Raiders of the Lost Art

The Class of 2011 chose Bilal Ahmed, M.D., associate professor of clinical medicine at the University of Rochester Medical Center and associate chief of medicine at Highland Hospital, as the faculty speaker at commencement. Ahmed, recently named a fellow in the Royal College of Physicians of the United Kingdom, the highest level of membership of the Royal College, spoke about the art of listening to patients and caring for them.

Thank you for inviting me to talk at your commencement ceremony today. It is indeed a great honor. Each one of you has chosen and been given the unique opportunity of pursuing medicine as a way of life. I personally cannot think of a higher calling in life.

I have titled my speech 'Raiders of the lost art". Unlike Harrison Ford, you will have to look for the Ark of the Covenant, not in the temple of doom, but in the patient's room. 

Now this probably tells you that I like poems, well I do, and I will start and finish my talk with poems that I have written for your commencement.

A number of you might already have realized that there is more to being a physician than eliciting symptoms and ordering tests.

Some of the physicians you might have come across have that nebulous and unquantifiable quality of connecting with their patients and pulling the right diagnoses out of thin air.

How do they do that?

Well allow me to unlock a secret for you today. Medicine is as much Art as it is Science.

The secret to that art lies in our ability to decipher the stories related to us by patients. You have entered a fascinating field where you will have the opportunity to listen to thousands of stories of human fallibility, greatness, hopelessness and determinism.

“The secret to that art lies in our ability to decipher the stories related to us by patients. You have entered a fascinating field where you will have the opportunity to listen to thousands of stories of human fallibility, greatness, hopelessness and determinism."
~Bilal Ahmed, M.D.

Learning from the narrative enables us to deal with patients as individuals and respect their uniqueness. I look at the patient's narrative as a compass that guides us through a sea of tests and interventions.

We learn from literature, the tests we prepare for, the wisdom of our teachers, but mostly we learn from what our patients teach us.

Yet when I conduct my bedside rounds with students and residents, I get the distinct impression that our patients have somehow managed to crawl behind the computer screen. Our examination skills have atrophied to extinction and the only way we can practice now is by using the crutch of technology. Therein lies the rub.

The complaints I hear from my patients are not about the dearth of technology but rather the lack of human touch.

The currency on the ward is ensuring all the boxes are checked and the dialogue has devolved to the flickering computer screen.

To be sure, technology has the potential to start revolutions as the recent world events have shown us , but what you see with a PET or an MRI scan is powerful but can also be a siren song.

The screen, in my opinion, has become the modern equivalent of the fire which draws the moths (you know the end of that story) and has the potential of burning you and even destroying you.

So what is one supposed to do?

As it turns out, our profession has a ritual which can be of immense help. Rituals might seem primitive, but if nothing else, the ritual of the bedside exam will bring you closer to the patient. Our sick patients seek the reassuring touch. Remember, the psychic wound of illness is not visible on any scan and does not generate abnormal test results.

In return for your years of toil, the society will give you a power that no one else has. You will hear the deepest darkest secrets and fears that people hesitate to tell anyone else.

“When we see suffering, do we look away, or go towards it? You may succumb to cynicism or frustration; after all you are graduating from Medical School, not the school of saints. But you are all expected to meet the basic human standard of looking towards suffering without congratulating ourselves about our benevolence.”
~Bilal Ahmed, M.D.

You will prescribe powerful drugs and perform transformative surgeries which could just as easily take life as they can preserve life. You will have the privilege of meeting people who will have a mass in the lung base, a new life forming in the womb, intractable pain or multiple organ failure.

But remember that all these people will have names; they will have lives that they live outside the hospital, they will have loved ones praying for them and hoping for them to recover and suddenly it will all make sense.

I have learned the lessons of my life from a parade of Mr. Culbertsons and Mrs. McGoverns and they have taught me lessons from their stories. So let me share a few short stories and tell you what they taught me:

I trained in the United Kingdom as a Pulmonary Consultant and had the privilege of knowing Mr. Cartwright. He was the man in bed 14 with a lung mass, but was he? Mr. Cartwright turned out to be a 73 year old retired British Army Major who was awarded the George Cross in the Battle of Tobruk in 1941. I later found out that quote "This is awarded for acts of greatest heroism and most conspicuous courage in circumstances of extreme danger." unquote. His lung biopsy confirmed a small cell lung cancer and I gave him the news in a professional yet, in retrospect, impersonal manner. We discussed the pros and cons of different treatment modalities and I begged leave in a very courteous manner. The next day I was surprised to see Mrs. Cartwright outside my office with a huge bouquet of roses and proceeded to tell me that the Major had shot himself in the head after our talk and had instructed to his wife to give me the flowers. He had fought a valiant battle against the forces of Rommel, and this act, in his mind was an honorable exit from a potentially agonizing last few months.

I felt the shot ringing in my ears and still do. This taught me HUMILITY and FALLABILITY.

I came to Rochester 16 years ago and met an exceedingly pleasant 91 year old Italian dowager, who was dying of metastatic colon cancer. She had moved to the United States from Sicily when she was three years old and had never felt the need to learn English. Her family was her world and after all, they all spoke Italian.  After interminable discussions about goals of care with her and a family of at least 40 relatives, she elected to enroll in Hospice care and die at home. For some reason, she reminded me of my grandmother and I decided to visit her as I was passing by her home in Webster. It turned out to be a one bedroom home with 20 cars parked outside and at least a 100 people inside. My arrival caused an upheaval.  'How did you Know?' they exclaimed, and I had no idea what they were referring to. Evidently, this lady had told everyone that I reminded her of the brother she had left behind in Sicily and her last wish was to see me before she died. She wanted me to kiss her and lie next to her in a bed bearing the evidence of her recent urinary incontinence. It was her last wish and I had no choice but to lie down next to her and kiss her.

Macabre, did you say? What matters to me is that she passed away an hour later content and peaceful.

This taught me the power of Empathy, Respect and Humaneness. Each one of you will encounter a different version of these stories. Thousands of these stories are unfolding here and around the globe as we speak. You will encounter different versions of the same question: When we see suffering, do we look away, or go towards it? You may succumb to cynicism or frustration; after all you are graduating from Medical School, not the school of saints. But you are all expected to meet the basic human standard of looking towards suffering without congratulating ourselves about our benevolence. You all sit here, because at some stage of your lives, people took care of you when you were suffering. These people picked you up when you fell, sometimes many times. So honor the act of humanities’ faith in you and pay your dues with your expertise, kindness and intellectual curiosity.

I will finish with a secret which will serve you well.

Those who suffer need you to be something more than a Doctor; they need you to be a healer. To be effective healers, every time you see a patient, for a fleeting moment, you will need to go through a transformative experience of taking your white coat off. Notice how Superman attains mortal qualities when he takes off his blue attire. Sometimes, taking the coat off can be more difficult than putting it on.

Only then will you embrace and treasure the memory of your frail humanity, of the dignity in every soul. Remember not to tower above the people you care for, their souls are just like yours. Instead, join them and become healers in this world of fear, constant change and fragmentation.

Let me finish with a poem I had written to emphasize the power of the patient's narrative