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Innovation Lecture

Drinking from a Fire Hydrant: Musings on Active Learning in Medical School

Almost everyone has seen a doctor at some point in their lives. Yet, for most, what actually goes on in medical school remains a mystery. Chances are that if you’re reading this, you have experienced the delightful experience that is medical school. Sleeping in late, eating well, and relaxing with friends and family on the weekend are just a few of the joys that we medical students get to experience. Just kidding. Medical school, as most of us know, is beyond challenging. At my school, faculty members fondly liken the medical school experience to drinking from a fire hydrant. As medical students, our pre-clinical days are comprised of hours and hours of lectures and power points. Then, when class is all over, we get to top off the day with several additional hours of studying. It’s challenging, it’s overwhelming, and at times, it seems downright impossible.

Part of what makes medical school such a unique challenge is the fact that medicine is a tactile discipline and yet, pre-clinical education is traditionally taught in a classroom setting. In response to this dichotomy, the University of Vermont’s Larner College of Medicine recently made headlines by announcing that it would become the first public American medical school to completely eliminate lectures from its curriculum, joining private Case Western Reserve University School of Medicine in Ohio (https://www.washingtonpost.com/news/to-your-health/wp/2017/07/29/medical-school-without-the-sage-on-a-stage/?utm_term=.6847516c2b31.) This change, which is expected to be fully implemented by the year 2019, comes in response to concern that the traditional lecture format does not promote knowledge retention and instead relies on “passive” learning where the learner is not actively engaged in their education. To draw an analogy, passive learning is like being fed while active learning requires learners to pick up the fork to feed themselves.

Although the University of Vermont and Case Western Reserve University seem to be the only two institutions whose medical schools have committed to becoming completely lecture-free, it’s interesting to realize that other schools have moved towards a more active learning format as well. In my school, the College of Osteopathic Medicine of the Pacific (COMP) , students pick their own small groups. These small student-led groups meet several times a month and work together to complete assignments and discuss scenarios that are based upon real clinical scenarios. Northwestern University’s Feinberg School of Medicine is one of several schools that employs a problem based learning curriculum, and in 2015, Harvard Medical School also restructured their curriculum to become more problem-based. Ultimately, medical school curriculums exist on a spectrum from passive to active curriculum styles and the continuum seems to be shifting to favor active learning styles at many medical institutions.

Moving away from a traditional lecture setting certainly presents its own unique challenges that affect learning. The non-lecture curriculum requires more self-reliance on the part of the students, who must teach themselves new material. The small groups used at COMP, for example, are completely student-led. A faculty member may pop in for a few minutes to make sure that the group is running smoothly, but often these faculty members are not experts in the subject matter at hand and are present to deal more with administrative issues than to teach content.  It also means that students are required to participate in groups, whereas many schools may have optional attendance for lectures. Perhaps the biggest challenge of the active learning curriculum, however, is the necessity for different personalities to work together to achieve a common goal. The traditional classroom setting involves one teacher who employs a specific style to reach multiple students. In the active learning curriculum, small groups are often used, in which each member has a different personality. Students in these groups must work together, sometimes despite personality differences, to master the curriculum and achieve common goals. Although the group setting closely resembles the team-based approach taken in most healthcare settings, it can undoubtedly be frustrating, especially for someone like myself who tends to be more introverted and likes to study on his/her own. In my personal experience, the members of my small group were incredibly supportive and had a variety of strengths, yet there were many days when I couldn’t wait to return to the comfort of my own room to be able to really learn the material myself. Sometimes trying to learn unfamiliar concepts with others was a distraction, and despite the best of intentions, small group was like the blind leading the blind when we were all confused on certain concepts. There were some times that the small group felt comforting, like someone holding my hand, and other times when it felt too overwhelming, like someone pressing my face up against that proverbial fire hydrant. Ultimately, I felt like the combination of both lectures and small groups was actually more dynamic than relying solely on one or the other. While the University of Vermont and Case Western Reserve University have both made the bold move to abstain from lectures altogether, they join the company of many medical schools, both allopathic and osteopathic, that have recognized the importance of active learning for the medical school curriculum. Let me know what alternatives your medical school offers to traditional lecture-style learning!

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Lecture The Medical Commencement Archive

Humanism in Medicine and Healthcare in the Community

Good afternoon, and thank you for inviting me to be your speaker today. My name is Paul Rothman, and I am the dean of the Johns Hopkins University School of Medicine and the CEO of Johns Hopkins Medicine. It’s my privilege to be here on this memorable occasion to celebrate you, the esteemed graduates of the Northwestern University Feinberg School of Medicine Class of 2016.

