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Commencement Address at Baylor College of Medicine

May 21, 2013
at Baylor College

First of all: congratulations!   Congratulations to all of you who are graduating, to the families that have supported you, and to Baylor’s distinguished faculty and administrators who have taught and guided you during the past few years.

Last week, nervously casting about for a topic for this talk, I tried to calm myself by asking a colleague if he could even remember the speaker at his medical school graduation.   To my dismay, he beamed and said “Of course.  It was Alan Alda, who played the doctor in MASH.”

But I don’t do humor, at least not well.   So instead I am going to spend my few minutes, hoping to make a lasting impression, by talking about a potentially overlooked aspect of the new status about to be conferred on today’s medical graduates.

I need first to acknowledge the obvious significance of this moment of transition.   You are on your way to being a fully vetted physician, holding a degree, if not yet a license, that will allow you to assume one of life’s greatest responsibilities: the capacity to care for someone who is ill.

It will also have occurred to most of you that your place in the world is changing in a more practical way: as you move from medical student to trainee, you are also changing from being someone who pays to someone who is paid.  That also means, for many of you, moving from someone who has been accumulating debt to someone now starting to pay it off, albeit slowly.   Congratulations on that too.

But today I want to emphasize a more subtle and perhaps more important point about your transition: when you place those two letters—M and D— after your name you will be hereafter labeled as a person with special knowledge and, more critically, special AUTHORITY.

I want to explore this idea in greater depth in a moment.  But first let me tell you what I learned from a similar, even analogous, exercise last year, when I was asked to speak at the commencement of the first class at the newly formed graduate school at Memorial Sloan Kettering Cancer Center.  

I told those graduating students, like those of you about to receive your PhD’s here today, that they were not just getting a doctorate and a ticket to become professional scientists.   They were also becoming GATEKEEPERS—people who bear the responsibility for bringing others through the gates of science.  That means identifying, encouraging, and instructing talented young people and thereby helping them to become scientists. 

Today I want to make a slightly different case about the receipt of a medical degree—namely, that you are getting more than a degree and an entry into a notable (even noble) profession.  You are being given respect and the mantle of AUTHORITY.

Why this automatic conferral of authority?   I see at least two reasons.

First, you will now be officially recognized as knowledgeable about human biology and disease—about the many ways in which life functions— physiological, genetic, behavioral—can go wrong.  And about what science has taught us about making things right.   Thus you will be seen as an expert on one of humanity’s most important and valued topics: health. 

Second, you will be viewed as someone who cares enough about the well-being of others to have worked hard—for the past four years and, I warn you, for more years to come—to get this knowledge.   And you will have pledged, as you will do formally today, to use it for the benefit of others.   

Here I want to introduce another possible dimension to your new status:  If you exercise your knowledge in the best possible ways and for the best possible purposes, you will also be thinking about much more than the individual patients who seek your guidance and help.

You will also be attentive to the health of the public; to the health of those who are now well, not just those who have become ill; and—most critically for my message today—to the many aspects of our complex society and its environment that affect the state of our health.

It is on this last point where the respect and authority vested in you by this degree may be most needed.   Your views and actions can—and should—extend well beyond the immediacy of medical practice.   Even beyond the precepts of preventive medicine—to those difficult places where medical knowledge and social policy intersect, to those places where public policies affect the health of our neighbors and even the future of our species.

Before telling you more about those intersections, allow me a moment of confession about my own relationship to medicine.

This notion of a physician’s AUTHORITY to improve the world did not affect my own decision to enter medical school or my choices about a career path after finishing it.   I decided to go to medical school for much more selfish reasons.    I left a graduate program in English, where I was heading towards a life as a teacher of literature, because I was attracted to a different idea: FLEXIBILITY.   

While struggling with the hard decision about what I wanted to do with my life, I read that Gertrude Stein, the author and noted art collector, had first attended medical school because she was told that medicine can open all doors.  I hoped it would do the same thing for me.

The story of my changing interests—from journalism to literary criticism in college; to psychiatry and clinical medicine in medical school; and then to basic medical research at the National Institutes of Health—is better suited for another time.   But I have always been glad to have the flexibility that the MD degree provides to conduct research, to teach, to run institutions, even to work for a federal research agency and in the political arena.  

