Dr. Richard Carmona, 17th Surgeon General of the U.S., Tells Ross Graduates to “Put Patients First” in Commencement Address


Dr. Richard Carmona, 17th Surgeon General of the U.S., Tells Ross Graduates to “Put Patients First” in Commencement Address

Commencement Address
Ross University School of Medicine
June 5, 2009
New York City

Richard Carmona, MD, MPH, FACS
17th Surgeon General of the United States

Good morning ladies and gentlemen. Good morning students. It is an honor and a pleasure to be here with you today. President Thomas Shepherd and Dean Mary Coleman, I thank you for the privilege and the opportunity to be with you today. And to the students, many people could have come before you today and when I have these opportunities it is always important for me to realize not only the significance to you, but also the privilege you extend to me by allowing me to address you on one of the most important days of your lives.

Congratulations to Ross University! For over 30 years this institution has taken young men and women and molded them into health professionals—more than 6,500 graduates, 540 of whom are actually walking here today. You’ve achieved parity with your colleagues in the U.S. You’ve passed your exams just like everybody else. Eighty percent of you go into primary care, so not only are you successful yourself but you are also meeting the needs of the nation which are still unmet as they relate to primary care. You have one of the most diverse classes I’ve seen in or out of the U.S.—diversity in your ethnicity, diversity in your backgrounds in general. It’s an extraordinary accomplishment and one that continues to exemplify the great contributions that Ross provides to the U.S.

Welcome to the fraternity! You now have an enviable title. Your participation here today signifies the perpetuation of the Ross legacy as much as it heralds your emergence as healers and scientists, leaders, mentors and stewards. For upon acceptance of this degree you enter into a sacred trust between you and the public, for you now have the obligation and duty to care for those fellow citizens that we call patients.

In our society, it is you and you alone who have the distinct privilege and utmost responsibility to enter the protected sanctuaries of our fellow citizens—to probe their hearts, minds and souls. To keep them healthy or deliver them from disease or despair. You certainly do that through science, and although unquantifiable you also do it just as importantly via your touch, your compassion and your mere presence. You bring dignity to the lives of those who have been marginalized or forgotten. You bring a voice to those who scream for help in apparent silence. You bring hope to a community, a country, a world that desperately seeks a better path to health, safety and security.

There will be days when you are tired, overworked and stressed. No matter, for in each patient encounter you must strive to have each patient believe for that moment in time that they are the only patient in your practice. It is in those moments by your presence and the dignity you afford every patient contact that the sacred bond we call the doctor–patient relationship is created, forged and strengthened. For being a physician is not just a job, it is a calling for which you and your families will sacrifice each and every day of your lives but for which you will receive rewards of the greatest personal satisfaction. Only you truly understand the privilege, obligation and responsibility of being a physician.

My road to becoming surgeon general of the United States was a very unusual one. I grew up just up the road from here, and some of the greatest lessons I learned that helped me to become the surgeon general were not taught in medical school or graduate school, but from being a kid growing up in Harlem in a poor, struggling family where English was a second language. The lessons I learned growing up are the same lessons you learned by going to school in an emerging country that is struggling itself. Because the social determinants of health that you witnessed in your education and I witnessed as a child are what sets us apart from so many others who haven’t had that experience. And so those best lessons that I learned from being poor, hungry and homeless at six years old and of having a mom who only wanted to see one of her four children graduate from high school, stuck with me throughout my life because I always thought, if I get the chance I want to be able to give back. I want to be able to do something for those people who don’t have a voice. Because I remember what it was like not to have healthcare and to hope that somebody would care for you when you were sick. I remember having a mother who cried herself to sleep every night because she wasn’t sure where the next meal would come from. I remember the indignities of being homeless and being swept off the streets by somebody you didn’t even know and a grandmother who didn’t have enough room on her own in her project apartment just north of here but still took in a family of 12. And yet, all of my memories of my childhood are good ones. They’re positive. We struggled, but we survived. I grew up at a time when parents were not responsible for their children’s extracurricular activities. When you wanted to play you went out in the street and played stickball and the biggest decision you needed to make was whether you’d play two or three sewers, depending on how many kids showed up. I learned how to swim in the Harlem River, which is why I’m so healthy today because I’ve been exposed to every pathogen known to mankind. And yet all of those experiences helped me to understand how inextricably we are tied not just to health but to the social determinants of health, locally, nationally, and even globally today.

