“Commencement, 2009”

Dr. David Guzick, M.D., Ph.D.

May 22, 2009

In this newsletter, we continue the tradition of publishing speeches given at Commencement of the School of Medicine and Dentistry. The speakers devote considerable time and effort on their remarks, which carry great meaning to all of us in the SMD community. It would be a pity to allow their insights to disappear into the thin air (rarified though it may be) of Eastman Theater.

The elected student speaker was athy Lee, who had also been voted Class President each of her four years. Born in Atlanta, Cathy (now Dr. Lee!) received a B.A. in Foreign Languages from the University of Georgia, and will be doing her residency in Pediatrics at the University of Wisconsin.

Frank Richeson, MD, Professor of Medicine in the Division of Cardiology, was elected by the students as their faculty speaker. Dr. Richeson was honored for his 15 years as an Advisory Dean to students, along with his work in teaching cardiovascular medicine. Extremely approachable, and with a humble yet engaging spirit, he has made a significant impact on launching the medical careers of hundreds of alumni.

The student-elected Commencement speaker was Carola Eisenberg, MD, who received the Eastman Medal from President Joel Seligman. Dr. Eisenberg is one of five founding members of Physicians for Human Rights, which shared the 1997 Nobel Peace Prize. In 1972, she was named the first female dean of student affairs at M.I.T., and six years later was appointed the first female dean of student affairs at Harvard Medical School.

Also receiving Eastman medals were Robert Rose, PhD, Richard Reichman, MD and William Bonnez, PhD, Rochester faculty members responsible for the virus-like particle and associated research findings that have been the basis for the vaccines that prevent infection with Human papillomavirus (HPV).

Cathy Lee, MD,
Student Speaker

Welcome family, friends, faculty and colleagues. As members of the Class of 2009, we have run together, eaten together, cooked together and celebrated together. We have cried, laughed, joked and recovered together. We have shared crises, festivities, parties, PBL rooms, study guides, cadavers and Medline searches. We have all lived together, as one multi-headed, multi-talented, and multi-tasking creature for four years. While some of the heads have changed we’ve all managed to reach the precipice of something great, with an opportunity to make an impact on the world around us. And it all started right here, in Rochester NY.

Some things in life you experience and you recognize, right away, their value and their importance. You never doubt that these things will play a significant role in your life, providing something for you, for your mind, for your body, for your soul. It’s classic love at first sight. For me, things that fall into this category include peanut butter cookies, my dog, the University of Georgia, my mother and father, tofu, Madison Wisconsin, Yogi Kombucha green tea, Victor Hugo, The Beatles, John Cusack, When Harry met Sally and pediatrics.

Rochester NY is not one of those things. I should have seen the warning signs when I came on my interview day, it was sunny and 45 degrees with 30mph winds and everyone kept raving about how good the weather was. When I arrived in Rochester, I knew no one. I had moved from Boulder Colorado, where I had had a community, a team, a boyfriend and mountains to support me only to arrive in this odd little city where everything was just a little off kilter. It’s not quite the Midwest, but not quite New England either. Where people seem to think it’s a sport to pronounce things strangely (come on, Chili??). Where the biggest attraction and the place to be seen is a super market. Where the signature food item would be thrown away in any other city, where the airport had one terminal and four gates. Where lake effect isn’t just a weather phenomenon, it’s a way of life. Where a bizarre geographical vortex means that every major city on the Eastern seaboard is a 6 hour drive away. Where fast ferries go to die. Where the 10 day forecast seems like it was determined by a random weather generator.

And I hated it. I hated the unfamiliarity of it and the foreignness of it. I couldn’t get used to the roads. I bought my groceries at Tops. I got lost running. I just couldn’t get the hang of living here.

And then a funny thing happened. Medical school orientation started, and I met 100 new people in about three days and I was absolutely blown away by how accomplished, how intelligent, how disproportionately good looking, how simply impressive everyone in the class of 2009 was. And then I took a step back to realize that all of these people would eventually, one day, today, become doctors. That took my breath away. But what shocked me even more was that I, somehow, was one of these people. Meeting my classmates was just what I needed to push me over the culture shock of Rochester, NY.

After meeting people and exploring the city with them, I began to see Rochester through a different lens. I began to see the parks and all the greenspace within walking distance of my house. I started to see how much pride people take in their city and their hometown. I went to mega-Wegmans, gazed around the produce section and I was a convert. As fall rolled around, the trees unveiled their fireworks display of color on every corner. I discovered the Little theatre and Boulder coffee and the seemingly endless number of minor league sports teams. But most of all, I stopped having unreasonable expectations of the city and just allowed it to be and began to appreciate Rochester for what it is. And after a while, I acquired a taste for Rochester. I now love this city and can say with unequivocal certainty that it’s an incredible place to live, an amazing place to raise children, an unparalleled community in which to learn and an extraordinary place to become what you will be and to achieve your full potential.

