Convocation Speech
August 16, 2000
Norman Oliver, M.D.
First, let me say that it’s a great honor to be here. I want to thank Dean Carey for inviting me, and I appreciate Dean Wheby’s kind words of introduction.
While preparing my remarks for tonight, I realized that exactly 10 years ago to the day I was sitting in a similar position as you all. People often see my gray hair and assume I’ve been in this profession for a long time; however, it was only 10 years ago today that I started medical school. I’d had a successful career in journalism. I’d written hard news stories about strikes, wars, revolutions; I’d written soft features about education and entertainment. In my last job as a journalist, I was a managing editor of a group of 10 medical magazines published by Harcourt Brace Jovanovich.
Throughout all those years as a journalist, I found myself most interested in the people about whom I was writing. No matter how momentous or meritless the event appeared from the viewpoint of its newsworthiness, real women, real men, real children were living those events. Their experiences in those events — their joy, their anger; their love, their hate; their triumph, their frustration; and, above all, their pain and suffering — their experiences, how they lived those events, is what captured my attention. I wanted to add fire to their passions, add my rage to theirs in denouncing the injustices they faced, be warmed by their love, exhilarated by their triumphs, and I wanted to be a salve to soothe their wounds. I wanted to ease their pain and suffering. I wanted to be a healer. I wanted to care for people.
And isn’t that what brought you all to medical school, as well? It certainly wasn’t the money! You all gave up the lure of the dotcoms to come to medical school. Not that physicians are poor. As a group, physicians fall well above the 90th percentile in income. We’re not suffering financially.
All I’m saying is that that’s not what gets us up in the morning. I’ve yet to meet a practicing physician whose primary motivation was making money. I’ll tell you what jazzes me: not making money, but making connections. I remember being a senior resident and walking through the cafeteria of the hospital where I trained. Myself, an intern, and a medical student were on our way to the wards to do our morning rounds. A young woman called out my name, ran over to me, and gave me a big hug, saying to my intern and medical student, "This man is so kind and wonderful! I hope you learn from him." I turned to them and said, "This is what I practice medicine for!" The previous month, her husband had died of lung cancer on the service I was on. I had been there with them, sharing their sorrow, and, with them, trying to make sense of his disease.
While living in Alaska, I worked in the Emergency Department a lot. For the last year of my stay in the bush, I was the Medical Director of the ED. I remember one winter night when a young teacher was brought into the ED by the Rescue Squad. She had fallen on the ice, hitting her head. She was conscious, and I walked up to the gurney to take her history and perform my physical examination. I noticed how frightened she appeared, so I took her hand and said, "You look scared. You know, it is scary; but we’ll help you through this."
My wife, Susan, met this teacher a few days later at a social event in the village. She told Susan that she had been surprised but greatly pleased that I was as concerned about her fear as I was about her head.
The other day, I made a home visit to see a new patient of mine. He’s a 92 year old gentleman who lives on a horse farm in Orange County. A year ago, he was still riding horses and fishing in the farm pond behind his house. Now, he’s bedridden, sickly, and declining. I talked at length with him and his family, getting as much of his medical history as possible. I did my physical exam, and then we discussed several specific complaints he had. Somehow, we got onto the subject of fishing. His wife told me how much he loved fishing in the farm’s pond. So, I asked him if he’d take me out fishing in the pond someday. His eyes just lit up! I believe that vision — perhaps more than anything else — will get that gentleman out of bed. I’m betting I’m going to get a call to go fishing one day. And when I do, I’ll grab my rod and reel and go.
It’s embarrassing, in a way, to tell these stories. I’m really not trying to toot my own horn. I’m just using some personal examples to show how it’s the caring, loving, and trusting relationship between physician and patient that makes being a physician such a joy. I believe it’s what our patients remember most, too. It’s what they take any from the clinical encounter. I’m also convinced that it’s in the context of such a physician-patient relationship that healing actually takes place.
In 1926, Francis Peabody, a rich, Harvard-trained physician gave the lecture in which we find the often quoted statement, "The secret of the care of the patient is in caring for the patient." In this lecture, printed in the Journal of the American Medical Association in 1927, Peabody spoke about the difference he saw between hospital care (which he considered disease-focused) and medical care provided at home (which he considered personal):
"The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both the diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients."
