Let me begin by congratulating you on the completion of your first two years of didactic studies here at the University of Kansas Medical Center. I have to say what a splendid idea I think it is to recognize this very important occasion formally. There will be many other graduations and ceremonies in the course of your careers, but the transition we celebrate today is a singularly important event. I believe it may be one of the most important - of your professional lives. This gathering marks the division of your career into two distinct chapters. There was that time before you were responsible for the care of another human being - and that time of solemn responsibility which is about to begin.
There’s a great deal of attention paid to the concept of responsibility. Many people outside the medical profession feel that responsibility for patient care begins when you become and MD, or when you start residency, and some people feel that you are only really responsible when you become staff.
It will be two more years until the government recognizes you as a doctor, awarding you the title - MD. But we in this room today - know that your moral, pragmatic responsibility begins from the moment that you don the white coat on your first clinical rotation. When we put on that symbol of the medical profession, and assume responsibility for the ongoing care of a human being, we are functionally doctoring in the pragmatic sense of the word.
No one needs to tell you that our educational process is rooted in delayed gratification. You waited to graduate from college, to start medical school, to finish first year take this test or that course. I’m here today to suggest to you that the part of you that always wanted to care for others and ease the suffering of mankind need not wait any longer, that time has at long last arrived. In point of fact, you will be doctors long before you have a diploma. And from this point forward, we will challenge you to see yourselves as physicians - to behave as you would want your doctor to behave. Many learners in the early third year of medicine still see themselves as students; I want to encourage you to unburden yourselves of this idea today. With the passage of time you will become less of a student, and more of a learner. In order to be a successful healer, you must be a life-learner.
You are about to be allowed to participate in the most intimate moments of the lives of complete strangers. They will invite you to hear about things they would never share with even their parents, siblings or spouses. You will have a window into the secret angst and hope of countless patients in your careers. You will even be invited to palliate deaths, and marvel at births. In the course of your training over the next two years, you will put your hard won didactic skills to the ultimate test. You will digest thousands of pages of lab reports, papers, radiographic studies, and clinical pearls. And for all of these trees, must not lose sight of the forest and of your duty to your patient.
It’s worth mentioning that probably never again in your careers will you have as much time to spend with each patient as will in your third year clinical clerkships. Many clinic doctors see 30-40 people a day. A senior resident on the wards has as many as 18 patients at one time. A hospitalist may carry 30 inpatients. You’ll likely start out with two or three patients to care for in a 10 hour day. I want to illustrate to you how medical students are in a unique position to use this time advantage to make a great difference in the lives of patients:
Last year a young woman was on my service. She had longstanding diabetes, and some complications from uncontrolled blood sugars. This admission she was in-house with new-onset urinary retention. Our medical team decided that his new problem was also part of her diabetes. She was given a catheter (a significant setback for an active young woman), and scheduled to follow up with urology in two weeks to talk about surgical options. The paperwork for discharge was complete, and we were finishing rounds for the day when her medical student approached me to discuss the case. He had spent more time with the patient than anyone else on the case, and was there on one occasion when the patient’s mother was visiting. The student learned that the patient’s mother suffered with MS, which tends to run in families. He researched this and found that it can cause urinary dysfunction. He advocated for his patient, and felt that she should not be discharged, but should be kept in house for an MRI instead. We did not discharge the patient that day, but instead ordered an MRI, which was highly suggestive of MS. The patient was transferred to a neurology service, where she began therapy for her newly diagnosed disease state. Had it not been for the medical student, this young woman might have undergone an unnecessary surgery, and suffered from her MS until someone had the time to understand her human experience. Disease does not exist in a vacuum. It has a context, and that context is the human experience.
When I was an intern, there was gentleman, also diabetic, who had a myocardial infarction. After recovering in house, he was encouraged to have coronary artery bypass grafting, which was the therapy of choice in his case. He would not hear of it. He was convinced that he was going to die on the table. No amount of discussion seemed to break down this inexplicable fear he had of cardiac surgery. He’d had several other surgeries, was otherwise in good health, and it seemed odd that he was refusing life saving therapy. Something did not make sense. Finally, deciding that patients had the right to make what we considered at the time to be a bad decision we were about to opt for medical therapy and hope for the best for him as an outpatient. His student learned one night that this man’s wife had very recently died - during heart surgery. Now it made sense. We had known that his wife was deceased, but did not realize the unfortunate timing or circumstances surrounding her death. The medical student provided the essential piece to this puzzle because she had time to not only delve deeper into the social history of the patient, but to earn the trust of this man long enough to hear his deepest fear; She had taken the time to understand his human experience, ultimately earning enough of his trust to allow the cardiac surgeons to pay a visit and discuss treatment options. Again, it was the medical student who changed the course of therapy.
These clinical students could not write for medications, or perform any special procedures, and yet their enthusiasm and investment in patient care proved more powerful and life altering than anything the rest of us could have done.
This powerful energy that flows between the patient and the healer is known as therapeutic alliance. It is this therapeutic alliance from which we derive our mandate to serve those who suffer. As a clinical learner you will now have an opportunity to engage the patient in a way that frankly most of us can only remember from our time as students. I encourage you to focus your minds and engage in this very special and relatively protected time in your careers to learn the art of listening to patients, to learning more about them than anyone else on the team. Your role can never be underestimated. You’re a vital patient advocate, and don’t let anyone ever tell you otherwise.
In the future, a select few of you will be asked to stay on as teaching faculty here or at another academic facility. Do not underestimate the vital importance of your own students at that time either.
Finally, I’d like to say a word about the future of our craft. You may have encountered those who say that the time to be a doctor was 40 years ago, that the golden age of medicine is has passed. This is clearly not the case. The present is a great time to be a doctor. The enduring rewards of medicine are still vibrant. The therapeutic alliance is still as magical as it ever was. I’d argue that with the advent of the empowered and informed patient, the alliance is stronger than ever. I believe we are more in league with our patients in this decade than ever before. The victories are sweeter because the patient shares today - more than ever - in decision making; ..and of course the feelings of loss are not any less real today either. The infrastructure of medicine may have changed. Do not allow yourselves to be distracted by that static. Disease and therapy, superstition and science, and suffering and compassion are still locked in epic battle just as they always have been. Physicians still advocate for their patients, and patients still seek the counsel and comfort provided by doctors the world over.
In the next 48 months you will stand at the side of a child’s bed - as the code is at long last called, you will touch the beating heart of a man, and help the transplant team place a liver into a young woman who would have otherwise died. And you will deliver a healthy baby to a set of new parents and experience their joy. With this new set of powers and privileges comes very real responsibility. You will need to take care of each other, and yourself, and your families. You must be courageous and patient – with those around you and also with yourself. Wake every day determined to do your best – to do some good – to ease suffering. Train yourself to hear your patient, and to listen to them as well. Your professional passion will foster your knowledge of the healing art, and strengthen the therapeutic alliance that surrounds you and those you serve.
I’m very grateful to the School of Medicine here at the University of Kansas, for allowing all of us here to follow our dreams, and for allowing me to participate in this ceremony with you today. It has been a pleasure to help welcome you to the enduring and noble order of clinical physicians. On behalf of the teaching faculty, fellows, residents, and interns: congratulations to you on this very important transition to clinical studies. We welcome you - as brothers and sisters in arms to the front lines of the war against disease, and we look forward to seeing each of you shine.
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The University of Kansas Medical Center