FACULTY ADDRESS
MAY 24, 2009
Fred J. Schiffman, MD, Professor of Medicine
INTRODUCTION
I am honored, touched and humbled by this opportunity to address you, the members of the graduating class of 2009, your mothers, your fathers, your spouses, significant others, and other family members, honored guests, and friends and officials of The Warren Alpert Medical School of Brown University.
This is the last lecture that you will receive as a medical school class. It is my chance as a representative of the faculty to address you as a captive audience. Your brain is undoubtedly brimming with information, [and if not, there is always Up to Date] But is there something that we've missed? Have we failed to mention some vital clinical pearl? Should we show you one last polymerase chain reaction? Perhaps a new tyrosine kinase inhibitor or one more electron micrograph? Should we conduct a last minute CPC or M&M Conference?1
No! Now as you approach internship and the gateway to your lives as a member of this still honored and honorable profession, I will try to impart the importance of being there in all the dimensions of that phrase, and also some of the consequences of not being there.
Being there, attending, bearing witness, being present - all of these would seem so natural and intuitive for caregivers. So exceedingly simple...Only it's not.
So I hope you will consider some of the stories which follow, as you are challenged with the need for yourselves to be there throughout your lives as physicians.
MOTHERS
My interest in the concept of being there is derived from several personal and professional experiences. Beginning with my mother. She was there for me at many critical times in my life.
For example, my mother was there for me when I began school. She brought me there and she began to weep. So did I. She then reluctantly placed me in the arms of my teachers. I recall vividly how hard I worked that morning. But then, to my delight, my mom returned to the school at noon with a jar of freshly made chicken soup with matzo balls, and lovingly fed it to me, spoonful by spoonful in the lunch room. The other students looked up from their peanut butter and jelly, tuna fish and egg salad sandwiches with what I believed was extreme envy. Where were their mothers, I wondered? Where were they? Didn't any other first-year medical student at N.Y.U. have a parent who cared and wanted to be there as much as mine did?
I'm only kidding.
This really happened when I started college.
And, you know, mothers want us to be there for them, too. Steven Chu, the new Energy Secretary of the United States, recently commented upon his mother's reaction to his winning the Nobel Prize in physics. He was asked, "Was anyone in your family impressed when you won the Nobel Prize?" He said, "I called my mother up when they announced the Nobel Prize, waiting until seven in the morning." She said "That's nice -- and when are you going to see me next?"2 [As my mother would say, with a slightly different accent, "You never call, you never write."]
So now several stories or vignettes (many with names changed), which illustrate the rewards and honor that accompanies being there and being able to view and participate in events surrounding a patient's illness. And also some consequences of not being there
PATIENT STORIES
1. JOSH
When my oldest son was five years of age, he fractured his hip in a schoolyard accident. I was still in training - a hematology fellow, but was transformed into the role of "father of a sick child" quite quickly. A skilled but somewhat impetuous orthopedic surgeon rounded every morning with his team for the first few days of my son's hospitalization. He dutifully examined the plaster cast and foot. But soon his appearances became intermittent and his presence token. If he examined Josh at all, it was fragmented or cursory. He was there, but not there. Especially when no exam was done, I felt deprived of an essential part of the therapeutic process. Touch did make a difference. The importance of the laying on of a healer's hands couldn't be overestimated. I ached for the magical powers of that touch, even when I knew rationally, that little difference was made. I felt that Josh and I were slighted...no, ...cheated if that interaction did not occur.
So, you must show up and you must touch. Your patients and their families will expect it, and as you recognize its importance, you will learn to do it in a focused and reassuring fashion. More about this now in another story...
2. NEAL KLIGER
The next story takes place several years later, while as a faculty member I was making rounds in the hospital. I noticed that most of the ward teams were rounding in groups. One resident, Neal Kliger, however, was not with his team but was sitting at a desk making phone calls.
"Neal" I asked. "Where is your team?"
"Oh, they're rounding across the hall, but I am doing it in my own way."
"What way is that?" I inquired.
"Watch, Dr. Schiffman." He looked at his patient list for a name, picked up the telephone and dialed the number. "Hello, Mrs. Johnson, this is Dr. Kliger. How are you doing this morning? How did you sleep last night? How is your breathing today?"
"Neal" I exclaimed, "She is down the hall. Why don't you just see her and for God's sake do a physical exam?"
