MD Program

  • Growth and Development of a Physician

    Presentation at the
    White Coat Ceremony
    University of Iowa

    Roy J. and Lucille A. Carver College of Medicine

    Friday August 23, 2002

    by
    Robert P. Kelch, M.D.
    Professor of Pediatrics
    Dean and Vice President for Statewide Health Services

    This afternoon we are gathered to launch members of the medical school class of 2006 on their journeys to become excellent physicians - modern day diagnosticians, counselors, and healers. In just a short while, they will recite the Hippocratic Oath as an act of initiation into the profession of medicine. Recitation of the Hippocratic Oath is a fundamental part of the Commencement Ceremony. In so doing, new physicians swear to uphold the ethical elements of medicine as they treat patients. Today, our entering students will take a modern version of this ancient oath after each has received her or his white coat - the symbol of the sanctity of the doctor-patient relationship. Students, I ask that you begin now - this very afternoon - to accept the responsibilities that shall be yours for a lifetime.

    As an attempt to help us prepare for the donning of the white coats and administration of the Oath, I would like to share with you some thoughts about the personal growth and professional development of physicians. I chose the title, "Growth and Development of a Physician," not just because I am a pediatrician and I am fascinated by the growth and development of children, but because I wish to emphasize that personal growth and professional development is or should be a lifelong, continuous process for physicians.

    In a recent article about teaching professionalism in medical schools, Stephenson and colleagues stated "Doctors must increasingly be aware of what they should be, as well as what they should know." (1) With that in mind, I ask that all of you think about what are the characteristics of an excellent physician, a physician whom you would seek for your own care or one to whom you would refer your patients and loved ones. Surveys tell us patients, first and foremost, want their physicians to be knowledgeable and competent, but they also want their physicians to be caring, respectful, and good communicators. Over the years, members of my family, especially my mother, have taught me much about the characteristics of excellent physicians. My mother would say, "He or she must know what they're doing, but I want them to listen to me and I want to feel that they care about me."

    Drs. Kern and colleagues from the Johns Hopkins Bayview Medical Center have studied this topic and have concluded that, "A physician's effectiveness depends on good communication and cognitive and technical skills used with wisdom, compassion, and integrity - wisdom, compassion, and integrity. Attaining the last attributes requires growth in awareness and management of one's feelings, attitudes, and life experiences." (2)

    I will return to these growth requirements, but before addressing the so-called "art of medicine," allow me a few words about today's science and how it has and will affect the practice of your art.

    Students, you have prepared yourselves well for admission to the college of medicine. You have compiled outstanding academic records and you have impressed a highly selective admission committee with your talents, accomplishments, and desire to become a physician. Undoubtedly, you are anxious and you may have some self-doubts at this point. This is normal, but I assure you that you have demonstrated the ability to succeed and that the faculty will work with you toward our mutual success. On the other hand, I can assure you that you must work hard to master the curriculum and that you will never be able to learn all that is known about any aspect of medicine.

    I entered medical school in 1963 and at that time, I believe that my classmates and I felt that we should be able to master all that was known about the functioning of the human body. Certainly, our professors crammed as much as humanly possible into the 36 to 40 hours of lectures we were required to attend each week. By the time of graduation, we felt proud - proud that we had survived and proud of all that we knew. Today, I believe that I know much more about the science of medicine, but I feel much less knowledgeable especially relative to all that has been discovered and is being discovered daily. Keep in mind that in the early 1960"s, human chromosome analysis was usually performed only in research laboratories and scientists had fairly recently reached agreement that there are only 23 pairs of chromosomes, not 24 as previously thought. Moreover, CT scans had not been invented, interventional cardiology was virtually unheard of, surgery was a major approach for peptic ulcer disease, and ampicillin had not been introduced into clinical medicine. Today, scientists have unraveled the entire human genome along with the genomes of many other species. We are beginning to understand the regulation of many genes and soon we will understand the structure of most if not all of the proteins coded by our genes. Moreover, the new field of glycomics is gaining significant momentum such that I predict that we will also understand how protein structure and function are modified by the addition of carbohydrates and other moieties. Indeed, I believe that we will develop a detailed understanding of the molecular machinery of the cell and in so doing, we will gain the ability to develop new molecules and other regulatory approaches to prevent or cure many of the most vexing and common diseases. For example, it is reasonable to expect that we will be able to cure or ameliorate juvenile diabetes mellitus through the transplantation of genetically engineered beta cells. We can reasonably expect to be able to decrease or prevent the intracellular accumulation of clumped proteins that lead to neuronal death in disorders such as mad cow disease, Huntington's chorea, and perhaps Alzheimer's disease. We can reasonably expect to have more specific cancer therapies, therapies that attack only the cancerous cells and not normally dividing cells.

    Technical advances will also continue at a rapid pace. Simultaneous assessment of the anatomy and function of organs and organ systems such as is possible with the new combined CT and PET scanners will improve quickly. In fact, I believe that this will challenge us to maintain our hands on physical diagnostic skills, skills that should not be lost as they are remarkably cost-effective and literally bring physician and patient together. Computer-assisted robotic surgery and magnetically-controlled, intravascular devices will allow us to operate on the innermost parts of the body in a safe, controlled manner. These are just a few of the advances expected during the early years of your careers as physicians.

    The current and anticipated explosion in medical knowledge should convince you that no one can learn all that is known - even all that is known about a specialized area of medicine. Thus it is important to realize that we must teach you how to evaluate your patients' problems and concerns, analyze data and findings, seek out new information, and apply what is known. These are the cognitive and technical goals of our curriculum.

