Robert and Lillian Brent White Coat Ceremony: Class of 2012

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

August 21, 2008

One of the wonderful things about an academic health center is the infusion of new students and trainees each summer. Their energy and enthusiasm lift our spirit and renew our commitment to the core mission of education.

This summer, we welcome 104 new medical students, 81 new PhD graduate students, and 245 new residents and fellows. Over the next several weeks, we will profile these talented groups of students and trainees; they represent our future, and the future of medicine and biomedical science.

We begin this week with the spirit-lifting Robert and Lillian White Coat Ceremony, to be followed in subsequent weeks by profiles of the Class of 2012, and of our entering graduate students and house officers.

After a week of orientation, both to medical school and to the profession of medicine, students and their families gather for a ceremony in which members of the Class of 2012 don their white coats for the first time, symbolizing their entry into the profession of medicine. While the text of the speakers, shown below, cannot capture the atmosphere of excitement and anticipation created by students, their families and our faculty, I'm confident that you will agree, based on the student-generated code of conduct and the messages of speakers, that the future is in great hands. We begin with the opening comments of Dr. Robert Brent (see newsletter Sept. 6, 2006), followed by the faculty and student speakers. We close with the student-composed Code of Conduct, recited by the class and led by Aaron Wiener.

Society's Gift to the Class of 2012
Robert Brent, MD, PhD

Good morning future fellow alumni. I am pleased to be permitted to discuss an important issue in keeping with the theme of your orientation that you are entering the profession of medicine.

Obtaining a medical education is costly for even those of you who have received scholarships or other forms of financial aid. You have heard about the major efforts of Dean Guzick and the alumni to provide financial aid; many alumni even have a dream of making medical school tuition free. At every turn, however, you find that there is a new bill to pay or a new expense. What if I told you that you have received a most precious gift and it will not cost you anything, not even one cent. The gift was given to you when you received your letter of acceptance from this medical school. Dr. Hansen, the Dean of Admissions did not give you the gift. Neither did Dr. Guzick or Dr. Lambert. The gift came from the bus driver who drove some of you here, workers at the shopping center and all the non-physicians in the audience here at the White Coat Ceremony. In essence, it is a gift from Society to you, the future physicians in the Class of 2012.

You will be given the privilege to examine the minds and bodies of your patients in a most intimate way. This is because you are considered by Society to be individuals with integrity and high ethical standards. Now, as you enter the profession of medicine, you must not transgress from these standards by exhibiting improper behavior at the personal or societal level. Remember that you have not been screened to determine whether you have high ethical standards. It is assumed that if you have made the decision to be a physician and to be of service to mankind, then it is likely that you have the integrity to be a "good" physician. However, every time a physician is in the news for an ethical transgression—a breach of professional integrity and of the Hippocratic Oath—he or she is sabotaging the gift from Society. In a recent national poll, nurses and doctors were judged to have the highest integrity and ethical standards. So cherish this gift and protect it by leading an exemplary life. It will be your gift to the next generation of doctors.

In closing, I want to remind you how lucky you are. With your education, your future is bright. We might say that you are one in a million. In reality you're one in fifty million. For every one of you there are fifty million people in the world who are not able to obtain the very magnificent education that you will receive at this great medical school, the University of Rochester School of Medicine and Dentistry. Good luck. Enjoy these four years for they are the most important four years of your adult life.

Faculty Speaker: Thomas Campbell, MD
William Rocktaschel Professor and Chair, Department of Family Medicine

Good morning. Several weeks ago, after being invited to talk at this special occasion, I solicited advice from members of my faculty. "This is a tremendous honor and responsibility," I said. "Can you help me make this a meaningful and memorable talk?" They responded: "Of course Tom... don't worry—most importantly, don't try to be clever, or brilliant, or humorous or inspiring—just be yourself!"

It is with this sense of humility and of great honor, that I would like to briefly share with you my thoughts about idealism and altruism in medical school, and how you can nurture these values throughout your education and your career. But let me begin with a story, a clinical case.