"Well," he said, "this takes me a shorter period of time and so I will have more time to look up her labs and her x-rays..." And I finished his sentence with him "So then you can call her on the phone later and tell her what her labs and x-rays showed."
"Yeah, yeah, that's right," he said."
He really wasn't there. Now I think: iPods, iPhones, iPatients, iDoctors ....
Abraham Verghese has said, "I have no illusions about the limitations of the physical exam, but I increasingly feel that the exam is an important ritual, whose importance has diminished for doctors because we have other ways of getting information. But it is still just as important for the patients. Important to the ritual of one patient baring his or her soul and body, and cannot be over estimated. Rituals are terribly important to human beings because they signify transformation. This is how you earn your right to say "I am your doctor." If, as a doctor, you shortchange the ritual, you end up making patients feel that you aren't interested. They lose trust. So, go see the patient. Examine the patient. Be there!
3. MELINDA STRATTON
Melinda Stratton was a 32-year-old woman whom I cared for during April of my internship year. She had been in a deep coma for two weeks following a massive brain hemorrhage. Soon, a death vigil began with the constant presence of her husband George and the occasional presence of her 2-year-old daughter, Christine. Melinda was unresponsive and her vital signs indicated that death was near. My team of interns and residents had begun to avoid her room on morning rounds, thinking that the outcome was inevitable. On this night, I had finally flopped down on the call room bed at 3AM after a 36 hour stretch with no rest. Following a brief and dreamless sleep, I began to dream that the phone was ringing. It was ringing... A nurse caring for the patient called to ask me if I could go to see Melinda in 472A. "Has she died? Is she dead? Are you calling me to pronounce her?" I asked.
"No, but she seems agitated and is thrashing about and the family is anxious."
"All right" I said. I silently grumbled and dragged myself to the bedside to find the patient's husband crouched on the floor, now at eye level with his wife who had not spoken nor apparently heard a thing in 14 full days. Standing there, I witnessed this patient, who was half woman, half bed sheet, open her eyes, look at her husband and loudly proclaim, "George, I am going to die now. I love you. Take care of Christine." She closed her eyes and turned her head, and she was gone. The nurse and George and I could not speak. I tried to say something, but could only choke back tears. I was grateful I could witness this, but was unsure of what I had just seen. But I was glad that I was there.
4. BABY DOROTHY'S DOCTOR
An apparently healthy little girl of two weeks was found lifeless in her crib by horrified and forever traumatized parents at 7 in the morning. They attempted resuscitation at home and then the EMTs took over. She was dead by the time she came to the Emergency Room. The baby's pediatrician was immediately contacted. She spoke briefly with the mother and father whose grief was unimaginable as they lingered in the Emergency Room. Her pediatrician wondered for a moment what her next response should be. The baby is dead. Another call to the family? A note? Attending the funeral? Of course. But what about now? She had nothing to offer medically. The child was gone. Correctly, however, she canceled her morning office hours and then rushed to the ER and spent time with the grieving parents, holding them, in alternating cadences of sobs and silence, and bearing witness to this tragedy.
When she could do nothing else, just being there was something. It was not enough, but it was important. She did the kind thing and did it first.3 She exemplified the precept that "...we cure sometimes, relieve often but [must] comfort always."4
5. IRVING SINGER
The final story is about Irving Singer. He was a successful business man in his 70s, dying of kidney cancer, He had a rich baritone voice that, when in good health, rang out in public and private concerts and sports events. He used to sing the "Star Spangled Banner" at McCoy Stadium for the Pawtucket Red Sox. But the ravages of his disease put public performances to an end.
Irving hadn't sung in months. He was slowly letting go of the world he loved, but throughout his decline he was even more resolutely embraced by a family of caregivers who adored him. (You know, I am asked frequently, "How can you be an oncologist, immersed in all that suffering every day?" It's not suffering, it's this heroism I get to see).
I made a house call one Saturday soon after palliative care was introduced. Irving, full of morphine, lay covered on the couch and was barely responsive. With a weak nod, he politely acknowledged my presence. Suddenly with wide eyes, this still strapping hulk of a man sat up, looked at us and belted out "Danny Boy" to a stunned audience. His gaze fixed in sequence on each one of us in the room. I still find it hard to take that all in. He was supposed to be on his death bed. This Captain of Industry whose family emigrated from Russia was serenading his Jewish doctor with a version of "Danny Boy" worthy of Bing Crosby singing it in County Cork, Ireland. You can't make this stuff up.
