Tuesday, March 29, 2011

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.

5 Comments:

At 4:28 PM, Anonymous Niraj said...

Excellent and thought provoking.

 
At 12:02 AM, Blogger Dev Avasarala said...

Excellent Bala.

 
At 9:11 AM, Blogger fehma said...

very well said, very appropriate to the chenging times, is it ok with u if I pass on these pearls to other physiaicans who'll benefit from it.
Fehma:)

 
At 1:10 PM, Anonymous Anonymous said...

Good listening, equanimity and nimbleness. These we learn, throughout our lives, are the qualities to attain if we want to become better persons and better doctors.
However, one major trait encapsulates all of the above and is the core of turning into the best doctor you can be: humbleness.
In humbleness, you find the peace of mind and self-confidence to be able to listen to the other person. Patients need to be listened to, not only because it allows us to create a good picture of their clinical history, but also because listening is healing.
In humbleness, you find that making mistakes in life and with patients is human, and that learning comes from mistakes. Arrogance does not allow you to forgive yourself for making a mistake, because you do not accept that you can commit mistakes. Being humble leads you to the path of forgiving yourself for having made a mistake. And these mistakes, which you forgive yourself for, are accompanied not by panic and despair, but by equanimity.
Finally, humbleness is always hand in hand with learning, because you embrace your ignorance and seek to improve it: learning medicine, learning science, learning from mistakes, learning how to learn. And you finally find, in all you’ve learned, the ability to be nimble.

 
At 10:28 PM, Anonymous Anonymous said...

Good listening, equanimity and nimbleness. These we learn, throughout our lives, are the qualities to attain if we want to become better persons and better doctors.
However, one major trait encapsulates all of the above and is the core of turning into the best doctor you can be: humbleness.
In humbleness, you find the peace of mind and self-confidence to be able to listen to the other person. Patients need to be listened to, not only because it allows us to create a good picture of their clinical history, but also because listening is healing.
In humbleness, you find that making mistakes in life and with patients is human, and that learning comes from mistakes. Arrogance does not allow you to forgive yourself for making a mistake, because you do not accept that you can commit mistakes. Being humble leads you to the path of forgiving yourself for having made a mistake. And humble mistakes are accompanied not by panic and despair, but by equanimity.
Finally, humbleness is always hand in hand with learning, because you embrace your ignorance and seek to improve it: learning medicine, learning from mistakes, learning how to learn. And you finally find, in all you’ve learned, the ability to be nimble.

 

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