Still, flexibility is a self-indulgent trait.   It has been good for me, but it now seems less significant than authority and its uses to benefit others.

So what are those uses?   

Let me acknowledge at the outset that there are many examples of MD’s who use their degree and its implied authority to make irresponsible pronouncements.   I often see their names, linked to their MD’s, emblazoned on the covers of self-help books that opine on diet plans, exercise programs, and paths to inner peace.   Let’s simply agree that from now on we are speaking only about using authority responsibly!

Before thinking about what you should consider, let’s look at a few earlier examples of MD’s who have strongly influenced public policies by speaking authoritatively, as physicians, about the consequences of policies for health.

Let’s start with a big one.  The International Physicians for the Prevention of Nuclear War (IPPNW or simply IPP) was founded in 1980 by a coalition of US and Soviet doctors.    The US contingent was led by Dr. Bernard Lown, an immigrant from Lithuania, who trained in the US and also invented the cardiac defibrillator; he is still active in Boston medicine in his early 90’s.   

Together with his colleagues from the US, the Soviet Union and ultimately over 60 other countries, Lown based its opposition to nuclear warfare on the direct experiences of Hiroshima and Nagasaki and on the precept that physicians have a responsibility to try to prevent what they cannot treat—the horrendous consequences of mass irradiation.   In the notable words of one former prime minister, the group “made medical reality a part of political reality.”  

In 1985, five years after its founding, the group received the Nobel Peace Prize for its work. The citation from the Nobel Committee noted that the IPP’s “service to mankind” was based on its “spreading authoritative information and….creating an awareness of the catastrophic consequences of atomic warfare.”  

The IPP certainly raised awareness of the enormous risks of nuclear weapons.   Still, its impact has been difficult to measure directly, since the Soviet Union was dissolved in 1991, dissipating the most tangible threat of a nuclear war.  But the IPP’s message is still relevant today, as nuclear threats arise from Iran, North Korea, and other places.

Moreover, the IPP inspired similar efforts by physicians to highlight the medical consequences of conflict.   For example, Physicians Against Land Mines has drawn widespread attention to the medical dangers posed by land mines—“the largest source of war-related disability on earth”—and has helped achieve passage of international laws banning anti-personnel mines.

I would also like to offer some recent personal experiences with the use of authority.   As someone who has headed Federal agencies for two Presidents, I have come to know how medical institutions and the people who run them can affect public policy.    But I am still learning the breadth of issues that I can address using my authority as a physician and cancer scientist.   

Robert Hormats, an Under Secretary of State, has recently given me two lessons about this.   One of Hormats’ areas of responsibility at the Department of State is conservation, especially the conservation of species.   Over the past few months, he has asked me to write short statements on two topics that rarely cross my desk at the National Cancer Institute— the murder of rhinoceruses and the loss of species diversity.  

Powder made from rhinocerus horns is prized not just for its alleged sexual powers but also as a claimed cancer therapy.   Hormats asked me to write a blog entry—something I’d never done before—about this. So I explained why I deplored the wounding of these remarkable animals to obtain medically worthless but extremely expensive materials, leaving behind a dying animal that belongs to a species threatened with extinction.

To my surprise, this first effort as a blogger was picked up by a few hundred magazines.   So Hormats then asked me to co-author a short essay (recently published in National Geographic) describing one of the consequences of unregulated development and overharvesting of timber: namely, how the loss of plant species, which historically have yielded some of our most useful drugs—agents that you’ve learned about at medical school: aspirin, digitalis, quinine, colchicine, artimisinins, and many others—might limit the discovery of new drugs in the future.

Thanks to Hormats, I now see this now as a very good use of authority to address problems not in my daily field of view.

What kinds of issues can I recommend to you?   Let me mention a few and then concentrate briefly on one.   Each topic addresses problems about which MD’s have some special expertise, but I believe to be inadequately addressed at present by physicians and their organizations.

The first is gun control.  (Yes, I know I am speaking in Texas!)   The ubiquity of guns in this country is a critical factor in our relatively high rates of gun-related morbidity and mortality.  Annually, about 30,000 deaths in the US involve the use of guns.  The press and the public debates talk mostly about the 10,000 homicides, especially the most recent mass shootings.   But, as recently emphasized in the New York Times, we tend to say less about the other 20,000 deaths, which are mostly suicides and some accidents.    We also say relatively little about the many severe wounds, including spinal paralysis, that result from use of guns.

