University of Virginia Health System

Brian Wispelwey, M.D.

I am very grateful for the honor and opportunity to address your class as you begin your medical education. In a take off of Garrison Keillor and Prairie Home Companion Welcome to Lake Woebegone Medical School - where the faculty are all strong, the deans are all good looking, and the medical students are all above average. This is of course true of UVA (at least the last statement). You are all above average academically, have worked hard and will, I dare say, succeed at achieving your goal - becoming a doctor of medicine. But realistically, beginnings are always intimidating and there will be periods where you will feel overwhelmed, overworked and perhaps wonder why you chose to do this. How do you cope? I'm reminded of an article entitled "Bowling Alone: America's Declining Social Capital" which decried the disturbing (as they put it) decline of organized bowling leagues in this country. This is in spite of the fact that (believe it or not) more people are bowling than ever (80 million in 1993) - even Dean Carey did not know that. The point of this seeming irrelevant fact? The decline of bowling leagues is seen as a metaphor for an overall decline of a sense of community. And that at the core, community is essential for the success of the individual. I would like to officially welcome you to the community that is the University of Virginia School of Medicine (In other words - our bowling league is alive and well). You are not, and in fact cannot, be in this alone. We are here as faculty because we choose to be - we are here for you. To extend this point - a story. Two medical residents (5-6 years beyond your stage) were debating in the cafeteria about what was the single most important discovery in the history of medicine (even at lunch we live and breathe our profession). One argued that it was the discovery of antibiotics. He noted that few things saved more lives in a shorter period of time (I must admit that I am partial to this viewpoint since Infectious Diseases is clearly the cornerstone of clinical medicine). The second resident laughed and said "nice try", but insisted that the invention of computer technology was clearly the most important - computers have revolutionized diagnosis, information management, and treatment. Witness the recently highly publicized computer regulated treatment of Parkinson's Disease. At the end of their table sat an old faculty physician quietly listening. Both residents who in general felt he had nothing to offer them, leaned over and asked him to break the tie -what was most important. He smiled knowingly and stated that the correct answer lies in the fact that they even cared to ask his opinion. The greatest discovery he said was the mentor. Each of you will become a living page in the textbook of medicine and all will have mentors who will stay with you the rest of you careers. 1) When you get sloppy - you think - what would she think of me now 2) When you're confused or uncertain - he will prod you back to the medical literature 3) When you're impatient you'll remember how she was patient with you or others 4) When you doubt - you'll remember that he believed in you. As someone said, "A teacher who is not fond of students and who does not suffer their foibles gladly, misses the greatest zest in life." Many faculty are here who experience that zest. Get to know them - they're there for you.

But all does not always appear to be so wonderful with our profession if you listen to others or the media. There has been a tendency today to treat medicine as a business, health care as a commodity, patients as covered lives or consumers and doctors as providers. Quality, it is argued, is sacrificed to profit and efficiency. Some have noted that more doctors are saying things like "If I had to do it over I would choose a different profession or tell my children to avoid a career in medicine". A little perspective is provided by the anecdote from Dr. John Owen, a recently retired faculty member and a mentor to me. His father was a country doctor (as he put it) and greater than 50 years ago when John was about 12, a patient arrived at their house and asked John if he wanted to be a doctor like his father. His father overhearing stated "I hope not, it's not the same anymore - becoming too socialized". There will always be the opportunity and perhaps the need to complain but how does one respond to these various concerns about our profession. Must be grim. In the words of General Marshall Foch - "My center is giving way, my right is in retreat; situation excellent, I will attack". Part of the counterattack can be found in the words of Robert Frost -

My object in living is to unite
My avocation and my vocation
As my two eyes make one in sight
Only when love and need are one
And the work is play for mortal stakes
Is the deed ever really done
For Heaven and the future's sake

