By Susan Dentzer
I recently had the honor of offering the address at the hooding ceremony at the University of Nevada School of Medicine. In attempting to craft a memorable message, I reflected on the journeys that these students had completed as well as those that they were undertaking, and how their futures were directly linked to our continuing pursuit of the Triple Aim. Here’s an abridged version of what I told them:
Thank you so much for the honor of addressing you today—the first day of the rest of your lives as doctors of medicine. And don’t let anybody tell you otherwise: You are beginning this first day of the rest of your lives in medicine at the most exciting time many of us can remember—both because of the opportunities that await you, and the challenges that we all must overcome.
These challenges and opportunities are best captured in the concept of the Triple Aim—thought up by very smart people who worked at the Institute for Healthcare Improvement in Cambridge, Massachusetts. They spent years studying the US health care system and concluded that we as a country needed to pursue three goals: We needed better health; we needed better health care; and we needed it all to cost less—or at least, not to get too much more expensive lest no one be able to afford it.
The concept remains relevant today, and will be for you as physicians. Consider its first goal, better health. I hope you will always think of yourselves as agents of better health—not just for your patients, but also for the whole country and the whole world. When it comes to life expectancy, the US is 29th among all nations. When riots broke out in Baltimore last month after the death of 25 year-old Freddie Gray, experts noted that life expectancy in that part of Baltimore is about 70 years—a decade less than the national average and roughly equal to that of Nigeria and Pakistan. The infant mortality rate in that same neighborhood is roughly equal to that of Algeria, Kazakhstan, or Belize. Freddie Gray struggled in school for much of his young life, a fact probably linked to the lead poisoning he suffered as a child.
Most of you know that health status is largely determined by the social determinants of health, such as education and income. I know many of you already have begun living your lives in medicine conscious and cognizant of these facts, such as by volunteering your services in clinics for the uninsured. In one respect, you are humble about how little health you can produce in people whose life circumstances have predisposed them already to such poor health. But at the same time, you are determined to do what you can to make things better. In serving those who are disadvantaged this way, you have already learned the lesson that Mahatma Gandhi preached: that “the best way to find yourself is to lose yourself in the service of others.”
Now consider the Triple Aim goal of having health care cost less. I hope you will think of yourselves as agents of a more affordable and sustainable system. There is a widespread sense that we as Americans don’t get enough value out of our health care system for the dollars that we spend on it. We know that our current system pays for care that isn’t always necessary. After all, as the great physician and author Lewis Thomas wrote, “The great secret” known to most people in medicine, but “still hidden from the general public, is that most things get better by themselves.”
We also know that much of the medicine we practice in this country isn’t always based on scientific evidence. As the Institute of Medicine has pointed out, some studies have shown that only 10 to 20 percent of clinical decisions may in fact be based on evidence. Some of that non-evidence-based care is just wasteful, and some of it is harmful, even though one of the cardinal rules of medicine is “Do no harm.”
I hope that you, as physicians, will always remember that doing no harm should also include doing no financial harm to patients, by avoiding giving them care that is unnecessary and costly, and no financial harm to our country. Be inspired by what Maimonides, the remarkable physician and philosopher, wrote more than 900 years ago: “Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit nor ambition for renown [to] interfere with my profession.”
We know that, thanks to enormous advances in biomedical research, we are making spectacular and important progress in saving lives. For all our scientific and technical proficiency, though, we know that our health care system has serious shortcomings. Take safety. The Joint Commission has reported that about 50 times per week in this country, a patient goes into surgery and has the wrong body part operated on because the team makes a mistake. The right brain gets operated on instead of the left brain; the right leg gets amputated instead of the left leg. And worse, sometimes it’s not just the wrong body part—it’s the wrong person. Mr. Smith was supposed to get the brain operation, not Ms. Jones. She was supposed to get her leg amputated, but she got the brain operation anyway.
In Crossing the Quality Chasm, a famous Institute of Medicine report released in 2001, the expert authors who crafted the report called for health care delivered in the US to be safer, more effective, more efficient, more timely, more equitable, and more patient-centered. That is an excellent list, but I think they left one important adjective: compassionate. We need a health care system that is compassionate, and that means we need you to be compassionate.
Compassionate doesn’t just mean that you have empathy with your patients. The word compassion comes from the Latin compatior, which means “to suffer” —patior —“with” —com. Being compassionate means suffering with your patients. Suffering with your patients is serving them, and taking a step on the road to self-fulfillment and enlightenment.
Let me illustrate this with the words of a young college student I know who experienced a serious illness recently. Here’s what he wrote about the doctors and nurses who cared for him:
If anyone was curious as to why I suddenly disappeared from campus, I was diagnosed with leukemia on February 26th… Since then, I’ve been in the hospital undergoing treatment and recovering. Today, after thirty-three days in Patient Room 123, I’m happy to be able to say that no leukemia cells were found in my biopsy and that I’m able to be discharged from care.
I won’t hesitate to say that the past five weeks have been the five that have most shaped and shaken me of any five that I remember.
I’ve been taken care of these past five weeks by two amazing groups of people—[a] world-class medical staff, and my unendingly supportive friends and family. I can’t adequately express my gratitude to either group in simple words.
Put simply, without the modern medicinal treatments I received… I would probably no longer be alive. But the medical system is more than simply the treatment technology. The doctors and nurses I’ve worked with have had an explanation and solution for every eddy in the seemingly endless stream of difficulties over the last few weeks. And at every step of the treatment, they’ve been as personally supportive as they have been technically supportive.
I wouldn’t have wanted to fight this battle with anybody else.
That note was written by my 20-year-old son, Will, who was diagnosed with acute promyelocytic leukemia last February. I’m delighted to tell you that he is in remission and his prognosis is excellent. But I don’t tell you this story to talk about my son; this story is about you.
Someday soon, if not already, some patient or group of patients will be writing just such a note to you or about you. They will laud your technical skills in healing them, but even more so, your compassion in caring for them and suffering with them. And when you read those notes from your patients, you will probably weep tears of gratitude and joy.
As physicians, you have been granted the privilege of touching the lives of other human beings in the profoundest of ways. The hope and wish of all of us here today is that you will now go forth, in this first day of the rest of your lives in medicine, to make the most of this priceless gift.
Good luck and Godspeed.