Friday, May 5, 2017

Graduation Keynote Speech at Hooding Ceremony Class of 2017 Mercer Medical School

Thank you for asking me to be here.  I have really enjoyed this event over each of the last several years but only as a spectator. It is a honor to speak. I have debated whether to highlight your accomplishments (or perhaps tribulations) over the past four years, there being an "awards ceremony" later, or take this last opportunity to tell you something constructive about preparing for next year and perhaps your whole career. I'll attempt both but I want to make sure you take home four recommendations. I will contrast my experience with your previous and likely future experiences. I will also  speculate on how the differences or similarities might relate.

The difficult role in education is in primary and secondary school where some students do not want to learn or even be there. The real heroes are at this level. These teachers can take a young student, maybe it was one of you, and perhaps against all odds, turn him or her in the right direction for the rest of their lives. In contrast, med school is where everyone is smart and accomplished as well as eager to learn. What a joy it is to teach here. I am amazed so many doctors can pass on the opportunity to be in my shoes. Especially when one gets a little older. At this point I am- desperate- to pass on everything I know. It took awhile and a lot of effort to obtain the knowledge. Why would I selfishly want to take it to the grave. Teaching you guys is like handing out money, except when I go to the bank it's still there.

It is imperative to discuss your impending metamorphosis from medical student to house officer.  I have firsthand experience with this years ago, and the unfortunate talent of remembering every painful  professional situation I have ever encumbered.  "Back in the day" as I like to say, (when I was student/intern/resident) there could not have been a more monumental transition as this one.  In preparation for this talk I spent a lot of time reminiscing on how difficult it was and why. I reread the novel House of God, an accurate and scathing indictment of an internal medicine residency program at a prestigious university hospital at exactly the time I was doing an internal medicine internship at a similar place. Almost everyone in my day read it.  Some of you have also and others have asked about it. After a great deal of contemplation, I concluded things have changed so much over the thirty years between my previous transition and your eminent one, the book is no longer relevant and accounts from my personal experience would not be enlightening. The details of this change however are worth mentioning for a historical perspective.

First of all, for me, medical school was all fun and no pressure whatsoever. Everyone in my class passed every test and most of us just showed up for the Step Exams and I think everyone passed those also. The results did not even go on our residency applications. There were more House Staff slots than American graduates and if one were low on the class rank, he or she usually received whatever residency field they wanted,  but perhaps at an undesirable location such as Detroit versus San Francisco.  I'm so sorry you did not have an identical experience, though it did appear to be somewhat fun for many of you.  The MDE tests here were significantly more difficult than any test I ever took in med school. You had to study full time- 6 weeks for each Step Test as well as part-time for Step during the rest of the curriculum.  You had shelf exams for each rotation. These toils were all outside of my experience. Then Step 2 CS. What is that? How can you fail someone for misdiagnosing a fake patient. Just another layer of worry for you. Finally there was a real chance you could have not matched for residency at all.  All adding up to much so more stress for you relative to my puny stress during med school. There is nothing unique about this here at Mercer. All medical students today are likewise inflicted.

On the brighter side, being house officer is not like it was back in the day.  I worked forty straight hours, from 8 AM one day to 10 PM the next, every fourth day for the entire year and rarely got home before 8:00 PM on the nights I was not on call. There were no electives or ER rotations where you did your shift and went home without more patients on your list like chain around your neck.  I did not see one attending during a several month rotation at a big county hospital and some of the senior residents were not too helpful. I think they were resting up for their moonlighting jobs. In the surgical fields the hours were even worse, though they did do a much better job of spreading the blame if things did not go well. This predicament was almost insurmountable.  Jumping off the top of the building, like Potts, a major character in House of God was not rare.  As sorry as I am about medical school not being all fun for you as it was for me, I'm delighted you do not have to go through the pain I had to as an intern. It was a sophisticated and dangerous form of hazing.  You will likely find residency more fun than medical school.  Since the four years in med school were so much more demanding for you than me, I believe you are better prepared than I was. Likely you will see your attending every day and receive some meaningful input.

