MD Program

  • The White Coat: Legacy and Promise

    Presentation at the
    White Coat Ceremony
    University of Iowa
    Roy J. and Lucille A. Carver College of Medicine

    Friday August 17, 2012

    by
    Jody R. Murph, M.D.
    Associate Professor, Department of Pediatrics

    It is both an honor and a privilege to have been asked to speak to you today during this White Coat ceremony marking your entry into medical school and the beginning of your journey into the field of medicine.   To each of you  I want to say "Congratulations!" and to welcome you and those who have loved and supported you through all of your struggles and achievements; your parents, friends and family.  You should be proud of your accomplishments and hard work.  We are certainly proud of you all and very happy that you have chosen Iowa as the place from which you will begin the amazing journey you are about to undertake.

    The word "legacy" means a gift, something received from an ancestor or predecessor; something handed down from the Past to the Future.  The White Coat is a symbol of a legacy handed down to you from physicians like Sir William Osler, Hippocrates, Henry Gray and Virginia Apgar. It is now your legacy to respect, to preserve, to add your own special contribution and then to hand down to those who come after you.  The White Coat also symbolizes a "promise"; a pledge or oath such as the one you will take this afternoon; a declaration that you will do something ...extraordinary. It is a reason for others to expect success and excellence from you and to trust you.

    As important as the promise you make to others, including your patients, your peers and society, is the promise you make to yourself.  The promise to always give your best, to be your best in whatever you chose to do; wherever you chose to go.  From here your journey may take you to an Indian reservation in South Dakota, to a lucrative orthopedic practice in Boston, a research fellowship at the National Institutes of Health, an academic appointment at Johns Hopkins or to life as a trauma surgeon in an inner city ER or at a military outpost in Afghanistan or the next war zone.  You might develop a new vaccine or cancer treatment that saves millions of lives or you might spend the next 50 years taking care of children and families in a small community in the mountains of North Carolina, teaching  inexperienced, overwhelmed young couples how to be parents.  The possibilities are limited primarily by your imagination. So study hard, dream large and set the bar high.

    Sir William Osler, describing the difference between a good physician and a great physician, said, "The good physician treats the disease; the great physician treats the patient who has the disease." 

    Every patient you will treat in your career has a story.  Their story includes, not only their known disease or diagnosis, but new symptoms or problems that you will uncover. It also includes all of those factors that may impact their access to care, their acceptance of your prescribed therapy and their compliance with the treatment plan.  For every patient these factors create either a strength or resilience that will help them remain healthy or recover from an illness or that present an impediment to their health or recovery and may lead to premature death. These variables include all of the Social Determinants of Health that account for between 60 and 90% of all disease and premature death; the patient's culture, beliefs, diet, behavior, family and social support, whether their insurance covers the medication you just prescribed and whether they have access to a dentist, needed subspecialty care, a grocery store, immunizations and safe places for children to play. These are all part of the patients story. To know that patient you have to take the time to listen to their story.

    For me, one of the most complex, frustrating and compelling examples of the importance of Social Determinants of Health has to do with mental, emotional and behavioral health and disorders. In the United States today, because of a lack of mental health services for prevention, diagnosis and treatment, the largest mental health placement facility for children and youth is often the juvenile justice and prison system.  In case you were thinking; "What does that have to do with me?" We look to you, to your generation of new physicians to change what we have been unable to.

    We know a great deal about the environmental factors necessary to help children grow into successful adults. We know children develop only within the context of relationships. To make a difference for children we must address not only the child, but also the family, the home, the neighborhood and the educational system, in addition to providing high quality comprehensive healthcare.

    One small example of this is the Perry Preschool Project (conducted between 1962-1967) which showed that children from the same impoverished inner city neighborhood who had access to high quality preschool at age 3-5 were much less likely (across the 40 years that they were followed) to spend time in jail, have a teenage pregnancy or require special education or government assistance. They were more likely to be successful socially, academically and in life in general.  This small investment in early childhood resulted in a return to the taxpayer of nearly $90,000 per child. So, you might think; "Good child care; how easy is that?".  Well, it turns out that much of the child care in the US is either mediocre or of poor quality.  We need for you to fix that too.

