I was honored to be the keynote speaker for the white coat ceremony at SUNY Downstate Medical School class of 2019 yesterday. I am passionate about the message I shared with this enthusiastic group of future physicians. I hope you find meaning and value in it as much as they did.
Hello everybody, good afternoon. How are you feeling? Thank you dean Pattoo, thank you president Williams, dean Putman thank you class of 2019 family and friends.
First let me tell you what an honor it is for me to be standing in front of you today. I must admit that I spent a lot of time trying to figure out how I can share with you in this unique day and maybe help inspire you in some small way with a true and passionate message that can last and a message that can stay with you for the next 4 years.
I found this to be very difficult because today is a day you and your families and friends will never forget regardless of what I say. It’s such a momentous occasion. It certainly stands on its own. It marks the start of the most life defining four years of your life.
You’ve worked so hard for so many years to get to today. The process of getting here has been grueling, highly competitive and even isolating.
Most of you probably knew you wanted to be doctors from the time you were little kids, many of you figured it out along the way. It gives me pause just to think how difficult it is to get into medical school. And yet, here you are.
You are unequivocally the few chosen ones.
And it’s such a joy to see your faces so full of excitement, hope and promise.
You are our future and YOU will define how that future looks in health care.
You are starting medical school in a time of major change. This is a very difficult time to become a doctor in our country. To be part of the class of 2019 you must not only excel academically, you must be dedicated and committed to overcoming so many obstacles to becoming a truly impactful physician. You are coming in at a time when healthcare is in such tremendous turmoil.
The position and role of the doctor which was so clear 40 years ago is now confused and confusing. The priorities of the industry have changed dramatically. Insurance companies, drug companies, academic institutions, all parties involved with healthcare have their own agendas and will be pulling you in their direction.
At the end of the next four years, as you finish medical school you will come out a very different person, but hopefully only from the standpoint of more knowledge, better understanding of your profession and clearer perspective on the health care system.
What I hope doesn’t change is what the look on your faces expresses today- excitement, promise and hope.
Fortunately you are part of a new breed of doctors that carry the mandate to change and the commitment to improve the way healthcare is delivered in this country. You are literally pioneers on the frontier of the new medicine that is starting to take shape now.
Medicine has changed dramatically over the past 50 years. We’ve waxed extreme from a uniquely relationship driven type of practice to a technologically advanced and financially driven system. The time has come for us to bring these extremes together. Only when these two models of medical practice are integrated will we truly deliver great healthcare. And you are the instruments of this crucial change.
This change can only be implemented by you and will be determined by your relationship with your patients.
You may think it’s premature for me to say that because you haven’t seen a patient yet, but this is the perfect time for you to hear the message. I promise.
Just stay with me and I will show you the very few but crucial ingredients you need to internalize, absorb and live by to become the best doctors anyone could ever hope to be…
In the next few minutes I’m going to share some of my experiences with patients that have deeply impacted me and the direction my practice of medicine has taken leading me to become the kind of doctor I am which I hope will serve to inspire you as well. What I’m about to tell you can not be found in the medical school curriculum and will take a while to figure out…. It’s a very individual process and it is all about who you are first as a human being and then a doctor.
You’ll figure out your specialty a lot faster and sooner but who YOU are, the kind of doctor you are, the impact you make on your patients will take a long time to understand, to really figure out.
That process is part of your journey. Medicine is not just a career, a trade or even a profession. It is a life calling, a passion. It will define of you as a human being, not just a doctor.
Let’s use today to just stop for a moment. I want you to take stock of who you are right now, today. Just stop and think… Why have you worked so hard and sacrificed so much to get here? What motivated you to be so passionate and determined? How come you out of tens of thousands who applied YOU are now the class of 2019?
Spend a moment and hold on tight to that most important part of you - the human being sitting here in front of me rearing to go.
So how are you feeling? I can’t hear you….How are you feeling?
I want you to know that these four words are the most important four words of your career.
Let me explain…
I’m gonna start with when I was a little kid in Romania where I was born. Our family doctor made house calls.
I remember to this day 60 years later that the man was a wonderful old man, he had grey hair and big warm hands and kind eyes and I actually looked forward to his visits. Even at five I understood at some subliminal level that he was there to take care of me. He would examine me and then, more often than not, he’d give me a shot. It was usually penicillin because fortunately for me I was born after penicillin was discovered.
