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Iowa City, Iowa 52242-2600
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Congratulations to the following students of the class of 2011 for their induction into the Gold Humanism Honor Society:
Kim Ephgrave, M.D. specializes in minimally invasive and bariatric surgery at the University of Iowa Hospitals and Clinics. A graduate of Loyola-Stritch School of Medicine in Chicago, she completed her residency at Parkland Memorial Hospital in Dallas and her internship at Loyola University Medical Center. Dr. Ephgrave is a fellow of the American College of Surgeons. She has received many awards, including the Outstanding Surgical Teacher Award presented by the Association of Surgical Education and the Society of University Surgeons’ Collegiate Teaching Award. She is also a four-time winner of the Carver College of Medicine’s award for Teacher of the Year.
Greetings to all of you: Senior medical students, Guests, Colleagues and Staff. I have been looking forward to this day since Dr. Cohen first contacted me, because for me this is the day that I get to meet the students joining the Gold Humanism Honor Society. Who would not want to meet them? The people joining the Humanism Society today are a select group culled from the 150 or so enormously talented folks who are currently senior medical students at the University of Iowa. The inductees we are honoring have been selected as the most outstanding because of their service to others, their ability to connect with others, and because their peers, professors, and staff here in the College of Medicine have recognized them as the kind of clinicians they hope will one day care for them.
I believe that I was chosen to speak for a number of reasons, one of which is that I was part of the process of selecting students for this honor society during the rapidly receding years (2002-2006) when I served as associate dean for students and curriculum. We had a committee of OSAC deans and staff who met annually for this with the founding faculty director Jerry Woodhead. Going over the Gold Humanism Honor Society nomination materials with that group was one of the most fun things I got to do as associate dean. I would marvel at the talent flowing through this medical school, agonize when we couldn’t include every worthy nominee, and leave those meetings inspired by all the good things related to medical education at Iowa.
I remember trying to look for patterns that would predict which would achieve this honor, but didn’t have too much success. Selection for the Humanism honor overlapped with selection for our academic achievement honor society (AOA), but not much more than you would predict by chance. Some of the students we honored for their humanism came from wonderful, supportive environments where they had learned by example to enjoy and find connections with their fellow human beings. Other Humanism society students came from extraordinarily challenging environments which probably generated their strong commitments to make the world a better place. Those two extreme origins both made some sense, but many other Humanism Honor students had backgrounds that seemed quite ordinary. It was quite a while ago when I was about to begin my own senior year as a medical student, in fact that was September of 1979. I was similar to these students in that I was about to embark on my residency interviews, but I was almost certainly less mature than any of them; I was still just 22 years old. I was unsure what specialty I wanted to pursue, and I had been too anxious about completing the academic requirements to have pursued service opportunities during medical school. Although I know my family would have been thrilled to see me honored for humanism in medicine, I definitely would not have made the cut.
So I sincerely admire these Iowa students’ day to day commitment and skills in serving others, which goes far beyond what I could have done as a medical student. I have an additional 3 decades of clinical experience now, though, so that should be time enough to have learned some things worth sharing with others. Don’t worry about memorizing any secrets, there are none. As Robert Fulgham pointed out in his book, Everything I really need to know I learned in kindergarten, the essentials of worthy human behavior are absolutely not secret. In fact, the core truths about human lives seem to have remained unchanged for at least 5 or 6 millennia. So although I hope some of my thoughts may be useful, I doubt that any of my advice will strike you as new or surprising.
Now-speaking directly to our honorees--We who are gathered here today can easily agree about what we DON’T want to happen in your future careers. You have all been in enough clinical situations to have heard your fellow students, your residents, and/or some practicing physicians speaking cynically. You may or may not have recognized in their behavior the signs of what we currently call burnout.
If you google the word burnout or consult Wikipedia, you will find that the first few stages of burnout are shared by nearly everyone in healthcare. The number one stage is, “A compulsion to prove oneself”, and number 2 is “Responding to setbacks by working harder”. It is hard for me to imagine anyone gaining admission to medical school without having achieved those first two stages! The next stages are also common in medicine but more hazardous, i.e.3) Neglecting one’s own needs, and 4) Decreasing time investment in friends and outside interests. The more obvious negative effects show up in the next stages, which are cynicism, substance use, and depression.
Burnout is not unique to us physicians; it is a risk for everyone in a helping profession. It impacts the care we attempt to give others, and it harms us as well. Most of you probably know that although physicians are in general leaner, healthier, and less likely to be smokers than the rest of the population, the rates of serious substance abuse are at least as high as average, and unfortunately the rates of depression and completed suicide for physicians are much higher, particularly for women in medicine.
