MD Program

  • Ten Things I Think I Think – On Becoming a Physician

    Presentation at the
    White Coat Ceremony
    University of Iowa

    Roy J. and Lucille A. Carver College of Medicine

    Friday August 20, 2004

    John P. Lawrence, M.D.
    Associate Professor, Department of Surgery

    Good afternoon, and welcome to the entering medical school class of 2008, their families and friends! It is an honor for me to be able to participate in your orientation experience to the Carver College of Medicine.

    The gathering here today has already gained notoriety and become truly newsworthy in that this is the largest assembly of individuals held in the State of Iowa in the past few months in which someone standing behind a podium did not mention a political candidate, or even attempt to slander the character of one.

    In preparing for this presentation I sought to find some convenient unifying theme in which I could package the advice, insight, or inspiration I could offer. After consulting with peers, browsing in texts, and looking through some journals, a mechanism surfaced by which I could organize my thoughts. The source of my direction in this regard was the periodical I continue to read most thoroughly, Sports Illustrated.

    In this magazine a columnist named Peter King writes a section called “10 Things I Think I Think”. Within it, Mr. King reflects on a variety of issues, some major, some trivial, some serious, and some humorous. He liberally expresses his opinions, but as the title suggests, leaves an air of uncertainty as to just how difficult it is to provide sound wisdom or judgment on any subject. As I attempt to provide an interpretation of what I believe are important concepts to consider as you embark on a career in medicine, remember that it represents no more than the musings of one individual, and not authorative doctrine.

    The full title of my talk then, “Ten Things I Think I Think – On Becoming a Physician” will allow me to lump together some disparate ideas I would like to share with you on entering the medical profession. Let me begin:

    Number 1. Don’t be overly impressed with your predecessors.

    As you gather here today an air of vulnerability may be beginning to permeate the atmosphere. Can I achieve what others before me have done? Do I have what it takes to measure up? Will I be the one who is long remembered for having passed out in the first gross anatomy lab? The seeds of insecurity which might have been planted already will no doubt be harvested in earnest by someone in the very near future in your basic science curriculum who will try to embellish their course content with a bit of medical history. Such an individual will delight in telling you, for instance, about Andreas Vesalius, who as a medical student in the 1530s wrote “De Humani, Corporis Fabrica” a 660 page treatise which overturned anatomical doctrine of the previous 1000 years and was the authoritative text on anatomy for nearly three centuries. Versalius also spoke four languages fluently, and had they been resurrected at that time, would likely have won nine gold medals in swimming in the 1536 Heidelberg Olympics.

    Bear in mind, however, that for every Andreas Versalius who has come along, there are far more medical students whose career was more like mine. Not only did I not author any books as a student, but in fact, I directly contributed to a net diminution of medical knowledge while a student by virtue of misplacing permanently several of the medical library’s holdings.

    Be secure; everyone in this class has the talent and abilities to succeed as surely as those in classes before. And remember that medical school is an extension of college; you need only to continue the academic skills you’ve honed to this point. Also, speaking from experience, medical school is like college in that you won’t get your diploma until you pay your library fines for lost books.

    Number 2. There’s no reason to despair over the future of medicine.

    Many of us have come in contact with individuals who grumble about how medicine is deteriorating, the good times have passed, malpractice is out of control, managed care is leading us to ruin, etc., etc. They make the immortal Chicken Little of “The Sky Is Falling” sound like an optimist. And yes, while adversity does face us on many fronts in the medical community today, remember that by becoming a physician you have the privilege to surround yourself with the best support group imaginable – your colleagues in health care. This is a collection of individuals who have made a conscious choice to devote their careers to facilitate the care of the sick and injured, and in the aggregate, based on my contacts, is an extraordinary group.

    The best evidence for me, however, that the future of medicine is secure is assembled with us today, namely this entering class. As a current member of the Medical School Admissions Committee, I had the chance to read through many of the applications of this group. Whether from personal statements, activities performed, or other accomplishments, this is a class that impressed me with its altruism, commitment, curiosity and dedication to honorable ideals, and you will surely leave the future of medicine in good hands.

