week. Many are wondering, ‘Am I good enough for these challenges?’ Which would you rather be: the mounte- bank or his zany? Trainee doctors must flourish in their chosen styles: it does not matter how you look or seem, it’s what you can do that will be evaluated. The patients must understand and value their doctors. Open com- munication must mean what it says. The days of coded messages, secret societies, and closed con- ventions are over. What is under- stood to be understood may be misleading. Spit it out, man! The answer surely lies in culti- vating diversity and doing our own thing while identifying the essentials of good practice and communication and ruthlessly proving we can do them. Confu- sions between quality, message, and style will continue until quali- ty standards are more fully assessed. This is the direction the profession is taking. Under the new rules, doctors will be legisla- tors, enforcers, conformists, or eccentrics. Politicians will set the aims on behalf of society. Clever doctors will set the rules. Enforcers will implement them gleefully. Conformists will follow them, grumbling. And eccentrics will set about ignoring them, breaking them, or looking odd. But they might at least wonder “Why?” This is the new medicine. Why not ask your consultants or colleagues for permission to change your style, or theirs? You’re looking stylish today, Doctor, but how will you fit in? Carl Gray, consultant histopatholo- gist, Harrogate District Hospital, Lancaster Park Road, Harrogate HG2 7SX carlgray@btinternet.com Briefing ● A shiver of anxiety ran through the body of employers in 1995 when the High Court awarded heavy compensation to a social worker who sustained a “psychological injury” caused by stressful conditions at work (IDS Brief 1999;648:7-8). A recent county court judgement strengthened this precedent, awarding damages equivalent to five years’ earnings to an employee who developed severe depression after being redeployed without appropriate training. The court agreed that the employer had been negligent in requiring her to undertake stressful and demanding work without assessing her ability to do it. ● Matching posts and candidates is an obvious application of electronic technologies. It’s interesting to observe how the metaphors used to describe the processes evolve. The website of the American Association of Family Physicians no longer advertises jobs: rather it offers placement opportunities. you can fill out the rather laborious online form at http://www.aafp.org/careers/ and wait to be emailed opportunities that conform to your preferred geographic, demographic, professional, and social factors. ● Annual ritual in a column is disturbing evidence of its longevity, but once again the Institute of Personnel and Development proves its capacity for zeitgeisty jargon generation. Delegates at its recent conference heard how “spiritual intelligence” is destined to be the last buzz phrase of the millennium. Individuals with high SQ (as it is known) will be needed to counter to the alarming tendency of executives to hold “fixed assumptions that stunt their ability to think laterally.” To which the appropriate response must surely be: “Amen.” o n 5 A p ril 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://w w w .b m j.co m / B M J: first p u b lish e d a s 1 0 .1 1 3 6 /b m j.3 1 9 .7 2 2 0 .2 o n 1 3 N o ve m b e r 1 9 9 9 . D o w n lo a d e d fro m http://www.bmj.com/