Of course, compassion without competence is crap. You have to learn the science, learn the evidence that backs up your biomedical practice. And you must become lifelong learners because what you learn today will become stale, and outdated tomorrow. You’ll need to refresh your stock of knowledge from time to time.
But learning the biomedical science is the easy part. Learning to care for patients — that’s tough! It’s more than learning communication skills. Caring is a form of joining, of connecting with others. We have to learn, first of all, to create a context for caring. That begins with understanding that everyone who comes into your office is worthy of recognition and deserves some positive regard from you. People clean up and put on their best clothes to come see us. They hold us in high regard. A kind word about how well a patient is doing about coming into the office regularly — although she is poorly managing her diabetes — shows recognition of the fact that she’s trying. It builds a bridge between you that may lead to her improving her management of her disease.
We build a caring relationship by making the patient feel as though we recognize her as part of her own world. We acknowledge her uniqueness by paying attention to her individual peculiarities, the details we know about her life. Her need to find child care in order to come to your office. The two buses she must take to get there. Her precarious situation at work, and what losing that job would mean for her and her family.
We build a caring relationship by sharing experiences, disclosing something of ourselves to her as we ask her to reveal herself to us. We can disclose something of ourselves as an example, as when I explain to a new Mom with a colicky baby my own experience walking the floor with my colicky daughter. We sometimes share our own experiences as a way of empathizing with a patient. I’m much more understanding of the patient who comes in to see me with gastroesophageal reflux — even if it’s at 3 a.m. in the Emergency Department — since having my own bout of it about a month ago.
In a caring relationship, the physician recognizes the meaning a patient’s symptom or illness takes on in her life. For example, recognizing how scary a fall on ice and blow to the head can be. Treatments can be scary, too. We should pay more attention to what our treatments mean to our patients’ lives.
We also show caring when we express real feeling. In one of your first-year classes, the Practice of Medicine, you will learn, among other things, the importance of being a good listener. We’ll help you acquire skills at reflective listening, where you elicit the patient’s feelings through reflecting them back in statements like "You’re angry about that," or "You seem sad." In a caring relationship, however, you go further, showing your own feeling. It’s one thing — an important one — to say, "You seem pleased." It’s another to say, "I’m really happy for you!"
Is caring a natural ability? An essential quality possessed by a select few? I don’t think so. It can be taught, and it can be learned. Put a lot of thought into this subject throughout your medical school years and throughout the rest of your careers. Make the effort to practice building caring relationships as you begin seeing patients. It’s important for their care — and for yours.
I’ve talked about caring for patients. However, I think we’re obligated to care for people outside out exam rooms, as well. I obviously don’t mean that we should seek to take care of all patients. As a physician, you can only attend to specific patients. However, the same moral necessity that drove you to medical school ought to make you outraged at the disparities in health between whites and racial minorities; ought to make you bemoan the lack of access to health care faced by millions in this country, and billions around the world; ought to make you lament the scourge of AIDS in Africa; ought to make you sick when you consider that some 4 million children around the world will die next year from the sequelae of measles — a disease that should kill no one.
The dilemma of how to respond to sick and suffering people outside our personal reach is a challenge to medicine. No matter how much you do in your clinic, there’s always more needy people elsewhere. Too often, we solve this dilemma by burying our heads in the sand. "Oh, those are social problems! I can’t deal with that; I can only handle the patients I see in clinic."
Rudolph Virchow had something to say on this subject. You’ll hear about Virchow a lot in the first couple of years of medical school. A noted German physician in the 19th Century, he is known as the "Father of pathology." You’ll learn of "Virchow’s node" and "Virchow’s triad" and, perhaps, of his campaign against cholera. Unfortunately, you may not learn that Virchow was not only a great physician, but a German revolutionary. He was active in the 1848 revolution to overthrow the Prussian king and establish a democratic republic. Virchow believed that the pain and suffering of millions in the Prussian Empire was the result of the social policy of its rulers, and he argued that being a good physician meant fighting to change social policy. It was Virchow who said, "Medicine is, above all, a social science, and politics is medicine practiced on a grand scale."
Let the moral exigency that brought you to medical school drive you to learn your science and practice the art of caring. Let that same necessity cause you to take off your white coat and join others in the social and political arena to care for the health and well-being of the millions who don’t make it to your exam room.
So, this is my challenge to you: take care of your patients. I have the utmost confidence that you’ll do just that. Welcome!