First, I want to say congratulations. You should be incredibly proud of yourselves. You have succeeded in one of the country’s most prestigious and rigorous programs, which is a testament to your immense talent, intelligence and drive.

Whether you are moving on to a residency, a postdoc, a job in industry or another professional stepping stone, today opens up great possibilities for you. You are forging ahead in an era of unprecedented opportunities in science and medicine.

In 2016, we are on the verge of some astounding breakthroughs, thanks to increasingly sophisticated medical imaging tools, next-generation gene sequencing, computational modeling, and other technologies that allow us to obtain and analyze complex data sets.

I started my career in 1984, when our work as medical professionals was far different than it is today. Over the past 30 years, I have had the pleasure of witnessing stupefying advances in medicine—progress that has had enormous impact on how we diagnose disease, deliver health care and conduct health-related research.

The rate of progress should be even more stunning during your careers. Soon, your whole genome is going to be accessible on your iPhone. An EKG will be self-administered at home with a hand-held device, and an iWatch will monitor seizure activity. Highly accurate autonomous robots will assist surgeons in the OR. And health behaviors will be tracked so closely that we will know in real time whether patients are adhering to their treatment regimens. There’s no doubt that technological innovation will save many, many lives.

Which raises the question, as I look out at all of you newly minted doctors: What is the role of the human doctor in this brave new world of medicine, which threatens to reduce the patient to a data set and “doctoring” to an algorithm? How can we harness the power of technology without undermining the doctor-patient relationship?

I recently read a striking study by an assistant professor of medicine here at Northwestern named Enid Montague. She used videos to analyze eye-gaze patterns in the exam room and found that doctors who use electronic health records spend roughly onethird of each visit staring at the computer. Not only is that alienating, but it can mean that we doctors aren’t picking up on important non-verbal cues from our patients.

And the more sophisticated our medical technologies get, the more potential there is for this distancing effect. For example, a hand-held ultrasound is more precise than a traditional physical exam—be it percussing a patient’s abdomen to determine the size of the liver or putting a stethoscope to someone’s chest to listen for abnormal heart rhythms.

But the human touch is an important part of building trust between doctor and patient. Can you imagine a scenario in which a doctor did a physical exam without once actually laying hands on the patient?

I like to argue that technology serves to get the unneeded variation out while the physician is there to keep the needed variation in health care.

The computer can ensure that the diagnostic process is efficient and thorough, with all potential diagnoses considered. But the physician must be there to help interpret findings or to say, maybe that patient can’t afford that drug, or that treatment regimen is too complex for that patient to manage. We as human doctors can factor in so many subtle observations and make an appropriate judgment call.

In order to do that, we need to listen. William Osler, one of Johns Hopkins’ founding fathers, is famous for saying: “Listen to your patient. He is telling you the diagnosis.” And I would take this opportunity today to echo that advice to all of you.

Here’s the thing: I believe that most of us who go into this field start out compassionate— motivated to help our fellow humans and relieve suffering. I can tell you that’s what drew me to medicine, and I’m sure the same is true for you.

It used to be we would train residents out of this inclination to be humanistic—through impossibly grueling hours and a culture of browbeating. When my wife and I trained, we worked more than 100 hours a week, and it took us years to start feeling human again after that.

Fortunately, I believe medical schools have made great strides over the past decade in nurturing empathy. We’ve changed our selection criteria to attract more caring, well-rounded people, and our residents are now limited to a somewhat more humane 80-hour workweek.

The problem is that in trying to teach our trainees to be more humanistic, we’re going against the grain of society. In 2016, efficiency is the name of the game, so doctors’ visits and hospital stays are growing shorter, making it harder to form meaningful relationships with our patients. Furthermore, so much of our communication today is now mediated through technology. Think about it: People vet potential mates through online dating sites. Friends stay in touch over Facebook. We communicate with our officemates via email.

Health care is a service industry, so look at other service industries and you’ll see a trend of dramatic depersonalization over the past couple of decades. When was the last time you spoke to a human while making a travel reservation or depositing a check? I just read that Wendy’s is adding self-service ordering kiosks to all its restaurants this year. For better or worse, DIY gene testing is already on the scene. As younger generations enter the workforce, this trend will only intensify.

But here is the really good news about your generation, and this gives me a lot of hope. Even though millennials have been raised on technology, study after study shows that your generation is more community-minded than the Gen Xers and baby boomers who preceded you.

You’re more likely than previous generations to state that you want to be leaders in your communities and make a contribution to society, and roughly 70 percent of people your age spend time volunteering in a given year. Not only do you all have the idealism of youth, but you’re also matching that idealism with action. And it’s inspiring.

