Those having torches will pass them on to others
Gary V. Desir, M.D. ’80, HS ’83, FW ’84, professor and chair of internal medicine, delivered the keynote address at the White Coat Ceremony welcoming the Class of 2020 to the School of Medicine.
Dean Alpern, thank you very much for the very kind introduction. Dean Belitsky, Dean Angoff, and Dean Lee, I thank you for the invitation to speak here today. Good afternoon ladies and gentleman, and good afternoon Class of 2020. I am delighted to be here, and grateful for the opportunity to welcome you to the Yale School of Medicine.
As you’ve heard from Dean Alpern, many of the experiences and events that have shaped my career, and my personal life have taken place at Yale. Many years ago, I was where you are now, looking forward to getting through orientation week, and looking forward to learning medicine at Yale. Like you, what attracted me to Yale was its reputation for outstanding research and clinical care, and of course the Yale System. I was looking forward a certain degree of intellectual freedom, and also to freedom from weekly tests.
And let me say at the outset that that my experience as a medical student at Yale was absolutely wonderful. I had to learn lots of facts, new words, and new concepts. But I felt privileged to have been taught by faculty who had either made important discoveries, who were in the process of making them, or were going to make them.
I also had to learn the language of medicine, its mechanics, how to interview and examine patients. As a second-year medical student, I first became acquainted with the seemingly magical process of clinical reasoning and diagnosis, as practiced by Dr. Thomas Duffy. Dr. Duffy is a hematologist and he was discussing an unknown case at a clinical conference in Fitkin amphitheatre. He was eloquent, he arrived at the correct diagnosis by effortlessly connecting seemingly disparate clues, and his knowledge of pathophysiology was extraordinary. To me, Dr. Duffy will always be the master clinician, a clinician sans pareil, one beyond compare. To honor Dr. Duffy for his contributions to the Yale School of Medicine, we have renamed the hematology firm as the Duffy firm.
I also met a young woman. I had shown up for anatomy lab a bit early, and was standing in the hallway, looking confused perhaps, when I was approached by one of my classmates. And he explained that he had been tasked with finding one other person to join his anatomy table, and asked if I was interested. I said yes, and walked over to the table, and there I met Deborah for the very first time: over a cadaver. And we were married three years later. So my advice to you is: go to class, show up on time, and great things might happen.
After graduating from Yale Med, I trained in internal medicine and nephrology at Yale New Haven Hospital, and then joined the faculty. And I have to admit that it was much later in my career, that I come to understand and fully appreciate the origin and intent of the Yale system, and its true value.
If you enter Sterling Hall of Medicine through Cedar Street, and look up above the entrance to the rotunda, you’ll see a Greek inscription, taken from Plato’s Republic, and which reads: “Those having torches will pass them on to others.” This inscription was chosen to celebrate the establishment of the Institute for Human Relations at the School of Medicine in May 1931. The institute brought together the department of psychology and the sections of research in economics, government, sociology, and child welfare and development. It was the brainchild of Dean Milton Winternitz, who had argued that medicine was a social science, and that the teaching of medicine was too disjointed, and its practice too specialized. So the medical school curriculum was patterned after that of graduate schools, and designed to be more elastic and to liberate the students’ time. And so, in late 1931, the Yale system was born.
It has changed and evolved over time. It is not the same as what I experienced as a medical student. But I believe the fundamental principles have remained constant. What I now understand, and hope you will also, what is unique is that Yale provides the intellectual environment for the molding of mind and character that enables ones adapt to different circumstances and changing obligations, and outfits one for life’s work in medicine.
And this is extremely important since you’ll be learning medicine and eventually practice it in what one could call “interesting times,” in a system of health care that is undergoing major changes.
On the one hand, we’ve made great progress in understanding disease mechanisms, and in many cases we have used this knowledge to develop remarkable treatments. For instance, we now have a much deeper understanding of the pathogenesis of cancer, and can design rather specific and effective treatment protocols that minimize toxicity. When I was a resident, I cared for patients with a mysterious and deadly disease. It went by different names such as GRID, ARC, and 4Hs. We now understand the pathogenesis of HIV/AIDS, and can prevent infection and treat the disease much more effectively. I also cared patients with non-A, non-B hepatitis, and then for patients with hepatitis C. And now we can cure hepatitis C in about eight to 12 weeks. The treatment is a bit expensive, but it’s curative, and getting cheaper. I marvel at the technical wizardry of interventional radiologists and cardiologists, and their ability to repair blood vessels and safely replace heart valves percutaneously without surgery. We can monitor gravely ill patients remotely from a virtual, electronic Intensive care unit, which could be located anywhere, and advise on appropriate treatments for them.
We are witnessing a new era of precision medicine, of personalized medicine. We discuss population health, global health, and are beginning to recognize the limits of medical interventions, and the extraordinary importance of the social context in determining health outcomes. These are all wonderful developments.
On the other hand, there is growing concern that some of the changes currently underway may not necessarily benefit patients. An article published a few months ago in The New York Times and entitled “Why the Economic Payoff from Technology Is So Elusive” examined why smart phones and computers and all that technical wizardry seem to be having so little impact on the economy. The government reports disappointingly slow growth, and, perhaps more importantly, a small decrease in productivity over the past few years. The authors argued that one of the best places to look at this disconnect was in the doctor’s office, and highlighted the case of a family physician practicing in Tennessee who had shifted to computerized patient records from paper in the last few years. This change made the physician feel less efficient and less productive. Quoting him, “I’m working harder and getting a little less, but I think my patients are better served, and I’m happier for that.”
