First, I want to say, on behalf of all of our faculty, we are so proud of you. Actually, we are in awe of you because you made it through all of the challenges of Covid. So, what’s next — internship and residency. Yes, I am reminding you that several weeks from now you will be intern physicians, the first step in what we call graduate medical education. What’s it going to be like?
Well, amidst the rather overwhelming turmoil in the world right now, we have begun to see major upheaval in graduate medical education in the last few years. The big news this year is unionization of interns, residents, and fellows at some of the best medical institutions in the world, including MGH and Brigham and Penn Medicine and I know several of you will be going to those programs. To many of us on medical faculties across the country this comes as a shock and has generated a lot of soul-searching and serious questions. Lisa Rosenbaum’s recent essays in the New England Journal of Medicine offer a window into the challenges facing both trainees and faculty and their titles alone give a strong sense of those struggles:
“Beyond moral injury—can we reclaim agency, belief and joy in medicine”; “On calling—from privileged professionals to cogs of capitalism”; “Being well and doing well—distinguishing necessary from unnecessary discomfort in training.” In her essays, Rosenbaum cites new doctors who say the system is broken and ask how can they find meaning in a system that often forces them to go against their principles, in which they can’t always do what’s best for their patients. She also quotes faculty members whose students are pushing back on many of the traditional rigors of training like reading outside of their on-call hours or staying after a shift to deal with some evolving illness. The overall picture given by the essays is one of a graduate medical education system at odds with itself, unsure how best to move forward.
Reading these essays genuinely troubled me and I am still struggling to know what we should do here at WashU, but it made me think back to what I experienced during my own internship and how it completely changed the rest of my life. It began in the second month of my internship at Children’s Hospital of Philadelphia when I was assigned to the Children’s Seashore House Annex rotation, a transitional unit of an Atlantic City pediatric rehab hospital that was supposed to be used for children who did not need high-intensity care to help them transition to Atlantic City or to home. This was a first-time rotation and for reasons about which I can only speculate now, there was no senior resident or attending physician assigned. That changed after the experience I am about to describe.
On my first day, I was called by the head nurse to see a newly admitted 17-year-old with shaking repetitive motions of her extremities who had just been transferred from the psychiatry ward of the Hospital of the University of Pennsylvania, what is called HUP, which was next door. I hope you parents will excuse me for a moment of medical speak that you graduates will understand. The movements of this patient’s extremities did not look like epileptic seizure activity, and I somehow figured out to do the Trousseau’s test for tetany. We sent some blood tests and found a calcium of 6.2, but also a bicarb of 3, and potassium of 2.1. Yes, this was an emergency but also a pattern that was not recognized by me as I stood there having been a physician for all of 4 weeks. Slightly panicked was an understatement and the head nurse had no idea how to help. I called the nephrology fellow who was wise enough to tell me that I could not run calcium and bicarb in the same IV so somehow, I started an IV in each hand and began infusing calcium and bicarb in the appropriate solutions and at the appropriate rates. At some point during those initial several hours I went back to the nurses’ station and saw the stack of medical records that had been sent over from HUP, a stack that reached up to my waist and had the contents of dozens of hospital admissions and outpatient visits. As I read through the charts, I realized that this patient had been in and out of the clinical center at the National Institutes of Health since she was three years old. Over the next 48 hours I read through dozens and dozens of admissions, workups, and medical complications trying to understand what was going on with this teenager. I discovered that she had some kind of immunodeficiency with low levels of immunoglobulins and then many different types of autoimmunity—atrophic gastritis with pernicious anemia, celiac disease with protein losing enteropathy and steatorrhea, what was then called chronic active hepatitis. The unifying diagnosis wasn’t in the charts, so I went to the literature, reading article after article, case after case over the next 48 hours.
Finally, I decided that, based on her history and presentation, she best fit something that had been described a year before in the Annals of Internal Medicine by a very famous physician labeling the condition—late onset immunoglobulin deficiency. The state of the field of clinical immunology at that time was apparently very confused about the combination of immune deficiency and auto-immunity. I asked to present her case to the faculty of the Department of Pediatrics in its weekly management conference to get her accepted for transfer into one of the acute care inpatient units of CHOP. I explained to the faculty what I thought was going on with her chronic and acute illnesses and that the patient and her family had become extremely difficult to work with because of depression, anxiety, and all of the trauma of her chronic illness and multiple illnesses with no answers from the best doctors at the NIH. This was why she had been admitted to the HUP Psychiatry Unit. I vividly remember that conference on a Friday morning. The patient was transferred in the afternoon and that night I walked home to my little apartment on 45th St. and Locust, stopping at a deli along the way to buy two corned beef sandwiches. I ate most of those sandwiches before I even made it home and fell asleep immediately after I walked in the door. I tell you this detail because I even remember how deeply I slept that night. It was the first time in my life that I really knew that I could make a difference in the world, even if it was only going to be for one patient, one family at a time.