At Johns Hopkins, all our trainees participate in service projects, and I suspect that’s true for most of you as well—whether it’s providing free hepatitis B screenings for community members in Chicago’s Chinatown or donating your time to CLOCC, Northwestern’s Consortium to Lower Obesity in Chicago Children. In my view, the very best physicians are those who possess a service ethos—who are not just humanists, but humanitarians.

Recently, I was helping my daughter with her medical school applications, and one of the essay prompts included this quote from the late Nobel Laureate George Wald: “The trouble with living with contradictions is that one gets used to them. The time has come when physicians must think not only of treating patients but also of trying to help heal society, if only so that their work is not incompatible with … surrounding circumstances, partly of their own making.”

Let’s unpack that quote.

In American cities, long-standing systemic inequities mean that many members of our communities lack access to adequate health care, decent schools and other advantages that many of us here today take for granted. What Wald is saying is that we can’t be content to cure sick people and lecture them on how to stay well without also addressing these underlying social conditions that contribute to poor health and the glaring health disparities we see in our cities.

We cannot satisfy ourselves with doing one and not the other—particularly in light of the social unrest that has been happening here in Chicago and in my city, Baltimore, over the last year and a half following the deaths of Laquan McDonald and Freddie Gray. These and other events have provoked Americans to confront some difficult truths. Wherever your career takes you next, I ask that you try to channel those feelings into positive action.

After all, why put such herculean efforts into healing people and finding cures if we will stand for an environment that contributes to shortening their lives?

When we do make scientific advances, we have to ensure that everyone in our society—regardless of race or income—has equal access to the latest and greatest medicine has to offer.

In January, the director of our gynecologic oncology service at Johns Hopkins published an article looking at trends in the way we treat cancer of the uterus.

It used to be when you operated on a patient with early-stage uterine cancer, you did a hysterectomy by slicing open the abdomen. The incisions were large and sometimes could lead to infection, blood clots, major blood loss, etc. These days, minimally invasive surgery (laparoscopic or robotic) has become the standard of care, curing roughly two-thirds of these patients with far fewer complications than the old method.

At Johns Hopkins, we choose this method more than 90 percent of the time, unless there’s a complicating factor. Yet when our scientists looked at the national data, they found a troubling trend: African-American and Hispanic women are less likely to get the better, minimally invasive brand of surgery, as are patients who are on Medicaid or are uninsured.

  • I wish I could say this was a shocking finding, but unfortunately, it’s all too common. Here are a few startling facts on health inequity in the U.S. today:
    African-American adults are at least 50 percent more likely to die prematurely of heart disease or stroke than their white counterparts.
  • The prevalence of adult diabetes is higher among low-income adults and those without college degrees.
  • The infant mortality rate for non-Hispanic blacks is more than double the rate for non-Hispanic whites.
  • In Chicago, predominately white communities have much lower rates of overweight/obese children than communities that are predominantly African-American and Hispanic.
  • In the area surrounding The Johns Hopkins Hospital in Baltimore, the life expectancy changes dramatically from neighborhood to neighborhood— by as much as 20 years!

In 1966, Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” So what can we—or, more specifically, you—do about it?

Any strategy health care professionals develop to address population health must address the root causes of poor health, including poverty. Of course, the problems associated with poverty are incredibly complex, and breaking the poverty cycle requires an approach with many prongs, beginning with education.

I don’t expect you all to have the answers right out of medical school. All I ask, as you set off on your quest to eradicate disease, is that you take seriously your role as leaders in the community. The degree you are earning today confers a measure of responsibility, and I have total faith that your generation will get us closer to solutions to these pressing problems.

As busy as we are, trying to make our mark on the profession and, by extension, “human health,” we can’t lose sight of the people in the very neighborhoods our institutions exist to serve. I believe the medical community has a real opportunity to lead in helping to heal our cities, conquer inequality and create better opportunities for all. That work starts with the humanity and compassion in each of you.

Again, I want to congratulate you for this terrific accomplishment. We know you are going to achieve great things. Thank you.

Paul B. Rothman is the Frances Watt Baker, M.D., and Lenox D. Baker Jr., M.D., Dean of the Medical Faculty, vice president for medicine of The Johns Hopkins University, and CEO of Johns Hopkins Medicine. As dean/CEO, Rothman oversees both the School of Medicine and the Johns Hopkins Health System, which encompasses six hospitals, hundreds of community physicians and a self-funded health plan.

Paul B. Rothman, MD
Northwestern University Feinberg School of Medicine Commencement Address

The Medical Commencement Archive
Volume 3, 2016

Categories
Lecture The Medical Commencement Archive

The Past, Present, and Future of Medicine

It is a special time in medicine.