One the changes you will enjoy is more of a team approach.  It is my understanding after night call these days, around noon, interns pass the patients to their fellow house officers and no more 40 hour shifts.  You will need to have a great working relationship with whomever you pass the patients. Lives will hinge on that relationship. I repeat-lives will hinge on that relationship. Mercer grads have an advantage as house officers. From the first year here in "group" you were forced for long hours to interact  constructively with students you did not choose. Next year you will be better prepared to work with your fellow house officers with whom you also did not choose. One of our previous students now in her first year internal medicine at Emory told me recently she can pick out the former Mercer students in the hospital (where there are apparently enough to notice) as they are the ones who rally their fellow house officers when a patient unexpectedly crashes. Recommendation #1: Don't ever pass on an opportunity help to your new colleagues next year even if it is not your duty.  Your patients will benefit when your colleagues are eager to reciprocate .

There has likely been little change from my time to yours on just how different it is to be the one 'in charge' of the patient as you will be this July, opposed to the more or less observant role we both had as med students. You would have to be in bubble not to know this. This is not simply a different level of stress which, as previously implied, will not be such an increment for you as it was for me. The experience of being in charge of patients' lives is-life altering- simultaneously uplifting and frightening.  The closest generally well known phenomenon I can think of, is having a child. For the few of you who have, you know what I mean. It's difficult tell you how to balance this feeling. Like parenting, there is no consensus prescription. I have no concrete advice. All I can say is to be ready. Hopefully it will be more uplifting for you than it was frightening for me. With the changes over the last few decades, I think it probably will be.

Now for the one which will take some time to defend and also the one you might not want to hear. Money.  The older and very accomplished jazz singer Tony Bennett told Amy Winehouse " life teaches you a lot if you live long enough",  which I have and unfortunately she did not.  What I have learned, among other things, is the human species does change much, that's biology, and if so, only a minutely so over millenniums but culture can change and dramatically so in short order.  Also, it is easy to go along with that which is culturally the norm and difficult  to go against  it.  How is this relevant? When I finished my residency I moved to Macon and within a short period of time was joined by four other Neurologists  from my generation to start a practice.  We all had some debt  but nothing like the magnitude you are facing.  Despite very diverse backgrounds: small town versus large town origin, one immigrant, one from New Jersey, one local, some with parents who had money, some not, we all had the same "cultural" approach to debt.

Baby boomers like myself are very conservative financially. Brain washed by our parents who all went through the great depression of the late 20's and 30's as youngsters, it was inconceivable  we would sign on to additional unnecessary debt when starting in practice. The five of us lived exactly as we did as residents until all debts were paid. It was easy. It was the culture. Everyone did it this way. Now I see young doctors, just out of residency, the same "people", genetically speaking as my colleagues and me, in  a different culture, owing a sizable amount of money for undergraduate and med school, with a different plan. Recommendation #2: Even if the bank says it is OK at that time to buy a big house and even if many of your colleagues are doing so, it is not OK.

And why not? Two reasons:

First, from the beginning of your career you will likely be negotiating your salaries with a hospital or health network or your fees with an insurance company, hospital or health network on a frequent basis, maybe yearly.  To be effective negotiator you need to be in a position to walk.  If you have a $3000/month student loan obligation, $5000 on your mortgage plus other fixed expenses you will take what they offer even if it is a significant cut from one year to the next. You won' be able to miss a payment. You want to be in the position my niece is in now, who finished a family residency nine months ago.  She lives in a small rental, identical to her situation as a resident and has saved a good portion of her salary already. She works for a prominent health network and a couple of months ago asked about a specific time off this summer for a vacation and could not get answer, likely benign bureaucratic indifference.  Frustrated, but  confident of her financial situation, she went to management recently and said "you are telling me when I can take my vacation tomorrow or I am resigning.” They did. And I am sure when it comes to next year salary offer, if not pleased, she has enough  money to live at her current level while she takes months to look for something else.

Secondly : "Time is money" is the old saying and perhaps there is truth to this but what is more relevant  is no money (or negative money-debt) means no time and no time in the medicine game is agony. After three years of practice I owed only a doable mortgage.  I always set my schedule at a pace I could do comfortably. Of course there were few difficult patients  but for the most part I enjoyed every day. I also enjoyed call at the hospital most of the time on my call days but having no control over the number of consults, occasionally they were excessive, and on those days, instead of being OK for most of day and a little tired at the end, I was miserable all day.  To avoid this I have recently move to night call only. Years ago older docs would say to me "better to be too busy than not busy enough". From day one I muttered under my breath "I don't think so".  Nothing is more disturbing to a doctor in charge of patients than to have too many to deal with safely. I am aware of some Neurologists, and I am certain this would be true of other fields, who set their schedule every day to see the number of patients that would be a misery for me to see, as I know it must  be for them, but they feel they need to, to cover their debt. Medical school is expensive and it fine to borrow and unreasonable to expect your parents to cover it. But I plead with you to go against the current culture of assuming more debt once you have finished training.

