Commencement, 2008 - School of Medicine & Dentistry

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

May 30, 2008

Commencement for the medical student Class of 2008 occurred in the Eastman Theatre on May 16th. As we have done since 2004, the remarks of our speakers are published below.

This year, it was a treat to hear from Joseph B. Martin, MD, PhD ‘71 as our Commencement speaker. A version of Dr. Martin’s address, entitled “Where have all the doctors gone,” was published yesterday in the Boston Globe. Dr. Martin served for 10 years as Dean of the Harvard Medical School, prior to which he was Dean of the School of Medicine at the University of California, San Francisco and then Chancellor of UCSF. A neurologist and neuroscientist, Dr. Martin has greatly improved our understanding of brain disorders through study of hypothalamic regulation of pituitary hormone secretion and the application of neurochemistry and molecular genetics. The Charles Force Hutchison and Marjorie Smith Hutchison Medal, the University’s highest recognition of personal achievement, was presented to Dr. Martin by President Seligman.

It is a great honor to be elected by the students as the faculty and student speakers. This year, our Faculty Speaker was David Kaufman, MD, Associate Professor of Surgery, and our student speaker--Class of 2008--was Maryann Overland, MD.

Commencement Address

“Where have all the doctors gone”
Joseph B. Martin, MD, PhD

Congratulations and thanks for the opportunity to speak to you today. I graduated from the Graduate School 37 years ago -- Time does fly, as they say.

I have entitled my comments: WHERE HAVE ALL THE DOCTORS GONE?

I’d like to suggest that there are three ways to examine this question. First, where do today’s graduating doctors go? Second, are we facing a shortage of doctors and if so in what areas of patient care? And third, Where should doctors go or be seen in an election year with Healthcare Reform atop the national political agenda, together with the economy and the unfortunate war.

First, where DO all the doctors go?

About two months ago I had a visit from a Harvard College graduating senior named John. John was completing premedical studies with an excellent academic record and a double major in economics and philosophy. His visit was to ask my advice about a career in Medicine as compared to entering the seminary for training for the ministry. He clearly was interested in doing good in his career. Perhaps he had heard that at one point in my own career I had taken a one year leave of absence from Medical School to undertake religious studies. My thoughts focused immediately on the extraordinary opportunities that a career in medicine offers. What other career offers so many opportunities?

You can choose to spend time in medicine or pediatrics or neurology or in surgery or urology or neurosurgery.
You can choose to work with pipettes, oscilloscopes, a PCR machine or move into whole genome mapping for your favorite disease.
You can choose to live and work in Rochester, or Ortega or Genesee or Costa Rico or Rwanda
You might choose to work on MRSA- methicillin resistant Staph Aureus or a vaccine for malaria
You might choose to work on a native-American reservation or open an office on Fifth Avenue in new York
Or you might get an MBA, and start a new internet or biotech company
You can choose to work an 8 hr day as a dermatologist or anesthesiologist or settle for a 16 hour day in primary care.
You can choose to take care of live people or look after dead ones- the field of pathology has grown in interest among medical students.
No other field offers so much--so where do all the doctors go?

The current view is that many of you are hitting the ROAD- Radiology, Ophthalmology, Anesthesiology, and Dermatology. I checked out your career plans from the residency match. You show similar choices to our students at Harvard. Out of your class of 91, 16% chose internal medicine, 15% pediatrics, 11% Obstetrics and Gynecology and 11% general surgery; only 7% primary care and family medicine.

Of course most of you will specialize, and only a few will go into rural areas. Students from a minority background are more likely to return to their communities to serve the underprivileged.

Which leads me to my second point: WHERE HAVE ALL THE DOCTORS GONE? Under urgent consideration today is the question of whether we have enough doctors to care for our patients, particularly if we move toward a new scheme for universal health coverage.

Interestingly, 15 to 20 years ago there were concerns about too many doctors, particularly in some specialties. Now, the Association of American Medical Colleges is requesting medical schools to increase enrollments by 30% over the next 7-10 years. There are fields like general surgery where serious shortages are expected, particularly in smaller urban centers and rural districts.