Days later the end came, but that luminous interlude, which lessened the pain of loss then, is what we now carry with us. I'm glad I was there. You have to be there.
BEING THERE TO TEACH
Besides being there for your patients and their families, you need to be there for your students as a teacher. It cannot be done long distance. Very often the most effective teaching occurs as you explain what you are doing as you are doing it. Narrating your thoughts and actions. You'll have incredible opportunity to teach every second of the day. But you need to be there. Teach everybody who will listen and they will teach you. You need to be there for that. Why teach? Because it's fun, because you learn, because a teacher affects eternity. You can never tell where your influence stops.5
In "A Man for All Seasons," Sir Thomas More's speech to Richard Rich, said it all. Rich is a bright young man not sure of his future. Sir Thomas More tells him, "Why not be a teacher? You'd be a fine teacher, perhaps a great one." Rich replies, "If I was who would know it?" More says, "You; your pupils; your friends; God. Not a bad public, that." 6 So teach. But you have to be there to teach.
YOUR HEALTH, YOUR FAMILY'S HEALTH
Being a physician, or parent, or partner must be done with your whole self. But if you are all those things, how many selves do you need?
The conundrum is an ancient one. As Rabbi Hillel has written, "If I am not for myself who will be for me? But if I am only for myself, what am I?"
One of your major challenges will be to draw the boundary between professional and private life. We must all learn to recognize the limitations of what we can do for our patients, and simultaneously we must nurture our own physical and emotional beings.
At the end of the day, you must figure out a way to give enough to your patients, while leaving enough "you" to regenerate.
As Rita Charon has written, "Medicine cannot be something one does with only part of the self. The boundaries within each doctor are as porous perhaps as those around illness or healing. Both the effectiveness of medicine and its rewards for the physician may be proportional to the ability of the physician to achieve engagement rather than detachment, intimacy rather than distance, relation rather than isolation, in the care of the patient."
CONCLUSIONS
So, in conclusion, "Your words... your words and reassurance, the power of your presence which help make up the therapeutic alliance of doctor and patient, will sometimes be as important as your hands writing out prescriptions or even transplanting livers and hearts." 7
I hope, as you try to decide whether you really need to see a patient, that you will recall the stories about Josh, Neil Kliger, Melinda Stratton, Baby Dorothy's Physician and Irving Singer.
So talk with your patients. At the end of a busy, confusing day, go back to your patients' rooms, sit on their beds. (It will take you five minutes but it will seem like hours to them). Turn off your cellphone!! Look them in the eyes, hold their hands, translate the data you have gathered and support them and listen. There is no substitute for being there with them. Wilfred Trotter, a great English neurosurgeon, said that "Disease often tells its secret in casual parentheses... Patients [and their families] want to be listened to and understood." Trotter characterized this as "...the power of attention, of giving one's whole mind to the patient without interposition of one's self. It sounds simple but only the very greatest doctors ever fully attain it."
Be adventurous sometimes. If your hospitalized patients are cared for by another physician, call or visit them. Everyone will be happily surprised...especially you.
Be a rebel. If you've worked 80 hours already, stay in the hospital a few more minutes to comfort a worried family who look to your for guidance.
So, here we are. It's the very end of medical school. You've learned the science and memorized the facts, which are absolutely critical to the delivery of excellent medical care. There must be a disciplined intellect at the bedside.8
To paraphrase Dr. Milton Hamolsky, we hope however, that molecular biology has not curdled the milk of your human kindness.
The division between science and intuition, between reason and romanticism, of which you have become so uncomfortably aware in medical school, can be annealed in the care of patients. Disease is what the physician finds... but illness is what the patient feels, what the patient fears. Patients are more than their images. Cure depends on science and care and art. The poetry of your presence may sometimes soothe your patient better than science and you will often treat despair along with disease.7 The comfort that comes from your reassuring hands,... stands for the promise... the very oath you will take in a few minutes in this holy place.
So, go forth, take good care of your patients, take good care of yourselves and your families. I wish you Godspeed.
FOOTNOTES/ATTRIBUTIONS
1.Paraphrased from Dr. Robert Gifford
2.From New York Times Magazine interview by Deborah Solomon, April 16, 2009
3.Sir William Osler
4.Dr. Edward Trudeau
5.Henry Brooks Adams
6.Robert Bolt
7.Quoted and paraphrased from Dr. Howard Spiro
8.Paraphrased from Dr. Michael Bishop