As I moved through life I never expected to go to medical school or train as a surgeon. A funny thing about surgeons is that when you ask a surgeon to name the best three surgeons in the world they always have trouble naming the other two. But after running emergency medical centers and trauma centers I decided that something was wrong because I was making a living based on the fact that people were getting sick or injured all the time. And I started looking at that and thinking there must be something perversely wrong with a healthcare system that allowed me to be compensated for all of the indiscretions of society. So I became cynical and I used to tell my trauma residents and medical students that I didn’t feel like a trauma surgeon—I felt like a repairer of society’s indiscretions. I put people back together who made bad decisions, either that day or every day of their whole lives. Gunshot wounds, stab wounds, drunk drivers, domestic violence, people who ate the wrong foods their whole lives and developed obesity and type 2 diabetes and then had aneurysms or strokes. Because if you show up in the emergency department with a pulse we may be able to save you, but we cannot save you from yourself. All we can do is tune you up and send you back out so you can repeat the same behaviors and it’s guaranteed that you’ll end up back in the emergency room. And that’s really the way the system is set up. It’s perversely incentivized. Folks, it’s not a ‘healthcare’ system, it’s a ‘sick care’ system. It’s a system that most of the 5,000 people here today don’t know how to navigate because it’s so cumbersome. It’s almost as difficult as trying to figure out how to do your taxes on a yearly basis. And it doesn’t serve the needs of the patient any longer. You all will inherit the legacy of fixing this system and making it right. Of translating it so it becomes a healthcare system and not a sick care system and putting the appropriate incentives in place so our practitioners strive to keep their patients healthy rather than only fix them when they’re sick.

When I got to the office of surgeon general, which again I never planned for, I had a lot of radical ideas based on my own experiences—experiences of life, of being a trauma surgeon, and also of going back to school and getting a master’s degree in public health administration and policy. The surgeon general’s job by statute is to protect, promote and advance the health, safety and security of the U.S.—piece of cake right? No big deal, what with two wars, anthrax, obesity, cardiovascular disease, national and global threats, etc. At times I often felt like a cemetery caretaker. People would ask me what I meant by that and I’d say, “Well, there is a lot of people under me but no one is listening.” And yet as I moved to that position and went through the vetting process and was ultimately selected as the 17th surgeon general of the United States, I joined a very unique fraternity. Only 17 of us in the history of the U.S. have held this position, and you come to learn quickly that people try to align you with different groups right away. But the surgeon general of the United States is not the surgeon general of the Republican or the Democratic Party. The surgeon general of the United States is the doctor of the nation and is responsible for the people. Their job is to take the best science and translate it so that those policymakers that you have elected make good policy ostensibly on your behalf. Now we know that doesn’t always happen because many of the challenges before us as a nation in public health are some of the most divisive issues that we deal with in the world—stem cells, abortion, bioterrorism, Plan B, etc. On the surface these issues look to be pretty straightforward as they relate to science, but once they are grabbed by either party and people start polarizing them we lose the science and it becomes more of a political debate. Again, another legacy that you will be inheriting because we need to bring more science to the forefront. We need to be transparent in everything we do because that’s what the nation needs today—and again it’s a legacy that you will inherit.

There is no way to prepare for the role of surgeon general. Just before I was due to go out for my confirmation hearing I remember pacing back and forth outside in the little anteroom wondering if they would make me look like a Nobel Laureate or a failure. And as I was about to walk out on the floor a very senior senator, who has been on the hill for decades and was on the Committee, came out to see me. He placed his hand on my shoulder in an almost paternalistic way and said, “Richard, thank you for your willingness to serve your country again.” I think he was trying to reassure me, but then he said, “Richard, you realize that you’re about to go before the most partisan Congress in history.” And I replied, “Yes, Senator I do.” He said, “You know, they’ve been known sometimes to grandstand, but don’t take it personally, this is all politics. Just answer the questions honestly as you have and I think you’ll do fine, but it may be tough.” I said, “Thanks, Senator. I really appreciate it.” And he shook my hand and said, “Go break a leg.” He started to walk away but then stopped and came back to me and said the most prophetic thing, which I didn’t understand at the time. He said, “Richard, I want to give you a little bit of advice.” I replied, “Senator, anything you could say that would help me through this confirmation hearing would be greatly appreciated.” He said, “No, Richard. It won’t help you through today. But should you make it through today it will help you understand what you’re getting into.” I said, “Okay Senator, what is it?” He said, “Richard, you’ve heard this before but you can’t possibly understand it.” And looking at me like a father would look at a son, like he really cared, he said, “Richard, when you come to Washington, if you want a friend you need to bring a dog.” And I said, “Senator, I’ve heard that before, I understand.” He just smiled and said, “You are clueless.” I said, “Well, okay Senator, I appreciate it, thanks.” We walked out on the floor and I had my confirmation hearing. It lasted a little over two hours (which is light speed in Washington, D.C.) and they say that for the first time in U.S. history the surgeon general was confirmed unanimously. From then on you have the burden of the nation on your shoulders. You walk in the shoes of some very great individuals who came before you. The lineage really goes back over 200 years to when President Adams created the Marine Hospital Service, the precursor of the U.S. Public Health Service in 1798 to protect the nation.

