The weekend before last, Diane and I had the singularly prideful experience of watching our daughter, Sarah, participate in the White Coat Ceremony for first year medical students at Emory University School of Medicine (SOM). It was a beautiful and cool autumn day in northeast Atlanta with a gentle breeze rustling the recently turned leaves around the inviting campus quads.
The event was held in the historic Glenn Memorial Auditorium and the crisp new first year medical students were exalted, but then reminded that they still had a long way to go before they would return to this building again for graduation. Several excellent, but distinctly different speakers addressed the students. The commonality they shared was their commitment to medical education and to the well-being of the 140 students gathered in that room.
The Associate Dean for Medical Education and Student Affairs and the Director of Admissions reviewed for the parents and families the background of the assembled students. The Class of 2020 hailed from almost every state in the union and from countries across the globe. They had been culled from more than 8,500 applications and reflected the best from the finest Universities around the country. Sarah was the proud representative of NYU. As opposed to my era of medicine, the majority of the students were women, were older and had made other social and professional contributions before applying to medical school.
As I listened, I was reminded of the tremendous investment that medicine makes in the training of its newest acolytes. It was mentioned by one speaker that the academic faculty at Emory University SOM numbered over 2000 and easily, there are hundreds if not a thousand more dedicated to supporting the efforts of the medical school class. With the possible exception of the United States military, I could not think of another institution that worked so intently, for so long, to prepare its next generation.
In just the month that Sarah has been in at Emory her life has already been touched by a hundred individuals committed to her education and the quality of her experience. She has shadowed several physicians, been offered other opportunities that she could not fit into her school schedule, joined a Women’s Health project, participated in community outreach activities and has met countless times with her Osler Society and small group mentors. As a parent, there is a comfort with the sharing of your child’s well-being.
Emory University SOM, as almost all other medical schools for that matter, makes an immense commitment to the success of this medical apprenticeship for as many of the students in Glenn Memorial Auditorium as is possible. The speakers warned the students of the increasing workload that lays before them and the escalating stress. Year after year, they have seen similar groups of elite troops rush into the breach. They know there will be causalities. Some will realize that medicine is not for them, others will have that realization put to them. Some will choose to expand their training by years in order to achieve complimentary degrees such as a Masters of Public Health or a variety of bio-medical PhDs.
One by one, each student walked across the stage and solemnly received their freshly starched and pressed white medical jacket. Returning to their seats, faces exploded into brilliant smiles and deep dimples. Their excitement was palpable and there was no reason to disbelieve the speaker’s description of their energy, selflessness, and compassion. The class was well selected. They were excited. They were motivated. They were ready.
However, one trait wasn’t mentioned, but should have been. That trait is courage. There are elements of medicine that will challenge the altruism of the White Coat ceremony. Forces that incessantly work on you to divert you from your beliefs, ideals and goals. I’ve been in medicine more than 30 years and I freely admit to having a healthy dose of cynicism and curmudgeoness (if that is a word; if it isn’t it should be). I worry for Sarah, and for all her classmates, that these forces will break more hearts and spirits than any gross anatomy or biochemistry examination.
The challenges that will be faced by Sarah’s class are remarkably different from my graduating class of 1980. The volume of scientific and medical knowledge that must be assimilated is a dozen-fold greater than what I had to master and it is growing every day. The library has been replaced by hand held devices with almost infinite reach. My learning is medical school was by didactic lecture from the unquestioned expert. Teaching techniques have now evolved to collective self-education, problem solving techniques and developing the tools for life-long learning. My class of 1980 didn’t even have a White Coat ceremony. I guess we were much more of a crap-shoot compared to Sarah’s all-star team.
Beyond medical school, Sarah and her classmates will confront greater challenges than I could ever imagine. Medicine has now practiced at the genetic level. Diagnostic tests and treatment protocols are increasingly complex. Everything done in medicine is now tracked in detail on obscure and illogical Electronic Medical Records (EMR). All that documentation must be completed before work hour restrictions kick in. This emotionally and physically exhausting medical school and residency training is compounded by the accumulation of massive educational debt.
Beyond training, there is medical practice. For most, it will raise issues of group practice and business finance; topics rarely, if ever, addressed in medical school or training even at an institution like Emory University. What equipment to buy? What routine testing to do? Which patients to see? How to advertise and market? How to balance the altruism of the White Coat ceremony against the bottom line reality of office mortgages, office staff salaries and professional reimbursement? These issues will demand personal courage. More than anticipated at Saturday’s White Coat ceremony.