And with an aging population there will be an increasing demand for geriatric medicine. I was interested in an article last week in the Wall Street Journal about the expected shortage of neuro-ophthalmologists- who unlike ophthalmologists, have a difficult time earning enough to pay back their school debts.

And there is grave concern about the lack of primary care doctors to work in settings where the patient load is high and the pay is less. Every year US medical schools graduate about 16,000 students. We welcome another 6500 foreign medical graduates into first year residency slots - 80% of these graduates will remain in the US, often unfortunately, depriving their home countries of the work force required to deliver adequate medical care there. And the majority of these FMG also specialize; fortunately many of them seem willing to work in rural and underserved parts of the country.

So what will we do to deliver the quality of care expected by and deserved by our patients? How will we increasingly focus on the importance of prevention and public health measures- encouraging parents to vaccinate their children, supporting major initiatives to stop smoking and to develop regimens for weight control that actually work.

So as you plan your careers you will face these challenges - where have all the doctors gone?

I strongly believe that the answer is not to train too many more doctors but to give those we train the right jobs with the pay commensurate with the contributions made. Perhaps we need to address the disparity in reimbursement where doing procedures pays well, but thinking deeply about a patient’s problems has financial limitations.

And I am convinced that the new requirements in medical care will demand new models of heath care delivery- a new focus on team work, where, for example, doctors, nurses, pharmacists, and social workers form efficient groupings to consider patient centered care.

Now to my third point: WHERE HAVE ALL THE DOCTORS GONE? OR BEEN?
What is our civic responsibility, yours and mine, in an election year featuring a major reorientation to how we should deliver the best health care possible, with greater access, particularly for the poor and uninsured, and at an affordable cost, which is in the country’s best economic interest? What is our responsibility to work with our governments, our cities, and our health departments to accomplish this?

Currently it is estimated that 47 million Americans are uninsured. In Massachusetts, where an experiment is under way to require everyone to obtain medical coverage, we are finding that there are not enough primary care venues to deliver the care that the new enrollees deserve.

I like to refer to the 5 As of health care that need to be respected and considered in the efforts to establish a more equitable and effective health care system.
Access to Affordable, Affable, Accurate, Advice

What does affordable mean? And how will the costs of coverage be divided between employer, employee, government and charitable organizations. We all agree that the care ought to be affable—caring and patient centered with the patient’s rights acknowledged. We seek to provide accurate care that depends upon the best evidence-based Medicine--delivered in accordance with recognized guidelines and tailored to the patient’s phenotype as it will emerge from genetic screening and pharmacogenomics. And what our patients really want is the best advice--good judgment given in a communication style and manner that evinces concern and seeks to advance compliance.

So where will you find yourselves in the decades ahead? You have a right to be proud and excited today. You deserve the best after many years of hard work. You will help to transform the world of health care.

And what by the way, did John decide. He sent me an email last week: “Currently, I’m leaning toward becoming a doctor…If I pursue medicine, I want to be creative with my practice, to use my influence to influence larger social change and close the inequalities that exist with accessing healthcare….this coming year, I want to pursue things that I think I would be passionate about” take a year off to contemplate the future.

A good decision it seemed to me.

So I would summarize the three components of my title-Where have all the doctors gone? Exercising choice, making commitments to best care, and engaging actively in society’s challenges.

Godspeed and again thanks for inviting me to be with you today.

Elected Faculty Speaker

“The Null Hypothesis”
David C. Kaufman, MD

Candidates for the degree Doctor of Medicine: Congratulations! It is, without a doubt, my greatest honor to be invited to address you, your family and friends, and your teachers on this monumental occasion.

I thought I would begin by telling you a story from my internship.

