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Keynote Speech: Bertram Spetzler, M.D.

   

White Coat Ceremony

Wow.  What a special day. Today you recite an oath and put on a white coat to represent the joining of an honorable profession. I'm honored to be able to address you today. As you can see, I have been able to have the perspective of being both physician and patient. And let me tell you, and don't ever forget it, even if it is three in the morning and you're exhausted, it is much easier being the physician than the patient. I know.

Now I hope I've peeked your budding medical curiosity. What happened to make this doctor in front of you somewhat spastic, occasionally short of breath unable to use his hands properly, I would expect all of you to take in what you see and try to formulate with your present limited knowledge base, a diagnosis.  Not because you are going to be tested later, but because that's what we do. We like to use our diagnostic acumen and challenge ourselves. Now, in social situations be careful to do that without pointing or obvious mannerisms. But, did I have a brain tumor that left residual after it was removed? Possibly, it could have been a viral infection of the spinal cord, or metabolic phenomena, even a vascular malformation with a bleed around the spinal cord, or a neurologic disease like Charcot Marie Tooth or multiple sclerosis. Have you considered a congenital or birth defect such as spastic cerebral palsy? And then always throw in the differential of trauma. Got you thinking? Good.  You need to keep that quality up for the rest of your career and life.

Now that we have the diagnosis out-of-the-way, let's focus on the purpose of today, the initiation into an honorable profession. Back when I graduated from medical school in 1975 we didn't have a white coat ceremony. As I recall, we were sent down to the laundry to pick up a couple of white lab coats in our size. But it was still a special feeling to put on a white coat, hang a stethoscope around my neck and walk into the hospital. There was also a sense of trepidation, fear of making an error or fool of myself. I knew, and you know, that this coat represents the start of a pathway. A pathway requiring perseverance and humility. But the coat also represents something to the patient and the larger community.  They see it as a sign of ability and expertise. You will have to grow into the coat. To be a physician is an incredible honor, an enormous responsibility, caring for the most intimate aspects of a person: his or her health. What a rewarding career it is to be a physician.  In terms of personal satisfaction, there is none greater than being able to help another human being.

When I was in my orthopedic residency, I remember my chief saying that to be successful in medicine you have to adhere to the three A's: Ability, availability and affability. I also realized since starting practice in the Roanoke Valley in 1980, that patients for the most part in this increasingly complex world of medicine can only judge availability and affability or what is a human connectedness factor in the doctor patient relationship. I won't talk about ability, since from the patient's side it is assumed. From the Virginia Tech Carilion side, I have seen your potential and abilities through the application process. I am duly impressed as I am sure your families are proud. But I am doubly sure that Dean Johnson through the next four years will take care of instilling the ability portion of the three A's.

The second “A”, availability, is self-explanatory. Illness unfortunately is not a 9 to 5 problem. We have to be available when the patients need us. Although work hours have gotten a lot better, there will still be times, depending on the specialty you choose, when you do not have control of your day. Just remember, when you make yourself available in those difficult hours, that it is truly easier being the doctor than the patient.

Now let me focus on the third  “A”, affability, a term with which I am not really all that comfortable. Affability sounds too much like likability or jokester. But I think what my orthopedic chief meant is that it is the factor which patients tend to call the bedside manner, or what we would like to refer to as the art of medicine. It is how we show our caring. Our compassion, our conscientiousness and our ability to communicate with our patients. It is remembering that no matter how fascinating a diagnoses is, or how critical a treatment regimen may be that this patient is a person: a mom, dad, son, daughter or friend who is worried, distracted or hopeful. What may be routine for you may be a life changing experience for him or her.

Consider when you are making rounds with your clinicians, eagerly learning differential diagnoses, pathophysiology or the pharmacology of treatment, to also observe how they interact with their patients. Do they put the patient's concerns first? Do they give the patient a chance to express themselves and to voice their anxieties? Does the clinician touch the patient?

This is not the “fluff” of medicine, I know firsthand how important it is. Two years ago, I was in a catastrophic care hospital in Atlanta after my bicycling accident, I had a very well trained physician who was double boarded in internal medicine and psychiatry and who was confined to a wheelchair. The ideal physician who could relate to and impart his knowledge to someone in my condition, but he lacked completely in the skills belonging to the art of medicine. He couldn't communicate, nor show compassion. When he made rounds in the morning, he always had a resident with him. He would come to the threshold of the room and even before crossing it ask “Anything you need done today?”  No good morning, no how did you sleep. When I was able to ask a question, he discussed it with a resident not even looking at me. He never touched me. I might have gotten the correct technical care, it could have been so much more.

The most common complaint that patients have is that their physicians don't communicate with them. Whether this is perception or truth is immaterial, for the patient, it is reality. Simple things allow you to show your caring and compassion that you so idealistically bring with you at the beginning of your journey.  Sit down and meet your patients eye to eye. Even with a follow up visit, for example for a medication check, lab pathology review, or even just blood pressure check, give the patient a chance to express themselves, and practice reflective listening and make a human connection by touching the patient. It almost seems too simplistic to iterate this in front of a group of talented students who are about to get their white coats. But observe carefully, your clinicians with whom you'll be working and learn from them how they connect with their patient.

