Medical School Commencement Talk: Mayo ClinicMay 18, 1996
Harold Varmus, M.D.
Director, National Institutes of Health
Doctors, doctors-to-be, families and friends of the doctors-to-be:
Thirty years ago my medical school classmates were joyfully receiving their diplomas from Columbia University's College of Physicians and Surgeons. But I was turning my fourth year elective at a mission hospital in India into a hiking expedition to a glacier in Kashmir. Despite the glories of that excursion, I was--perhaps purposefully and even perversely--missing some important things that all of you will get from today's ceremony. A chance to participate in a final assembly of the people with whom you have shared a long, dramatic, life-altering experience. And a rare chance to allow your family and friends to look briefly at your life--to see what your classmates are like; to celebrate what you have accomplished; and to get some sense of the work you have chosen.
This last aspiration--to make your work understood and appreciated--is not easily achieved, and does not need to be completed today. In fact, most of you will spend plenty of time throughout your careers trying to explain your work and its demands to family and friends, patients and strangers. (I hope you will be more successful at this than I have been!)
Given its centrality in our society, I am surprised how infrequently we try to understand the daily work of our fellow citizens, instead of their love lives, crimes, or political views. I am often frustrated, for example, by the poor public understanding of what it is like to be a scientist and to do a scientist's job. This is very different from the scientists' common complaint that most people don't know much about what science has accomplished. But it is equally important. In fact, a genuine understanding of science cannot be divorced from some knowledge of how scientists make discoveries, interact with their colleagues, obtain grant support, and contend with many adversities.
There are, of course, some exceptions to the general lack of attention to how people work. Television and movies often try to show us what it is like to be an athlete, a cop, a journalist, or a doctor. But, until recently, the media's perception of a physician's work has been unduly romanticized--as in the televised portrayals, popular in my youth, of Drs. Casey, Kildare, and Welby. That has recently changed for the better, as I learned several months ago when--wondering what I might say to you today--I was persuaded to watch my first (but certainly not my last) episode of "ER."
Before we get serious about this show--and we will get serious about it--I must acknowledge to my high-minded friends that parts of it can be as repetitive and trivial as any soap opera or Marcus Welby rerun. But it is also gratifyingly graphic about some social realities: the intensity and physical demands of medicine as a work experience; the importance of collegial teamwork for delivery of care; and the diversity of the team, with plenty of women, members of racial minorities, and authoritative people who are not doctors. And after a long week of being nice and politic, I enjoy hearing my wife say: "You know why you love this show? Because no ever comes through those doors calling for alternative medicine!"
"ER" is now so popular--attracting not just medical students and residents but many millions of all kinds of viewers each week--that those of us concerned with the public's understanding of health and medical science must be--or at least ought to be--interested in what takes place. What have the "ER" scriptwriters done with their extraordinary opportunity to educate, as well as entertain? Perhaps surprisingly, that opportunity has not been entirely lost.
For example. On last year's pre-Christmas show (now you know roughly how long I've been hooked!), a 35 year-old man was brought to the ER unconscious after a skimobile accident. An imaging procedure shows a herniated cerebral hemisphere, and a signed transplant donor card is found in the patient's wallet. So Dr. Peter Benton, the impulsive, energetic surgical resident, strides to a computer terminal and links up with a national tissue matching program, hoping to find suitable recipients for a heart, a liver, and two kidneys. He does this despite warnings from his supervisor that a reluctant relative could overrule the signed donor card. Naturally, when the patient's estranged, guilt-ridden wife turns up, she wants a second opinion about the verdict of brain-death. Time is running out. Helicopters from three cities are heading for Chicago to pick up organs. Benton is agitated. Mark Greene, Dr. Nice Guy, bails out Benton by talking sympathetically with the, wife who then signs the permit to allow the helicopter pilots to fly back to waiting patients with their Christmas gifts.
All in all, this episode told a remarkably realistic and ultimately moving account of current practices in the world of organ transplantation. It introduced viewers to the concept of brain death, the legalities of organ donation, the existence of computerized matching services, the urgency of transporting donated organs, and the anguish of patients waiting for them. I would be surprised if the show did not produce greater acceptance of donation; certainly, it enlarged understanding and promoted altruism.
I have, of course, been especially interested in "ER's" portrayal of research. Emergency medical practices pose special problems for clinical investigation. Informed consent is impossible when patients are unconscious and relatives are unavailable. ER practitioners might be reluctant to try novel procedures when the medical situation is immediately life-threatening. Even the speed of emergency medicine seems culturally incompatible with the contemplative mode of research. Here is meat for some powerful and instructive dramas. But, disappointingly, "ER" has portrayed research in a singularly negative and cynical fashion.
The only investigator on view in the past several months has been the satanic, arrogant vascular surgeon, Carl Vucelich. Dr. Vucelich is apparently testing a new procedure for the repair of dissecting aortic aneurysms. He is intensely competitive and derives local authority from the grant monies he brings to his institution. (Until recently, no one mentioned whether the NIH was the source of his funding; two nights ago I was relieved to learn that his latest award--$3 million--is from a pharmaceutical company.)