Every spring and fall, members of my Department, including faculty, residents, medical students along with a dentist or two, spend 2 weeks in San Jose, a small village in the mountains of Southwestern Honduras. For the past 4 years, our Department has partnered with this community to help them improve their health and wellbeing. This village has enormous needs. It is located in the poorest region of Honduras, which is the second poorest country in the Western Hemisphere. The average per capita income is less than $2 per day, and 20% of the children are malnourished. There is no running water or electricity. Most of our work is focused on improving the social determinants of health, and include several water and sanitation projects, the distribution of ventilated cookstoves that reduce indoor smoke and use of precious fuel, a fluoride program in the schools which has dramatically decreased the incidence of dental caries and a series of other community health projects. We also run a medical and dental clinic and see up to 100 patients per day.

This past spring, I had the pleasure of joining our brigade for the first time and was incredibly impressed by the group's accomplishments, its close partnership with the community and the significant impact of these projects on the health of the villagers.
One afternoon, we made a home visit to see two young brothers, Enrique and Carlos, ages 18 and 22. They are the youngest of 11 children and have an undiagnosed genetic disorder which results mild mental retardation, multiple orthopedic anomalies and unusual and distinctive facial characteristics. They look like they are 10 and 12 years old. The older boy, Carlos, has not been able to walk for years and is carried about by members of his family. (Wheelchairs are both unavailable and largely useless in this mountainous terrain). Enrique, on the other hand, walked with difficulty until several months before our arrival when he developed multiple pressure sores on his deformed feet and became unable to walk. Brad van Heukelum, a second year family medicine resident and I cleaned and gently debrided the sores which were filthy and covered with flies. We applied antibiotic cream and a clean dressing. We treated both Enrique and Carlos for scabies, roundworms and vitamin deficiency, all of which are endemic among children in Honduras. However, when we were done, we realized that there was no way that Enrique's family could keep his dressings clean, prevent his wounds from getting infected and allow them to heal. He had no shoes and within a day or two, our nice clean dressing was certain to become black with soot and dirt and there was little hope of healing his sores and allowing him to walk without protecting his feet. The next day, Brad and I hiked an hour uphill in the other direction to the main road where there was a general store that sold shoes. The only shoes available were shiny black dress shoes that cost six dollars and were clearly fancier than any piece of clothing that the family owned. We returned to the family's home the next day and fitted Enrique with his new shoes. The smile on his face was indescribable and unforgettable, and the shoes did the trick. (I wish I could show his picture.) The shoes kept his dressing clean, protected his ulcers and gave him enough support so that he could start to walk again. We carefully explained to his family that these shoes were for everyday wear and not to be reserved for special occasions. Recently we received an email from Matt Malek, a fourth year Rochester medical student who is spending 6 months in San Jose. He informed us that Enrique was still wearing the shoes, was walking with only a minor limp and that his sores had almost completely healed.

"So why are you all here today? Or perhaps better asked: "what motivated you to suffer the trial and tribulations of pre-med courses to come to medical school?" Based upon your personal statements and interviews, most of you come here with a strong desire to help others, to improve the health and wellbeing of patients and to make the world a better place. Of course, an interest in science or fascination with human physiology likely played a role, but idealism ("the pursuit of high and noble goals") and altruism ("the desire to help others) are what distinguishes medicine from most other professions, and is one of the things that makes your class such an extraordinary group of individuals.

But here is the bad news: multiple studies have demonstrated that these high levels of idealism and altruism decrease throughout medical school, starting even during the first semester, and for some are replaced by cynicism and self-centeredness. Further research has shown that this decline in altruism is accompanied by decreased empathy towards patients, especially those who are the least fortunate or the most unlike us – the poor, the elderly, and the chronically ill. One recent study published in Academic Medicine was entitled "Is there hardening of the heart during medical school?" Unfortunately, the authors' answer was yes.

