University of Virginia Health System

I am your designated welcoming speaker tonight and, as I see it, my role is not only to welcome you to the University of Virginia School of Medicine but to welcome you to the profession of medicine. I know you're not doctors yet, and you may think that a welcome into the profession might be more appropriately pronounced four years from now at your graduation, but the truth is that, as of this day, you have indeed entered the profession of medicine.

It may already be apparent to you that this is not just an orientation of the sort that you've experienced before; it's not the kind of introduction you would receive if you were starting a graduate program in physics or history. Entering medical school is a different sort of undertaking -- and we mark that difference by the covenant we will read together. You are tonight beginning to profess medicine, a declaration that means that you will profess, ultimately, to know certain things and to be capable of doing certain things -- and it means that you now profess to be a certain kind of person, a person who will receive and use your new knowledge and abilities with integrity and compassion.

The first part of professing medicine -- the part that says you will know and be able to do things that can foster healing -- that is what most people associate with the process of medical education. And I'm sure I don't need to prepare you any further for that aspect, for the academic rigors of the career path you have chosen. In fact, there are only two things I want to say about the scientific knowledge and technical skills that you are going to acquire and that will enable you to call yourself a physician.

One is that what you will be learning really is fascinating, at all levels of comprehension, and I hope you won't lose sight of that in the crush of all the work. The predictably accurate unfolding of the human embryo, the intricately precise movement of ions across the cells of the renal tubule, all the chemical conversations and molecular committee meetings that keep the human infrastructure functioning: it is all so interesting and so beautiful in its complexity and its integration, and it is all very important to know if you want to help people whose biology has become disordered.

The other thing I want to say is that you would not be sitting here tonight if we were not quite sure that you can do this work, and I hope you won't lose sight of that fact either. The work to come is going to be hard, but not harder than you can handle.

It is the second part of the act of profession -- the part in which we each claim to be a certain kind of person -- that I want to talk about with you tonight. It is because of that portion of your profession that you are going to be allowed not just to attend lectures but also to talk with patients. Very soon you will be privileged to hear first-hand the stories people tell about their lives, about their afflictions and their suffering, their strengths, fears, hopes, memories. Soon you will begin hearing fragile and painful stories, the sort of stories that are told only to people who can be trusted to hold them gently and use them rightly.

You are here tonight, making your entrance into the profession we now share, not only because we know you are intellectually capable of doing the academic work but also because we believe that each of you is or can be the kind of person who can receive those stories with integrity, who can embrace with respect the lives that will be placed in your hands.

You are, after all, entering medical school not to become human biologists, not to be physiologists or microbiologists. You are here to become physicians, and being a physician involves more than what you'll be learning in lectures and labs over the next few years. For, somehow, at the end of this phase of your education, you will have to be able to use your new knowledge of human biology in a way that is of direct benefit to the person who comes to you for help. But you will have learned population norms and people are notoriously individual. You will have learned generic human biology, and every person comes with a name. You will spend the next few years learning to speak a new language with your colleagues, but the patients who come to you will still be speaking the old one. You will have obtained your knowledge from pictures and charts, from pieces of tissue and sections of bones, and from compliant and very quiet cadavers. But human beings are whole and three-dimensional, and gloriously, stubbornly, loudly alive.

So what does it take to be the kind of person who can both receive what patients have to tell you, verbally and physically, and translate abstract knowledge into words and prescriptions and procedures that are fitting for that specific patient situated in her or his particular life? What is asked of you in order that you may not just profess medical knowledge, but profess medicine? Of course, there is a long list of attributes I could go through in detail, starting with humility and continuing through fidelity and conscientiousness and a constant eagerness to learn more. There's not enough time tonight to do justice to that whole list, not even to the need for a sense of justice.

It is my choice to focus on only two characteristics: confidentiality and openness to risk. I pick these two not only because they will be expected of you from the very beginning of your apprenticeship in medicine, as soon as you begin interviewing patients within the next few weeks, but also because they are representative of the larger, fundamental concerns of this profession: our relationships with and respect for patients and the degree to which we each become an authentic part of those relationships.

The notion of confidentiality in medicine seems as if it ought to be fairly simple and clear-cut. What you know about your patient cannot be shared with anyone without the patient's consent. Seems simple. It is not. You will be tempted over and over again, as we all are, to tell too much of what you know about your patients, even to share the secrets they will divulge to you.

When I was a medical student, one of my patients was a woman quite well known in that city, who was having a not-very-secret affair with an equally well-known politician. She was hospitalized after taking an overdose of sleeping pills, apparently in reaction to the dramatic end of the affair. When I arrived to do my history and physical exam, she had waked up enough to be very talkative, and she regaled me for three hours with all the details of her affair and her relationship with her also well-known husband. I was fascinated. A few days later, I was at a social event where this particular affair and its climactic end were the major topic of conversation and speculation -- and, of course, they had the facts all wrong. I knew that I couldn't reveal what I had learned from her, but at least I wanted to say, "Well, as her doctor, I know the facts of the situation but, of course, I'm not at liberty to divulge them." It is so tempting. But the seal of confidentiality requires that I not even let on that I had ever met her in a professional situation, much less was privy to any juicy details.