Surprisingly… I was never scared or afraid of our old house call making doctor. After he was done with me he would sit at the kitchen table with my mother and have a cup of coffee. I have no idea what they chatted about but it was clear to me they were both comfortable and had a lot in common. He was part of the community. A member of the family, a friend. In fact he went to weddings and funerals, he was kind of omnipresent in our lives…..
Those days are long gone. Medicine has changed a lot.
As it changed, we went from having few or no tools for diagnosing and treating disease to becoming experts and specialists. And technologically so advanced, we have genetic testing, CT scans and MRIs, blood tests to drown the entire earth in, advanced surgical procedures, lasers, robots, radiation and chemotherapy, certainly amazing stuff has been developed.
On one hand this is great and it helps us provide highly advanced care, but on the other hand in the process…. we traded the human touch.
This kind of trade is just too extreme.
The outcome is a huge canyon, a chasm that led to a terribly dangerous disconnect between the doctor and the patient.
Suddenly we are faced with a system where the most important person in the system is also the most overlooked- the patient.
The patient and the doctor are no longer sitting at the proverbial kitchen table talking and very few doctors show up at their patients’ weddings and funerals.
In fact too often the relationship has become adversarial.
That just doesn’t work. In fact from where I stand I honestly and strongly believe this disconnect is one of the primary reasons our health care system is in such shambles.
The wrong priorities define the kind of care we provide. But don’t worry you can change the system you can make it better. Remember, you are the agents of change.
Let me go back in time again..
When I first went into private practice I remember a guy coming into the office to see me. My usual greeting you already know…. It was and always is: How are you feeling? How can I help you?
And the patient, this man, just looks at me. And I am really young at this point in my early 30s and he says to me how should I know? You’re the doctor…
A light bulb goes off in my head and I say to myself how should I know you are the patient.
I don’t live inside your body. I have no way to know what’s going on inside your body so how could I possibly be able to tell you what’s wrong with you. If you tell me how YOU feel I probably will be able to start working with you and together we can try to figure out what’s really going on inside of you.
I don’t think the guy got it.
But I did. Doctors don’t live inside the patient. So unless we communicate really well with each other, we don’t stand a chance of helping the patient. So I understood I need to be able to communicate with the patient. And the patient needs to understand that even though I have an MD after my name, I am not a mind reader.
Shortly after that incident I started questioning things like if we are spending 5- 10 minutes with a patient in the frenzy to make more money working for an insurance company, a drug company, anyone but the patient, how can we honestly expect to help the patient.
How can I just write a prescription for a patient and tell him what to do when I don’t even know him…
How is his family? His job? What does he eat? Does he sleep? Does he work out? What’s stressing him? How many kids is she putting through school?
Honestly, you can get the answers to these questions in three minutes and they certainly will put the million dollar blood and MRI work-up into context.
And if I don’t know the patient why would she or he listen to me? Just because I’m a doctor? Seriously?… those days are also long gone…. Nobody believes the doctor knows best anymore…. What’s wrong with that expectation?
So let’s move on a little bit.
Again, years ago when I was in my 30s I went into private practice. Doctors I had been working with in the hospital took pity on me because I didn’t have any patients.
Someone sent me a woman in her 50s with end stage breast cancer and she had undergone chemo, radiation, surgery and there was nothing left for the conventional medical system to do for her. So my buddies sent her to me. They always told me I was someone the patient could talk to. At the time I had just ended 5 years of running the emergency department at a major academic trauma center and had just gone into internal medicine practice and I really was not very knowledgeable or clear on what to do with people when you can no longer DO things to them anymore.
So the woman came in crying- it was October and she was saying she wasn’t going to see Thanksgiving… I felt very guilty that I was young, healthy, had all my life ahead of me and that she was at the end of hers, it seemed to me so unfair that she was on her last days and I had nothing to offer.
But because I was trained to believe I am a healer, a physician who has to find something, anything, to do I couldn’t just tell her I had nothing to give her so I thought really hard.
I have no idea how this came out then, but now I know it came from my heart. So I said to her: if you think you’re going to die before thanksgiving why don’t you have thanksgiving at your house next weekend and bring your family together.
The woman stopped crying and looked at me. After what seemed like a very long time but was a few seconds, she said- I never thought of doing anything like that. No one mentioned that option….
I hesitated but told the truth. I said I have nothing else to give you so just try doing that.
And she tried it.
She had thanksgiving in October.
And she stayed my patient and she didn’t die.
