Casting a Cold Eye, on Life on Death.
Doctor, thinker, entrepreneur, activist, chief executive, but probably best known to an entire cohort of doctors as the editor to the BMJ. A man who inspired a generation.
“Richard Smith is primarily known for what he is not: he is not the editor of the BMJ, but he once was; and he is not Arthur Smith, the stand up comedian and “grumpy old man” but his brother. Smith graduated in medicine from Edinburgh Medical School and did junior house jobs in Scotland and New Zealand.
In 1979 he became an assistant editor at the BMJ, writing series of articles on alcohol and health, prison health care, unemployment and health, research policy, and the General Medical Council. While at the BMJ he also worked as the BBC Breakfast Time doctor, and later worked as the doctor for TV-AM. He had bizarre experiences with both.
After a year at the Stanford Business School in California, a year that had a big influence on him, he became the editor of the BMJ and chief executive of the BMJ publishing Group. After 25 years at the BMJ he left to become the chief executive of UnitedHealth Europe, a job he did not enjoy. Within a few years, however, he became the UnitedHealth director of programme with the US National Heart, Lung, and Blood Institute to create 11 centres in low and middle income countries to build capacity, do research, and advise on policy in relation to non-communicable disease.
After that, he was for six years the chair of icddr,b [formerly the International Centre for Diarrhoeal Disease, Bangladesh], perhaps the most challenging job of his career. For five years he was the co-chair of the Lancet Commission on the Value of Death, and now he is the chair of the UK Health Alliance on Climate Change, the Point of Care Foundation, which works to humanise care, and Patients Know Best, a company that brings together all the care records of patients and citizens and puts them under their control.
Smith enjoys hill walking, cooking, theatre, art, and music, but his biggest passion is reading. Lin, his wife, thinks that like Don Quixote he has been driven mad by too much reading. His three children and four grandchildren, who know him as “silly grandad,” find him an object of amusement.”
Enjoy the video, listen to the podcast, read the interview.
978-1853156731 First published in 2006 by Oxford University Press
So many roles; editor, businessman, writer, and you now describe yourself as a professional reader. Richard, could we say you’re a restless soul?
Richard Smith: I like doing different things. I mean, to me the idea that you would start a job at 18 and carry on till you’re 65, doing essentially the same thing, that doesn’t appeal to me at all. And, actually, I look around and see people who, it seems to me, just go on too long. I think it’s classically politicians, but there are lots of people for whom you think it would have been smarter to get out sooner. My brother, who’s a stand-up comedian, says “… you want to get off the stage before people are beginning to look at their watches”. And I am frivolous. I mean that, ultimately, I’m not a serious person, although I may seem like that to lots of people.
DMacA: What about all those serious issues you addressed through the BMJ and through your career, are they all useless?
RS: It depends what perspective you take doesn’t it. If you think we’re just a rock at the edge of the universe then they are useless but, if you think, well, I’ve got to do something while I’m here, there are lots of things that are in a bad way and maybe by doing something I could improve them a bit. I remember that, for a meeting of GPs, I totted up a list of successes and a list of failures. And the failures far outnumbered the successes. Lots of things I launched into just fizzled out, never really went anywhere, never made a difference.
DMacA: So, do you think medicine is a bit of a waste of space?
RS: There’s a big question. I’m always struck how, when doctors are interviewed, those pieces they have in the BMJ, those questionnaires, people always say ” it’s been the most enormous privilege, it’s been the most wonderful thing I’ve ever done, I never would have wanted to do anything else…” It’s almost as if you’re obliged to say that.