As I embraced the city, I truly felt that it embraced me back and my classmates and I have been able to explore all the hidden treasures upstate New York has to offer. I would not trade my time in Rochester for anything else and while my love for this place was certainly not immediate, I think it is all the richer for the strength and the fortitude that lie beneath it. So much of that love is due to the incomparable community I have found in Rochester, both within and outside the medical center.

As we go our separate ways and establish ourselves out in the world, I know that the knowledge we’ve gained and the relationships we’ve built during our time here in the Flower City will serve us and our patients well.

Over the past four years, we have become mothers, fathers, aunts, uncles, mentors, mentees, teachers, learners, brothers and sisters. And now, all together, we become physicians.

Congratulations to the Class of 2009 and Meliora.

J. Franklin Richeson, M.D.
Faculty Speaker
“Secrets of Great Doctoring: Three Drugs and an Elixir”

I am delighted and greatly honored by your invitation to speak on this important day. For me, today’s celebration represents a bittersweet occasion. Today’s hooding will be my final function as an Associate Dean; but today is sweet because I’m basking in the reflected success of all of you. I know many of you have had great obstacles to overcome to get here, and your graduation today is particularly sweet, both for you and for me. I congratulate all of today’s graduates and your families, and I welcome you to the noblest and most privileged family that I can imagine.

I am a card-carrying geezer, and I’ve sat through many of these Commencement exercises. I know that none of my words today will be remembered, and that the only good Commencement speech is a short one. If I were really smart, I would merely congratulate you and sit down.

Unfortunately for you, I’m not that smart.

At a time when the money-changers have hijacked and threaten to destroy the Temple of Medicine, you and I need a refresher course in fundamentals: a short pharmacology lecture on those medicines that will not only restore patients’ health, but our profession as well. I’d like to remind you of three under-appreciated drugs, and one great elixir. These are rarely spoken of in medical school and under-utilized by today’s doctors. They are not drugs in the chemical sense, but they are, nonetheless, the secrets of great doctoring.

With a lead-in like that, you’re probably expecting some profundities, something akin to teaching you the secret handshake of the profession. But these are quite pedestrian drugs. I speak of them because of their importance and our tendency to forget to prescribe them. Anticipating the question that follows most of my lectures – “Will this stuff be on the exam?” – I would answer, “Yes, it will – and the exam will last for decades.”

The first drug on my list is Time. We use Time many ways – diagnostically and therapeutically – in our practices, but I’m specifically speaking of Face-Time with the patient. It has an extremely steep dose-response curve. When one asks patients what they think of their medical care, they will usually predicate their answer upon the dosage of sit-down, eye-contact, physical-contact, listen-to-the-patient Face-Time their doctor has employed. So-called healthcare systems have an inverted view of Time, valuing instead the brevity of encounters between doctors and patients and the length of Paperwork-Time. This prioritization squanders one of our most potent drugs. Abraham Verghese has lamented that in today’s medicine, the patient has become a computer icon, and the computer icon has become the patient. Residents conduct rounds, not at the bedside, but at the computer terminal. Break away from the computer screen and spend your Time at the bedside. The stories you will hear will edify you, your diagnoses will become more enlightened, and the Time investment will be of great therapeutic value to the patient.

The second great medicine is Hope. It would seem obvious that Hope should be a great drug – it is a powerful force throughout our society. It forms the basis of many religions, it fuels the lottery, it underpins national economies and political movements – but it is also a powerful healer. Doctors, however, sometimes hesitate to use it, as they confuse offering Hope with providing a misleadingly rosy prognosis. Since we are obliged to be truthful to our patients, and since Hope is an irrationality – usually a defiance of the odds – we sometimes hedge in providing it. Even patients with the worst prognoses, however, are hopeful for something, and it’s useful to specifically ask such patients what they hope for – and strive to help them achieve it. Hope is available over-the-counter, but it is a much stronger drug when prescribed by doctors. Unlike Time, Hope has a flat dose-response curve, and even a small dosing will often suffice.

I can see that those of you who are not nodding off now are placing wagers on the identity of my final great drug. Some of you, knowing my affinity for the nineteenth century, are betting on digitalis leaf. Given the tenor of the talk so far, others are contending that it’s likely to be Laughter. I won’t dispute the therapeutic value of Laughter, but its appropriateness and dosing are very difficult to master, so I’ve omitted it from my list. Instead, I’ve saved the greatest drug for the last. It is Care. Francis Peabody, in his famous 1925 monograph on The Care of the Patient, said all that needs to be said about Care; his concluding statement was: “The secret in the care of the patient is Caring [about] the patient.” Most patients are very astute in recognizing the dosing of this drug. If you don’t Care about them, they know it in a flash, and your treatment will be ineffectual. An appropriate dose of Care sharpens the physician’s intellect and lubricates the communication between doctor and patient. I had intended to say at this point that the dose-response curve is, like the Starling curve, parabolic (having a descending limb) – that doctors’ objectivity is lost if emotional investment becomes too intense. On reflection, however, I believe that, like the Starling curve, the descending limb is only theoretic, and that one cannot overdose the patient with Care.