But what do patients think the current state of affairs in medicine?
Let me tell you a story that might provide some insight. The patient is an elderly, frail gentleman who falls down a flight of stairs, and is brought to the emergency room. It turns out he has sustained a cervical spine fracture, and he has respiratory arrest. The medical team responds appropriately, he is intubated and bought back to life. Two weeks later he is transferred to a rehabilitation facility and eventually returns home a month later.
He subsequently obtained his medical records and is now reflecting on these events and writes the following. “What did this experience teach me about the current state of medical care in the U.S.? Quite a lot, as it turns out. I always knew that the treatment of the critically ill in our best teaching hospitals was excellent. But what I hadn’t appreciated was the extent to which, when there is no emergency, new technologies and electronic record-keeping affect how doctors do their work. Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient.” He continues: “Reading the physicians’ notes, I found only a few brief descriptions of how I felt or looked, but there were copious reports of the data from tests and monitoring devices. Conversations with my physicians were infrequent, brief, and hardly ever reported.” The patient was a graduate of our residency program, and his name was Arnold Relman, emeritus professor of medicine at Harvard, and former editor of the New England Journal of Medicine (1977–91). And he tells the story in a piece published about two years ago, and entitled “On breaking one’s neck.”
You’ll be learning and eventually practice medicine at a time when the health care system is changing.
So what should be your focus, our focus? I’d submit we should focus on the fundamentals tenets of medicine, well, the cornerstone of medical practice and medical research is the bond of trust between the patient and health care providers. Interpersonal trust develops when patients believe that physicians will act in their best interests. The key attributes identified by patients as fostering trust include technical and interpersonal competency, and fiduciary duty. Since you will have graduated from Yale, patients will make certain assumptions about you. They will assume, and rightly so, that you are smart, that your clinical skills are outstanding, and that you can make the correct diagnosis and prescribe the appropriate treatment.
That’s a good start, but only a start, and is not enough. What you will also have to do is prove to them that you care, that you are willing to listen and hear their story, that you always provide them with complete and honest information, and that you will always act in their best interest, and put their welfare ahead of other considerations.
Our health care system is not particularly well designed to foster trust between the patient and the doctor. Yet, somehow, as patients have become better-informed, and have grown increasingly more distrustful of the health care system, of government, of lobbyists, and of corporations, their faith in nurses, pharmacists and physicians has proved remarkably durable. According to a gallop poll published about eight months ago, most of those surveyed still believe health care providers to be ethical and honest. Eighty-five percent believed that nurses were ethical and honest, and 67 percent believed the same of physicians and pharmacists (an improvement of 2 percent over last year).
Each one of you will have the extraordinary opportunity to play a critical role in maintaining and improving the health of patients either through clinical work and or research, and as you do so, please make sure you earn, and preserve their trust.
Let me finish with another story, one that highlights the importance of trust, and touches on the power of being present.
I am originally from Haiti and go back quite often to visit with friends and family. But the trip to Haiti in March of 2010 was very different. I was traveling with a group of four Yale physicians including two trauma surgeons, a pediatric intensivist, and an emergency room physician, along with six nurses. And were going to work for a week at the main public hospital in Port-au-Prince, the capital city. Three months prior, approximately 10 percent of the population of Port-au-Prince, or about 300,00 people, had perished in an earthquake. The quake had destroyed or damaged 16 of 18 government buildings including the national palace, a large number of businesses had been affected, the elementary and high schools I had attended had been leveled. The hospital and the medical school had been severely damaged and the building housing the nursing school had collapsed, killing 200 nursing students.
Our group was assigned the night shift, and was responsible for about 300 patients. The pediatric ward was in a tent in the courtyard, as was the intensive care unit. The medicine ward was inside a one-story building. Few medications were on hand, and lab tests were not available. On my ward, there were several young women who had developed severe heart failure following a normal pregnancy, several patients with severe kidney disease who needed dialysis, which we could not provide, one patient with leukemia, and many others. Our routine was to visit with each patient, examine them, talk to them, meet their family, and get to know their story a bit better, and write a very short, daily note in each chart.
We could not do very much and had very few options for therapies. At times, the team expressed frustration, and talked about the futility of what we were trying to contribute, and wondered if we were contributing anything at all. But to everyone’s surprise, our patients did not see it that way at all. As we were getting ready to leave, they expressed extraordinary gratitude to us for being there and caring for them, and said they trusted us and believed we were doing the best we could for them, given the circumstances.
This experience reminded me that when the usual accoutrements of modern medicine are not available, or we reach the limits medical science, and of what we can do, one can more easily and fully appreciate the human side of medicine, the value of empathy, of understanding, of humility, and the extraordinary power of being present, of being there for someone in their time of need.
Let me close by reminding you that in our daily lives, we experience and shape the culture of the institution. Here at Yale, we foster excellence and collaboration. And we aspire to cultivate an inclusive and professional culture that celebrates diversity, respects individual differences, recognizes and rewards diverse talents, and helps each person reach their full potential. You are all very talented, and have extraordinary potential, and can accomplish great things. So in that spirit, we will pass our torches on to you, we will help you carry them for a while, and then the rest will be up to you.
Once again, welcome to the Yale School of Medicine.