What else is it about this experience that makes me want to share it with you today? I do not wish to say, as you might imagine a Boomer could, you should have seen how it was in my day. So much has changed in medicine since I was that panicked intern, as it should. HIPAA, for one. Another is the fact that I would have had to hand that case over to someone else. And then there are the paper charts, which, like the dodo and cassette tapes, have gone extinct. Medicine has changed and medicine will continue to change. Each generation figures out how to drive this vocation toward the best version of itself and from what I know about this class, you will find a way to bring your own talents to its challenges. But I want to also point out what hasn’t changed – what will never change – that we have all chosen a profession that has imperfection and failure at its very core. Human bodies fail and they suffer, and they hurt each other, and we are the ones charged with fixing them, comforting them, and figuring out ways to get them back on their feet, ways to help them live as long and as healthfully as possible. And so rarely does this happen in a routine or easily controllable way, a way that would conform to a 9-to-5 schedule.
The story I just told you should never have happened. A broken system sent me a patient who should have been in a facility that could handle her needs and a team of physicians that had more experience – any experience! – and I had every reason to complain or quit or try to send her somewhere else. But I was the physician at that moment and in that place, faced with a patient in distress, and I somehow figured out how to use all of what I had been taught to help her. I had to become a detective, hunting down any small piece of information or advice that could help me put together the puzzle of her illness. And when I think back through my training and my career, nothing even comes close to the satisfaction that I felt once I had done my part – however small – in figuring out what was causing this patient to suffer and what next steps needed to be taken to try to alleviate that suffering. And every one of your faculty mentors sitting up here on this stage can tell a similar story that inspired them, just as you heard so beautifully from Dr. Schillinger.
We are living in a moment of backlash against a kind of genuine love for and dedication to work. Your job will not love you back, is a phrase with which some of you might be familiar. On entering the work force or climbing up professional ladders you are warned against giving too much of yourselves to systems that ultimately don’t care about you and can easily replace you. In our time, the idea of sacrificing something for your work is now being thought of by some as anathema. But medicine is a profession like no other, one that is built around vulnerable people looking to experts for answers and relief. If you work hard and learn well, at the end of your training you will be that kind of expert. And unlike most people in this world, you will have the kind of expertise that can be the difference between life and death, between suffering and ease. This is no small thing, and it can feel like a burden and a gift, sometimes at the very same time.
An important postscript to my story is that my patient got transferred over to one of the inpatient units of CHOP and my whole intern class took care of her on many admissions over the months that followed. We became her doctors, and we all came to know and love her family until she passed away. Decades later I ran into Mary Ellen Conley, who had been on the CHOP faculty at the time and who subsequently became one of the most famous clinical immunologists in the world. I didn’t think she would remember me, but she did, and it was because I had been the doctor who presented this mysterious case. And then she told me that she had saved a sample from that patient and her lab had recently used it to define the genetic mechanism of the immunodeficiency I had recognized all those years ago. As I was remembering all of this to share it with you today, it struck me that we doctors are individuals doing a job, but we are also part of something bigger, an intricate network of inquiry and healing that spans time and space. The detective work we do, the time we spend with a patient trying to figure out a diagnosis or simply talk them through a procedure, the extra time we take to understand their lives and their families and to make sure that they’re getting what they need can reverberate and have an impact we may never know about.
Today you join this network and become part of this team of people who have chosen a way of life that somehow has to be different, somehow must be counter to the prevailing culture. This way of life does depend – not always but sometimes critically – on intensity and negation of the self and striving for excellence. Today you become part of a hallowed tradition of those who set aside their own needs, if only temporarily, to help another human being. Those who came before you have found incredible satisfaction in this work and in being able to do things, we never thought possible. We have tried to leave the world better than we found it and please always remember that your faculty here at WashU Medicine know that you will make it even better, that you embody everything we believe in and you will lift up the very soul of the human condition in ways that go far beyond what we could have taught you and far beyond what we could even imagine. Class of 2024, congratulations, and God speed.