Finally, allow me to mention an indispensable elixir, or vehicle, in which we suspend these, and all of the other drugs that we use. The name of this elixir is Trust. We’ve thought a lot about Trust in recent months, having been disappointed by the demonstrated un-Trustworthiness of many of our long-Trusted institutions. A virus called greed had contaminated those Trusting relationships, and society now views those institutions now with scorn, rather than Trust. In Medicine, we are susceptible to suffer a similar fate. Trusting one’s doctor is the necessary glue that holds the doctor and patient together. On the second day of Medical School Orientation, nearly four years ago, you were told about an encounter between a middle-age man meeting his young female physician for the first time. You heard him discuss his sexual impotence, watched him disrobe and submit himself to intimate questionings and probings by this person who had been a stranger to him an hour before. In no other setting in our society is such an encounter sanctioned – and it is the presumption of the doctor’s Trustworthiness that allows it to occur. Just as we’ve learned that our economy grinds to a halt when credit dries up, our profession will grind to a halt if Trust in the doctor is lost.

What is society Trusting us to be or do? Of course, it’s Trusting us to respond to calls for help and to have and to dispense expertise in our field of practice. But I believe it is also Trusting us to put the patients’ needs ahead of our own. In recent decades, society has questioned our mantle of Trustworthiness. TV commercials and T-shirts reading “Trust me, I’m a doctor,” are thinly-veiled indications that Trustworthiness of doctors has not only eroded, but it has even become the subject of jokes. Some doctors have opted to pursue their own personal objectives over service to their patients. Some doctors’ incomes have become obscenely high. Some doctors’ greed and prodigality have contributed to the exploding health care expenses that are eating at the fabric of an already struggling society. It is no wonder that Trust – and hence our future as a profession – is in jeopardy. In other segments of our society, greed has torn huge holes in the social fabric, and Trusted institutions have fallen. We must not give society cause to tar us with that same brush – there is no room for greed in medicine.

Earlier, I welcomed you to the noblest and most privileged family I can imagine. Our nobility takes origin from the Oath you will soon recite and from our use of drugs such as I’ve mentioned. Our privilege is derived from the Trust we’ve been offered. You and I must not squander them. As a proud UR graduate, I know these drugs flow freely through our institutional culture, and I am confident that your class and your generation will dispense these fundamental drugs and justify society’s Trust. The members of your class are already on a trajectory toward greatness, and I am proud to have been associated with you. Again, I want to congratulate each of you for all of your accomplishments, to thank you for the fond memories I will have of you, and to wish you well in your future endeavors.

Carola Eisenberg, MD
Commencement Speaker
“Caring ”

President Seligman, Deans, Faculty members, and, most importantly, students and their families: Thank you for asking me to speak. It’s enormously flattering – and also anxiety-provoking – to be asked to address this group. You have had to listen to so many lectures that each of you now ranks as a connoisseur, but I doubt that you have heard many from a 91-year-old woman – physician – immigrant.

First, let me speak to the students. Today, your status in the country of medicine changes from that of a paying tourist to that of a fully legal citizen. Full citizenship carries both enormous privilege and enormous responsibility. This talk of citizenship calls to mind a talk I gave several years ago. Judge Douglas Woodcock of the Federal Court of Appeals in Boston asked me to speak at the Kennedy Library naturalization ceremony for new American citizens. I was happy to do so because it stirred fond memories of the wonderful day when I became a citizen 50 years earlier. The move to North America enriched my life in countless ways. I came to Johns Hopkins to study child psychiatry for a year and stayed for a lifetime.

I still don’t know how I had the courage to do it. I was alone; I knew nobody; I felt anxious; my English was rudimentary. I flew from Buenos Aires to Miami and took the train to Baltimore. Nervously, I listened for the conductor to call out “Bal – ti – mor - e”, but what I heard was “Balmer”, a town not on my travel schedule. It wasn’t until I got to Wilmington that I learned I had to change trains and ride back to “Balmer”.

A far more important discovery awaited me. When I went to buy stamps or get official documents, I didn’t have to offer a “cuña”, a bribe, to get what I needed. That was standard operating procedure in Argentina. Automatically, you folded pesos in your document. In the U.S., civil servants were expected to work for the public, not the other way around. My new friends criticized the government without looking over their shoulder to see who was listening. It was the first time in my adult life I could vote. ** What an exciting moment it was for me! How free my new country was! I could say what I thought. People listened what I had to say, even if they didn’t agree. Since becoming a citizen, I have voted in every election – national, state, and municipal – every year since I got that right.

