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Ross University School of Medicine's Commencement Address - June 10, 2005 Commencement Speaker - Amy E. Pollack, M.D., M.P.H.

Graduation Commencement Speech

06/10/05

Years ago, when I was 19 and trying to define my own career ambitions I interrupted my education in the arts. I had wanted to be a painter. I also wanted to see the world. I spent time in Europe and then traveled further east and eventually lived in India in a remote village in the north. I was planning to return to art school in Boston in a few months, then in the middle of one night the people living in our small gated compound were awoken by wailing. At the gate of the compound was a man carrying a small woman in his arms, trailed by several young children. The man was covered in his wife's blood. His wife, who was my age then, had been in labor for 2 days. They had no transportation or money and we were the closest populated place that they could reach. They came into the compound. We had no medical experience among us, no vehicles for transportation, and no means to communicate with the closest clinic or hospital, which was 20 kilometers away on bad dirt road.

In short order I watched this young woman bleed to death in childbirth, in the presence of her husband and children. They wailed in gut wrenching agony. Have you ever seen a woman die in childbirth? It is war, individualized. In the final moments it is two hearts and two souls exposed in death. It is, in at least three quarters of the cases, preventable, and therefore, it is one of society's greatest failures. When you have been there as a participant, or as a witness, a part of those souls remain with you. Forever.

An epiphany is described as a sudden intuitive perception of or insight into the reality or meaning of something, usually initiated by some occurrence. I had my epiphany in India. More than half a million women die in childbirth each year. Almost all of those deaths are in poor countries where women deliver without any kind of medical assistance. Those are preventable deaths. My experience guided my career choice first to study medicine, and then my choice to study obstetrics and gynecology and then public health. This journey through pre-medical and medical studies, through two residencies and through each and every new experience that has followed is not a moment lost. For those of us who study medicine, we are still the lucky few. The privilege of human intimacy that comes with being a physician is not comparable with anything else. The privilege of knowledge and the ability, always, to do something, is what makes us the lucky few.

Thank you Dr. Shepherd, Thank you Mr. Keller for inviting me here to speak today.

I am honored and delighted to address one of the largest classes of medical students graduating and moving into post graduate residency training in the US. (ever). I am honored to be able to celebrate with you, your joy and your achievement and your relief!

Today, you are 561 individuals who have completed your first phase of medical training and who will receive your Medical Degree. Not only are you the largest single graduating class, but also certainly one of the most diverse. A mini-United Nations in some respects.

You are entering medicine at a time of global transition.

All of you will continue to study and then practice medicine in a world where new vaccines, robotic technology and the fields of genomics and bioinformatics hold enormous promise and we can presume will transform the practice of medicine and surgery in ways that we cannot imagine. You will study and practice medicine in the midst of one of the most devastating global epidemics - The Aids epidemic. More than 20 million already dead and 40 million infected individuals together have catalyzed the transition of globalization from economics to public health.

Although today is a remarkably significant day in your personal history, it is only the beginning of a career that will take each and every one of you down a different road, influenced by every experience that you brought to Dominica several years ago, every experience that you had while at Ross, and by your personal aspirations for your own future. Today you become more the master of your own fate than ever before. The one thing that your training thus far will give each and every one of you without exception is an open door to create your future. Today I want to talk to you about the choices that lie ahead. In your lifetime these next few years of residency may be the most intensely dense years of your life in terms of personal growth and experience, but in the long term, these years are short compared to the time that you will have after that; the time that you will have to make an impact on both individual lives, and the state of the world that we live in.

My own personal history is one of zig zag career choices, but I did have a personal vision as far back as I can remember. Having that and embracing your choices and the flexibility that a career in medicine affords you, you might consider the following three things:

The first thing:

Find and follow your dreams.

Stay open minded and flexible, not an easy task for people who choose medicine as a career. So what I mean by remain flexible is this. You have already completed the first phase of your medical training- the door is open. In the life ahead of you, you can change your path many times, building on your knowledge and your skills as long as you remain inspired to keep learning. When you lose that inspiration, actively go find it. The depth that you build will never go away and as long as you remain inspired you will do great work.

During the next few years you should not have to look far for inspiration. Residencies, by nature, offer huge exposure to diverse mentors and experience. Although it is difficult sometimes to see and understand by ourselves our own greatest talents or lack of them, it is often completely apparent to others. By understanding early on what things come easy to each of us, what our talents are, we can try to match these to our dreams. Thus, I believe in the role of mentors and in fact I think that it is by chance, even serendipity, that we run head on into our mentors who then help us define our dreams. A good mentor is an unimposing guide.