That's a fairly obvious situation, but the opportunities to violate confidentiality are often much harder to recognize -- especially when it's a matter of talking with your colleagues -- though no less tempting. It is so easy to forget the seriousness of what we are involved in, so easy to have it become our daily routine, and to allow the most important, most catastrophic events in people's lives to become topics of casual gossip for us. Confidentiality is a rigorous, demanding obligation. From this evening on, you give up the right to talk freely about what you see and do and hear as a student doctor. For, from the moment you enter the profession of medicine, even as an apprentice, you become a person set apart to receive intimate knowledge of other people.

Hippocrates said that things that are holy are revealed only to people who are holy. He was writing before the word "holy" had taken on any of its specifically religious connotations. In the ancient Greek the word means simply "set apart." The things that people set apart, the things that are too painful or scary, too private to be part of every-day conversation -- or even every-day thought -- but that can profoundly influence health and the possibility of healing, those holy things often must be revealed, they have to be let out if healing is to happen. But they will be revealed only to people who are holy, to people who are themselves set apart to receive such things and hold them close, to accept them and the people who bear them without flinching, without judging, without turning away in disgust or fear or disinterest.

You are this day becoming holy people, in this sense of the word. You are becoming now someone set apart to receive special knowledge. Not just the kind of knowledge that you're really excited about learning -- about diseases and their causes and their treatments. You will also receive knowledge you may not want to have -- about how difficult and painful life is for some people, about what people are capable of doing to each other and to themselves, about how people your own age, or your parents' age, or your children's age can be hurt and can die.

Each year in my DPI class -- that's the course in which you will begin interviewing patients -- there is at least one student who strongly resists the notion that doctors need to or should hear about the intimate details of patients' lives, about their sexual relationships, or their problems at work or school, or their family conflicts. My only answer to that resistance is this: It doesn't really matter whether you want to hear it, or whether you think you should hear it. Your patients will bring it to you. If you want to be a physician, if you want to participate in the process of healing, not only are you going to have to hear it willingly, you're even going to have to ask for it.

A patient will come to you with headaches caused not by a brain tumor but by the stress of living with an alcoholic spouse. Or with aches and pains caused not by flu but by the fear that his unacknowledged homosexual activity has resulted in AIDS. Or with abdominal pain caused not by appendicitis but by fear of failing in school and disappointing her parents. A patient will come to you with uncontrolled hypertension who is not taking his medication because he can't afford it, or because it makes him impotent, and he will not be able to tell you that unless you ask him those specific questions. You cannot help relieve the symptoms, much less attend to the underlying distress, if you are not willing and able to ask gently and professionally hard, intrusive questions and then to receive quietly and professionally the sometimes profoundly disturbing answers.

Your promise to protect your patients' confidentiality enables them to have confidence in you, to trust you to receive the stories that have to be told. But placing yourself in the receiver's position also entails some risk for you -- and that is why openness to risk is the other attribute of your now professional self that I want to focus on tonight.

There are lots of risks involved in being a physician. There is the obvious risk of being sued and the equally obvious risk of catching something from a patient. There are few students who can get through the rotation in pediatrics without coming down with diarrhea or pinkeye or at least a cold. You're going to hear a lot -- and appropriately so -- about our risk of contracting the HIV virus from contaminated body fluids. There are lots of risks; I even got socked in the jaw once by an irate mother. But these are not the risks I want to talk about. The risk that you take on when you agree to hear what patients have to tell you is not so much the risk of disease or injury as it is the risk of personal distress.

Approximately one in eight of the patients you will see has lived in a family in which at least one family member was alcoholic. Based on a study of medical students, we estimate that one in four of you comes from a family that includes an alcoholic. Approximately one in four of the patients you will see and one in four of you, men and women alike, were sexually molested in some fashion during childhood. Some of you have never experienced the death of someone you love; some of you have experienced one death too many. When you begin hearing patients' stories, you will at one point or another hear portions of your own story. Their tragedies and their fears are human events, and you are human. You are going to hear things that may trigger memories you have been sitting on for years. You will hear things that may make you furious, or make you weep, not only because of their intrinsic emotional content, but because you're still so angry or so sad about something that happened to you. You will hear things that may make you withdraw from your patient because you're not yet ready to face that subject. You will hear things that may repel you because you have not yet started to reckon with the difficult distinction between rules and people. Ideally, we have all already dealt effectively with the skeletons in our own closets, and are now able to hear and receive our patient's skeletons with the grace and equanimity and humility that come only from knowing that we all have them and that they all have to come out into the light of day if we are to be whole and real. But, if we have not yet faced those demons, whatever the patient triggers in us may make us protect ourselves by trying to take over the patient's story and fix it our way, in order either to keep our own fears quiet or to act out our own anger or sadness. Either way, whether we react with apparent indifference or with indignation, if we have not worked on our own stories, we are much less able to hear and respond appropriately to the needs of the person who has sought our help.