Now I turn to my second audience, your family, not just as a former Dean and Faculty member, but as a parent who has herself seen two sons through medical school and as a woman who has been married to two physicians. ** Be proud of your family member and of what they have accomplished; but remember, they wouldn’t be here without the support and encouragement you provided. It’s not just a figure of speech to say you deserve the diploma as much as they do; I’ll just tell you not to get carried away. Don’t put out a shingle and open your own medical office; the District Attorney won’t be very understanding. Your children did the work; they earned their diplomas; but they couldn’t have done it without you.

What makes the transition from tourist to citizen so rewarding is that it celebrates admission to a profession that provides the opportunity for self-fulfillment by helping others. Yes, I know that not all doctors are wonderful. They come in all shapes and sizes. What I celebrate is an ideal and an opportunity for its realization. Medicine offers a wonderful opportunity to serve those in society who need us most; it offers a bully pulpit to champion human rights and the needs of the oppressed. I hope that you avail yourselves of the opportunity.

To my Rochester faculty colleagues, I say congratulations on having produced such splendid graduates. How can I speak about the quality of Rochester graduates? Am I just making it up? Not at all! When I was Dean of Student Affairs at Harvard Medical School, I met yearly with the Deans of 13 medical schools who constituted a self-appointed consortium. I learned of the exceptional job Rochester did in producing skilled bio-psycho-social clinicians. I also accumulated information from my son, Advisory Dean Larry Guttmacher, who keeps me updated. I know whereof I speak when I congratulate you on the young doctors you produce.

Now I turn to issues that face medical students in general. You have been exposed to stories of demoralized physicians, of climbing malpractice claims, declining income, and ever increasing paperwork.

It stands the world on its head to suggest that the liabilities of a career in medicine outweigh the assets. Of course, there are major problems in the delivery of medical care, and we ought to be in the vanguard of those seeking solutions to them. But to lose sight of just how lucky we are to have a profession in which we do well for ourselves by doing well for others reflects a puzzling loss of perspective. The satisfaction of being able to relieve pain and restore function, the intellectual challenge of solving complex clinical problems, and the variety of human issues we confront in daily clinical practice will remain the essence of doctoring, whatever the organizational and economic structure of medicine.

Although physicians’ incomes have declined in real dollars in the 1980s, they remain in the upper decile. Although the practice of medicine is increasingly vexed by bureaucratic constraints, doctors still retain a degree of autonomy in their clinical activities that is rarely found in other occupations. Although research support may not have kept up with inflation, the opportunities for young investigators in this country exceed those to be found anywhere else in the world and are several orders of magnitude greater than they were 40 years ago.

Let us put first things first. Medicine is still a great profession, one held in high esteem by the majority of the public. We must remember the personal gratifications medicine brings and the obligation to public service it entails.

For medicine to be effective, knowledge must be enriched by wisdom and compassion. What we are and how we act is no less important than what we know. All of this was said beautifully by Francis Weld Peabody, Professor of Medicine at Harvard and Chief of the Fourth Medical Service at Boston City Hospital some seventy years ago. He wrote:

“The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the physician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

To the graduates. As interns, you will become the teachers of medical students; in a few years, many of you will hold faculty appointments.
If there is to be change, you are the agents of that change. You will construct the medical education of the future, hopefully in a way which will allow your students to profit from your recognition of where we have fallen short.

Finally, Libanius, a physician of the fourth century AD, addressed the following words to young physicians starting out on a medical career:

You desire to be one of the healers of sickness;
You had the benefit of good teachers.
Now, practice your art faithfully.
Be reliable; Cultivate love of [hu]man[kind];
If you are called to your patient, hasten to go;
When you enter the sickroom, apply all your .. ability to the case in hand;
Share in the pain of those who suffer;
Rejoice with those who have found relief;
Consider yourself a partner in the disease;
Muster all you know for the fight to be fought;
Consider yourself to be of your contemporaries, the brother [or the sister],
Of those who are your elders, the son [or the daughter],
Of those who are younger, the father [or the mother],
And if any one of them neglects his own affairs,
Remember that this is not permissible for you,
.. it is your duty to be to the sick what the constellation of the Dioscuri are to the sailor in distress, an unchanging beacon of safety.

I will close with the final paragraph of my own remarks at this year’s Commencement: “Class of 2009, you are about to embark on the exciting next chapter of your training that will shape the specific type of medicine you will practice. But regardless of your specialty, your medical roots are forever here in Rochester. We are so proud of you. Go out and change the world, and Meliora to each one of you.”

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry
University of Rochester

Dean's Newsletter

Posted May 28, 2009:
A Fond Farewell to the University of Rochester

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