I remember the night and can surmise from my memory that it must have been the summer of 1988. It was an election year with Michael Dukakis beating out Jessie Jackson for the Democratic ticket only to lose to George W. Bush’s father. The Soviet Union and The Berlin Wall were both still standing. Late that particular night I was called by an oncology nurse to see a patient who was “short of breath”. It was the very beginning of my internship and any confidence I had was riding the wave of the circulating adrenaline that was piped in constantly from my adrenal glands. The patient was in her early thirties and had metastatic breast cancer. Her breathing was deep and loud. She did not appear uncomfortable but the noise was distressing. Her vigilant and understandably desperate mother was sitting at her bedside. The mother looked at me as I entered the room, mistaking my long white coat for some measure of wisdom and asked me to do something. I did. I ordered one milligram of Morphine, IV push. I stayed as the nurse administered the narcotic, figuring I had shot my arrow somewhere between placebo and homeopathy. Here is where my memory becomes vague. I believe the nurse was pushing the Morphine when the patient’s breathing stopped…but it may have been just after. Either way, the patient’s mother took one look at her dead offspring, darted her eyes in my direction, and accusingly said “you killed my daughter”.

Did I? If you say no, are you certain? If you say yes, are you certain of that interpretation. I was, and still am, filled with ambiguity. Indeed, I am less certain today then I was then.

Working in an ICU, I have filled out more death certificates than most physicians and, in the beginning, I was certain I knew what to write down for the “cause of death”. I am less certain now then I was in those days. Sure, I know what the medical examiner wants. He wants to know the reason that led to the person’s death: the name of the cancer, the stroke, or the ruptured aneurysm. As a medical student, I was once on a rotation in pathology and attended a CPC. A CPC, for the non-medical members of this audience, is a clinicopathological correlation. It is a gathering where a unique patient is presented to a group who is naive to the outcome with the exception of a pathologist who knows the result of the single test that secured the diagnosis. A master clinician presents his reasoning and, finally, his proposed diagnosis. Next the pathologist presents the correct answer. Both the Chief Resident in Medicine and Pathology attended this particular conference. The patient presented had lymphoma and, at autopsy, most of his organs were filled with cancer. The Chief Pathology Resident showed the autopsy slides, one by one revealing the tumors in each of the varied organs. At the end the Chief Medical Resident stood up and told him that his presentation was all well and good but he had not answered the clinicians’ fundamental question, which was why had this poor gentleman died? There was nothing but cancer everywhere; no pneumonia, no pulmonary embolus, and no myocardial infarction. The Pathology Resident, once again, said it was because of all the cancer. The Medical Resident would not let this fish go and asked his question again. Exasperated, the Pathology Resident stood up and said emphatically, “Look, he just up and died”. With that, the fish got away and the Chief Medical Resident reeled in his broken line. Years later, it occurred to me that perhaps the answer all depends on how proximate you want to be to someone’s death when you are documenting the “cause” of death on a Death Certificate. Ultimately, we all die because we are born. Who was right? And, more importantly, are you certain?

In preparation for this speech I did what I often do when I have to get something done and I find the task daunting: I read a book instead. But first, the School of Medicine needed a title from me for your commencement program. Not having any experience, I wondered how many authors title their work before they take pen to paper. Perhaps they do and then have the luxury of changing these early designations. Who knows, maybe Melville started with the working title “Jaws” and switched to Moby Dick after his epic novel was complete. On the other hand Shakespeare’s “Much Ado About Nothing” is too good a title not to have started out that way.

I want to give the graduating class something; something that I value and something that I have learned. I realize that a gift may not always be appreciated and it may even be presumptuous to assume that it is valuable to anyone but me. However, this is where I was at the beginning of this adventure. So back to the title: After many false starts and great patience from Paula Smith in the Office of Medical Education, I settled on “The Null Hypothesis”. Next I read a book entitled “On Being Certain” by the neurologist Robert Burton. Dr. Burton postulates that “despite how certainty feels, it is neither a conscious choice nor even a thought process. Certainty and similar states of “knowing what we know” arise out of involuntary brain mechanisms that, like love or anger, function independently of reason.” This statement makes sense to me. While one of us is chemically wired to see a black and white world another one of us has the circuitry that is chockfull of shades of grey. Dr. Burton writes about how artificial neural networks create a rubric that is more likely analogous to our brains than your average personal computer. Artificial Neural Networks do not create a program line by line but the programmers input equations that weigh incoming information. These weightings take place in what is called the hidden layer and is akin to our subconscious. Our neurologist /author points out that this hidden layer does not exist in a discrete anatomic location but is a function of the entire neural network. Think about it: As you sit here and attempt to listen to me do you believe your subconscious is turned off and any random thoughts such as what you are going to have for dinner or how proud you are of your partner, son, or daughter randomly springs into your consciousness from thin air. Or are those the thoughts that break through to the surface based on a complex algorithm that, at its core, is written on electrified tissue. The survival benefits of a hidden layer that allow our brains to contemplate while we focus on the task at hand are immense. Indeed, for better or worse, this speech was written by my hidden layer and handed upstream to a copy editor.