    The World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

    It is important to understand that your obligation and responsibility; to your patients and their families, to your practice, to the legacy that you leave behind, to society and to the future; to each patient that you see in your office or in the operating room and to those that you will never know, encompasses much more than what you can accomplish with a prescription pad or a scalpel. It includes advocating for what that patient needs; advocating for equitable access to health care; to effective treatments and medication. It means helping to change the traditional focus of medicine in America from a tertiary perspective where we throw vast sums of money at the treatment of diseases that are already well established, to a primary prevention focus where we work to prevent the development of diseases or conditions.

    It means understanding that access to high quality child care, safe places for children to play and safe walking or biking paths in the neighborhood are at least as important as treating ear infections, giving vaccines and removing tonsils.

    We routinely screen newborns for approximately 50 different inherited conditions, vaccinate them against hepatitis b and give them vitamin K and erythromycin eye drops in the delivery room to prevent infectious diseases and rare bleeding conditions. But if we fail to recognize the family at risk until the infant comes in as a fatality of Shaken Baby Syndrome, we have failed to identify and address those Social Determinants of Health that could have averted the infant's death.

    Over the next 4 years you will learn to take a comprehensive history, perform a careful physical exam, obtain appropriate diagnostic tests, make an accurate diagnosis and formulate a sound treatment plan.  Sometimes you will have huge successes, sometimes heart wrenching failures, and sometimes you will make mistakes.  Never be afraid to say "I don't know" or to admit when you've made a mistake and say "I'm sorry". Sometimes you will laugh with your patients and sometimes you will cry with them.  Sometimes you need to hold their hand and sometimes you need to know when to let go.

    During my training I took care of a 12 year old boy, David, with Acute Myelogenous Leukemia who had undergone years of chemotherapy with multiple relapses and remissions. We had no magic to help him, no new therapy to try, and no treatment that was likely to be successful.  He knew that he was tired of the pain and he was ready to let go.  But his parents weren't there yet. This young man wanted more than anything to plan his funeral. He knew who he wanted to come, exactly what music he wanted to be played and he knew he wanted to be buried in a lime green disco suit.  His parents weren't prepared to accept his choice to stop treatment or to listen to his plans for his funeral. So at the end of the day David and I and sometimes one of the social workers would often sit together and he would talk about his wishes, his fears, things that he would miss and what he thought it would be like after he died.  And this special little guy had a very full agenda of all of the things he was going to do after he died. Eventually, his parents were able to be there for him, helping him and one another. But in that window of time when they each had a different picture of reality, it was important for the physician to be that bridge; meeting the needs of patient and parents.  Being able to be present and to help patients at the end of life is both a great gift and a great responsibility; and it will be one of the hardest things you will ever do.

    There is an artist, Brian Andreas whose works are called Story People because, in addition to a colorful abstract drawing of people, there is also a story (a life lesson) on each of his pictures. One of his pictures depicts an angel and on the picture it says; "In my dream, the Angel shrugged and said if we fail this time it will be a failure of imagination; and then she placed the world gently in the palm of my hand".   Today you also hold the world, and the future, in your hands. For your journey, which will prepare you to become a truly "great" physician, you will need imagination, courage, compassion, an insatiable curiosity, an agile mind and an open heart.

    You are among the best and the brightest of your generation.  I challenge you to work hard to become the best physician you can be whether that is a pediatrician or a neurosurgeon; whether you practice in an academic setting, in private practice or public health, as a researcher, a teacher or a clinician. But always remember that through healthcare alone; what we do within the walls of our hospitals and clinics, we can only hope to impact 10% of the causes of premature death.   The Social Determinants of Health lie outside of the "traditional" definition of healthcare but must be part of what we each define as our responsibility. Master both the art and science of medicine and use your knowledge and skill within the walls where medicine is practiced and those where public health policy is determined and implemented.  Never doubt that you can make a difference. Never hesitate to try.  And never think that you are alone.

    Thank you and good luck.

    References

    Gruen, RL, Pearson SD, Brennan TA.  Physician-Citizens-Public Roles and Professional Obligations.  JAMA, January 7, 2004;291(1):94-98.

    McGinnis JM, Williams-Russo P, Knickman JR.  The Case for More Active Policy Attention to Health Promotion.  Health Affairs.  March-April 2002;21(2):78-93.

    Lee JH, Sadana R.  Improving Equity in Health by Addressing Social Determinants.  The Commission on Social Determinants of Health Knowledge Networks, ed.  2011, World Health Organization.