White Coat address: "Lessons learned as a medical student: my near misses"

Address to first-year students at the White Coat Ceremony

August 15, 2013

George Lister, M.D. ’73

Welcome students, welcome parents and welcome friends and supporting cast.

When I was a student during the baby boomer boom many of us were told, “look to the left; look to the right; 50 percent of you will not be here at graduation.” I am now pleased to tell you that not only will 50 percent of you be here at graduation but 50 percent of you will be here many years past graduation, particularly with the Yale system.

No, parents, Yale is not the school for slow learners. Rather, it is a place where there is a lifetime investment for exceptional students, but with exceptional expectations bestowed simultaneously. This additional time will not be frittered away. The lack of grades and the Yale curriculum are not intended to give you protracted relaxation. They will only free you to exercise your industrious nature, extend your reach past your current imagination, and stimulate those around you with your questions and insights.

Our job is to help you develop the empathy to understand the human condition of your patients while simultaneously helping you acquire the tools to think critically about their health. As was said by Yeats, “Education is not the filling of the pail, but the lighting of a fire.” Where does that fire arise in medicine? From the bond that develops between patient and physician while they pursue the very same goal: the improvement of health. What I hope to convey today is that this intersection of empathy and your unrelenting scientific inquiry will become the basis for the durable relationships you develop with your patients; it can also provide the energy for remaining on the steep part of your learning curve throughout your career.

Although we all have a huge interest and investment in your education, no one here at Yale nor at home will be waking in the morning trying to figure out how to make your day more interesting, what experiences you personally need to become the physician you desire, or where your steps should be precisely placed to achieve your aspirations.

Our function is to provide you the sophisticated foundation and conceptual framework for you to develop and test expanding comprehension of medicine, so that you can become the master of your education.

There is no way we could provide all the detailed information needed for you to be a contemporary physician. No one of us knows what medicine’s going to look like in 5 years, let alone 25 years when you will be in stride in your career. Rather than cultivate an expansive memory bank, we must help you develop the skills to explore and understand what you have never confronted before and the nimbleness to adapt to a changing landscape of medicine. You will be provided an open field with many roads untraveled. The itinerary will fall on your shoulders to develop. We intend to provide opportunities for you to discover your passions, but it is up to you to make your career interesting enough to engage you for a long time, complex enough to keep you up at night thinking and learning, and gratifying enough to sustain you, while you revel in the satisfaction of helping others and the privilege of building those personal bonds.

But why the thesis? Why the investment on having you learn to become physician scientist? Why the time to explore novel ideas? Skeptics might look at your education here and say, “Why do you need this if you are going to be a practitioner of medicine?”

Because regardless of the path that your career takes, the advancement of medical science and the care of patients are inextricably linked. The habits cultivated by formulating and pursuing an important question through a thesis here can foster the very qualities that make you a better physician. When you become deeply invested in the questions prompted by the care of your patients and demonstrate curiosity and an intrepid pursuit of these, coupled with compassion, your patients will recognize and benefit from that deep interest. The thesis can also tap the creativity and excitement of those of you who have never engaged in research and it will potentially redirect your career.

It’s now appropriate to confess to you: I love being a physician and wake up every day with excitement. When I started at Yale Medical School, I do not recall any reception or white coat ceremony, but I certainly remember my first days of classes. I was simply overwhelmed and in awe of my classmates. Although I could name most of the major body parts, I was lost in the details of anatomy. I was familiar with a few diseases, but the acronyms and eponyms went flying about and I was quickly lost. I quickly realized that I was destined become an acronym challenged physician. I even made up acronyms so I would be in the swing of things. TEON (Two Eyes One Nose) remains my best contribution.

Perhaps you like me, may be quite intimidated by the language of medicine and the facts that others have already acquired. Don’t worry, you will learn these in due time and often without realizing it. Thankfully, however, I was able to appreciate the extraordinary talent that surrounded me and savor the intelligence, creativity and diversity of my classmates. Although I knew I would learn much from the faculty – and indeed I did – the constant refinement, revision, exploration of an idea, even one that was not well formed, came from my daily interactions and nightly interactions with my classmates, as it will for you. They helped me develop rigor and accountability in my ideas. I was forced to make sense when asking a question or trying to propose a concept. Even today, as I serve as a preceptor in one of the first year courses, I know that the group is really clicking when I see students teaching each other and I am silent.

In my early interactions with patients I often felt uncertain of my role or, even worse, like an imposter or intruder. However, I also learned my most critical lessons from these moments and discovered that my interactions with my patients would create the greatest motivation for my learning. I would now like to share some of these lessons.

While not doing so well with cadavers, my first encounter with a patient was even more disconcerting. My faculty preceptor worked with individuals with chronic illness and I was scheduled to meet and interview one of his patients. I dressed up, combed my hair (ah, for those days), reviewed all the questions I needed to ask, rehearsed the order, put on my white coat and headed for my first clinical encounter. I met this tall, somewhat weathered and jaundiced individual and asked him why he was at the hospital. He then said he had Banti’s syndrome. I looked at him, he looked at me, I looked at the ground. He knew I didn’t know what he was talking about. I sheepishly asked him to explain it, which he kindly did, letting me know it was chronic enlargement of the spleen cause by back up from high pressure in the liver. There’s more to it, but that was enough to start the conversation. Just imagine if the tables had been reversed and I told him he had Banti’s syndrome without explaining what it meant. What did I learn? Certainly less about Banti’s syndrome than an important lesson, one that I shall not forget: speak to patients in clear language; they will appreciate understanding what you have to say. Now, I often stop rounds when they are riddled with jargon that leave many, most importantly the patient or family out of the conversation. Everyone is often nodding as if they understand, but no one has the courage to ask.