This is indeed such an exciting and yes even fun time to be part of medicine. We have learned so much scientifically and there is so much more awaiting the curious mind. Think of HIV/AIDS. I saw my first patient with AIDS 15 years ago. We have never moved faster in the history of medicine since that time. We now have therapies which dramatically prolong life to the point of whispering, at least, the word cure. Only two years ago, these therapies were considered unrealistic fantasy. However, the explosive growth of our knowledge about AIDS specifically and medicine generally, is at times daunting for those learning, teaching, and practicing. A quote from Francis Peabody: "When one considers the amazing progress of science in its relation to medicine in the last 30 years and the enormous mass of scientific material which must be made available to the modern physician, it is not surprising that the schools have tended to concern themselves more and more with this phase of the educational problem. And while they have been absorbed in the difficult task of digesting and correlating new knowledge it has been easy to overlook the fact that the application of the principles of science to the diagnosis and treatment of disease is only one limited aspect of medical practice (could have been last week - in fact 1927)". We are definitely here to train you to be scientifically competent in the practice of medicine, but if that is all - you will not be a physician. Medicine is after all a human endeavor, subject to all the limitations that mark human beings - and it is still as much art as science. How do we really go on the counterattack regarding the previously mentioned concerns? By remembering our roots, the roots of being a physician, first and foremost it meant simply to care. Science teaches us that detachment and equanimity are necessary traits for its success. But while detachment is necessary for our scientific selves, it can spell death to the concept of being a complete physician. Mechanization and the scientific enterprise as part of medicine are obviously here to stay - they work. But, we must also not allow this process to crowd out or extinguish empathy in our practice of medicine, that sense that in meeting our patients (all of them) -that I might be you or indeed I am you. Your patients again, all of them, are and must be seen for what they are - a gift - literally your textbook. Be grateful to them and for them as they teach you. Remember too, that they open their lives to you - and only to you. And - be humble. Don't be afraid to say I don't know or to ask - we're most dangerous when we don't acknowledge our limitations. While the basic aim of medicine is maintenance of health, it has be argued by one of our faculty (Dr. Childress) that environment, lifestyle, social context and genetics contributes up to 94% of what constitutes good health, while medical intervention contributes as little as 6% (are you humble yet?). So, why, with such a modest impact, a medical profession because we draw our substance from the extraordinary moral commitment of a society to care for the ill (all of them). We are here to serve and to do it well - we need science and emotion, reason and intuition, technology and narratives, equanimity and empathy.

Indeed, we have all been cautioned about not getting too emotionally involved and there is certainly some validity to this, but Lewis Thomas in his book the "Youngest Science" tells of an event that lends some perspective to this. He had just been appointed Chairman of Medicine at NYU. At his first case conference an intern presented a case of a patient with pneumonia and meningitis that he had been caring for for the last week. The patient had taken a turn for the worse the evening before. The intern described in detail what was done medically in a thorough and efficient manner, bringing to bear all of the available expertise and despite this the patient died. Halfway through the presentation the intern's eye's filled with tears, not of frustration but of genuine grief. Thomas stated that then he knew the kind of hospital he was in - he was definitely in the right place. We need to care. In order to treat the disease and potentially cure it we need the best available science, but in order to treat the illness, the patient's complete experience of the disease we need to be the best possible physicians.

Abraham Verghese, an African born of Indian parents, in his book, "My Own Country" stated that he come to the United States for medical training because he wanted to learn how to cure. However, in the process he stated he forgot how to heal. AIDS particularly has reminded us of both human mortality and the limits of medical science. Death, we have been taught, is a failure. I would argue that it is a reality. We have been taught with the following paradigm - Don't just stand there, do something - but at times we need to learn the more difficult lesson - don't just do something, stand there - but definitely stand there and be an instrument of healing when cure is no longer possible. The physician can care and heal when the scientist has failed. Importantly, caring does not stop with the patient. You have permission and in fact, a mandate, to care for yourselves.

Well, to finish, I return to Lewis Thomas as he said, "If I were a medical student or intern just getting ready to begin, I would be apprehensive that my real job, caring for sick people might be soon taken away, leaving me with the quite different occupation of looking after a machine. To do it right has never been easy; it takes the best of doctors, the best of friends". Looking over the class of 2001, I'm confident you'll do it right.

Thanks and good luck.