Below is the text of my remarks to the 2011 medical school inductees of the University of Utah Alpha Omega Alpha medical honor society delivered March 29 at Alumni Hall:

Thank you very much for a warm introduction and thank you to the students of AOA for the invitation to speak. It is my deep honor to spend this evening with you too, and to share my thoughts with the AOA Inductees of the University of Utah for 2011.

First, my hearty congratulations. After 20+ years of grueling study and work and school, college and med school, long hours in the hospital, and countless tests and trials, you are now recognized as the cream of your class, and more importantly, you are almost ready to start paying off your student loans!

But seriously, as you commence a new phase, it would be very nice to have a crystal ball. I don’t have one, but let me to take some time with you to do 3 things: caution you, counsel you, and challenge you.

Caution

Here are 4 notes of caution I’d like to strike. First, you are entering your profession in a time of treacherous shoals for medicine and for America. Fundamental insolvency of Social Security, Medicare, many states, and the federal government are real risks that are going to affect each of us in countless ways. All will lead to cost-cutting strategies premised on increased compliance enforcement, electronic medical records, and expanding scope of practice of non-physicians, each of which are daggers aimed at the heart of current clinical practice.

Second, the exponential growth of knowledge, medicines, technology, and media will strain your memory banks, stretch your attention, and overload your bandwidth. The ability to read, write, think, and ponder coherently and patiently is becoming increasingly rare and will be more prized as idea and vision become elusive with the fragmentation of thought and consideration.

Third, be conscious of the demons of desire and despair, and master them so they not disturb your peace yet still employ them to effect positive change.

Fourth, avoid the twin seductive sirens of greed and self-righteousness; humility is the best antidote to both.

Counsel

Next, let me share some words of counsel. Although I am not much older than you – at 33, I may be younger than some of you, yet in medicine I am a dinosaur! I went to med school before there was Internet and finished 2 residencies before cell phones. So while my knowledge is probably obsolete, I hope my experience and battle scars may be of some use to you as you hone your own judgment; good judgment is an asset that will keep you out of trouble, help you take necessary and good risks, and evaluate opportunity vs. hazard. Contrary to what you may have heard, it is vital to NOT be non-judgmental. The hard part of judgment is, as Mark Twain said, “Good judgment comes from experience; experience, well, that comes from bad judgment.”

Of all the skills and qualities you have and will need to foster, focus on cultivating three in particular: good listening, equanimity, and nimbleness.

Good listening is the foundation for almost every facet of your professional career: building bonds with your patients, learning from your colleagues and mentors, being there for your staff and residents, and so much more. Any search for truth must begin with the words “I don’t know” and a willingness to listen and learn from others. When you don’t listen, you wind up in a bubble which leads to stupid decisions. You fail to appreciate the other person, where they’re coming from, and the importance of their perspective and thoughts; you lose the ability to put yourself in their shoes. You deny yourself a lot of important insight, and screw things up more. Being a good listener is something one has to work at, consciously. And it’s the basis of what patients are looking for. Doctors care about diagnosis; you need to be a good listener for that. Patients care about prognosis – and you need to understand the patient’s needs, perspectives, and values to truly be their guide and champion in their time of duress, which is what they really value you for and what they think makes you a good doctor or not, more than your competence, knowledge, or skill (all of those are assumed).

Equanimity is what Sir William Osler deemed the first among virtues for the physician: no matter the situation, mental calmness affords clarity and steadfastness. The Bible, in Ecclesiastes, states, “The race is not always to the swift, nor the battle to the strong, neither yet bread to the wise, nor favor to men of skill; but time and chance overtaketh them all.” One of the Geeta’s core precepts is encapsulated in this verse from Lord Krishna to Arjuna in a moment of doubt and despair, “You must perform the right action, but you are not entitled to the fruits of action. Let no desire of the fruits be your motive, and yet be not attached to inaction.” I first read this 11 years ago when I was a senior resident, and wrestled with the concept for a long time. It finally dawned that what it means is that in a crisis, you must focus on doing your best to do what is right, but be detached from the outcome. It helped me be a better surgeon by helping me concentrate in the moment during a case.

