Commencement Address to the Class of 2000, Harvard Medical School

It was an Irishman who gave the best advice I've heard regarding the delivery of a commencement speech. Father Flynn was the president of St. John's University, where a young man was anxiously preparing to speak for the first time. That young man, Mario Cuomo, the future governor of New York, asked the priest how he should approach it. "Commencement speakers," said Father Flynn, "should think of themselves as the body at an old-fashioned Irish wake. They need you in order to have the party, but nobody expects you to say very much."

It's true that only so much can be said in the 10 minutes or so that I have on this special day, this day when we, the graduating class, are being honored. But I hope that by the end of these 10 minutes, I will have adequately conveyed to you something that I learned over the past few years that has become extremely important to me.

But before I begin, as I look across the faces of all the people gathered here to honor us, I can't help but think that these honors . . . are misdirected. Today, we students spend much of our time talking excitedly about the recent improvements in medicine or the new services in our hospitals, but we don't often realize that things haven't always been this way. We also don't recognize the great costs that have been borne by the physicians before us . . . to make things the way they are today.

One of America's best-known physicians in the early 1900s, Dr. Richard C. Cabot, was not only an exceptional medical scientist, but also a champion for greater humanitarianism within medicine. So deeply felt were his convictions, that Dr. Cabot chose to leave medical science altogether, to focus solely on patients' concerns. Among many other achievements, he went on to start the first hospital program for social work in the country. At the time, many of Dr. Cabot's colleagues vehemently disagreed with his vision, some going so far as to say that the hospital's concern ended . . . when the patient went out the door. In 1912, Dr. Cabot was passed over for the prestigious Jackson Professor of Medicine, a Harvard Medical School position that many would later come to believe he clearly had deserved. Though he was rejected in his own time, it is the generations after him, those doctors who came before us, who accepted Dr. Cabot's vision. In fact they not only accepted it, they embraced it, working hard to institutionalize it . . . before handing it down to us.

Today, every hospital in this country incorporates social work as a key component of patient care--because of them. . . And yet the irony is, today is set aside to honor us. Incredible sacrifices have not only been made by those in the medical community; they have also been made . . .by the people sitting right behind us, the people all around us. The people who have traveled from all over the world to be here and honor us-- our loved ones.

It's our families and friends-- those who spent years putting food in our mouths, and changing our diapers, cleaning up after us and supporting us through thick and thin. They were the ones who taught us the core values that no one else really could; all the while never expecting to be repaid for this.. . . And yet the irony is, today is set aside, to honor us.

So how can we thank them for this? How can we repay our teachers, our loved ones for their decades . . . of changing the world for us? Well I believe that there is a way. And we can learn it . . . from them. We can learn it by asking them . . . what their professors gave to them, and what their parents did for them. And by that tiny gleam you can barely catch in their eyes, that distance you can faintly hear in their voice, you begin to understand how they are thanking their own professors and parents-- through us. And it dawns on you, that there is much more than just "us" and "them." You realize that we are really just the next chapter in a long, long story; we are really a gift of gratitude from the generation before us, to the generations past. And now we can fully understand how it is that we can repay them. We repay them by making this world a better place . . . for our children, a better place for our students . . . a better place for our patients.

Now, as an HST student, I firmly believe in the value of medical research, but it isn't what I learned from science that I want to share with you today. Nor is it everything I learned as a medical student, or a "fledgling" doctor. What I want to share with you is what I learned . . . as a patient. And I would also like to share with you my thoughts on how we can further improve medicine, just as the generations before us have.

You see I started having SZ's over 2 years ago. And I soon found out, that they were due to cancer . . . an oligodendroglioma, or a type of malignant brain tumor. What's more, the MRI showed that it was too big to fully remove, so surgeons here at the Brigham Hospital just took out as much of it as they could. Unfortunately, the tumor continued to grow, and soon I was having 3 SZ's a day, even while taking over 20 pills of medications. So I underwent chemoTx for the next year. And what happened since then? Well, the chemo certainly helped, but unfortunately I still have SZ's. I keep track of them every day, and since the beginning, I've had well over a thousand. And because of them, I had to give up driving completely, long over a year ago. I also just had another surgery 5 months ago, getting this electronic anti-SZ prosthesis, a pacemaker-like device, implanted in my chest, pulsing my Vagal nerve every 5 minutes. One of its side effects is an alteration of my voice, through the recurrent laryngeal nerve. So when you hear me get "something stuck in my throat," which is what I tell people, it's not because I really have something stuck in my throat. If you were to look at your watch, you'd see me get something stuck in my throat again, exactly 5 minutes later. Fortunately, it appears that some combination of the device and the medications, has led to a decrease in my rate of SZ's, and for that I am thankful. But as for the tumor itself, it's still there. When I look at it, in my latest MRI, it looks right back at me. It's estimated, that there is a 30% chance of fatality.Upon hearing this, a close family friend smiled and said to me, "You know, things could be worse. It could've been a 30% chance of survival." And you know what? I think he's absolutely right.

So there are some things I can share with you; one thing really, that I learned through being a patient. And what is that? What is the important component of medicine that I learned through being a patient? Could it be the MRI, which enables us to see my tumor? Or maybe it's the chemotherapy, an approach that appears to have slowed the tumor's advancement. Or perhaps it's the incredible surgery--brain surgery I underwent while kept awake. Which of these do I feel is most important?

I would have to say this: as truly valuable as they all are, it really is none of them. You see it turns out that because of the nature and size of my tumor, the question of even undergoing surgery was not at all agreed upon. One highly respected neurosurgeon I saw recommended surgery, while another one felt strongly that we should not proceed.