I know that there are at least two sides to these discussions and that the ubiquity of guns does not explain all of this damage.   Further, the improvements that new regulations and laws might bring are not easily achieved, as our Congress and many state legislatures have proven.    But I’d like to hear more MD’s using their authority to describe the effects of guns on public health, not just murders, but also suicides, accidents, and severe injuries.

A second topic is the nation’s uneven performance in science and math education in years from kindergarten to twelfth grade.   If we want to improve the ability of our citizens to adapt to rapid changes in medical science, we need more than the kind of medical training and medical research that is done here at Baylor.   We also need a general population taught at earlier stages to understand, appreciate, and evaluate the evidence that will increasingly serve as a basis for healthy living and good medical practice.  But I don’t hear many medical voices making such points in the debates over education methods and policies.

A third topic concerns our very survival as a species: the potentially devastating consequences for health that are implicit in many of the environmental issues that are now quite openly discussed: climate change; the rising demands for—and shortages of—clean energy in countries rich and poor; the continued and unsustainable growth of the human population; and the loss of species diversity.  

While we talk often about rising carbon dioxide levels and global temperatures, about alternative energy sources, and about legislation and treaties that seem never to get passed, I don’t hear much comment about their implications for health or for the future of our species.    Where are the authoritative medical voices noting the health effects of rising ocean levels on people living in lowland habitats?  The voices pointing out that warming will produce a resurgence of insect vectors for malaria, dengue, and other infectious diseases?   The medics who warn how crowding and hunger and water shortages will predispose our species to violence and other social maladies?

On all of these topics, regardless of what policy changes are recommended, physicians have important perspectives to bring to the debates.   But I don’t hear our voices often enough amidst the general din.   But, as of today, you have the authority to make reasoned statements that will be heard, listened to, respected.  And I hope and expect to hear from you.

I have saved one important topic to the end, because it is the one that will immediately affect the way you practice medicine with your new degree.   

Despite divergent views of the Affordable Care Act, virtually everyone in the US is concerned about the costs of health care.    If we don’t do a better job controlling costs, our entire economy, not just our entitlement programs, will be further jeopardized.

Many solutions have been proposed.   One that I find especially provocative would not only affect you, it would require your participation.  This proposal was made about a year and a half ago, in the New York Review of Books, by the Harvard physician, Arnold (Bud) Relman, who, like Bernard Lown, is operating in high gear as he enters his 90’s. (Relman also speaks with an especially high level of authority: he was for many years the editor of the New England Journal of Medicine.) 

In his article, Relman laments the inexorable rise of medical costs; the fee-for-service structure of our health care system that encourages costs; and the improbability that our grid-locked, partisan Congress would pass the kind of legislation that might move us in a better direction.

But he is not a pessimist.   He takes comfort in the idea that medical care might be reformed—and indeed is being reformed at this moment—by the many physicians entering multi-disciplinary group practices that pay salaries and charge per enrolled patient, not for each service.   He writes that nearly 200,000 doctors, nearly one fourth of practicing physicians in the US, are probably now in such practices, and that the numbers are increasing swiftly.   

The practices are popular with newly minted doctors—like you—because they don’t have to incur more debt to start their own practices, because working schedules are flexible, because the groups are collegial and stimulating, and because the care is sound and the costs to patients are well-controlled.    Continued movement in this direction, he argues, might ultimately drive the legislative changes that would presumably be required to bring about a full transformation of our system.    For these reasons, his article is entitled “How Doctors Could Rescue Health Care.”

My point today is not whether Bud Relman is right or wrong, although I happen to favor the kinds of changes he seeks.   I hold up his thoughtful article as the kind of contribution physicians should be making to the social, political, economic, and environmental dilemmas that beset us.   And I point to Relman’s authority—as physician and editor—to encourage you to believe that the new authority you acquire today will allow your voices to be heard.  

I too am an optimist.  I know from direct observation of medical students around the country that your generation is more engaged with social and political issues than mine was.   I see this especially in your passionate engagement with the global health movement and other domains as well.

This makes me confident that you will use your new authority wisely.  You will then have earned the respect that you will from now on receive.

Congratulations again for a job well done and thanks for listening to my plea.

  • Posted: May 23, 2013