Another lesson came later in medical school, when I was working in the emergency room during the night. I was told by a resident who graciously woke me from my coma at 3 in the morning, that I could go see the next patient. The patient was a 14-year-old girl who came with her mother because of an upper respiratory illness, also known as a cold. My first inclination was to wonder why a 14-year-old needed to come in the middle of the night for a cold and disturb my sleep. Was this simply convenience for her and inconvenience for me? Then, just before I might have said something highly inappropriate and regrettable, I realized that no patient ever set an alarm clock for the middle of the night to wake a doctor he or she has never met. My responsibility and challenge was not to chide her for coming to the Emergency Room, but to understand why and what problem created the impetus to do so. As it turned out, she was scheduled to have cardiac surgery in two weeks and was having palpitations and had an irregular and abnormal heart beat. This experience certainly taught me: Do not to challenge the reason but try to understand the basis for it when a patient seeks your care.

On another evening in the Emergency Room I saw an infant with fever and irritability and what I thought might be an ear infection. It was good practice for me as a pediatrician, where everything you do not understand with an irritable infant could be an ear infection. I was not sure what he really had or whether the treatment would be helpful, and the thought of not knowing was really gnawing at me. I soon realized the only way I would figure out was to call his parents the next day and ask how their child was. This was a game changing experience for me. The family was astounded that a “doctor” whom they hardly knew was interested enough to find out how their child was doing. I, of course, wanted to know whether I had been close to correct in my diagnosis or management and this was my only hope of learning. Most patients get better independent of the doctor, so I am not so sure I was going to learn precisely what I wanted to know. However, what I really learned is how important it was to show a family that I cared. Many have said this, but I reinforce the lesson: call your patient before you are called; you can learn about the course of an illness and change the relationship completely.

When I was a 3^rd year student on a rotation in internal medicine at an outlying hospital, I was asked to substitute for an intern who had been ill. I was assigned a patient with a complex history and one who, regrettably, had drained the emotions of everyone around him including his family. He was being seen by a consulting neurosurgeon to discuss a possible operation that everyone thought was necessary. However, after asking a few questions of the surgeon, he turned to me and asked what I thought. I was no sage, no expert, and certainly not even headed towards neurosurgery. However, I had spent time with the patient, perhaps much more than others could afford. For this fleeting moment, I no longer felt like a fifth wheel, I was his doctor. He showed me at that time that authority can arise from trust, not just station.. His question stopped me in my tracks. As I said, I no longer felt like a fifth wheel or an intruder, but potentially useful to a patient. That still didn’t make me an authority who should give advice, but it showed me that I would not be superfluous if I took the time to engage with my patient. It also showed me that responsibility, not grades, is the most compelling driver for education, which is the very basis of the Yale system.

Perhaps my most humbling moment occurred during my first rotation on surgery. I apparently was not a stellar student there. When I received my evaluation from the chief of the service, he let me know in a cordial way that perhaps this was not the field for me. I said you mean surgery? No, his look made me think he meant medicine.

I was demoralized. My confidence and spirits were at their lowest. However, I was fortunately assigned to pediatrics next and in short order found my home. I helped care for an infant with severe congenital heart disease and watched a cardiac catheterization to figure out the nature of her abnormality. She had a tragic outcome, but I was mesmerized by the utter challenge to understand the complexities of oxygenating her tissues that were created by her abnormal anatomy. I then approached one of the cardiologists shortly after the tragic death of the infant with a barrage of questions to learn if I could find a means to quantify the circulatory disturbances. I regret my utter insensitivity in failing to realize the inappropriateness of my timing, but for reasons that mystified me at the time, my questions were welcomed. I was told that they could not be readily answered but they might be the basis for a study. I was told I might want to pursue this then two of the pediatric cardiologists, who became lifelong friends, proposed me for a research project and fellowship at another institution, which I was fortunate to receive. When I arrived one day in the research laboratory of a renowned investigator, he handed a stack of papers and equations concerning a method to measure metabolism in infants, a key to the questions I asked. I was fascinated by the problem given to me, stayed up all night, proposed a possible solution, and started to build equipment to test the solution while my mentor headed to a research meeting. I was hooked forever. This actually became my thesis, my first publication. Suddenly, my career had challenge, momentum and direction.

So what’s the message? I discovered my path here, not by deliberation or deliberate planning but by serendipity, because of the generosity of spirit from those around me and the unrelenting expectation that I would find my way given the freedom to explore. I am driven in my field of critical care pediatrics by an intense pursuit of the basis for illnesses that afflict my patients. The seeds for this drive were planted through my experiences here at medical school. It is this pursuit that helps me bond to my patients and their families, invigorates me and keeps me from tiring and becoming complacent. I feel extraordinarily fortunate to have found this source of fuel so that I look forward to coming to work every day and do not find it tedious even 40 years after graduating. I have no doubt you can savor that very same spirit – take a risk and follow something fascinating. This is your opportunity to do that.

I do not expect you to leave here today with a lasting memory of my stories, but I have tried to prime you for what is to come. I hope that you can reflect someday on the opportunities here that opened the door for your exploration and on the many experiences with your patients that forged the way you practice medicine.

You are the next generation of this field and our best hope for shaping medicine and health care in the future. Your vast talents brought you to this point. Each time you don your white coat you have the obligation and a privilege to make this world better. We are counting on you.

Good luck.