Every scientist and every philosopher knows that you cannot prove a negative but you can disprove one and it only takes one event to do it. And every good physician is part scientist and part philosopher. So you have your alternative hypothesis that you want to test, say, all once and future URSMD students understand acid-base. The null hypothesis would be that NOT allURSMD students understand acid-base. Together, these hypotheses cover all possible answers but only one can be true. I can’t prove that all once and future students understand acid-base (some aren’t even born yet). So if every student that I find understands acid-base then I can reject the null hypothesis. Since there are only two hypotheses and I have rejected one, I must accept the other. But, watch the slight of hand, I have not directly proven the alternative hypothesis but just rejected the null hypothesis.

This statistical logic is just a reminder that in the practice of science and medicine we must have doubt. Did I kill this dying young girl? In the practice of medicine time is always a confounding variable, making single interpretations of our individual experience treacherous. Maybe she would have died at that same moment anyway. Maybe your philosophical tendencies bend more towards the utilitarian and you feel it was imminent and does not matter. Either way, doubt remains.

The ICU is a wonderful place to work if you like the big life and death questions and trying to wed and unwed complex mammals to and from simple machines. I have learned that there is a single approach that is universally beneficial when discussing continuing or stopping life support when the odds are clearly against an incapacitated patient surviving. This approach is predicated on the realization that absolute certainty is a fundamental fallacy. As you sit down with the patient’s family (and always sit down, never have a conversation of even minor significance standing up!), tell them what you believe you know from the literature and what you believe you know from your experience. Those that want to withdraw life support will have your permission and those that aren’t ready will wait but not feel that you are abandoning your efforts. I often tell loved ones that when it is time to stop life sustaining measures they will just know from their hearts and they will not have to weigh the pros and cons in their heads. This approach has never failed me but many other approaches have. I guess what I really have been saying to these families is that a decision of such magnitude should be agreed upon by the electrochemical streaming in their subconscious and rise to their consciousness, as if out of the blue.

Within the past year I was caring for a very young woman who had taken an overdose of Tylenol in a moment of despair. The chief of transplant and I had a long discussion, as we have so many times in the past, about whether or not he should accept the next liver offered for her. Her liver was failing rapidly and she was developing cerebral edema. To the best of our combined clinical judgment she would not recover without a transplant. Perhaps it is these situations that lead me to believe there are no simple answers. If she was transplanted someone else would die on the waiting list. But, this was her only chance. Her family desperately wanted to proceed and it appeared that they would support her after the surgery. We took a chance and she survived and is back with her family. I am not telling you this story because of the successful outcome. I know all too well that this outcome was unlikely. Don’t just doubt when you are wrong but doubt when you are right as well.

When you graduate from medical school you may feel certain about some things. However, embrace doubt, don’t be fearful of it. There is evidence that some of us are willing to live with more doubt then others. Black and white or shades of gray: Which one are you? Can you live with ambiguity? I propose to you that, public perceptions aside, physicians should have doubt. Patients and families will respect you for it. Ironically, doubt will give you certainty of purpose.

Thank you, my new colleagues and candidates for the degree Doctor of Medicine, for this rare and privileged opportunity.

Elected Student Speaker

Maryann Overland, MD

Good afternoon distinguished friends, family, mentors and classmates. It is my great pleasure to speak to you today.