Knowledge of others gives us power over them; knowledge of ourselves governs our use of that power. Over the next few years you will acquire a lot of knowledge about people in general, and the patients you care for will give you even more knowledge about themselves in particular. That knowledge will endow you with extraordinary power. But to profess medicine fully is not only to know others; it is also to know yourself thoroughly and well, so that you will exercise your power for the benefit of the patient who trusts you.

You are beginning a risky business, a profession that demands more of you as a person, not just as a thinking machine, than you can now imagine. But it is also a profession that will give you more than you can imagine. You are becoming a professional privileged to be present with people at the times of crisis and of choice, the times that determine what their lives will be like from then on. You will be there to catch them when they are born and rejoice over them with their parents. You will be there to ease them as they die and mourn their loss with the others who love them. You will be the one to bring them news of joy and comfort: You're going to be fine, it's not cancer, the baby's normal. And you will be the one to bring them news that heralds pain and loss: It is cancer, the baby has some problems, we need to do more tests.

You will be present not only for those obvious crises, but for many of the other, more subtle but no less critical concerns: whether to use contraception, how to discipline a child, how to care for an aging parent, how to live with one's own aging. The almost routine questions and worries your patients will bring to you will allow you into their lives in a manner granted to no one else. The richness of what we do, of what we see and hear and know, the privilege and pleasure of having this window on the human condition, of knowing other people so intimately -- it is almost beyond telling.

It is difficult to recount the sorts of stories that exemplify the privilege of being a physician without sounding either self-congratulatory or voyeuristic. What should keep such tales from being self-congratulatory is knowing that all of us have stories of how our patients have trusted and loved us, and have allowed us into their lives in ways that are healing and nurturing not only for the patient but for the doctor. My experiences are unique to me, but they are not unique within the profession. As for voyeurism, there is a fine line between letting you see enough for you to understand what I mean when I use the word "privilege" but not adding lurid details that only titillate without teaching. I hope I can walk that line successfully with these few examples of my experience of the high privilege of being a physician:

In a small town in central South Carolina, there is a 10-year-old girl named for me. Her sister was in the hospital, as my patient, for all of her 5-month-long life, during the period when I directed a pediatric intensive care unit and cared for children with kidney disease. For two years after her death, her parents agonized with me, in many meetings, about having another child and about the risk of recurrence of the first baby's disease. They did have another child, completely healthy, and they named her Margaret -- they call her Maggie.

Now I'm a primary care pediatrician and I hear even more complex stories. The mother of a 13-year-old patient of mine asked to speak with me privately during her child's visit to clinic. She wanted to talk about her concern that her daughter was getting far too interested in a 22-year-old man and she was at a loss to know how to talk with her. So, I asked her what it had been like for her at 13. She was quiet for a moment and then she started crying and told me her story. She had been raped daily by her stepfather from age 11 to 13; at 13 she eloped with a 21-year-old man in order to get out of her house. She had her first child when she was 14. She had never told anyone about her stepfather's abuse. What is my role? I can receive this story; I can encourage her to seek help for herself from a counselor; I can help her find ways of talking with her daughter. I cannot fix her memories or her life. The high privilege here lies in the trust placed in me by this woman, that she would tell me this most painful secret because she believes I will hold it carefully and respectfully. And I know -- and I think she does, too -- that the telling of that story is the only way for her own healing to begin, even if I am not the one who can complete it.

But, then, how can I bear to hear and carry such a story? Let me tell you one more tale: A few weeks ago I had Sunday lunch in the hospital cafeteria -- because I was in my office working on this talk. A 5-year-old patient of mine was there, too, visiting someone with her family. When she caught sight of me, her eyes grew big and, with her catsup packet dangling from her mouth -- she had been just about to tear it open -- she leaned over to her mother and said, in a sort of stage whisper, "That's my doctor!" This same child just a few months ago had shrieked the same sentence at me in the produce section of Kroger. I love it.

Hippocrates also said that "some people, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician." That is a heavy statement, capable of many interpretations. But I want to leave it with you because of its clear-eyed understanding that there is more to healing than we know, more to healing and health than is encompassed in our science, and that in some way the person of the physician -- who you are -- is involved in that healing.

We believe you worthy of our trust, but more important we believe you are worthy of being trusted by our patients -- your patients. We welcome you to our profession of trustworthiness, of humility, of fidelity to those who seek our aid, of respect for their confidences, for their pains, for their pleasures. We welcome you to the high obligations and extraordinary privileges of the profession of medicine. And I wish you joy of it.

UVA School of Medicine
Welcoming Convocation/Class of 2000
August 19, 1996