I got off to a shaky start in medicine. I’ve written quite a lot, and I’m always talking about Ivan Illich who still has a huge influence on me, and I felt a lot of what was going on in the Royal Infirmary in Edinburgh was more for the benefit of the doctors than the patients in a way that quite disturbed me. And then when I heard Ivan Illich say, and I’m paraphrasing slightly, that the major threat to health in the world today is modern medicine, it seemed like an outrageous idea. But the more I’ve reflected on it, the more I think it’s true, because I think doctors are not the least bit interested in health. If you look at the average medical textbook, it’s a thousand pages long. There are 995 pages on diseases and then five pages at the front on health, usually written by a philosopher, and not read by anybody who reads the textbook because you are never examined on that.
On inspiration:
“I don’t suppose Ivan Illich had any idea that some young long-haired tearaway medical student would be hugely influenced by the things he said, and that his whole life would be affected by it so, in that way. Perhaps I’ve said something somewhere that’s motivated somebody to go on and do something more and have an interesting time doing it.”
Report of the Lancet Commission on the Value of Death: bringing death back into life
We’ve developed a sickness system not a health system which I think is a big mistake. It struck me recently that these sickness systems are inevitably doomed because of two simple human things. The first human thing is that if you’re confronted by somebody who’s sick, say a child with meningitis and beside him or her an obese child, of course you’re going to concentrate on the sick child. So, just as we would do as individuals, so our sickness system concentrates on the sick and sucks resources away from things that are actually far more important for health. We’re familiar with the idea that probably only 10% of health is attributable to health systems, most of it is down to socioeconomic factors, the social determinants. So, you suck money away from benefits, from education, from housing, from the environment, all those things that have far more influence on health.
And, the second simple human urge is to do better. We’ll try and invent something more. We invent endless new drugs, new this, new that, and that’s what drives up the cost of health systems. Although politicians always say it’s due to the aging population, and it is to some extent, but it’s much more driven by the fact that there are simply many more things that can be done. Call it health but it’s sickness really. It’s not spent on health.
As you know I’m fascinated by death and I think how we relate to death is one of the most crucial things about being a human being. I mean death is fundamental, death is valuable. I chaired the Lancet Commission on “The Value of Death” and the title was very much intended. Death is valuable. Without death every birth would be a tragedy. We are maybe there already. Death through evolution drives life. Death’s also valuable because, to be around people at the end of life and caring for them is one of the most interesting and rewarding things you can do- as Gandhi describes very vividly in his biography. And, I think, to be constantly aware of your mortality, your death, is very life enhancing. It means- let’s just make the most of what we’ve got here and not keep putting things off.
On Death:
“As you know I’m fascinated by death and I think how we relate to death is one of the most crucial things about being a human being. I mean death is fundamental, death is valuable”
Painting by Richard Smith
DMacA: Let me bring it back to the message from Illich and Skrabanek, and James McCormack, about the therapeutic nihilism of medicine. The people at the centre are the doctors. You’ve met some pretty important, and self-important, doctors so looking back, what do you think of doctors?
RS: I think they’re just like everybody else, they’re not different. Some of them get tempted to behave as mini Gods but they suffer from all the same human weaknesses as everybody else. Some of them are good, some of them are bad, some are greedy, some are prone to anger, some are corrupt, some are saintly. You get every kind of doctor, just as you get every kind of human being. They are human beings and the worst thing that can happen to a doctor is to forget that, and then you’re really on the road to ruin.
DMacA: Listening to your opinion of medicine and health…if I were to grow up in that household I would have a pretty cynical approach to medicine and doctors. Has the fact that your daughter studied medicine changed that at all?
RS: I suppose one of the reasons I think I might be cynical about medicine is that I don’t think I ever could have been a good doctor. I was too doubtful about the whole endeavour. I think she’s a much better doctor than ever I would have been. She’s very kind, practical, very empathetic, very good at communication but, at the same time, to use the cliché we used to have in BMJ editorials, she doesn’t well suffer fools gladly. I think she’s exactly the sort of person you’d want to have look after you. And I didn’t share my cynicism with her, although she wouldn’t have had to go far to find it written down in various places. Her story is the sort of tale you hear all the time of people who set off into medicine with great enthusiasm, all sorts of wonderful aims and aspirations, and then slowly but surely get ground down by the system. I spend quite a lot of time with younger doctors and I certainly come across a lot who feel very bruised by the system.