I had to choose one, and I chose to proceed--not out of any false hope, or any study, or because of the incredible reputation of the doctor . . . but because of the look in his eyes. I chose to get my head shaved, my skull opened, and part of my brain -- my very mind -- taken away. All . . . because . . . he, Dr. Peter Black, truly cared.

Now medicine has come an incredibly long way over the years. And because of our doctors and professors and even Dr. Richard Cabot, not only has the science of medicine advanced, but the very thinking of medicine itself has changed. And yet, the most important aspect of medicine, that which we talk about so little, hasn't changed at all. Caring for your patients . . . just caring . . . IS the most important part of medicine.

It's ironic, because compared to all the complicated aspects of medicine, the stuff that we've spent so much time on these past several years in medical school--things as complex as the MRI, or chemotherapy, or neurosurgery--compared to all of this, caring is really the simplest thing of all. And, of course, the ultimate irony is that it's the one thing you can't be taught. And that's because understanding the MRI or chemotherapy or neurosurgery--that all comes from your head. But caring, truly caring, that comes from someplace else. And I don't think you need a brain tumor to know that.

And yet, therein may lie the problem. Because of its almost un-intellectual origin, caring just isn't treated the same way as most other aspects of medicine. Caring isn't given the same level of respect, isn't emphasized to the same degree. What textbook did we read that taught us how to befriend our patients? What class did we take that taught us how to inspire those we cared for? Does that sound crazy? Possibly. But then again, is it sensible that we remember a patient's cholesterol level, but not his name? And why is it that today, while we can cure more diseases than we ever could before, more patients are turning away, . . . turning to different kinds of medicine than they ever did before.

You see, it's because we're only doing "half of it." We're doing the "science of medicine" part, but we've forgotten the "care of medicine" part. That's why I brought in this patient's chart. I brought it not to show you all the important things that truly are in there, but more to show you all the important things that are not. You see this patient is me. And I am only here with you today,because I was lucky enough to receive the "medical treatment" that doesn't appear in this chart.

I'm lucky in that MY doctors, with my family and friends, have been working hard not only to lower my seizures, but also to raise my spirits. And they've not only been fighting to kill off my tumor, but also to keep alive my hope. But here in my chart, which coldly follows our "official approach to medicine," you can't see all of that. Oh, you can can certainly read plenty about my seizures and my tumor, . . .but what does it say about my spirits and my hope? Nothing. But I'm standing here with you today, only because of both science AND compassion.

So to repay the generations before us, let's give this gift to the next generation. Let's teach them how to truly care for their patients. And we can do this only by teaching them to give care the same degree of respect that we give the MRI or surgery or medical science in general. How do we do that? How can we make this happen?

I think this first step would be to stop penalizing a physician for spending more time with his patients. Today, because of our advances, our patients' cases are more complex than ever before. But today's doctor is not only NOT encouraged to spend more time with his patients, he's actually penalized for doing so. In fact, we could go even further. Rather than just have insurance companies dictate the entire basis for a doctor's compensation, we could let the patient thank his doctor, by letting the patients reward their doctors through the insurance companies. By asking each patient to express how well they've been treated by answering some simple questions, we could base a small portion of the insurance bill on what the patient said. For the first time this would let the patient have a say in the value of a doctor.

Now what have some people said about taking such a different approach? Many are reluctant to have the system of finances enter into the world of inter-personal care. I've heard doctors saying things like: "this is not a proper role for the medical community" or even that this excessive level of interaction "should be handled by charities and not by medical staff." But this is actually kind of ironic. It's ironic because these things weren't just said today, they were also said almost a century ago, said to Dr. Cabot. They were said, as he implored that . . . caring for patients after they left the hospital shouldn't be done simply out of charity. Rather they should make it a part of their system, a system of social work. But it wasn't until the next generation of doctors came along, that this was finally accepted.

So just like nearly a century ago, it may not be obvious at first pass how this small change might begin to alter our whole approach, change our patients' lives, even change medicine itself. It would undoubtedly change our own lives, because now, for the first time we would be judged on our ability to communicate. We would see, clear as day, how well we are speaking with our patients. And it could change our patients' lives, as now for the first time they would be told that what they feel, what they think, really does matter. But possibly even more than patients or doctors, such a shift would change the lives . . of patients' loved ones. A subtle message would begin to reverberate through out the health care system, even . . . from the hospital bills. What loved ones would be seeing, is that patient care gets billed along with everything else -- lab tests, radiologic studies -- everything. But what they'd be realizing, and slowly internalizing, is that the compassion the patient receives--that thing which is often all the loved can really offer them -- is every bit as valuable as what doctors provide. While this may not sound like much, I can assure you, as a patient . . . that even this small sense of empowerment to both patients and their loved ones . . . is truly life-sustaining. That alone . . . should be reason enough for us to do this.

But enough dwelling on the future and the past, today is a day to celebrate the present.

On this special day, we the Harvard Medical School class of 2000, are surrounded by the generation before us. We are gathered with our teachers and our families, gathered to honor and celebrate one another. We honor our professors, who taught our minds to practice medicine. While we honor our families, who taught our hearts to care for patients. And today, we, the students, are honored, both for completing one journey, and for beginning another. For accepting the challenge that lies ahead of us, the same challenge that lay ahead of every generation that has come before us. And that challenge is to continue in the work that those before us have so nobly carried out, and today, is so faithfully entrusted to us.

Thank You.