Now I believe that these changes in medical students occurs much less at the University of Rochester because of our deeply held values, our focus on the biopsychosocial model, our community outreach programs and multiple other unique programs. However, we do know that during medical school, there is a fairly precipitous and dramatic decline in the number of medical students who express an interest in less well paid specialties, such as primary care (whether it is pediatrics, internal medicine or family medicine) and an increased interest in more lucrative, sometimes called the lifestyle specialties. Joseph Martin, former Dean of Harvard Medical School and a graduate of this medical school spoke about this trend in his May commencement address here in a talk entitled "Where have all the doctors gone?" This trend is captured by the response of a 4th year medical student who was asked why he changed from primary care to a more lucrative subspecialty – his reply was simple: "twice the pay for half the work".

But few of you chose medicine as a profession for twice the pay and half the work. You chose medicine, I suspect, because you wanted to find a path in the world that would guarantee you the scope and freedom to act on your ideals throughout your lifetime. So what happens? It turns out that there is a hidden curriculum in all medical schools, an informal process of socialization that occurs after you put on this white coat and that has as strong an effect on your training as the courses you take and the lectures that you attend. It is part of the culture of medicine and there are at least two themes that run through this hidden curriculum. First is one notion of clinical detachment – that you need to separate yourself emotionally from the patients that you care for, so that you can dissect your first patient during anatomy or do a painful procedure on a small child during your pediatrics clerkship. If taken too far, this clinical detachment leads to loss of empathy and viewing patients as objects rather than people. One of the greatest challenges in medical school is to learn how to remain emotionally involved with your patients without over-identifying with them in a way that impedes your role as a physician. A second theme is the false dichotomy between caring and curing and the perception that caring is for nurses and other non-physician staff and that our focus should be on curing disease. This false distinction is most problematic in end-of-life care where caring becomes the physician's primary role.
So what can you do to preserve your sense of idealism and your strong desire to help others and make the world a better place? Let me offer a few suggestions:

First, reread the personal essay that you wrote when applying to medical school and write your own personal mission statement. Steve Covey, author of The Seven Habits of Highly Effective People, a book that I highly recommend, writes about the importance of knowing where you are headed and what your goals and values are. He states that it is as important for the individual to have a personal mission statement as it is for organizations like this medical center, to be sure that you are staying on track, following your goals and sticking to your values. Share this mission statement with your colleagues, friends and perhaps most importantly your parents, as they are the ones that had the greatest influence on your values and your mission. Review your personal mission statement and reread your personal essay on a regular basis, at least twice a year. Consider sewing it into your new white coat, so that it stays with you on all of your clinical rotations and reminds you why you are here.

Two 4th year medical students from University of Vermont recently wrote about their own experience in medical school and commented "before long, we forgot what are we trying to do here. We forgot what it is like before medical school, to want to be a doctor. We forgot our ideals and our dreams."

Having a personal mission statement that you review regularly will help you remember your dreams and aspirations and the reasons that you are here starting medical school.

Second, develop and strengthen your empathic interviewing skills. Empathy is the ability to put yourself in the shoes of someone else and understand what they are experiencing. It is absolutely crucial to becoming an outstanding physician. It is the emotional glue that binds physician and patient and distinguishes our profession from most others. Patients complain that we don't listen to them, that we don't hear their concerns and their fears. Learning to actively listen to patients and their families and to identify and address emotional concerns is critical skill that takes training and practice. Developing and maintaining empathy towards patients who are very different from you is the key to maintaining your altruism.

Third, practice your altruism by volunteering in our community all 4 years of medical school. Discover the challenges that many kids in our city schools face through the Saturday morning tutoring program or Hoops for Health. Learn more about caring for uninsured patients by working at the student run URWell free clinic at St Joseph's Community Center. Talk to Adrienne Morgan who runs SRO (Students of Rochester Outreach) about all the opportunities to give back to Rochester and help this very needy city

Next, work in developing countries, as much as your schedule will allow. Like our project in Honduras, there is no more powerful reminder about how privileged we are, as a society and as a profession and how needy others may be, than to leave our comfortable lives and join with another community to improve its health. Be sure your experience is not medical tourism, but involves sustainable improvements in health. In your clinical rotations, find time to care for dying patients, for homeless patients, for those with severe developmental disabilities. Make home visits on your patients to learn what their life is really like. Attend the funerals or calling hours of your patients who die. You will not forget these experiences.