On doctors:
“Some of them get tempted to behave as mini Gods but they suffer from all the same human weaknesses as everybody else. Some of them are good, some of them are bad, some are greedy, some are prone to anger, some are corrupt, some are saintly. You get every kind of doctor, just as you get every kind of human being. They are human beings and the worst thing that can happen to a doctor is to forget that, and then you’re really on the road to ruin.”
Image by Lin Smith
DMacA: It used to be that you mortgaged your life away for a reward at the end in terms of seniority…
RS: …so a pretty cynical materialist bargain- I look after all these poor people and get up at night but in the end, I’ll live in a big house and have a yacht. Some doctors, of course, are going to be motivated by that but I think a lot are not. If you want to get really wealthy medicine’s not the best way to do it, which is why I think, you see a lot of younger people thinking – I’ll go into business, I’ll run a company, I’ll be an entrepreneur.
DMacA: Do I sense that, even behind that cynicism, there’s some optimism about young people in medicine?
RS: Yes. When I am asked that question, am I an optimist or a cynic, I always quote Gramsci (Antonio Gramsci 1891–1937), I’m an optimist of the heart and a pessimist of the brain or the mind, which I think is probably the best way to be. So, while I might sound rather dismal here, I’m not at all. In that sense I’m optimistic.
I’m pretty pessimistic about the state of the planet. What takes up most of my time these days is being chair of the UK Health Alliance on Climate Change (https://ukhealthalliance.org/about/our-team/). I think that, unfortunately, the more you know about the science of what’s happening to our planet, the bleaker you are. We just seem incapable of doing the things we need to do, even though those things would improve our health. You know, of course, that health systems themselves are major emitters of greenhouse gases and produce a massive amount of waste which is ending up in the rivers and seas and soil.
On climate change:
“…unfortunately, the more you know about the science of what’s happening to our planet, the bleaker you are. We just seem incapable of doing the things we need to do, even though those things would improve our health”
DMacA: You’re very interested, almost preoccupied by death, and you’ve written a lot about it but I want to ask you about something that’s related. You used to say that doctors should write their own obituaries. Have you written yours?
RS: Funny you should ask. I did write one, I wrote a spoof one. But, I’ve a sort of sideline of writing or editing obituaries of people before they die. I had a particular experience with Sir Anthony Grabham, who was chair of the Journal Committee of the BMA, so he was my boss in a sense, and he’d also been the Chairman of Council. He was a very aristocratic looking surgeon and we were very different people but actually we got on remarkably well. Eight years after I had left the BMJ, and I hadn’t really had any contact with him, he contacted me and said he wanted to talk to me. I thought he was going to tell me off because I’d just written that notorious piece about the best way to die being cancer which caused a lot of fuss. But no, he wanted me to write his obituary because he knew he was near his end with cancer. So, I travelled up to see him and we sat and drank and talked for three hours and had a wonderful time, and then I went back and wrote his obituary. I knew that this is a man who wants to control his legacy and his story, but I thought that the great thing is that because his wife and family would know that he’d written it with me, it gave more opportunity to get in light and dark. So I did.
At the moment I’ve been editing the obituary of Joanne Roberts, whom you might remember as John Roberts when he was at the BMJ and subsequently, long ago, he made the transition to become Joanne. That’s been very interesting for me because absolutely clearly the right thing happened. John was a pretty disturbed individual whereas Joanne is a wonderful calm person who is very close to death. But, she said to me – “you better write your obituary because you’ll find it’s not so easy”.
“I suppose I will be remembered by my children and even my grandchildren but then I’ll be completely forgotten. Who’s going to be remembered? “
DMacA: I’m glad you came back to that because I thought you had dodged the question… A self-written obituary is how one would like to be remembered, so, the question is, how would you like to be remembered?