There’s a great book I urge you all to read, “How Doctors Think” by Dr. Jerome Groopman. It guides doctors and patients on a journey of what kinds of errors doctors can make and why and how to avoid and mitigate them; his discussions on different types of “cognitive traps” are illuminating. As a surgeon, I realized long ago how important it is to minimize mistakes and how it is even more important how you to react to mistakes. Panic and despair make you lose your mental equilibrium and you make further decisions which stack up and aggregate and make the situation worse. Sometimes no matter what you do, the outcome will not be good or what you want but you do the best you can anyway. As Dr. Groopman emphasizes in his book, lowering your emotional temperature in a tough situation is key to slowing down your thought, enhancing your perception and analysis, and thus permitting clarity to dispel clouded thinking. Pressing for a solution when none is apparent can be the worst course of action. “Picking up a scalpel and cutting can be just the wrong thing” when you don’t see the whole picture. The good surgeon is not defined by technical dexterity or superior hand-eye coordination, but by sound decision-making and judgment that enable clarity and effectiveness in the operating room. Understanding issues and realizing what intervention can and can’t remedy takes a while to learn in a surgical career. Groopman, an oncologist, relates one of his mentor’s quips, “Don’t just do something, stand there” as he counsels against the impulse to jump in and do things. It’s awfully hard to do that as a surgeon. We by nature are gamblers, risk-takers who have to have confidence (perhaps arrogance) in what we do. Especially because inaction is also a decision, and can sometimes be harder to correct than a wrong decision. It all depends on context.

Equanimity is also about righting yourself in hard times. If the present is dim & bitter, and the future seems cold & barren, it is tempting to forfeit hope and forget that your life is an integral thread in the universe’s tapestry. Remember: it could always be worse, and if it can’t, then it can only get better! Be grateful for your blessings – health, home, friends, faith. Cultivate equanimity with literature – Frost, Kipling, Max Ehrmann, and Osler. Foster also your hobbies – hiking, photography, meditation, or yoga. And while others can take away so much from you – your money, job, reputation, even people you love – be thankful for the things which can’t be taken away: personal honor, what you’ve learned, and the satisfaction of service.

Nimbleness encapsulates several qualities – resilience, courage, flexibility, versatility. Pandora released the world’s evils from her notorious box but the last thing that came out was hope. While sometimes memory and even hope can feel like a prison, in truth they are the roots of change. George Bernard Shaw said, “The reasonable man tries to adapt to the world; the unreasonable man tries to make the world adapt to him. Therefore, all progress depends on the unreasonable man.” Success does lie in effort as much as in result. The need for struggle is not grounds for avoidance. As Bruce Wayne’s father said in Batman Begins, “Why do we fall? So we can learn to pick ourselves up.”

What gives you the strength to do these things is both courage and possessing different skill sets. It is very easy to fall into a rut and never learn anything after residency or fellowship. But medical training does not end when practice starts; indeed, practice is just another phase of training. I urge you to consider developing interests and knowledge in other areas – whether it be business, engineering, genetics, or whatever. The best innovations happen at interfaces. Further, if you are good at just one thing, you are very vulnerable. Always ask yourself – what jobs need to be done in America by Americans? If you become so focused as to know just one thing, could your job be automated, outsourced, or insourced? By being versatile, you can differentiate yourself and lay a foundation for being independent of government or insurance. And you make your mind more open to learning new things in the future the more you experience and learn along the way. Nimbleness – it confers joy, recoverability, the ability to think broadly from other perspectives, the ability to persist and roll with the punches while holding fast to your principles, and the ability to take doubt and use it to find and know faith.

When in doubt here are 4 principles that help cover most things:
• Promises are made to be kept
• Rules are made to be bent
• Records are made to be broken
• Schedules are made to be changed

With your finances, exercise caution and think of any financial mistake you make as tuition. Think ahead – fail to plan, and you plan to fail. When you must make a choice that is hard, ask yourself 3 questions: Is it good for the patient? Is it good for the profession? And if the answer to both is yes and only then, ask, is it good for me? Last bit of advice –till now, your time has been judged worthless by others. From now on, the value of your time will grow – so guard it jealously from fools and irritants yet be generous with it to your family, your trainees, and community.