So, what are you going to do now that you have this burden? Several years later I was on the Hill testifying at a committee on terrorism and I saw the senator that I just spoke to you about. I’d seen him before but normally our lives are so scripted that we don’t have a lot of free time. But this time we had an extra five minutes. I went over to him and we chitchatted for a few minutes and then he said, “Richard how’s everything?” I said, “Great, Senator. I want to thank you again for helping me through the process a few years back. I don’t think I can ever thank you enough.” He said, “You’re doing a great job. Thank you for serving.” I said, “No, Senator. I want to thank you for the advice you gave me.” And he stopped and put his hand on my shoulder again and said, “About the dog?” I said, “Yes.” He said, “You understand now, don’t you?” I said, “Senator, yes I do but respectfully, I disagree with you.” And he said, “How can you disagree with me? I don’t understand.” I said, “Senator, I’ve been here for a few years now on the Hill and it’s come to my attention that if you want a friend in Washington you need to bring two dogs.” And he said, “Why? I don’t understand.” And I said, “Senator, during your tenure one of those dogs will turn on you.” And he laughed and gave me a big hug and said, “Can I use that from now on? It’s better than the advice I gave you.”

So now as surgeon general you have this burden and what do you do? You tackle the evidence. The fact is that $2.5 trillion dollars a year is spent on healthcare. Seventeen percent of our GDP and $.75 cents of every dollar, three quarters of the entire healthcare budget, is spent on chronic diseases—almost all of which are preventable if you pick them up early enough. Again, another legacy that you will inherit because you are all going to have to shape the new system from one that is incentivized and driven by sick care to one that is driven by pursuing optimal health and wellness through prevention strategies to reduce the cost of care and improve the quality of life. Prevention has to be number one. Smoking is still a huge problem; almost half a million people a year are dying from tobacco-related causes. Millions more are dying from associated comorbidities—pulmonary diseases, cancers, and so on. You know all of the statistics and yet the debate continues. It seems to me that there is no debate. Tobacco is the single largest cause of cost in our economy. Yet we continue to subsidize tobacco growing. It doesn’t make a whole lot of sense when you’re telling the surgeon general to keep the nation healthy and this is the largest preventable cause of death in the nation. Again, a legacy that you will inherit.

We have a childhood obesity epidemic—nine million children are overweight or obese—we have unprecedented rates of type 2 diabetes and now we are seeing hypertension in children in grammar school. We’re seeing middle-aged disease ratcheted down to children. But in Washington when I was trying to get traction on these issues the country was also dealing with two wars, anthrax and terrorism. So you have to figure out a way to sell healthcare arguments or they will be overshadowed by other issues and won’t go anywhere. But the fact of the matter is that childhood obesity is a national security issue. Why? Because when you look 10 or 15 years into the future and start thinking, where are all the policemen, firemen, soldiers, sailors and others who protect our communities and our nation going to come from, you’ll see that the cohort of individuals who were supposed to be filling those shoes won’t be able to. Because, as my epidemiologist at the Centers for Disease Control and Prevention told me, this could be the first generation of children that lives less than its parents unless we do something about the trajectory of this curve. Again, a legacy that you will all inherit to make better on our behalf.

So, as surgeon general I looked at prevention and preparedness. A nation at war, 300 million people who are still not sure what to do when various challenges occur. Whether it’s a naturally occurring challenge like Hurricane Katrina or a man-made terrorist event, the issues are complex. The public has lost its capacity to operate under a civil defense mentality. We had that back in the 50s and 60s because we understood the threat. It was bad guys, it was a single problem. Now, it’s chemical, biological or nuclear—man-made or naturally occurring. Do we shelter in place or do we run? How do we build resilience into society to be able to make our nation healthier, safer, and more secure? And you start to see that what you will be doing the rest of your life, the health of this nation, is inextricably tied to its national security and global presence. It’s not just about health—it’s bigger than health. Health is the common denominator that makes us the nation we are, as strong as we are, and allows us to do what we do. So your job becomes ultimately much more important.