    The non-cognitive goals of the curriculum are also ambitious and are, at least equally important. At my medical school orientation, a wise professor emphasized several points that I would like to share with you. - He reminded us that medical school was not a continuation of our undergraduate experiences. He also told us that we needed to mature professionally, socially, and psychologically much faster than our peers - if we were to become good physicians. Finally, he told us that our powers of observation would, and indeed, must increase dramatically. These comments are just as true today as they were in 1963.

    When speaking about the art of medicine, Sir William Osler considered by many to be the father of modern medicine said, "The art of the practice of medicine is to be learned only by experience; 'tis not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert." (3) I assure you, your families and friends, and your future patients that we will work with you to enhance your powers of observation and communication skills, but you must commit to continue to work on these skills as well as your current knowledge throughout your career. We will use problem-solving techniques, clinical simulations, faculty evaluations, patient evaluations, peer evaluations and self-evaluations to help you improve. Moreover, the faculty will teach you by example as they manage their patients.

    But how will you gain the wisdom required to become an excellent physician? In the earlier quote from Drs Kern and colleagues, I tried to emphasize that the attainment of wisdom requires considerable personal growth - growth in self-awareness and growth in your ability to manage your feelings, attitudes, beliefs, and life experiences. I did not fully understand these requirements when I began medical school and I suspect that most of you as students do not have a complete understanding either. Perhaps I was a bit slower than some because I remember becoming very angry when the old time country doctor who had cared for my wife's family for many years was quoted as saying, "It'll take him a while before he knows what he's doing." I still don't know exactly why my father-in-law decided to share that personal confidence with me - and shortly after graduation mind you, but my father-in-law is a very wise man in his own right. I do know that I have learned a great deal from my family, patients, my teachers, and yes, my students and that you will as well.

    When physicians were queried by Kern and colleagues about which processes had the greatest positive effects on their personal growth, they listed "powerful experiences, helping relationships, and introspection." (2) Powerful experiences have certainly helped me gain a better sense of what is professional wisdom. Allow me to share an early experience for emphasis.

    As a resident physician in pediatric training, I cared for a teenage girl who was referred to the University Hospital because of a severe lobar pneumonia. She was a very bright, talkative, but frightened teenager. I reassured her repeatedly that we would be able to cure her within a matter of days. After all, she merely had lobar pneumonia and I presumed that she would respond rapidly to antibiotics. She did not improve, however. Her condition steadily worsened despite all that I and my attending physicians and support staff tried. The laboratory tests available at the time told us that she had an atypical, cold-agglutinin positive type of pneumonia. Despite extensive medical and respiratory support, she died on a night that I was on in-house call. I was devastated; I couldn't believe that we failed to cure her, a previously healthy vigorous teenager. I didn't know how I could face the family! I also dreaded the thought of calling the referring physician. But I did call her private physician - at about three a.m. I quickly told him what happened and he, despite the hour, began asking me a few questions and then, sensing how distraught I was, he began counseling and consoling me. He taught me so much over the next 20 minutes or so. He prepared me for other losses; he helped me understand that we don't and can't know everything; and he taught me how to not only approach the family, but how to help them and share their grief. I became a bit wiser because he was eager to listen and share his wisdom with me in the middle of the night.

    Powerful experiences such as this as well as countless other less intense experiences and interactions will shape and improve your professional behavior, but it will require growth in self awareness and ability to manage your feelings, and attitudes. Through introspection and self-analysis you can continue to learn and improve. Ask how you might have handled a challenging situation differently; how you might have asked a more open-ended and less judgmental question; how you might have paid attention to what was not said as well as what was spoken; and how you could have known that the patient's body language was telling you something entirely different from what he was saying. Discuss your questions and experiences with trusted colleagues to seek their advice.

    Some additional advice that I would like to share with each entering student is: take care of yourself. I believe, as an old maxim says, you must take reasonable care of yourself if you expect to be able to care well for others. Do let us know when we can be helpful.

    The practice of medicine is demanding and can become all-consuming. To avoid that pitfall, I urge you to continue any and all interests that you may have in other activities, and I would add, especially the arts. I firmly believe that your non-scientific interests will make you a better physician - a better practitioner of the art of medicine. For me reading good literature - fiction and non-fiction is both refreshing and helpful. I also love to view fine paintings and I dabble with watercolors. Some of my colleagues prefer poetry or music to both enjoy and learn from. Yes, a personal appreciation of the arts will help you become a better physician through enhanced self-awareness.

    I'll close my remarks with just a few comments about the current challenges we are facing as practitioners. Despite increasing diagnostic and therapeutic abilities, we are witnessing increasing disparities in the delivery of health care. Despite spending more on health care than other developed nations we have one of the highest percentages of uninsured. Moreover, both the private sector and our government have been treating health care as a marketable commodity and have failed to realize that market forces do not have a social conscience. Current challenges have led some to become disillusioned and cynical. Beware of this pitfall, but as opportunities arise, do work to improve the financing and delivery of good health care for all.

    Thatês more than enough advice for today. I ask you to remember that this is the most exciting time I have ever experienced during my nearly 40 years in medicine. We can see that our diagnostic, therapeutic, and perhaps most importantly, our preventive abilities are improving dramatically. This is a glorious time to enter the time-honored profession of medicine! Do not allow anyone to convince you otherwise. Thank you.

    References:

    1) Stephenson A. Higgs R. and Sugarman J, Teaching professional development in medical schools, Lancet. 357(9259):867-70, 2001.

    2) Kern DE. Wright SM. Carrese JA. Lipkin M Jr. Simmons JM. Novack DH. Kalet A. and Frankel R., Personal growth in medical faculty: a qualitative study, Western Journal of Medicine. 175(2):92-8, 2001

    3) Sir William Osler, Aphorisms from his bedside teachings and writing (collected by Robert Bennett Bean), edited by William Bennett Bean, special fourth printing, Charles C. Thomas, Springfield, IL, 2001.