    Number 3. Maintain humility.

    As you acquire medical skills, knowledge, and master the jargon of medical-ese it becomes easy to find yourself drifting slightly above mortal men and women. Or, to restate an adage applying to my specialty, surgery, when asked to list the three greatest surgeons in the history of the world, most surgeons struggle with knowing who to fill in at the number 2 and 3 spots…after themselves, of course. Try to avoid falling into this trap. A great source for maintaining grounding in this regard is your family and friends.

    In my instance, the ability to achieve perspective on this issue was best provided by my youngest daughter. One afternoon I found myself in the parental rule of chauffeur for my daughter and one of her friends when both were about eight years of age. As they chatted in the back seat of the car, hair in pigtails, and generally oblivious to my presence I heard my daughter ask her friend, “What does your dad do?” to which her friend responded, “He’s a teacher, he teaches sixth grade.” My daughter’s friend then returned the query, “What does your dad do?” My daughter responded, “He’s a pediatric surgeon”. Her friend countered “What’s that?”

    My mind raced as I wondered how the many experiences I had recounted at home of caring for sick or injured children would have been synthesized by one so young and innocent. Would the compassion invested and delicate nature of what I did be adequately reflected in her answer? Prepared to burst with pride at what the response might be, it occurred to me that just perhaps her answer might be tainted by some of the things she might have heard her older sister and brother express. As I peered back at my daughter in the rearview mirror she summarily answered, “A pediatric surgeon? Oh, that’s the kind of doctor that makes buttholes for babies that are born without one.” Giggling ensued. I had received my dose of humility.

    Number 4. Error on the side of treating everyone with too much respect.

    To be ill is a degrading experience; it implies weakness or defeat. An immediate way to gain trust and confidence from your patients is to demonstrate respect for them, and in so doing, abate the inherent superior position you possess in the doctor-patient relationship. Don’t be afraid to call someone “Sir” or Ma’m”, very few people object to these terms if you are sincere. Far more will appreciate the understated respect they imply.

    This premise was taught to me nearly thirty-five years ago when my great-grandmother was hospitalized near the end of her life. I was sitting in her hospital room when a nurse came in to introduce herself. She stated her name, and then described how she had been taught that to break down barriers of formality, she should call her “clients” (a vogue term many substituted for ‘patient’ at that time) by their first name. After taking a set of vital signs this nurse left; once she was out of the room my great-grandmother hissed, “Doesn’t anyone learn manners anymore? Someone younger than me should address me as Mrs. Preston unless I say otherwise.” I learned a basic lesson in respect; my great-grandmother bristled at this nurse for the remainder of the day. And, after hearing my great-grandmother’s first name, which happened to be Vesta, spoken out loud about ten more times in that one afternoon, I decided some family names are simply too unique to pass on.

    Remember that dignity is easily lost with ill health; later today you will be donning white coats, an act which has many symbolic elements. Among them is an implicit respect from patients; do what you can to reciprocate that respect, and in the process maintain their dignity. (Incidentally, you will also find that wearing a white coat gives you instant status as a hospital global positioning device. When attired in one, be prepared to know where the cafeteria, parking ramps, and all restrooms are from your present location.)

    Number 5. Maintain a sense of humor.

    Medicine is a serious entity; death, disability, and disfigurement are not trivial or funny matters. Be appropriate, but remember the saying, “laughter is the best medicine” has survived because there is truth in it. When used appropriately, possessing a sense of humor makes you seem more human in the eyes of your patients. It is also a good coping mechanism for helping to deal with the many issues we encounter in our medical careers that we can’t control.