And lastly, become a mindful or reflective practitioner – that is, learn to reflect upon your experience as a medical student, not just what you are learning, but what you are feeling, for this will allow you to make conscious decisions about how you would like to be changed by your experiences. Identify faculty who share your values and aspirations and cultivate them as mentors. You are lucky to have a group of Advisory Deans who fit these criteria.

Finally, the good news: there is an added bonus to all of this, to maintaining your idealism and your altruism through medical school and into the rest of your life. In addition to becoming a better doctor, you will become a happier and healthier person. A growing body of research has demonstrated that altruism and having a sense of meaning in one's life are the two best predictors of happiness, and that fame and fortune are poor predictors and very often are negatively associated with long term happiness. The best way to ensure that you will be happy and satisfied in your professional (and personal) life is to have a sense of meaning in your work (remember your mission statement) and make giving to others your top priority.

Hold onto your idealism throughout medical school and beyond. Remember your dreams. Don't listen to the cynics. You can change the world, in fact upon accepting these white coats, we expect you to change the world. For me, being part of a global health project that is changing the health of a Honduran village and experiencing the smile and thanks from a young man whose life we were able to improve, as well as my day to day care of indigent patients in Rochester helps me to sustain my idealism and altruism. May you find similar experiences in medical school and in your careers.

Student Speaker: Stephen G. George, MS4

Welcome, Class of 2012! Even though you have heard this from those before me, and will hear it from many after me, I would like to congratulate you for earning the seats that you occupy and the white coats that you will soon wear.
But I ask you, "Do you really know what you have just signed up for?"

Just a few years ago, I sat in those seats, listening to a fourth year student talk about how he remembered sitting in the very same seats. I was excited, relieved, and nervous. The resolve that I had, after deciding where I was going to attend medical school, quickly disappeared as the reality that ‘now I have to start medical school' began to take hold.

My row congregated at the front of the stage, and I inched forward as each name was called, taking special care not to step on my new classmate's dainty red pumps. Before long, the words "Stephen Graham George" resonated throughout the chapel. That was my cue to step forward, climb two stairs, walk four paces, turn left, put on the coveted coat, and march back to my seat, all without tripping. It's funny how nerves can make you question your ability to complete toddler-level tasks.

As soon as the crisp white cotton hugged the now moist nape of my neck, something changed. My shoulders were broader, my strides were longer, I had better posture, and I was no longer bothered the hard pews and I was even compelled to listen to the speaker.

When you receive your white coat, search the pockets, see if they contain anything. If your coat is anything like mine, it won't come with a prescription for "Instant Doctor Pills: take one tablet, three times a day with food, for four years." However, as you will soon find out, it does come with the remarkable ability to conceal your fear, uncertainty, and lack of medical knowledge. Unfortunately, this will become virtually impossible for your coat as the year progresses, and you unabashedly fill your pockets with every piece of literature, notes, and overpriced electronic devices that you can find. The white cloth will stretch over your shoulder, like the rim of a drum. At that point, it will be blatantly clear that you have no idea what you're doing. But, you'll gladly accept that fact, as long as you know the answer to your next medical questions is written on one of the pages, in one of the chapters of one of the books, in one of your pockets. Have fun finding it.