As surgeon general you also spend a lot of time dealing with health disparities. We are a nation divided by our health metrics. The fact is that if you’re African American, Hispanic American, Native American or a lower socioeconomic class you will get less healthcare and will have more difficulty getting that healthcare when you do get it. You will be afforded less medications and options for care. You will die sooner and cost society more money. That’s not just the surgeon general’s opinion. That has been memorialized in countless publications. And yet we turn a blind eye. The fact of the matter is that if you look at our nation the worst health disparities are not in my lineage—Hispanic—or African American, or even the poor people. Look at the Native American reservations in this nation. It’s a disgrace. The greatest morbidity and mortality, smoking, dropout rates and adolescent suicide rates are on these reservations where these once robust cultures flourished. In 1900, when the average American only lived to 48 or 50 years of age because they died of an infectious disease, the average American Indian lived 30 or 40 years longer. Why? They stayed physically active their whole lives, they hunted and gathered, everything they ate was organic because they grew it themselves. So we take a population that’s robust, put them in the most desolate land there is, deprive them of their language, their culture, their ability to hunt and gather and what we have is a laboratory that shows us what happens when you become sedentary and eat the wrong foods. All of a sudden you have the highest obesity and type 2 diabetes rates as well as all of the comorbidities I mentioned earlier. Another problem plaguing our nation in addition to preparedness, prevention and health disparity is health literacy. You will be challenged every day by the prospect of taking the best science in the world and translating it into a culturally competent, health-literate manner to diverse populations in order to do one thing only—change their behavior. Eat a little less, walk a little more, wear a seatbelt, wear a helmet. The things that will keep people healthy are very simple things; it’s not rocket science. The difficulty we have as a nation, at the individual level or the surgeon general’s level with the biggest practice in the world taking care of 300 million people, is translating science so it resonates with the diverse populations that we have the privilege to serve so that they change their behaviors to appreciate optimal health and wellness. You have a leg up on most because you have been educated in a diverse environment and have the most diverse class I have ever seen. So you come with the sensitivities necessary to change the world and make it a better place. You can apply your knowledge in a way that few graduates can.

In addition to prevention, preparedness, health disparity and health literacy there is the issue of global health. We are inextricably tied to the rest of the world. The threats and the challenges our nation is experiencing do not recognize our geopolitical borders. Think about it—SARS, avian flu, monkey pox, smallpox, terrorism. Borders are immaterial. Borders often are impediments to good public health. Borders are necessary to protect us but they also are impediments to health and to commercial ventures—the economy. So how do we preserve our rights and yet deal with the border issue sensitively so we can take our appropriate roles as global leaders in health? Health diplomacy is part of public health and you all have learned a lot about health diplomacy during your time in an emerging country. One of the greatest powers that this nation has to secure peace, health and prosperity—which remains largely unleveraged—is health diplomacy. Exporting what we do best as a nation. Humanitarian assistance programs, the Peace Corps, things like that. I witnessed this firsthand in Indonesia.

We have a way that we have dealt with the rest of the world that we call forced projection. We show everyone how strong and tough we are. How many planes, how many battleships, and so on. I am a soldier, so I understand the importance of that. But there’s another thing that is unleveraged in this country. When the tsunami hit in Indonesia and that whole country was decimated—a Muslim country where there was a lot of animosity towards Americans—and we sent Navy ships to help the Indonesian people, the leaders of that country did not want us. They said, “We don’t trust you. Do not come in.” Our guys had to bargain to enter the country and help the Indonesians. They were only allowed to work two hours a day at first and were supervised by police and military because there was a lack of trust. After a few weeks they were permitted to stay for a whole day and then they were allowed to sleep in the villages at night. Several months later when it was over and our soldiers had helped to restore sanitation, store clean water and provide medical care and had to pull out, the leadership called and said, “Surgeon General, can you leave these people? They are good people and we trust them.”

When you think of what causes terrorism—the asymmetries of health, wealth, ideology and theology and poor governance—just a group of healthcare workers like you embedded in an indigenous environment can change the whole way the United States is perceived because of the humanitarian assistance we can give. I would say to you that health diplomacy is an unleveraged power that you all have. Use it wisely as you move forward. You will be the agents of change.

Go forth now with this privilege you have earned and Ross and society have afforded you. Change the world incrementally in everything you do. As your president, Thomas Shepherd, said, “There are very few people who have the ability to dignify the existence of others every single day.” Each one of those patient encounters is sacred. Each one of those patients should leave your presence thinking you’re the greatest person in the world because you made them feel like they were your only patient. There is a healing ability in your presence and your touch that we can’t quantify but everybody sees. It’s that patient–doctor relationship. Nurture it, treasure it, and be responsible for it. Be a mentor, be a steward, teach others because those are some of the greatest powers you have—more sometimes than the pharmacology, technology or operations at your disposal. It’s gaining the trust of those fellow citizens we call patients who will place their lives in your hands so that you can make them better, so that you can keep them healthy and deliver them from disease. Don’t ever underestimate the power you have as a physician. Bring great honor to your families who sacrificed much so you could be here today. And last but not least, keep your goals and dreams just beyond your reach and your integrity beyond reproach.

Thank you very much for the privilege of being with you today.

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About Ross University School of Medicine
Ross University was founded in 1978 and is a provider of medical and veterinary education offering doctor of medicine and doctor of veterinary medicine degree programs. Located in Dominica, West Indies, the School of Medicine places more students into U.S. residencies than any other medical school in the world and has clinical education centers in Miami, FL, Saginaw, MI, and Freeport, Grand Bahama. The School of Veterinary Medicine is located in St. Kitts.

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