RS: I should be forgotten. I don’t expect to be remembered. I mean I think it’s a kind of arrogance to expect to be remembered. I suppose I will be remembered by my children and even my grandchildren but then I’ll be completely forgotten. Who’s going to be remembered? It seems to me that it’s arrogance to expect to be remembered. The vast majority of people are forgotten. It’s a handful of people who aren’t forgotten and, even people who were remembered for quite a while, are then forgotten. Unless you’re Plato or Shakespeare and, even then, those people that are remembered turn from what they were into some kind of myth. They’re not remembered as they actually were, they turn into something different. So, I don’t expect to be remembered.
The photograph appears in a blog where Richard writes: “and Lin took a picture of me in the sands that I think of as the definitive portrait of me.”
DMacA: But, you’ve been an inspiration to so many other people and influenced a lot of what has happened, particularly in medical publishing. So, when you look at medical publishing and some of the areas where you may have had some influence, are there any that stand out?
RS: One of the thoughts that comes into my mind is research misconduct. Stephen Lock, who was my predecessor as editor and, by the way is still going strong at 94, I speak to him every few weeks, he got me to write about this in the 1980s, when we didn’t sign things, even about various egregious examples of medical scientists misbehaving and doing all sorts of things, inventing data, distorting data. And I wrote about that and Stephen became more and more obsessed with it. But then when I became the editor, slowly but surely I came across more and more examples. One of the things we did, together with Richard Horton from the Lancet and Mike Farthing the Editor of Gut, was to create something called the Committee on Publication Ethics, which has now taken on quite a big life. (https://publicationethics.org/about/history)
I’m involved these days with Retraction Watch. (https://retractionwatch.com). It’s run by journalists and they really demonstrated the extent of misconduct in medicine. That’s something I’ve been very interested in.
But, things are no better and things may well be worse and, just like I’ve become very sceptical of medicine, I’ve become very sceptical of journals. I think the whole business of producing a lot of original research and sending it off to practising clinicians on a weekly basis makes no sense whatsoever because they don’t read it and, if even if they did, the idea that they would change their practice in the light of one trial in a particular journal, and when you think that there are hundreds of thousands if not millions of research studies being done every year and you send people a small random selection of some of them, makes no sense whatsoever. What I think journals can do is just what the mass media do, raises issues, dig into issues, speak truth to power, expose corruption. But the publishing of science should be another thing all together and there are much better ways to distribute science.
On Journals:
“…I’ve become very sceptical of journals. I think the whole business of producing a lot of original research and sending it off to practising clinicians on a weekly basis makes no sense whatsoever because they don’t read it and, if even if they did, the idea that they would change their practice in the light of one trial in a particular journal, and when you think that there are hundreds of thousands, if not millions, of research studies being done every year and you send people a small random selection of some of them, makes no sense whatsoever.”
Richard with Jeff Drazen former Editor of the New England Journal of Medicine
RS: I like the idea that I might have inspired somebody. I always think about once when I was in Kumasi in Ghana running a course and not many people turned up and then we had rather a lovely dinner and I sat next to the Dean and I was expressing that I’m not sure this was a big success and he said, “Well, you know you never know, you may have planted something in somebody’s mind that is like an acorn that will grow up into an oak tree. You would never even know that you’d planted that thought”.
I don’t suppose Ivan Illich had any idea that some young long-haired tearaway medical student would be hugely influenced by the things he said, and that his whole life would be affected by it so, in that way. Perhaps I’ve said something somewhere that’s motivated somebody to go on and do something more and have an interesting time doing it.
Image by Lin Smith
DMacA: I love that image of planting the acorn. Because you did an immense amount to inspire a whole generation in medicine. Although you may sound a bit bleak and cynical and perhaps a little bit depressing, I have to thank you for your inspiration- to me and a whole generation. Richard it’s just been a pleasure chatting to you.