After being asked to address your class, I deliberated over what was necessary to mention. A story came to mind from my third year Pediatrics Clerkship. The patient was a one day old girl, Emily, born of a 27 year-old first time mother, Sarah. Baby Emily had an uncomplicated birth, with weight, height, and head circumference within normal limits. However, our service was consulted because Baby Emily appeared to be "turning yellow." To the novice ear, this may sound like the first scene of your favorite science-fiction film. Nonetheless, this is a very common presentation, of a relatively common condition found in neonates, called jaundice. It's usually caused by the increased presence of bilirubin, a component of red blood cells. The condition is often the result of red blood cells being destroyed faster than the body can properly dispose of the breakdown products, due to the low capacity of a neonate's immature liver. When too much bilirubin collects in the blood, it permeates to the surface of the skin, giving the skin a yellow, tawny color. While at the surface of the skin, bilirubin becomes exposed to light, which actually alters its chemical structure to a form that the body can more readily dispose of. The condition is usually benign, but depending on the underlying cause, it has the potential of leading to more severe side-effects, which include permanent brain dysfunction.

We initially treated Baby Emily conservatively, using standard phototherapy, while we continued to search for the etiology of her condition. Further workup led us to discover that her jaundice was being caused by a mechanism where antibodies from the mother crosses the placenta before birth and binds to the surface of the neonate's red blood cells, leading to their eventual destruction. This process usually resolves on its own, but requires close monitoring because of its ability to escalate to more serious complications.

Baby Emily's levels continued to climb, and the team decided that it was necessary to be more aggressive with her treatment. This called for administration of intravenous immunoglobulin, also known as IVIG, which is a blood product that contains extracted antibodies from thousands of other donors. The attending physician and I met with Sarah and discussed Baby Emily's condition and potential treatments. We explained that our hope was to get "informed consent" to use IVIG therapy. With a warranted sense of concern, she asked, "Well, how does this I-V-I-G thing work? I thought you just told me that Emily had too many of those antibody things to begin with?" The attending physician responded by saying, "I understand your concern, IVIG is widely used to treat a variety of conditions, including this one, with great success. Although we know what it contains, there's still uncertainty regarding how it actually works." The new mother looked at us as if she was waiting for a "just kidding," but instead she was confronted with two slow motion eye blinks from the physician, and a confirmatory head nod from me. Despite our possibly unsettling explanation, Sarah took a deep breath and replied, "Okay, if you think it'll work," putting her confidence in the team's judgment.

This situation truly highlights the element of trust built into the idea "informed consent," and, in addition, the ambiguity of the word "informed." Sarah certainly wanted the best treatment for her daughter; however, she had to accept the fact there was some level of uncertainty regarding how the treatment was going to work.

In a similar fashion, you, the Class of 2012, sit here, after recently "consenting" to start this journey toward a career in medicine. Though you've done your research and homework prior to committing to this journey, I contend that your "informed consent" also has a significant element of trust build into it, in addition to an ambiguous connotation of the word "informed." Perhaps your trust is rooted in your knowledge of the upstanding history of the field of medicine, or advice from a friend or family member, or simply blind faith. Whatever it is, your perseverance to this point indicates that you are confident that medical school will beget more good than bad, more positive than negative, and more growth than atrophy. Good news for you, I think that everybody in this chapel would agree that those are realistic expectation.

Though you may look to professors, physicians, mentors, and students, to help elucidate exactly how the medical school experience will actually accomplish this task, unfortunately, yet at the same time, fortunately, there is no definitive answer. Your prior experiences, and future decisions, will eventually, for the most part, dictate the answers that you look for today.

However, here are a few pearls that will hopefully help you meet and surpass your expectations:

Find a mentor—This is not a passive task, where you rely on serendipity. It will inevitably require emailing and door knocking. Although sometimes helpful, your mentor doesn't need to be in your specific field of interest, just an experienced person, who can relate to you, and is willing to guide you. Each of you will have your own additional requirements for a good mentor, and this may be difficult to find in one individual. Therefore, it's often beneficial to have more than one mentor at the medical center.
Care for classmates, both academically and socially—Each of you was hand-selected from some of the most outstanding applicants in the country. Yes, you can relax; your acceptance was not a result of a glitch in the system. Each of you brings a unique background, interesting experiences, and a great wealth of knowledge. One thing that you all share is the desire to become physicians. Help each other. Remember that your ability to succeed is not dependent on your classmates' ability to fail. Also, trust me when I say that there will be a time when you'll need to rely on your classmates for help with course work, clinical obligations, or moral support. Make sure your day-to-day actions warrant your expectation that your classmates will be there for you.
Humble yourself, learn from everybody, and don't be afraid to ask for help—During my time as a medical student, I have found it very easy to pay close attention to my senior colleagues, instructors, and attending physicians; however, I've noticed that a significant portion of the valuable information that I've acquired in my short tenure at the University of Rochester came from administrative assistants, fellow classmates, patients that I've cared for, nurses, and various other health care support staff. Don't take these casual interactions for granted; because these are often the people that have the most time to teach you.
Be curious, ask questions, and actively pursuit the answer—At your stage of academic training, you will start to realize that many of your sophisticated clinical, epidemiological, and basic science questions do not have definite or satisfying answers. Don't let this discourage your curiosity. Instead, use it as the motivation that will drive you to figure out the answer. Fortunately, you will be attending an institution that will always endorse your desire to pursuit deeper understanding.
Get involved—As you already know, the field of medicine, the way health care is delivered, and the way medical school is run, are all far from perfect. It is truly up to our generation to take responsibility for their directions and trajectories. Don't develop the passive mindset of "I'm only a medical student." Instead, try to develop the mentality that was once articulated as, "that which we do not change, we choose." Maya Angelou once said "I've learned that you shouldn't go through life with a catcher's mitt on both hands; you need to be able to throw something back." These words are particularly pertinent regarding community service, and local and international outreach. We have all been given a wealth of opportunity, and with that, we should all feel a natural obligation to serve others at all levels of our training. Trust me; it will certainly make your medical school experience more productive and rewarding.
Sir William Osler, a Canadian physician who is often regarded as the Father of Modern Medicine, stated, "Live neither in the past nor in the future, but let each day's work absorb your entire energies." I urge you to take the medical school experience one day at a time. Without a doubt you will be challenged, and during these times you should always realize that medical school is not the endpoint, but instead, just one step. However, it's important that you fully engage yourself during these next four years. Manage your time. Don't fall behind. Avoid "cramming" at all costs. Don't study because you need to pass your next exam, study because your patients trust and depend on your thorough understanding of the material.
Figure out what you love most outside of medical school, and let it help you stay grounded through the hardships that you will inevitably face during your journey.
And lastly, be yourself and enjoy the experience.

Class of 2012, it has been a great honor to speak to you. Though you still may not be adequately "informed" about what the next four years, hopefully you are just a bit more prepared. Again, welcome, congratulations, and good luck.

Code of Conduct
(Written collectively by members of the Class of 2012)

Humbled by the privilege to enter the study and practice of medicine, we recognize our roles as individuals, family members, colleagues, and citizens of society. Endeavoring to benefit mankind, we will uphold and exercise the following ideals within our various theaters of practice throughout the world.

We respect ourselves and others by embracing the human family. As part of this larger family, we celebrate our strengths and recognize our limitations. Humility and humor will draw us closer together.

We devote ourselves to the ongoing study of the science and art of medicine. We will work to educate ourselves, patients, colleagues, and the greater community.

We acknowledge the legacy of our profession as we strive to uphold its integrity and ethical standards, always approaching issues with an open mind. We embrace the challenges inherent in this path and honor the responsibilities entrusted to us as a part of this profession.

We commit ourselves to providing compassionate and ethical treatment for our patients. We will strive to be thorough caregivers guided by the principles of evidence-based medicine.

We will advocate on behalf of our patients in the pursuits of both science and policy. We resolve to improve not only their physical well-being, but also their social and psychological health.

As the Class of 2012, we are a fellowship striving to uphold the sanctity of our profession.

Meliora,

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

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