This is a time of the most rapid transformation in generations! You have scientific knowledge and technical abilities that far surpass those of your predecessors. You can multitask better than most. I know– I’ve seen you on the wards and in clinics—whipping out your smart phones, clicking on answers to clever questions barely out of my mouth. Us older  physicians struggle to keep up with you.

What a privilege you have for a patient to say, “That’s my doctor!” You will care for thousands of patients during your careers. But remember, they will only see a small number of doctors. You will be very special to them in ways beyond your comprehension. They need an anchor, a belief that someone is thinking about and looking after them…and you will provide this without even knowing.

You will experience a better balance between your work and your family life than existed for our generation. You will no longer be such a slave to the profession in which family and friends who nourished us were too long neglected. Our multi-professional teams help us achieve this, with each member complementing and supporting each other. Such a balance is healthy, leads to better care and prevents burnout!

It is a challenging time in medicine.

The demographics are changing in our society. There is an increased demand for your services due to population growth and aging, as well as the arrival of healthcare reform. Soon, the majority of our nation’s population will be “ethnic minorities,” looking like New Mexico. Diversity brings a rich sharing of culture, language and values. But it also poses threats that could divide us. We must find
a way to overcome divides by race and ethnicity, by gender and sexual preference, by income and geographic isolation.

Your challenge is to bridge these divides, finding connections with patients far removed from your own upbringing, economic status, religious or ethnic beliefs. While we have the means to treat virtually everyone that crosses our doors, access to our care is not guaranteed—either because of transportation challenges, linguistic barriers, financial impediments or social marginalization of certain
groups.

Our nuclear families are shrinking as young people leave for schooling or for jobs. This leaves no grandmother around to offer guidance to a young, single mom about how to treat her feverish child in the middle of the night. In such an isolaisolation-
generating environment, clinics and emergency rooms often replace family for comfort, re-assurance and social connection. Some people feel so alienated, they have given up on the healthcare system except for late night runs to the emergency room for a neglected toothache, or an infected needle track, or for a sick teen who delayed treatment while waiting for access to the lone family car.

We will be challenged to gain skills and an understanding of domains far from our traditional areas of strength—population health, management of health teams, the business of medicine. Thus, our generation of physicians leaves you both with a legacy and a mess!

Medicine has a powerful history.

Look how rapidly our field has progressed in just a few generations and what a terrific time it is to enter the physician workforce.

First, let me recall some recent history: when your entered medical school four years ago. I’m sure the week you began medical school your grandma asked you, “What’s this bump on my arm?” You protested, “Grandma, I’m only a beginning medical student!” But she said, “Yes, I know, but just tell me what you think this is.” That’s when you found out that what you think of yourself in this
profession is not important—it’s what your family, your patients and your society thinks of you that is so very important.

There is an expectation of your competence and ability to heal which feels uncomfortable—an expectation you can’t fulfill. But, as time marches on, you’ll grow into these new clothes.

Now, let’s go back further in history and reflect on what doctors in New Mexico faced more than a century ago.

We begin with impotence in the face of diphtheria. In 1882, there were no immunizations against diphtheria, so the physician’s presence at the bedside WAS the medicine in his “doctor’s bag.”

Still, the cases were difficult:

Case 1- “I was called to bedside on Saturday. Found patient with difficult respiration and suppression of urine. On introduction of catheter, no urine was found in bladder. Performed tracheotomy; breathing very difficult; death in about 24 hours.”

Case 2 – “Patient a five year old…performed tracheostomy…lamp went out…operated with difficulty taking about ½ hour…spasms…died in about 12 hours.”

In Las Vegas, NM in 1914, doctors had many medicinal purposes for whiskey—to steady their own nerves, to use as anti-septic in the belief that they could kill off germs that cause diphtheria, even in kids, and as a pain killer. I relate to this last use, for I once had shingles, which felt like a hot branding iron on my side. I went to the local hospital and was prescribed narcotics, which didn’t
touch the pain. I was desperate. A colleague suggested I try alcohol. “I don’t drink,” I objected. But I bought a bottle of whiskey. It tasted terrible…and my pain disappeared. Swigging whiskey, I remained drunk for a week and felt no pain!

Prejudice and stigmatization were as rampant among our forebears as they are today with AIDS, mental illness, or in the attitudes of some toward immigrants. In 1904 a distinguished physician from Las Cruces warned of those with tuberculosis coming to NM for “the cure.” He said, “The army of tubercular invalids should be brought under control, promiscuous expectoration should be stopped
and every possible means taken to prevent these unfortunates from becoming a danger to the population… I most assuredly do believe that in return for the health-giving properties of our glorious climate, they should be willing to submit to some legal regulation!”

This sounds remarkably like our national political dialogue today.