    When my medical school class began our first clinical rotations as third year students it was a time for high anxiety. Collectively we felt insecure and burdensome to the teams to which we were assigned. We had been informed that to contact one another, we could call the switchboard operator and have our colleagues paged overhead. Our main teaching hospital was a product of the turn of the century, but the paging system within it permeated every room, corner, and walkway in the facility. As a group we began to bond by paging each other over this system, often for nonessential reasons such as making plans to meet for lunch. There was an aura of having arrived that came with hearing your name paged, primarily in a nasal tone, “John Lawrence, John Lawrence, please call the operator.” Our class stamped its identity on the hospital several days later with what started innocently enough with the page “Steven S. Johnson, Steven S. Johnson please call the operator.” We knew that no one in our class had that name, but instead it represented a type of dermatologic reaction; it wasn’t long before a scene reminiscent of Bart Simpson placing calls for fictitious people in Mo’s Bar had been enacted. Common bacteria had never received such publicity, “Sue Damonas, Sue Damonas please call the operator”, as did a variety of anatomic parts and commonly used drugs. Regrettably, by the end of the day, someone, no doubt wearing a heavily starched white coat, had heard enough and a list of authorized medical student names had been sent from the Dean’s office to the switchboard. We may not have had much status, but we quickly had notoriety.

    Number 6. Learn to accept failure, defeat, and complications.

    One of the most difficult aspects of training a physician is to take a successful individual such as any of you in the entering class and teach them how to cope with failure. Infections may ignore our efforts to treat them; tumors recur despite attempts to eradicate them. Still more disturbing are complications, where our best intentions to provide healing result in adverse outcomes. A recent survey indicates that medical errors are the cause of 195,000 deaths per year in the US, the sixth leading cause of death nationwide, ahead of pneumonia and diabetes. Obviously, we need to focus on what we can do to prevent this type of occurrence individually and collectively, but human error is to some degree inevitable.

    Be prepared to deal with complications; avoid the temptation of bearing their burden alone. Seek support from superiors or your peers; and learn from your mistakes.

    My first encounter with the world of complications came within days of starting my clinical work as a third year student. Assigned to admit Mr. B, a gentleman newly diagnosed with systemic lupus erythematous, a generalized inflammatory condition, I performed a thorough history and physical and then prepared to draw his admitting blood tests, a role in the job description of students in those days. I had carefully gathered my supplies; blood tubes, labels, spare needles, vacutainer, alcohol wipes, cotton ball, band-aid, and tourniquet. As I applied the tourniquet I was delighted to see a large vein distended at the elbow joint and, though haltingly, I managed to enter it on the first pass of my needle. Deftly I attached tube after tube of blood until the four or five I needed had all been filled. I withdrew the needle, placed the cotton ball on the entry site and asked Mr. B to hold onto the cotton ball while I shook the tubes which I had been instructed needed shaking, and applied the labels. Turning back to Mr. B I removed the cotton ball to apply a band-aid when to my horror, a thin geyser of blood spurted from his arm and onto the bedside table. I quickly reapplied the cotton ball and held steady pressure and made small talk, thinking that in his weakened condition Mr. B had not pressed firmly enough. After several minutes I cautiously removed the cotton ball and again a jet of blood squirted out. I reapplied pressure and tried to remain calm as beads of sweat appeared on my forehead; suddenly Mr. B looked paler than what I remembered when I first entered the room. I began to wonder if I could have mistakenly struck the brachial artery on my very first blood draw, or if a low platelet count that went along with his condition might be contributing. It occurred to me then that to prevent him from going into full-blown shock it would be prudent to lay him down. As I did so, his floppy hospital gown fell back and revealed that no more than four inches or so above where I was tenaciously holding the cotton ball to his arm, the tourniquet was still tightly in place. Casually I said, “Let’s go ahead and remove this now” and the crisis was resolved. This was my initiation rite into the realm of medical errors, a blight we all must coexist with in the practice of medicine.

    Number 7. Find ways to allow your humanistic spirit to flourish.

    I alluded previously to my involvement in the medical school admissions process, and how it allowed me the privilege to have read through applications of many individuals on this stage. It was truly inspiring to find that Generation X or the so-called “Me First Generation” could produce a class of individuals distinguished not only by academic prowess, but by a record of volunteer service, altruistic behavior, and commitment to those in need.