Let me relate to you my care of a patient from about 15 years ago, that I will always remember. I had picked up a tip, from a plastic surgeon, in one of the many throwaway magazines that you will get  in your medical careers, who recommended that you keep thank you and sympathy cards in your desk, so that whenever you were moved to write a note that it would always be available at your fingertips. That idea really resonated with me and I went out and bought a couple of boxes of cards and kept them in my desk drawer. Thereafter whenever an occasion arose to express sympathy or to say thank you or congratulations I would write a quick note and my nurse was kind enough to find the address and send it on. It allowed me to more frequently express myself to my patients than if I needed to first run out to the drugstore, search for a card and deal with the hassles of shopping. It worked well for me, and I'm sure even in the Internet era it could work well for you.

Now, to the patient I want tell you about. She was a frail 88 to 89-year-old woman, short of stature,  with the associated comorbidities of her age. I had been treating her for over a year with a painful left hip. She had a total hip replacement about 10 years earlier on that side and it had become loose and was painful to the point where it was limiting her function. She was a salt of the earth type of woman from Southwest Virginia. She had running water in the house and she was quite proud of it but she still had an outside commode, yes an outhouse. It is hard to believe but it does still rarely exist. She had eight children and oodles of loving grandchildren. They could have afforded to take her to a retirement or nursing home. But she was adamant, she wanted to stay in her own home! Over the year of my treatment with her and the assistance of  her daughters we obtained for her a bedside commode, walker, tried some mild pain meds, and short focused physical therapies. Nothing really worked well for this lady and she was losing her independence. She wanted to be able to walk and be free of pain. Finally, I convened a family conference with the patient and daughters explaining the whole risk-benefit  of hip revision surgery including the risk of death. I told them not to make a decision right then and there but to talk it over with the greater family and give me a call back. Within two weeks, I received a call stating they understood the risks and wanted to go forward with the surgery.

After tuning her up, preparing backup units of blood, I operated on her. She was thin, anesthesia went well and the operation took a little less than two hours. I was quite pleased. I saw her the next morning, she was smiling, alert, eager to get up and I went out to talk to the family usually a group of 10+ people and told them that I thought everything looked great. I thought I might turn out to be a hero after all. Unfortunately, medicine doesn't always have fairy tale endings. This lady's internal organs decided to shut down the second day after surgery. She went into acute renal failure, did not respond to medical management and resolutely refused any short-term or long-term dialysis. It was obvious at this point that she was going to die, as her physician and operating surgeon, I went to her bedside. This was, as you can imagine, very emotional for me. I held her hand, telling her that I'm sorry;  I wished it had been different. She was still alert enough that she understood and her response was a faint smile. Over the next couple of days as she slipped into unconsciousness she was visited by so many friends and relatives it was hard to comprehend. The day she died I had a heavy heart; I cared about this patient on a very human and personal level. As I sat at my desk, I pulled out a sympathy card. I wrote, to the number one daughter, something to the effect that there's nothing more difficult for a surgeon than to bring a patient to the hospital and then have her leave as your mother, Mrs. Suthpin, left. You all are in my thoughts and prayers at this difficult time. Then I added a further note: that when I die if I am surrounded by the love of family and friends such as Ms. Suthpin was then I will have considered my life a success.

Over the next couple of weeks, my patient and her family went through my mind on a number of occasions. I started to wonder, would they get upset, would they get into a revengeful state reflecting about the death of their mother; would they want to do the all-American thing and sue. I felt at peace with my decisions, I thought I had adequately prepared the family and the patient, I had done the best I could. But the buts, and what if's, and second-guessing never cease, if it is done as a critical self examination then it makes us better physicians. One has to learn from both one's successes and failures.

After another few days, I was seeing patients in the office when a package arrived from the Sutphin family. I did not want to deal with it immediately and asked my staff to put it on my desk. So at the end of the day it was much to my relief that rather than a legal brief I was greeted with a large potted mum and a card. In the card they said thank you for taking care of our mother and your kind thoughts. They had passed my card amongst themselves and then gave it to their minister who read it in his sermon, before a packed country church, as part of a testament to her life.

So what is the point that I want to make, as you progress on your pathway in this very noble profession of medicine, on this special day as you receive your white coats? I am not concerned about your ability to become good physicians. You will have intense learning over the next number of years and then you will continue that process for the rest of your career. But I want you to start early and carry it with you throughout your careers on how you relate to and treat your patients. That relating to your patients is one of the most essential, and powerful, tools of a successful physician.

It is encompassed in a very simple rule:  every religion states it in one form or another. Many of the Eastern religions state it in the negative: don't do onto others as you would not have them do onto you. Those who come from the three Abrahamic faiths state it in the positive: do onto others as you would have them do onto you.

So, I leave you with this,….. remain positive, maintain your idealism and treat your patients by the Golden Rule. Do this and you will have a long, satisfying career in a very special profession where you hold the trust of the patients and their health in your hands. Thank you for allowing me to share with you on this special day.


Photo Gallery: Day 1

    VTCDayOne

After years of planning and preparation, the Virginia Tech Carilion School of Medicine opened its doors to welcome the charter class on Aug. 2, 2010. See the day in photos.