When you are not in hurry you will have time not just to be a better doctor but a better person. There are several things that make me happy as a doctor. Atul Gwande a surgeon and prolific writer says "you become a doctor because you feel you will enjoy the work and what you find out is, you enjoy doing the work- competently." I can attest to that. I was tormented my first several month of internship because I assessed -my- competence as "suspect" (at best) despite never receiving any bad feedback. I don't think anyone cared. Of course you will take your training seriously and get competent as soon as possible as I eventually did. But other than competence, which is absolutely essential, what does it take for a doc to be happy? Do I like it when I am consulted on a case and no one has a clue and I solve the riddle?  Yes I do. I am that shallow. It turns out this is not a true joy, and just a brief thrill. That's my job, and it is not as much a thrill now as it was when my partners and I were long ago trying to establish credibility for the field of Neurology in its infancy here in middle Georgia.

Which leads me to-Recommendation # 3 Have the right patient attitude and that will make you happy. What gives me the greatest and longest lasting satisfaction begins with having  extra -time- on a difficult case. Sometimes this occurs when circumstances are beyond my control such as finishing up with one patient in the ER and waiting for another on the way. This happened three evenings ago. Sometimes it's when I have to go in the middle of night.  Once there, what's the hurry?  It's nice to go back to the patient's room, spend some extra time and perhaps address his or hers fears. But most importantly, it is an opportunity for me now and you later to be genuinely kind to someone desperately in need. This takes time. Usually no one but the patient notices and it is unlikely you will ever receive any kudos and certainly no extra money. But I know, just as I knew my competence was suspect early in internship,  and you will too when one of these many opportunities arises. Being kind to a distressed sick patient when I don't have to is my greatest and most enduring satisfaction. I hope it will be for you.

I am sure when you have your own practice your patients will all be compliant with their meds, never smoke or overeat and their definition of needing a drink is a glass of water after their daily jog you suggested. But next year in many of the hospitals I've noted you will be working, some, if not many of those patients will be there as a result of bad behavior-not taking meds, smoking, overeating, gun and knife club, driving while intoxicated. It's a mistake to be judgmental and angry. Just do your job. I wouldn't make a point of thanking them, but their poor choices likely led to an excellent training opportunity for you.

Recommendation # 4 Always, and I mean after residency, be a student. No profession lends itself to this concept more than medicine. Every field is in constant evolution. Our team has PhDs and MDs working a gazillion hours coming up with new approaches and treatment and making their results available to those who are curious. There is a fork in the road and of course you can go one of two ways: the wrong way- head buried in the sand, annoyed, bored and indifferent, or the right way- stimulated and energized by the new concepts. I see both groups of travelers and the latter are not only much better physicians but much happier people.

So in summary, in case you drifted off, the four recommendations are 1) Be  generous to your fellow house officers. 2) Don't buy that big house too soon, being overly financially responsible will buy you time every day. 3) Attitude: in addition to being the most competent you can, be kind your patients and non judgmental. 4)make a vow to be a permanent student which will best insure your satisfaction throughout your career.

In closing I would like to add something on another level altogether. For decades I was only peripherally involved  with the Medical School  having an occasional 4th year elective rotation. My main responsibilities were  my practice, the hospital and the Internal Med residency program. With the exception of the few med students who wound up staying here for Internal Medicine, like Dr. Sumner (to this day still the best resident ever) I did not have the chance to really know anyone. Of all my work over four decades, teaching you and the others classes over the last five years has been my favorite. The contact starting with the basic sciences in the first two years and through the clinical portion of your training in your last two years has provided me with the opportunity to not only to teach but to know many of you in some depth. I will always cherish these relationships. The best to each and every one of you. Thank you for the opportunity to be part of your training and thank you for asking me to speak tonight and to be part of the hooding process.