During our first year of medical school, Dr. Quill taught us that some of the most important information comes from patients at the end of a clinical encounter, when our hand is on the doorknob and we’re almost out the door. Since our hands are now officially on the doorknobs of medical school, you’ll have to forgive me for starting at the end of my speech. As I look at my classmates today, I am humbled by the trail of good works and great successes that they have created during medical school. We are in the midst of distinguished scholars and activists who have run the UR Well free clinic, completed international work on virtually every continent, provided hundreds of free school physicals to Rochester area kids, and published original research in some of medicine’s leading journals. It has been a great honor of my life to learn and work by your side for the past 4 years.

When I was growing up, my mom had a set of three fundamental rules to steer her children’s behavior. Mom’s rules were all encompassing. Following these rules could avert any potential form of mischief, danger or incarceration. They were:

Watch where you’re going.
Stay out of my stuff.
Don’t panic until you have the facts.

Rule number one not only helped prevent head injuries and skinned knees, but also had a broader impact. Implicit in “watch where you’re going” is that you actually are going somewhere, that you have a direction, that there is a future impact to your current actions, and that life has a trajectory that is impossible to fully know, but is a product of this moment. “Watch where you’re going” forced my brothers and me to pay attention for opportunities that may arise, even if they weren’t what we thought we wanted. It taught us to be mindful of our actions, because everything we do has an impact on our surroundings. In medicine, it is vitally important to watch where we’re going. For one thing, patients tend to frown upon interns tripping over their foley catheters. But perhaps equally important,we will now, more than ever before, be representatives of this great institution called medicine. Our individual behaviors and choices will reflect on each other, our colleagues, our hospitals, and the larger culture of medicine.

Rule number two, “stay out of my stuff,” was originally borne out of my penchant for sampling my mom’s array of lotions and potions, but it acquired a deeper meaning as I grew up. It reminded me to mind my own business, and that privacy is of the utmost importance. Rule number two, however, needed minor alterations when I chose to pursue a career in medicine – it is impossible to be a good physician and simultaneously stay out of someone’s stuff. Indeed, we will now and forever be completely enmeshed in other people’s stuff. Our days and nights will be filled with the secrets, stories, pains, aspirations and fears of our patients. It is our job to bear witness and protect the stories of others. “Stay out of my stuff” reminds us that patient privacy is to be protected at all costs, and as physicians we will bear the responsibility of being trusted with another person’s life. It is one of the most important privileges a physician has.

Rule number three, “Don’t panic until you have the facts” taught me at an early age that there are multiple sides to every story, and multiple perspectives to consider before making up one’s mind. Now, there aren’t too many sides of the story when, for example, you find your brother with scissors in one hand and your My Little Pony doll suddenly sporting a Mohawk in the other, but in general this rule has served me well. “Don’t panic until you have the facts” encourages us to be open to new information. It reminds us that sometimes the plans have to change as new data arise-- that we shouldn’t let the pride of being right get in the way of doing good.

Following this rule prevents premature rush to judgment. I will never forget the homeless patient on my subinternship who had fallen onto bad times and presented to the hospital with what everyone assumed was a desire for a place to sleep and three square meals. He ended up being truly ill, with a small bowel obstruction, and our daily conversations revealed a keen mind and a voracious appetite for reading and discussing the New York Times. The hospitals and clinics of our future will be filled with people better served if we do not rush to judge them. Let us not attempt to put them in a convenient category and file them away without gathering all of the facts.

At the end of our medical school career, I now present Mom’s rules, as adapted for a new physician:

Watch out for opportunities to honor and be a custodian of the culture of medicine.
Cherish your patient’s life stories as gifts and responsibilities.
Don’t panic until you have the facts about your patients.

With my hand now officially on the doorknob, I leave you with a quote. Marian Wright Edelman, founder of the Children’s Defense Fund, once said, “Service is the rent we pay to be living. It is the very purpose of life and not something you do in your spare time.”

I am confident that, in the spirit of Meliora, the good will, entrepreneurship, and endless energy of the University of Rochester School of Medicine Class of 2008 will rise to the challenges ahead to help shape and improve the art and science of medicine to the betterment of all.

Good luck everyone!

Meliora,

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