    The physical, emotional, intellectual and fiscal challenges of medical education have a way of supplanting those ideals unfortunately and replacing them with something that might begin to resemble, heaven forbid, a job. I would encourage you to find a means to preserve the ideals you possess today, for in the long-term your satisfaction will be better maintained. Be assured, the medical skills and knowledge you will obtain are of value and appreciated by every person in this country and worldwide whose access to them is limited.

    In my situation, I have found that one to two week volunteer trips to developing countries overseas allows me to fulfill some of my own aspirations to share the expertise I have acquired with the less fortunate. Though activities of this sort can offer value, they can also lead to frustration over how unjust health inequities are. A few years ago, I had traveled to a hospital in Haiti, where as a visiting surgeon a large clinic of patients awaited me on my arrival. On a sultry day I saw bench after bench of patients who in aggregate resembled a textbook of surgical pathology; gigantic abdominal aortic aneurysms, advanced cancers, untreated spinal cord defects, non-healing fractures and the like were shuttled in and out of two tiny exam rooms. Unfortunately between my limited surgical capabilities and the limited supplies in this hospital, I had seen no more than two out of about fifty patients that day who I felt I could safely operate upon. Hot and discouraged, I peered out the door of the exam room and saw one last patient, an elderly man with his hand wrapped in a dirty piece of cloth. I asked through the translator why he was here and the man replied he had cut his finger while working on an engine three days previously. As he unwrapped the cloth, he revealed a near complete amputation of his index finger with signs of early infection. After providing local anesthesia, completing the amputation, and giving a dose of antibiotics, I was thanked by the man and in particular for seeing him that day, as he was concerned that due to his late arrival he might not be treated until the following day. That single encounter highlighted my entire trip and continues to teach me about how extraordinary a profession medicine can be if we preserve our ideals and find ways to apply them.

    Number 8. Learn to be a participant in the health care team.

    As youth participating in sports or other activities, many of us may have heard a coach say, “and remember, there is no “I” in team.” Unfortunately, there are two “I’s” in ‘medicine’, and worse still, it starts with a capital ‘ME’. Don’t use this as a license to think that successful patient care is dependent solely on you. A vast network of support is essential to completing even minor tasks; realize that many types of expertise are vital to health care. Acknowledge these other individuals, listen to what they say, and build rapport with as many colleagues as possible as it will be of benefit both to you and your patients.

    Number 9. Pay careful attention to your own experiences as a patient.

    Undoubtably some of the most insightful moments that shaped my practice were provided during times when I was a patient. The sentiment, “treat others as you would like to be treated” achieves new significance in both major and minor ways. Not quite four weeks ago I was involved in a bicycle accident in which I fell and broke my clavicle. I was brought to an esteemed teaching hospital just up the hill from here, where I am pleased to say I received outstanding care. What stood out from that visit was the compassionate care of a radiology technician, who on seeing how much pain I was in as I tried to get my arm positioned for a final x-ray said, “Why don’t you rest for just a minute, we’re not in any rush here.” Remember how it feels to be a patient when you treat others. Try to replicate positive features of your own experiences as patients.

    Number 10.

    Lastly, I will come full circle and having begun by imploring you not to be overly impressed by your predecessors, I will conclude by suggesting that on occasion this is not a bad idea. The rapid turnover of medical knowledge makes what I, and many of my peers learned in medical school largely obsolete.

    But becoming a physician is not based just on science, but also on art. Don’t hesitate to seek out more senior individuals as mentors, to provide a dose of advice or wisdom from their experience, for it can be invaluable in guiding you.

    As I close, I feel obliged to pay credence to a remote predecessor of mine, the Renaissance anatomist and surgeon Andreas Vesalius who I referred to earlier. No speech of this type can be complete without a quote from at least one famous individual, and thus far the only one I’ve quoted directly is Chicken Little. Thus, let me conclude by mentioning a passage from the introduction to Vesalius’ book, known as “The Fabrica” in which he eloquently states his goal,

    “…I shall devote my discourse to the art that looks after the health of mankind and that is at once the most useful, the most vital, the most difficult, and the most laborious of all arts discovered by human genius.”

    I wish you all success in becoming practitioners of the art and science that is Medicine.