You have skills and tools for diagnosis and treatment that many of us on stage could only have dreamed of when we were students. Not long ago, when I was a student, we treated congestive heart failure by bleeding patients and tying tourniquets to their limbs to prevent too much venous blood returning to overwhelm their failing hearts. Today, you’re equipped with powerful diuretics, medicines
to lessen heart stress, and coronary catheters to unblock clogged arteries.

Not long ago we warehoused the mentally ill, the developmentally disabled and the tuberculous in sanatoriums. Today, with stronger therapeutic means at your disposal, and better understanding of the pathophysiology of disease, most of these individuals live at home or in the community.

And not long ago, at the turn of the last century, most health providers were physicians. Today, physicians make up less than 10% of the health workforce—for we train with and rely on multi-professional teams to better care for our patients. While we train mostly in isolation from other health professions, we will spend our professional careers in interdependent collaboration with a growing number of health professionals skilled in vital areas which complement our own skills. We depend upon pharmacists, nurses, physical therapists, occupational therapists and even community health workers.

And look what we face today. No matter what specialty you enter, the care you give will be affected by the social determinants of disease faced by your patients: educational attainment, income and poverty, access to nutritious food, yearning for social inclusion. These socioeconomic forces contribute more to health than all the medical care we provide. This is a humbling thought. But we’re
rising to the challenge. Community health workers, our frontline in addressing social determinants, are now hired for each of our primary care clinics. Our own Gwen Blueeyes sent me this note summarizing her work with one of our patients:

“Patient came to see me in clinic so I could help her obtain food. She appeared overwhelmed with her current situation. She said, “I’m losing my car at the end of this month because I’m behind on my car payments. I’m afraid I’ll be evicted because I’m unable to pay my rent. I receive some social security benefits, but it’s not enough to cover my living expenses. My  local churches couldn’t find me any assistance.

I did the following: Helped her complete her food voucher benefits application, connected her with “adopted families” to
help pay last month’s rent, helped her complete paperwork for the Income Support Division to help cover cost of her Medicare premiums, and scheduled an appointment for her with the hospital Patient Financial Services Office,
which I’ll also attend to give her moral support.”

Now THAT’s an example of a powerful
addition to our heath team!

You should all be engaged in health policy. I want you to promise me that whatever field you enter, you will ALWAYS ask of the patient coming to clinic or admitted to the hospital bed, “How could this visit or admission have been prevented?” Our Chief of Neurosurgery asked, “Why do so many patients from rural hospitals with strokes and head injuries have to be flown to our Hospital at enormous
expense to patients and to those rural hospitals?” He set up a telemedicine program to review head CT scans sent from rural sites so he could advise local physicians on which patients to send, and which could safely stay put in their home community.

A pediatric endocrinologist wondered why her diabetic patients in New Mexico had to travel so far to Albuquerque for checkups. Half her diabetic children were on insulin pumps, allowing them to use the internet to download their glucose readings and send them to Albuquerque for review. This doctor can now advise patients on fine-tuning their management in their homes, sharply reducing
their trips to Albuquerque.

One of your classmates noticed that despite the recommendation that all patients with congestive heart failure contact their doctor at the first sign they are retaining too much fluid—3 lb in a day or 5 lb in a week- when asked, 4 of 5 patients admitted with congestive failure on our service had no bathroom scale. So she is working with cardiology and our hospital administration to propose buying $20 digital scales for all discharged patients with congestive failure who don’t have scales, which is aimed at reducing re-admissions for this condition.

And finally, a medical student and resident on our inpatient service explored how they could have prevented the admission of two patients admitted to our service in diabetic ketoacidosis. Both were poor, on UNM Care, and since insulin was so expensive, they had to use our hospital pharmacy to get affordable insulin. The problem, they discovered, was that our UNM Pharmacy was only open
8-5 when the patients were at work. They worked at jobs without benefits and feared if they took off from work, they could lose their jobs. The student and resident presented their findings to the UNM Pharmacy which agreed to stay open after-hours. Different generations teach each other.

Like Jedis, we taught you the ancient ways of diagnosis–using the “scratch test” to assess liver size, tapping muscles to check for “myo-edema” to diagnose protein malnutrition, and observing “sighing respiration,” a sign of anxiety.

But you upstarts taught our generation how to use dynamic documentation, how to quickly pull up x-rays on the computer, and how to access the latest evidence on your iPhones in seconds.

Older and younger generations in medicine offer continuity and mutual learning. I experienced this in my own home when I bought my first iPhone. I was typing away with my thumbs when my son looked over and asked what I was doing. “I’m texting,” I said. “No you’re not,” he said. “What am I doing?” I asked. “You’re e-mailing!” he said. “What’s the difference?” I asked. He had to show me that
little texting icon. Don’t ask me about Twitter!