What can we do to prevent that kind of trouble? Maintaining your sense of control over your life, maintaining your connections to others, and working with others who share your values are associated with low scores on standard burnout inventories. Another essential—which is particularly important for me since I’m a surgeon—is maintaining humility. When we study those who are considered outstanding by their peers (whether in primary care, education, or whatever) those who earn others’ respect generally are well aware of their own shortcomings and are constantly on the lookout for ways that they can serve others better.
Another bit of insurance against burnout is to find opportunities to teach: whether those are with physician colleagues, hospital or clinic staff, or with actual tuition-paying students. When we teach we question what we do and why we do it, which repeatedly reminds us of our original goals. We also recharge our batteries, receiving the enthusiasm of those who are encountering for the very first time things that we have come to find commonplace. You who are outstanding in humanism are well-equipped to teach because the data show you are already adept at seeing situations from others’ point of view. These skills help you as well as others; data also show that primary care doctors who precept students are happier than those who don’t, and the Association of American Medical Colleges has work satisfaction data from 10’s of thousands of physicians showing that being an academic physician is a strongest predictor of satisfaction with a medical career.
There is also an interesting article in the September 2010 issue of Academic Medicine reporting that an intervention to remind medical students to try to imagine the clinical situation from the patient’s point of view significantly increased patient satisfaction. It is not trivial to satisfy patients and forge strong therapeutic alliances; Connecting with patients is tightly linked to control of chronic diseases. The studies in the current Academic Medicine manuscript included one which showed that the race of the patient did not matter; not surprisingly all ethnicities seemed to benefit from practitioners who can understand the patient’s point of view. Less predictably, the last study investigated the medical student’s baseline habits of “perspective-taking” in their interactions with friends and family, and demonstrated that while the students who were above average at perspective-taking in their daily lives improved their patient interactions with a brief pre-test reminder to take the patient’s point of view, the intervention did NOT help the half of medical students who were less adept at taking others’ points of view.
There is no question that all of you being inducted into the Gold Humanism Honor Society are able to connect well with others and thus would fall into the group of practitioners who do even better with brief reminders to take their patients’ point of view. My hope for the future is that you, who are exemplars for humanism in medicine, may some day find ways to help your colleagues who are below average in this area. Helping your less-able colleagues’ perspective-taking would improve healthcare, and help them directly, by decreasing their chances of suffering burnout.
There is another technique which can be useful as an antidote to cynicism, which you may be familiar with. This is called appreciative inquiry. I hope some of you have already learned this approach at some point in your education. Our natural human tendency is to focus on flaws, whether in our political systems, our healthcare systems, or in the people around us. Appreciative inquiry turns this around to focus on the positives that we often overlook. In appreciative inquiry we ask about the stories of things that are going right. From that base of identifying and analyzing what is going well, we can often discover how we can help each other do more of what we are proud of, as well as get a morale boost that is opposite of the impact of our more common sessions devoted to airing complaints.
My last thought for today may be my most important, which is this: Be Not Afraid to Change.
When I entered medical school, it was with the intention of a primary care career in an underserved area, some place like the rural African-American community in South Carolina where I had interned as an undergraduate. I surprised myself by veering into general surgery and then academic medicine. Perhaps stemming from guilt about all of that, I always felt regret when I saw talented and humanistic medical students choose careers other than primary care.
I realize now how foolish that was.
Over the last 3 decades, I have seen wonderful physicians leave careers in internal medicine, in interventional radiology, and in family practice in order to pursue a new or old passion for surgery. Similarly, I have seen surgeons leave and become quite happy as anesthesiologists, radiologists, pathologists, and even psychiatrists. I’ve known epidemiologists who happily retrained as clinicians, and clinicians who re-trained in occupational medicine. What is essential is that you follow your passion, and recognize that the fields that make you happy can change over time. You may have seen the bumper stickers or sweatshirts with the motto “If mama ain’t happy ain’t nobody happy”—the sentiment is true, and unhappy physicians wreak havoc as well.
From a personal standpoint, many of you may know that after years 23 here on the faculty I was diagnosed with Stage IV lung cancer. That was about 18 months ago now. I can tell you from that very intense point of view (having your life threatened is definitely intense) that I was truly fortunate to have a humanistic and idealistic physician in pathology do my initial fine needle aspirate, another in radiology to do my needle biopsy, and another in anesthesia to put me to sleep. These ‘non-clinical’ physicians helped me immensely with their humanistic care just as did other humanistic and technically skilled practitioners in nursing, oncology, surgery, and radiation therapy.
On this day, September 13th 2010, we are all very proud of what these senior students, our new inductees in the Gold Humanism Honor Society, have accomplished. Their futures are bright: There is truly no more rewarding career than that of a physician. Whatever they pursue in their future careers, we can be certain that the humanistic qualities of these wonderful Iowa students will be a gift to those around them.
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