During my obstetrics and gynecology residency I worked in Seattle in a University department that had a large caseload of gynecologic cancer patients. Cancer surgery is long and hard, and caring for and working with both patients and families is intensely intimate and difficult. After all- these patients were forced into confrontation with their own mortality by their disease. I had many professors who were great surgeons, but I regret to say that most of them had not an ounce of mentoring in them, and their bedside manner was not much better. However, I did have one most remarkable professor. She was hands on all the way. She spent 12 hours in the operating room on many days and then several hours in consultation with families and the local referring physicians, and she was always teaching. I spent several months each year working closely with her and by the end of my third year I was sold on becoming an oncologist. I feared the 4 additional years of training it would require and the rough nature of most of the others going that route- and even the depressing nature of the work at times, but I loved the surgery, and I loved the intense contact with patients. I talked with Joanna (my professor) about this. It didn't take long for her to respond frankly. Joanna knew that I had dreamed of going into public health and that it was my commitment to women's health that had influenced my choice to do gynecology which is a surgical specialty. She reminded me that a career in gynecologic oncology was about individual care. We talked about my talents. She gently pointed out that although I was an excellent surgeon it did not come easy to me- I worked hard and diligently at it. Surgical oncology is not a career chosen lightly, not only because of the technical challenge, but as you might imagine, because of the personal challenge of working day in and day out with critically ill or terminal patients. Few are actually well suited to do this for the duration of their careers.

My way of applying my years of training, knowledge building, and experience has been to work in the field of women's health and rights. First I trained as a surgeon. Excellence in surgery comes almost exclusively from practice, not witty intelligence. But to learn to be a surgeon you have to practice on humans, and so you have to grapple every day during your training, with this truth. Your moral obligation is to do your absolute best, in "real time", because you are learning new procedures and skills on patients who have entrusted themselves to you. I loved surgery, but life is long, and it was not my dream to become a great surgeon. I surprised a lot of people the day that I announced that I was leaving the University based clinical practice to work in public health. I had to measure the trade-off between giving up the satisfaction of individual patient care, with the opportunity to have an impact on a larger scale-to help change policy or practice in a whole community or even at a national level.

I have spent many years refining the match between my personal talents with the right day to day work, so that in the end I can do those things that I dreamed of years ago. It is a big dream- mine is about health equity and poverty alleviation.

I spent the last 10 years as CEO of EngenderHealth, an international non-profit that delivers health services in over 40 of the poorest countries in the world. I have traveled down dirt roads to villages in Cambodia and Kenya where the health intervention is to help dig a well first because there is no clean water, and then, only then build the clinic.

As most of you know, the Gates Foundation is a driving force in the effort to shift global disease burden in the coming decade. About two years ago Bill and Gates announced that they would commit 200 million dollars to a program called Grand Challenges in Global Health. The program initially proposed that any individual could submit a problem to the Foundation- one that, if solved, would be groundbreaking advance in the health field. The Foundation invited global scientists to submit proposals to solve a selection of these problems. These are the dreams that drive change. Last week the Gates Foundation announced that they would add $250 million to the Grand Challenges health program. They have pledged a total of $5.6 billion since 1995.

I have talked to the Gates Foundation about vaccines for women's cancers and about simple drugs that prevent women from bleeding to death in childbirth.

Dare to dream about your life, about changing the lives of others, and about changing the world.

The second thing:

Grapple with this notion 'do no harm', the Hippocratic oath and what it really means in your everyday world. The Hippocratic oath has been translated and re-interpreted many times. Although not a meaningless relic I think it takes a modern day application to make it real. Perhaps it should be changed to 'do the right thing'.

As a resident- to do no harm will mean giving it your all. That includes: listening to patients, keeping up with changes in medical practice on a regular basis- new drug treatments, new technologies: doing “due diligence- meeting the specialists who you most often refer patients to, and not least of all getting know and understand insurance practice and barriers to good patient care.

It means listening with your eyes wide open.

I remember our out-patient clinic days. As a resident I had several days a week in the operating room and the other days in clinic. Because residents provide most of the services to folks who have no insurance, (how else would they get care?), I had, and you will have, very busy clinic days. I would go in and out of rooms generally exhausted from taking night call. Much of the practice of medicine is not terribly challenging once you learn about the most common things. I could whip along until I would get into a room with a patient and I'd be hurrying and then all of a sudden the patient would somehow make it clear that this was not going to be a routine visit and that she needed my attention. Of course everything stopped. I'd have to slow down, sit down, take a breath, pay attention; decide whether to make a decision or call for another opinion which would inevitably hold me up, or offer my judgement about something without hearing more from the patient, ultimately limiting or even disrespecting her autonomy.