Finally…why is your class so great?

I interviewed faculty and staff who worked with you over the past 4 years. And their general
consensus was: “You’re just so damned nice!” Your class character has made a great impression on all of us.

You have to be the kindest, most mutually supportive, most community-minded class in a generation. The welfare of your classmates and their academic and professional success, not just your own achievement, meant something to you. In the community, you helped the homeless, the immigrants, the disabled, the elderly and youth at risk. You’ve increased access to a life-saving drug- Narcan- for opiate overdoses; you’ve testified at the state legislature for health improvement bills; you’ve helped communities fight youth obesity; you’ve brought a range of services to inner city school kids, from dental health to sex ed; you’ve organized one of the largest, free flu shot clinics imaginable (>3,000 received shots in our parking lot).

You’ve shown the power of medical students as leaders, reviving and sharply increasing participation in the Student Council as a force
for positive change in our academic health center. You’ve organized mentors within your class to help all pass the Boards! And during Match Day, instead of rushing the table to grab and open your residency match envelopes like most classes, you politely approached the table calmly, helping each other find your respective named envelopes.

These are the skills that predict success in our highly social, interdependent field of Medicine. I was touched by an e-mail I received from one of your schoolmates relating an experience she had during her first year PIE rotation in rural New Mexico. She was attending a school-based clinic near her clinical site. Through fresh eyes, she summarized her following interaction with a teen patient:

“I can’t get out of my mind a 16 year old I saw today. She wouldn’t look me in the eye, and sat in the exam room sort of slumped over. I asked “What’s going on?” “My stomach hurts and I have a headache,” she said. Then all this craziness
started pouring out. “I haven’t slept in days,” she said. “My aunt keeps getting incredibly drunk. Last night my uncle was beating her and my aunt was so drunk, she wandered away.” “I can’t concentrate… My grandfather is dying. I
just lost 3 family members to alcohol. My mom says there’s not enough room in her house for me. I was just
separated from my sister…the one person who understands me. I can’t call her—her phone’s been disconnected.
I only eat what they have here in school—I get one or two meals a day…there’s no food at home. Even when I do eat, I sometimes throw up…I can’t help it…I’m so tired.”
With my mouth gaping, I collected myself. I got her some extra food from the school cafeteria, gave her a little something to settle her stomach, gave her a hug, and referred her to New Horizons. Deep down, I wanted to adopt her. She said she trusted me. God, she trusted me!”

THESE are the qualities that our field is looking for. Class of 2016, you’ve got it!

 

Dr. Kaufman received his medical degree from the State University of New York, Brooklyn in 1969 and
is Board Certified in Internal Medicine and Family Practice. He served in the U.S. Indian Health Service,
caring for Sioux Indians in South Dakota and Pueblo and Navajo Indians in New Mexico, before joining the
Department of Family and Community Medicine at the University of New Mexico in 1974, where he has
remained throughout his career, providing leadership in teaching, research and clinical service. He was promoted
to full Professor in 1984 and Department Chair in 1993. In 2007, he was appointed as the first Vice
Chancellor for Community Health, and was promoted to Distinguished Professor in 2011.

Arthur Kaufman, MD
University of New Mexico
School of Medicine Commencement

The Medical Commencement Archive
Volume 3, 2016

Categories
Lecture The Medical Commencement Archive

The Power of Not Knowing

Dr. Akram Boutros joined The MetroHealth System as President and Chief Executive Officer in June 2013. He serves as the leader of The MetroHealth System and is its primary public representative, reporting to the MetroHealth Board of Trustees. He works in partnership with the Board to ensure that the organization fulfills its mission and creates strategies that ensure its future success.

Dr. Boutros has more than 20 years of leadership experience in large community hospitals, specialty hospitals and academic medical centers. Most recently, he was President of BusinessFirst Healthcare Solutions, a health care advisory firm focused on clinical  transformation, operational turnarounds and emerging health delivery and reimbursement models. Dr. Boutros previously served as Executive Vice President and Chief Administrative Officer of St. Francis Hospital – The Heart Center in Roslyn, New York, and as  executive Vice President, Chief Medical Officer and Chief Operating Officer of South Nassau Hospital in Oceanside, New York. An internist, Dr. Boutros received his Doctor of Medicine from the State University of New York Health Sciences Center at Brooklyn. He is a graduate of Harvard Business School’s Advanced Management Program and is a recognized thought leader in management systems.

