An Alumnus Addresses the School of Medicine's Class of 2010

The University of Rochester School of Medicine and Dentistry Class of 2010 selected Timothy E. Quill, M.D., director of the Center for Ethics, Humanities and Palliative Care at the University of Rochester Medical Center, as the faculty commencement speaker. This is a text of his talk:

I want to thank you for giving me the honor of speaking with you today on this important day. I have had the privilege of working with many of you in different phases of your training, and have come to know some of you quite well over the last four years.
Many of you know that I went to medical school here in the 1970s, and I thought I would begin by reflecting on what I learned from some of my mentors in training:
- George Engel was very centrally involved in teaching in those days, and he introduced us to the biopsychosocial model, to systems theory, and to the centrality of the relationships we have in medicine with patients, families, students, and with each other. This model and approach is still applicable today, whether we are talking about clinical care, educational innovation, or translational research.
- Art Schmale was also one of my mentors. He trained in both medicine and psychiatry, and his practice was on the oncology service. While people were getting their treatments, Art would sit and listen to them, hear their life stories, and learn about their hopes and fears. In doing so he would lessen the isolation that often accompanies treatment when the outcome is uncertain.
- Mack Lipkin taught me how to apply this person-centered medical practice to primary care. In those days, the primary care providers played a central role whether one was at home, in the hospital or in intensive care. Taking care of patients across settings, maintaining continuity, and committing to caring for those with extremely serious illness as well as those who are going to get better was central.
- Finally Bob Klein would always ask hospitalized patients who their doctor was. The doctor he was looking for would stay involved in good times and in bad. In today's fragmented medical world, those who have a doctor committed to care for them no matter where their illness takes them have a tremendous advantage. In whatever field you are going into, I want to encourage you to be that kind of doctor.
My work over 35 years in medicine has been primarily in two areas:
- As a primary care physician, I cared for a large group of patients for close to 30 years. Over that time frame I got to know most of them reasonably well, in the context of their families and their ailments. There was a wide range of healthy and sick patients in primary care practice, and I cared for them in the outpatient arena and the hospital. When serious decisions had to be made, I was able to guide them based on my medical knowledge, but also because of my knowledge of their values and priorities and the trust that had been built up between us over time.
- The rest of my medical work has been in palliative care. Palliative care directs itself toward the care of seriously ill patients. Many erroneously equate palliative care with end of life care, but while some of our palliative care patients die, many get better or live for long periods of time despite serious illness. The four pillars of palliative care are:
  - First, at the same time we ensure patients are receiving the best possible disease management, we pay careful attention to relieving pain and suffering. The simultaneous treatment of suffering and of the underlying disease ought to be standard of care, but it is amazing how frequently we hold off fully addressing suffering until medical treatment is stopped and the patient is referred to hospice. Addressing physical and psychosocial suffering should simply be a core part of all excellent medical care.
  - Second, we assist patients and families with difficult decision-making. When patients are in the hospital, we talk with all of the different teams involved to try to get a sense of what is going on medically, to help patient and family understand options and odds, and to help them use the system in a way that meets their goals in light of their medical condition. In this domain, we may be serving a function that in the past would have been carried out by the primary doctor who may now be more absent.
  - Thirdly, we try to provide continuity, support and relationship to the patient and family. If there is a main treating doctor, we would not serve in this role. But if someone is not clearly identified, then we would potentially step up. This is particularly important if treatment is going to be stopped, and it is not clear who will provide continuity during the last phase of a patient's illness.
  - Fourthly, we try to be mindful about the perils of both over- and under-involvement. Integrated into this process is education about the self awareness needed to understand and explore the personal impact on us as clinicians of working with very sick patients. Palliative care can be one of the most meaningful and enriching parts of medicine, but it can also be draining and exhausting if one goes at it alone. We have therefore learned it is important to do this work as a member of a multidisciplinary team that talks together, divvies up the work, and supports one another. Many of you spent time with our palliative care team in your training, and learned first-hand about the meaning and challenge of this work.
As you graduate, you will be facing enormous challenges and opportunities in health care.
New and expanding medical technologies are offering us unprecedented opportunities to help patients.
The recently passed healthcare reform is giving us a desperately needed ability to expand coverage to a wider range of patients.
- Thirty million more patients will be covered by insurance, potentially gaining access to primary and preventive care and not just waiting to access the system until they are so sick that their needs can no longer be ignored.
- As part of this reform package, there is a genuine attempt to improve primary care, making it more economically attractive to physicians and also to improve continuity of care over time.
Unfortunately the healthcare reform debate still skirted the issue of addressing the limits of medicine.
An attempt to encourage doctors and patients to have conversation about what kinds of treatment one would and would not want if one loses decision-making capacity in the future was framed as a "death panel," and was promptly dropped from the package. Similarly, any discussion about limiting medicine under any circumstances was framed as "rationing."