I had an 18 year old patient who came to me because of an abnormal pap smear. She had a rare diagnosis of cervical cancer at her age. The problem was that she was pregnant. She had a remarkably tough decision to make- have surgery to remove her uterus and the cancer with it along with the early pregnancy, or complete the 8 months remaining of her pregnancy and take the chance that her cancer would be advanced by the time she delivered. She was alone too. I had my own opinion, but there was no evidence or science that I could provide that would guide her objectively to a decision about the right thing to do. Let's face it. You all, we all, are human; doctors or not, we have opinions, moral judgements, and belief systems, the limitation of our own intelligence or past experience. Somewhere into my residency I realized the significance of this.

I spent some time every day for two weeks just talking with this young woman. She decided to take the risk and have the only child, by birth, that she would ever have. She delivered and had her cancer surgery, her uterus out at the same time. They are both alive and well today. The young woman had to change her roadmap- she did eventually make it to college as she had dreamed of.

There are many other moments when you will have to decide to do the right thing.

You know, in most cases nobody but you yourself will know if you went the extra mile. It is not until you are the responsible physician taking the stat call to the emergency room in the middle of the night, or left to deliver the severely premature infant to parents who question the need to intervene, that the moral obligation, the essence of the Hippocratic oath, becomes more than a conceptual code of behavior. Then in the immediacy of those moments your decisions will reflect your own commitment to treat the sick to the best of your ability.

Not only will each of you have to search your soul at some point to define for yourself your position regarding ethical dilemmas such as euthanasia, and patient confidentiality, but looming large is your relationship with the US health care system. Although advances in medical technology, in pharmacology, biomedicine and our intelligence regarding human physiology provides us with the capability to prevent, treat, and cure more disease, more musculoskeletal disorder, more organ malfunction than imaginable even 25 years ago, the U.S. remains crippled in its ability to solve the dilemma of basic health care delivery systems for the 42.6 million people in the US without health insurance today. You, as you graduate, will become from day 1, the lifeline for many of those 42.6 million people. The humble poor in this country are, for surgery residents in particular, your opportunity. They need your help and you need them, and their willingness to trust you to remove their gall-bladder, deliver their baby, perform their amputation. As a resident your choice about providing those services and to whom will be mandated by the circumstance of residency. After that you will become the gatekeeper. The gatekeeper to access to services, if not knowledge. Martin Luther King Jr. once said :of all the forms of inequality, injustice in healthcare is the most shocking and inhumane."

So today, Primum non nocere- do no harm- has far-reaching significance in an indirect way.

First, educate your patient, embrace your patients questions and willingness to self inform and make choices. Do not fear their efforts to search the internet, and ask for second opinions. Do not hold tight to your knowledge. It is not mystical in nature. Most people will tell you when they don't want more information, or they want you to make a decision for them. Know your health systems and insurers. I live in NYC where many private health care providers do not even take third party reimbursements any more. Share as much of the burden of our dysfunctional health care system with your patients. They need your help maneuvering through as much as they need your medical expertise. A small amount of time advocating for your patients goes a long way. It is not enough to not discriminate yourself. Protect your patients against discrimination. And the third thing:

Be an activist. Yes, that means fighting for the right to decent health care for all. There is no doubt in my mind- and there should be none in yours, that health care and education are the shamefully weak links in this rich country of ours, and who better to fight for change?

Joseph Conrad said "All a man can betray is his conscience."

Physicians in today's world need to have a voice. Your experience over the next few years will give you the knowledge, the knowing about people and their lives. Medical skills alone are not enough to make you either a healer, or a change agent. Years of medical practice may make you a healer, but still will you have fulfilled your obligation in society?

You must know the health care system well enough to have an opinion. Go beyond accepting the status quo.

I have one close friend who is is a primary care physician. She is actively involved in community work targeting at risk youth. I have another close friend who spends time at a community center helping older people access health care. Do your share, whatever it is.

You will be called upon by your colleagues and your community, even your country, to have an opinion.

Hold before you, the mother, one of the 43 million without health insurance, who grapples with a complex health care system to find minimal preventive health care by any standards, for her children.

The maternal mortality rate (the number of women who die in childbirth)in New York city is almost 3 times higher than the national norm and it is no surprise that those deaths are clustered in the poorest communities.

You are over 500 strong. There are an estimated 15,000 other graduates who will enter their Residencies with you this year. Together you all will make up a next generation of physicians.

Follow your dreams and do not betray your conscience Embrace a your opportunity to do good - know yourself, your patients and your healthcare system in order to do no harm. And be a voice. Being an activist in your field does not mean that you are a radical. You all are a rare group and as individuals and as a group you can guide the change that needs desperately to occur in the provision of health care.

For all of our sake- I wish you great success.