Dr. Boutros also serves on the boards of the Greater Cleveland Partnership, United Way of Greater Cleveland, the Cuyahoga Community College Foundation and the Cleveland Ballet. Most recently, he served as Chair of the American Heart Association 2015 Cleveland Heart Ball, the most successful in the city’s history. He has been named to Power 150 by Crain’s Cleveland Business, Power 100 by Inside Business Magazine and EY 2015 Entrepreneur of the Year for Community Impact in Northeast Ohio.

Twenty-eight years ago, I sat where you sat, thought what you thought, and asked myself, is medical school really over? 

Will I be a good doctor?
What will the future of health care look like?
Where do I fit into that future?
Will I survive those coming changes?

My answer to each of those questions was the same: I don’t know. No one knows. But I do know a few things after nearly 30 years in this crazy profession that you are a “flip of a tassel” away from entering. I learned the first one when I was a little older than most of you.

I was in my second year of residency, near the end of one of my every-third-night ICU rotations. Exhausted, I had fallen into a deep sleep when a nurse woke me to tell me a patient who was septic – filled with infection – had become acidotic – possessing a level of acid in bodily fluids so high, it can kill you. Still foggy, I sat up in bed and said, “Give her an amp of bicarb.” It was a reflexive response. I knew bicarbonate, a base, would correct the acidosis. And as soon as I said it, I laid my head down and fell back asleep.

Five minutes later I woke again, covered in cold sweat. I’m not just using that phrase here. I was in a cold sweat. Somewhere in my subconscious, I remembered that this woman, this septic patient, also had end-stage renal disease. Her kidneys had failed. And she was retaining so much fluid it was straining her heart. As many of you know, bicarb is short for sodium bicarbonate and sodium is salt and that salt would make her retain even more fluid. I had just ordered a remedy that could kill her.

Fully awake, heart racing, I ran to her room. I was too late. The nurse had followed my orders. What I experienced next was panic. My stomach churned. My heart raced even harder. Will she die? God, I hope not. How am I going to fix this? Who should I tell? What should I do? Is this the end of my career? What the hell is wrong with me?

No one likes to risk their reputation, to claim they made a mistake, especially a potentially deadly one. But at 2 a.m., I called my ICU attending. I called the patient’s attending. I called the nursing supervisor. I called the renal fellow. And I told them all the same thing: “I screwed up.”

Nobody yelled. And nobody fired me. Instead, together, we agreed to assemble a team to perform ultrafiltration to draw off the fluid – before it did its damage. It worked. The patient made it. She survived. Not because of me. Because of the team that gathered around me. They all wanted her to live. And they all wanted me to succeed.

Everybody wants you to succeed, too. That’s the first thing I want to leave you with today, one of the things I hope you’ll never forget: We are ALL rooting for you. Your teachers are rooting for you. Your bosses are rooting for you. The institution you work for is rooting for you. So are your patients, your family, your friends, and your spouse. ALL of us. We love you. We need you. We want you to be happy, confident, good at what you do, and in love with it. We want that for all kinds of reasons.

One of those is that someday we may need you to take our pain away, to help us walk again, to give us back enough energy to play with our kids or grandkids, to save our lives. Close your eyes now, for just a minute, and picture in your mind, the world of people who are behind you. So many of them are here today. Imagine them, in the stands, on their feet, cheering you on. And whenever you find yourself in a tough situation, come back to that image. Imagine everyone who cares about you cheering you on. Because we are.

I have another message today. This one comes from a different moment early in my career, another one I’ll never forget. It was July 1, 1988: the first day of my internship, and my first day as a doctor. I was on call and because my last name begins with B, I got the first admission to internal medicine: a transfer from another hospital. When I walked into the room in the ED, a middle-aged woman was sitting up in bed, dressed in a hospital gown, looking very anxious. I began with the textbook question: “What brought you to the hospital?”

“They think I have Churg-Strauss vasculitis,” she said.

I remembered that I’d studied the disease awhile back. I remembered that it was serious. But I couldn’t remember what it was or what organ system it affected. In fact, I couldn’t remember anything else about it. I felt unprepared, like I had nothing to offer, that I was useless.

But I kept going. I thought, alright Akram, just keep asking questions – as many questions as possible – and maybe you’ll get a clue. If that doesn’t work, try the ‘fake it ‘til you make it’ method. Maybe that works for doctors, too. I took a detailed history, asking questions about diseases in her family and what medications she was on. As I was wrapping up, she looked at me and said “So what do you think, Doc?”

I stopped and thought for a few seconds. I thought about saying “Oh, we’ll have to see,” or “We need to run some tests” or something else that would make me sound like I really knew what was going on. But when I looked at her again, I saw how concerned she was. And different words popped out of my mouth.

“I don’t know.”