In fact she lived another 20 years. She lived to dance at her daughter’s wedding. The cancer never came back. I never did anything about the cancer.
But I, made a little connection. I made the connection that you don’t always have to do something medical. You don’t always have to give meds, radiate, operate, do a test, you just don’t.
You need to learn to stop and listen to the patient, to see the patient like your mother, your sister, your grandmother, another human being just like you…. Then you’re probably going to come up with a common sense solution for the moment because all we have is this one moment.
And if you don’t have any idea what to do…. Just empathize. Feel for real. Feel for the patient. They are you.
And you know what? Today, you know how to empathize better than you will four years from now. I promise that is a fact. You are experts at feeling. Hold on, to that expertise.
So let’s go on... I’ve been very fortunate in my career because I’ve seen a lot of patients and have learned so much from them.
Eventually I got out of acute medicine and internal medicine because they are all about waiting for patients to get sick…. In our culture and medical training, disease unfortunately has the highest status. And I decided that maybe disease shouldn’t have the highest status and maybe keeping people healthy was the higher status.. at least for me and my patients.
From my perspective.. life is a continuum of health with minor interruptions when we are sick.
So I began focusing on how to help patients lead the highest quality life possible, less worry about missing a disease, more time healthy and enjoying life.
But before I got there…. While I was on call one night in my late 30s I remember another interesting turning point story.
This woman came in with a little girl around 10 years old. The little girl had blue skin from her neck down to her waist. The rest of her body was just fine. She didn’t have any shortness of breath, she didn’t have any blood pressure problems, was speaking perfectly well. When I asked the girl how she was feeling, she said fine with a smile. The mom was concerned. So I examined the kid from head to toe and couldn’t come up with anything wrong…
How are you feeling? I asked again clueless as to the cause of The blue trunk.
Finally I took a 4x4 sponge soaked it in warm water and soap and just rubbed the girl’s forearm and the blue came right off. So I asked the mom if the girl wore a blue sweater or sweatshirt. The mom said: oh yeah.
So I said: did she get wet while wearing it?
And the mother said: yeah we just got caught in the rain this afternoon right before I noticed her turn blue….
So I said just take your daughter home and give her a shower and don’t worry about it. Just soap her up. It’ll all come off. It’s just the dye that ran off the sweatshirt.
On their way out, the mom highly relieved and the daughter happy I didn’t poke her too much, the little girl looked at my nametag. It said E. Schwartz. The little girl said what does the E stand for and I said Erika. She said: omg my dog’s name is Erika! We both laughed.
And for a second I realized something that for the following 30 years of my life has affected the way I practice medicine every day. I realized the little girl and I had connected at a level where the girl and I were equals. The ten year old and me the doctor were pals. We had something in common. My name was Erika and she had a dog named Erica.
Suddenly the distance between me the doctor and her the 10 year old patient disappeared and was replaced by only the similarity between us. We were both just two humans sharing a personal anecdote. She felt safe.
So these little stories I shared with you should give you a little insight into what really makes the difference in the practice of medicine.
Over the next four years you’re going to study a lot of advanced, esoteric and very important scientific facts. You will become experts: experts in various areas of medicine, you will understand biochemistry, physiology, anatomy, pathology, genetics, you will understand very difficult concepts, how the human body works, how drugs work, you will become experts at diagnosing disease.
You will become experts at treating disease. And while we’re on the topic of disease, let me tell you one more thing.
Don’t treat disease.
The disease doesn’t need your help.
Treat patients, the patient needs your help…
And finally, at the end of your training you will become part of the hierarchy that is our medical profession.
Some of you will become interested in research, some will become clinicians, and some of you will work for drug companies or insurance companies while some of you will be very clear they have become doctors for only one reason.
Just like I did 40 years ago, you too can decide to only work for the patient.
To listen to the patient, to respect the patient, to connect with the patient, to never scare the patient and to serve the patient.
And you know what, I never regretted making that decision and I never got burned out. That decision has served me really well. I love what I do. I wake up every morning excited to go to work. That’s because I love my patients. And they love me. And medicine at the end of the day no matter how scientific or lucrative it is, is an art, it’s the art of listening and the art of caring. And it’s the art of being compassionate.
So I wish you a great career, I wish you a great 4 years at the end of which I hope you come out as human and as caring and as passionate about saving the world as you are today.
Congratulations and don’t forget those four life-defining words: How are you feeling????