Vucelich and his clinical research methods became entwined in the show's story line for several months after Peter Benton helped him repair an elderly woman's aneurysm. When the patient fared poorly post-operatively, Vucelich consoled Benton by attributing the outcome to her preoperative condition rather than the procedure itself. This meant that she was deemed inappropriate for inclusion in the study. Benton seemed bewildered by this post facto manipulation, but did not object. As a reward, he was invited to join the research team and provided with some pleasant perks: a parking space near the hospital, a key to a quiet room for study, and a check for accruing patients.
The medical student, John Carter, was then drawn into the research project. (Like all of you, Carter graduated this week, so he is now Dr. Carter; like me, he missed his commencement exercises, though he had more noble reasons. The ever-eager Benton also missed his, to do an emergency hemorrhoidectomy!)
Carter was understandably tempted by the $1000 bounty offered by Vucelich for finding patients with aneurysms. (The temptation was so great that Carter's first claim was based on a radiological reading by his girlfriend, after he missed the diagnosis.) This patient, a relatively young man, also did poorly. So Vucelich excluded him too from the study, attributing neurological damage to an allergy to the anesthetic. Benton now gets suspicious, reviews the charts of many patients, and confronts Vucelich with the accusation of biased exclusion of several patients.
So far, the story is interesting and even instructive about clinical trials, even if hardly flattering to medical science. Now we face a whistle blower's dilemma and an institution's response to allegations--serious issues in current discussions of misconduct in science. But the issues are treated in only a stereotyped and cynical fashion.
Vucelich fires Benton and says publicly that Benton has resigned from the research team, allegedly to protect Benton's reputation. The senior staff tell Benton that he is either arrogant (who is he to challenge Vucelich's criteria for accruing patients?) or politically foolish (doesn't he realize that the hospital is dependent on Vucelich's grants?) Even Benton's colleagues urge restraint--he will hurt only himself, they say. So he vacillates. When he finally registers a written complaint a few months later, it is returned with two unconvincing rebuttals: why did he wait so long? and didn't he know that Vucelich had appended the histories of the excluded patients to the now published report? The episode ends with the announcement that Benton has been named Resident of the Year. His nominator? Carl Vucelich!
There is plenty here to disturb those of us who think clinical research deserves a more balanced hearing. Why couldn't an episode about research include an investigator who is not diabolical? A project with comprehensible objectives? A purpose other than revenue and privilege? Or an outcome other than accusations of misconduct--especially accusations that are not taken seriously?
Not even I expect that a show like "ER" will risk sacrificing its appeal as entertainment for the purposes of people like me. But the episodes I have described do show that serious issues--like transplantation or the conduct of research--can be confronted in interesting ways for an amazingly large audience. And there is ample evidence that the show could approach other weighty matters--new medical discoveries or debates over health care financing--without loss of viewer appeal.
Leon Lederman, the Chicago-based Nobel Prize-winning physicist and educator, has proposed a network show, called "The Dean," to portray the work and ethical dilemmas of scientists in a dramatic serial to be set in a high tech university. But he has not yet found a major sponsor. So those of us who believe that the public would welcome serious airings of such must salivate over "ER's" ratings and plead with its producers to tell our stories. Such pleading is now easier, because "ER" has a World Wide Web site that invites submission of ideas for scripts.
Consider a very brief episode on a recent show, with the kernal of a good story line. Mark Greene attempts to hospitalize a patient who has had transient cerebral ischemic attacks (TIAs). But the patient is summarily discharged because the number of attacks did not meet the requirements for insurance reimbursement. The knowledgeable viewer knows that TIAs are often precursors to strokes. That strokes have recently become treatable diseases, deserving at least as much acute attention as heart attacks. That health care is increasingly dominated by reimbursement plans with short-range, highly competitive perspectives.
So let's work with this. Bring on the compassionate clinical investigator who is doing a new study to compare a new drug with the recently validated, partially effective therapy for stroke (tissue plasminogen activator). To have any effect, therapy must be initiated within a few hours after onset of the stroke. So the investigator joins up with Dr. Greene to argue with a representative of a managed care organization, an extremely attractive and articulate woman whose arguments Greene finds hard to resist. All right, you get the idea. This could go on for many weeks, the public learning a lot about strokes, clinical trials, and managed care, while also waiting to learn whether Greene will find consolation for his marital breakdown.
As you now enter the medical profession--whether as an ER resident or a laboratory scientist--your life will be affected by public perceptions of what you do. Consider today's unorthodox digression on a popular TV show as one manifestation of concern about how the work that you and I do is perceived. As you go proudly from this place to do a lifetime of good deeds, I hope we can both find more informative ways to describe our work to the society we serve.
Thank you and good luck.