I was embarrassed to admit it. But, to my surprise, she wasn’t angry or afraid. She chose understanding instead. Immediately, I promised her that I would learn as much as I could about Churg-Strauss before the next day. I told her that every day she was there, in the hospital, I would do my very best to gain the knowledge I needed to take good care of her.

She died. But it was 13 years later. And every one of those 13 years, she was my patient. During those years, she told me, more than once, that the reason she trusted me with her life was because I had been honest with her. That honesty humanized me. Those three little words – “I don’t know” – made her believe in me.

I kept my promise to her. I sought out those who knew more about her deadly vasculitis than I did. And I asked them to teach me what they knew, to be my partners in her care. Together, we gave her 13 years she might never have had.

“I don’t know.” Don’t ever be afraid of those words. They are the start of something beautiful. And they’re a reminder, every day, that we are doctors, not Supermen or Superwomen.

In America, we celebrate the Lone Ranger. And what we really need to celebrate is the Fantastic Four, no The Justice League. Sometimes – no, often – you need the Elongated Man, the Red Tornado and Wonder Woman to get the job done. Having Martian
Manhunter with his genius intellect and regenerative healing helps, too.

Remember: You don’t have to be able to do it all or know everything. Your teachers don’t expect you to. Your colleagues don’t expect you to. And your patients don’t expect you to. The only person who insists that you have all the answers is you.

Say “I don’t know.” It’s one of the smartest, bravest things you can say. It will take the pressure off. People will trust you. Nobody believes a know-it-all. Amazing things will happen when you say “I don’t know.”

I think the late poet Wislawa Szymborska said it best. In her 1997 speech accepting the Nobel Prize for literature, she talked about why she loved that three-word phrase:

“It’s small,” she said, “but it flies on mighty wings. It expands our lives to include the spaces within us as well as those outer expanses in which our tiny Earth hangs suspended. If Isaac Newton had never said to himself “I don’t know,” the apples in his little orchard might have dropped to the ground like hailstones and at best he would have stooped to pick them up and gobble them with gusto. Had my compatriot Marie Sklodowska-Curie never said to herself “I don’t know,” she probably would have wound up teaching chemistry at some private high school for young ladies from good families, and would have ended her days performing this otherwise perfectly  respectable job. But she kept on saying “I don’t know,” and these words led her, not just once but twice, to Stockholm, where restless,
questing spirits are occasionally rewarded with the Nobel Prize.”

Be restless, questing spirits. Explore, always. Exploring leads to discovery, and discovery to whole new worlds. And those worlds to the theory of radioactivity, the laws of motion and great things we never imagined were possible, things that make the world a better place.

That is why you – with this beautiful knowledge you’ve spent years acquiring – are here. You are here to make your patients better, your communities better, and the world better. And you do that by being restless, questing spirits. You do that by saying “I don’t
know.” Those three words are the start of something beautiful. THAT is one thing I know for sure.

 

Akram Boutros, MD
Northeast Ohio Medical University
Commencement Address

The Medical Commencement Archive Volume 3, 2016

 

 

Categories
General Lecture

Hazardous Attitudes

A few months ago I attended a medical conference organised by The Medical Student Journal Club in Slovenia. The conference consisted of debates between medical students, which is a great concept that I thought worked very well. Two medical students, usually from different countries, take on the same topic, one presenting the Pro side and the other the Contra side. They have a short Powerpoint presentation, after which the audience is invited to comment and ask questions. This was the third Pro et Contra congress I attended, having been an active participant each year since it was first organized. It was an easy decision to come back each year because it’s different than the medical conferences I’m used to. It takes place during the weekend, and it’s a perfect blend of learning about medicine in a more interactive way, sharing opinions with my peers and senior doctors, meeting medical students from different countries and having a nice time exploring Slovenia. Not to mention the organization is absolutely amazing, with every moment of our stay taken care of.

I realize most of the readers of this Blog are from the USA, and the likelihood of one of you visiting this medical congress in Slovenia is very low. I’d be happy if I got more people to attend the Pro et Contra congress; however that’s not what this post is about. Even though the debates at the last Pro et Contra congress were amazing, the opening ceremony involved a group of doctors performing a few popular song parodies on different medical hot topics, the audience participated in discussions more than ever before, and I went home with a prize for the best foreign speaker (a generous gift of Harrison’s manual of medicine), what made the biggest impact on me was the guest lecture given by a pilot, captain Tomaž Prezelj. Yes, a pilot gave a lecture at a medical conference, and it was simply superb. It is almost two hours long, but I advise you to take time out of your busy schedule to watch it. Captain Prezelj compares five different attitudes of pilots and the ways they can affect flight safety. The great responsibility, human nature, and high risk environment pilots work in easily translate to the experience of doctors and medicine. It’s all about human error. So, without further ado –