If we continue to offer all potential technologies no matter how improbable in terms of effectiveness and how expensive we will definitely break the bank.
This conversation will need to come, and we can only hope that our culture, our politicians and you as the next generation of physicians will be ready to lead it.
So we want you to be doctors who will help patients take full advantage of the remarkable advances that are available in medicine, but at the same time give patients and families information and practical guidance that keeps it real and honest.
Let me illustrate this process with three cases:
- Brian was a patient with AIDS who I cared for as his primary care physician in the 1980s and early 90s. In those days, there were minimal effective therapies, and lots of people were dying. Brian had tried all of the experimental therapies, and his brain was eventually giving way to the relentless progression of the virus. We had the painful discussion that as he was beginning to lose his memory, and that it was time to move toward hospice and focus exclusively on his comfort and dignity. Over the next two months on hospice, Brian was kept comfortable, but he was getting weaker and less responsive. Some new treatments called protease inhibitors became available that were easy to take and seemed to be having an effect that was well beyond what past drugs had done. I discussed this with Brian's family as he did not have decision-making capacity at this point, and we all agreed he would want to give it a try. Over the next several weeks, Brian "woke up," got stronger and lived quite well for another 8 years before he eventually died. Real medical breakthroughs like this do not come along very often, but we must be open to them even when we have embarked on a hospice oriented approach. For Brian and his family (and many others), this particular breakthrough made a world of difference.
- The second case is Mrs. C, a middle aged woman with chronic liver disease whose second liver transplant was failing. She was in extreme pain, and wanted to stop treatment. I was asked to see her as a palliative care consultant to help care for her for the last phase of her life. I initially convinced her that before we make any major decision about stopping treatment, we should aggressively treat her pain and her depression. Once they were adequately treated, if she still wanted to stop treatment we would set up hospice and pursue a purely comfort oriented approach. However, with good pain and depression treatment, Mrs. C re-found the will continue to fight her disease. With careful medical management of her liver disease alongside intensive palliation of her symptoms, she was able to live another 5 years, mainly out of the hospital, with a reasonably good quality of life. During that time she had many wonderful experiences with her family alongside some very serious medical challenges. On balance, however, by combining the best possible palliative treatment with the best possible disease management, she had an excellent quality of life and her life span was substantially lengthened.
- The third patient story will focus on my mother. She turned 91 years old this past July. Although her quality of life had been generally good, over the past year she was beginning to fail and fall regularly from her advancing Parkinson's disease. My mom was fiercely independent, but she was reaching the point where she could no longer live without 24 hour supervision. She began hoping in earnest that she would go to bed one night and not wake up. We were making plans to move her to Rochester so we could better care for her when I got a call from her doctor that she had developed painless jaundice. Given her declining functional status and her clearly stated wishes for no medical interventions, her doctor recommended no workup at all, and we initiated a purely comfort oriented approach. We moved up the plan to get her to Rochester, setting up a wonderful and sad weekend of goodbyes for her family and friends north of Boston, and a road trip bringing her to Rochester. We had to make a pit stop along the way, and I put my Red Sox hat on my mother and took her into the handicapped section of the men's bathroom. As we entered, I advised her to keep her blinders up, and she quipped back that she doubted there would be much to see in there. I arranged for a wonderful palliative care doctor to take care of her here in Rochester, and we admitted her to one of our community's two bed hospice houses. She got excellent care, and died 10 days later with her dignity and personhood remaining fully intact.
So what does all this mean to the graduating class of 2010, many of whom have spent time with us on the palliative care service and on the medical floors caring for our seriously ill patients and their families?
In every field of medicine, there are truly outstanding clinicians, educators and researchers. You know who they are. Perhaps they inspired you to choose the field you have chosen. The acid test is that they provide care that you would want for a family member or for yourself.
Your challenge is to become one of those physicians who:
- Helps patients take full advantage of new medical developments, but is also aware and not afraid to talk about the limits of medicine.
- Pays careful attention to the relief of suffering as well as to the disease-related aspects of illness.
- Develops deep and meaningful relationships with patients, families, students and colleagues, and who really cares about the outcomes.
- Learns how to care for himself or herself, along with your families, because if you strive for some kind of balance between your work life and your personal life, you will be able to stay with the practice of medicine for the long run.
As you progress with training, your lives will fall in and out of balance, so keep taking to one another, to family and friends, and find mentors and colleagues who will also tell you the truth and help you stay on track. I have had the privilege of having some wonderful role models and mentors as I was emerging as a physician, and I have worked with some of you in this way. It is a highly sustaining and satisfying process.
I thank you for giving me this opportunity to pontificate a bit, and to share this joyous occasion with you.