Challenges

So I have sounded caution and offered counsel. Let me now throw down some challenges to you. First challenge is to get involved. For too long, physicians have been objects in health care battles. Learn about the issues and see if you can effect change. Perhaps some of these may capture your interest: tort reform, tax deduction for charity care (why can hospitals and sometimes lawyers write off charity work but not physicians), whether accountable care organizations will be anything other than capitation redux with its substituting of payments for services with incentives to do nothing, the Independent Payment Advisory Board impacting physicians in 2014 but exempting hospitals until 2020, forming a guild fund for medical education, encroachment on physician autonomy by hospitals (for example, physicians cannot own hospitals but no one says anything about hospitals owning physicians), and physician extenders (optometrists doing eye surgery, CRNAs replacing anesthesiologists). After all, neither hospitals nor ancillary staff take the Hippocratic Oath.

More importantly, to this point in time and for the next several training years, your path is clear. Landmarks of applications, tests, certifications, and so on are well defined. But once you are done, the road becomes hazy. You have to figure out what you want your own milestones to be. Will your primary goal be the personal maximization of wealth? There is nothing wrong with that, I encourage all of you to be capitalists, and you have a right to make money. But take a moment to consider – what is medicine to you? A job, a career, or a calling? If it’s a job, then you will make a living, and over time, coast with the least amount of effort to make the most amount of money. If that’s what you want, fine, but I hope all of your professors have not spent all this time training body mechanics. If it’s a career, you will set down several goals – papers, rank, awards, practice-building, etc. and hopefully achieve them. But hopefully, medicine is more than just a job or a career to you – I hope it will be your calling, an integral part of how you fulfill yourself as a person. And that is about things that aren’t dollars made or goals achieved, although money and achievement are important to secure. The original meanings of the word doctor are:
- One who makes things better and
- One who teaches

How will you make things better, make a difference? I think it’s about service – doing things beyond the remit of obligation or purview of compensation, things that you are not easily replaced for by someone else. Things like research, teaching, public health, overseas work, public policy. One of the most fulfilling things I do is to work with ORBIS.
Just wanted to show a video... : http://www.youtube.com/watch?v=5RgOow2LUUY

To conclude, I’d like to share a quote, also from Mark Twain, “There are 3 types of people in the world: those who make things happen, those who watch things happen, and those who don’t know what happened.” To be truly worthy to serve the suffering, let’s all try to be of the first kind. Thank you very much.

Reflections

Those of you who are close to me know I have been going through some rough times recently; those of you who aren’t may have inferred that from the previous post. While I will not discuss details or circumstances here, I choose to write this post in the hope that it may help someone somewhere in a tough spot as well as perhaps help me be a better person as well.

Besides events that have happened, the other thing that prompted me to write this was reading “How Doctors Think” by Dr. Jerome Groopman, which made me reflect on how I think and do things. While the book guides doctors and patients on a journey of what kinds of errors doctors can make and why and how to avoid and mitigate them, his discussions on different types of “cognitive traps” are illuminating in a personal sense as well. Recently, I attended a “Night for Sight” event where Neil Beidelman, a guide mountaineer, related the events of “Into Thin Air”: in 1996, 8 climbers on Mount Everest died during a storm. When he talked about how a cascade of decisions, decisions that were a bit off but taken in unbelievably challenging moments, “stacked up in the aggregate” and led to the tragic outcome, that really hit home.

As a surgeon, I realized long ago how important it is to minimize mistakes and how it is even more important how you to react to mistakes. Panic and despair make you lose your mental equilibrium and you make further decisions which “stack up” and make the situation worse. And sometimes no matter what you do, the outcome will not be good or what you want but you do the best you can anyway. I teach these lessons and focus on them in training my residents and students, but probably should have, somewhere along the way, tried to absorb these lessons in my heart as well. As Dr. Groopman emphasizes in his book, lowering your emotional temperature in a tough situation is key to slowing down your thought, enhancing your perception and analysis, and thus permitting clarity to dispel clouded thinking. It’s just really hard to do when it comes to your own life.

