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.