The White Coat Ceremony closed with the Class of 2020 reciting in unison the “Oath of Hippocrates.” Hippocrates of Cos (460-377 BC) is considered the Father of Medicine and his oath is considered the moral and ethical road map that physicians should follow in order to find that courage. The language of the Hippocratic Oath has evolved over time in order to remain current. While the words were a bit different, the Oath that Sarah and her class recited was familiar to me from my own medical school graduation.
My prayer today is that twenty years after her graduation, Sarah will not be reciting a new Hippocratic Oath which has further evolved to remain consistent with contemporaneous medical practice. A sad Hippocratic Oath that is not nearly as inspiring as the original version.
THE HIPPOCRATIC OATH (Officially modified 2040, AMA/ACGME)
I swear by all I regard as holy, always to maintain the honor and dignity of my profession;
That I will be loyal to the Profession of Medicine and just and generous to its members at least in accordance with my contractual obligations and considering the enforceability of my restrictive covenant agreement.
I will hold my knowledge as a sacred trust to be used in the service of the sick and for the prevention of disease. I will follow the regime which according to my abilities and judgement, and currently existing best practices guidelines published in WebMD and highlighted by my hospital’s EMR, that I consider for the benefit of my patients;
And will abstain from whatever is deleterious or mischievous or litigious or requires a diagnostic test or referral not available under the health plan or institutional insurance company affiliation.
I will give no deadly dose of medicine to anyone, if asked, nor suggest such counsel without competitive bidding, formulary approval and intense Big Pharma television marketing.
With purity and holiness, I will pass my life and practice my Art while remaining within the parameters of my merit compensation package and maintaining a 5-star online patient satisfaction score.
I will not cut a person who is suffering with a stone unless reimbursement is superior to a percutaneous nephrostomy, or, will leave this to be done by others as long as they are within the referral network of our hospital’s provider group.
Into whatsoever houses I shall enter, it will certainly be by telemedicine and I will go into them for the benefit of the sick and will abstain from the seduction of females or males, bond or free, except for in Occam’s Razor.
Whether, in connection with my professional practice or not in connection with it, whatever I may see or hear in the lives of men or women which ought not to be spoken of abroad, I will keep inviolably secret except for purposes of patient profiling, marketing and practice plan recruitment.
While I continue to keep this oath unviolated, may it be granted me to enjoy life and the practice of the Art, respected by all men and women in all times, making me relatively immune to medicolegal allegations and accusations of fraud. But should I trespass and violate this oath, may I experience practice exclusion, loss of Big Pharma consultancy fees and stock options, and exposure of safe harbor arrangements.
My apologies to Hippocrates of Cos for the twisting of his words. The intent was hyperbole. However, after 30 plus years of academic practice I can promise each of the new first year medical students that you will confront challenges to both your own moral and ethical code as well as the professional code of Hippocrates. Confronting those challenges will require personal courage. You will lose some of those challenges and you’ll regret those failures the rest of your life. You will win some and that’ll be warming, but may, on occasion, prove to be a pyric victory.
My fear is that I will not be able to adequately warn Sarah regarding these challenges. I feel good about the ability of Emory University SOM to nurture what is best in my daughter. But beyond that will be residency training and then practice. How can I prepare her for the business and financial pressures of corporate medicine? Can she survive the least common conformity demanded by an office practice or multi specialty group? How will she handle the massive debt that her education and training will cost. Will the trade of medicine outstrip the art of medicine and bleed the joy, compassion, dedication, enthusiasm and empathy out of her?
I don’t know the answers to those questions. I am sure that Sarah came to Emory with all the tools necessary to master the art and science of medicine. I believe that Emory will make these tools stronger. She will need precision tools when life begins to bore in. I might not be there to help her or tell her what to do. So I warn her now to anticipate the challenges that will strain her heart, soul and conscience. At that moment, her courage will be challenged. The late President John F. Kennedy understood, “A man does what he must- in spite of personal consequences, in spite of obstacles and dangers and pressure- and that is the basis of all human morality.”
As always, the need for personal courage and conviction is also understood by Bruce Springsteen. The obvious choice might be “The Promised Land” from Darkness on the Edge of Town. “A twister is coming to blow everything down that doesn’t have the faith to stand its ground.” Ultimately, though, I choose another, which also happens to be a personal favorite. Possibly the best record on his first album, Greetings From Asbury Park, “Growin’ Up” combines rebellious youth with humor and the realization that sooner or later you’d have to screw up your confidence and take a stand. The protagonist grows from rebel without a cause to the matured confidence and courage of “I strolled all alone through a fall-out zone and came out with my soul untouched. I hid in the clouded wrath of the crowd and when they said sit down, I stood up.”
I am Professor and Maas Endowed Chair of Reproductive Sciences at the Medical University of South Carolina. I have practiced at that facility for more than 30 years. However, the opinions expressed in this blog are mine alone and do not necessarily reflect the opinion of the University.