Pressing for a solution when none is apparent can be the exact wrong thing to do. “Picking up a scalpel and cutting can be just the wrong thing” when you don’t see the whole picture. The good surgeon is not defined by technical dexterity or superior hand-eye coordination, but by sound decision-making and judgment that enable clarity and effectiveness in the operating room. Understanding issues and realizing what intervention can and can’t remedy takes a while to learn in a surgical career; I guess it takes even longer to learn that in life. Groopman, an oncologist, relates one of his mentor’s quips, “Don’t just do something, stand there” as he counsels against the impulse to jump in and do things. It’s awfully hard to do that as a surgeon, who by nature are gamblers, risk-takers who have to have confidence (perhaps arrogance) in what they do.

Which ties into one of the most essential qualities to being a doctor, indeed a good person: that of being a good listener. When I fall into panic and despair, I’ve realized I sometimes lose the ability to listen. And when you don’t listen, you make even more stupid decisions. You fail to appreciate the other person, where they’re coming from, and the importance of their perspective and thoughts; you lose the ability to put yourself in their shoes. You deny yourself a lot of important insight, and screw things up more. Being a good listener is something one has to work at, consciously, and something I can get better at.

I wonder a lot about “what ifs” and “if onlys”. It is, I suppose, the natural thing to do after bad things happen. But there is no rewind button on the VCR of life, no matter how ashamed I am of all my mistakes or tears I have caused. Theodore Roosevelt provides a little solace:
"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat."
Falling short and the gnawing sense of not being good enough are awful things, but it is better to have loved and lost, to have tried and failed, than to have never loved, never tried at all. Or is it? That doubt can be banished only by the knowledge of all the good that I experienced, which outweighs whatever pain I am now left with.

The ancients provide some guidance. The Bible, in Ecclesiastes, states, “The race is not always to the swift, nor the battle to the strong, neither yet bread to the wise, nor favor to men of skill; but time and chance overtake them all.” One of the Geeta’s core precepts is encapsulated in this verse from Lord Krishna to Arjuna in a moment of doubt and despair, “You must perform the right action, but you are not entitled to the fruits of action. Let no desire of the fruits be your motive, and yet be not attached to inaction.” I first read this 11 years ago when I was a senior resident, and wrestled with the concept for a long time. It finally dawned that what it means is that in a crisis, you must focus on doing your best to do what is right, but be detached from the outcome. It helped me be a better surgeon by helping me concentrate in the moment during a case. How much harder it is to accept on a personal level…

When you feel useless, the present is dim & bitter, and the future seems cold & barren, it is tempting to forfeit hope. Yet one (I) must remain grateful for life’s blessings – health, a life in the US as opposed to suffering in the Middle East or Africa, a good career where I can still make a difference, wonderful friends who are good listeners and care. And while others or the world can take away so much from you – your money, job, reputation, even people you love – be thankful for what can’t be taken away: personal honor, what you’ve learned, and service.

Pandora released the world’s evils from her notorious box but the last thing that came out was hope. While sometimes memory and even hope can feel like a prison, in truth they are the roots of change. Why you may ask? As for memory, Mark Twain said, “Good judgment comes from experience; experience, well, that comes from bad judgment.”

And, as for hope, George Bernard Shaw said, “The reasonable man tries to adapt to the world; the unreasonable man tries to make the world adapt to him. Therefore, all progress depends on the unreasonable man.” Perhaps success does lie in effort as much as in result. And the need for struggle is not grounds for avoidance.

As Bruce Wayne’s father said in Batman Begins, “Why do we fall? So we can learn to pick ourselves up.” All I can do now is take a long look in the mirror, make some changes to try to be the best person I can be, and hope for the best. I’ll try to start as I head off tomorrow from Salt Lake to Australia.