Graduation Address by Dr. David Byrd, Associate Professor of Surgery, University of Washington
Good afternoon, doctors. Get used to the sound of it. You earned it. Good morning to your families, friends, and supporters. This is a wonderful day. You will leave here today bound for all corners of the country. Every human emotion is present around you from elation, joy, and anxiety, to confusion, boredom, and even sadness.
You are starting your careers at the beginning of a new direction in medicine resulting from the explosion in information about the human genome. Within the next 25-50 years, we will likely have detailed predictions about the genetic susceptibility to nearly all diseases. A check-up may consist of a history form, a total body imaging scan and a blood sample all channeled into an informatics template, complete with diagnosis and treatment recommendations. You may spend much of your time with patients discussing the results of these recommendations and methods of prevention. Do not underestimate the impact of genetic technology on health care. Look ahead, stay informed, and stay focused.
In the next month, most of you will begin your internship, fresh with enthusiasm, energy, compassion, and a fair knowledge base. You will quickly become exhausted, you will make mistakes that will be pointed out to you in constructive and less-than-constructive ways, and your ego will sink to a level only rivaled by the beginning of your third year clerkships. You will be convinced that you have actually lost knowledge during your first year. You will be out of balance, professionally and personally. But then you will begin to rally as you learn the rules of residency, adjust to sleep deprivation, and watch your smiling patients go home from the hospital cured of their problems by your intervention. You will discover that you actually know a great deal of clinical medicine. Here comes the risk that your ego will rise out of proportion to your capabilities. Residency is similar to a blindfolded skydive. You will survive it and you will be changed by it.
I received a valuable lesson during my fourth year of medical school. I was not someone who awakened each morning passionately ready to "seize the day." I went to one of my professors and mentors, Dr. Earl Peacock, and asked him how he seemed to live each day with passion for his work. Without hesitation, he answered "Frequent collisions." He was describing purposely seeking encounters with others or situations where one is put off balance and forced to change direction, stop and think, or act in a different way than the day before. There will be collision opportunities in your clinic practice that will strengthen your vigilance and patient skills if you see them and let them change you. I challenge you to not overlook these opportunities.
When you begin your clinical practice, you will feel a profound sense of responsibility for each of your patients. There will be no attending to walk with you and behind you, only colleagues who are available only if you ask for their help or advice. You will feel the pressure of time management. In the hospital setting, you will be confronted with life-threatening illness. You will see that patients and families want and need more from you than medical opinions. They need you to sit down with them and talk to them and to listen. They will ask you about the role of faith in the treatment and recovery of their disease. Some may ask you about your personal faith and you will be forced to work out your answer to that question. You may recall that you have passed by the hospital chaplain and numerous clergy over the months or years with barely a thought. If you think about it, you will be surprised by the near total absence of dialogue or discussions among health care professionals about the impact of faith and religion on illness and recovery. Don't shy away from these opportunities for collision.
In the clinic setting, you will hone your clinical skills to interact with the grateful patient, the demanding patient, and the angry patient. It is in the routine clinic visit that your clinical vigilance will be tested. It is easy to be lulled into complacency that each patient is healthy until proved otherwise. Remember that your patients will tell you what the diagnosis is, but you have to be listening.
I want to tell you a story to bring the doctor-patient relationship back to the center today. About two years ago, I had one final patient in melanoma clinic after a long afternoon. This was a routine three-month follow-up to see a very pleasant man in his 60s about two years out from his treatment. He had a fairly early melanoma with an excellent chance of cure. I went in the clinic room with my surgery intern, we warmly shook hands, and I asked him how he was doing. He answered with a smile, "Physically fine." I was faced with an unexpected decision about the direction of this clinic visit. He had given me complete control of the next step, knowing that I was running behind and the day was long. The quickest "out" that I had was to say, "I'm glad that you're not having symptoms, let me examine your shoulder." I'm fully convinced that he would have unconditionally accepted my "feint," without jeopardizing our good relationship. Instead, I asked, "Tell me what is going on." He calmly said, "My wife died last night." I was silent for a moment, absorbing the shock. I looked at my intern, whose mouth was literally open, and we both sat down.
My patient explained that his healthy wife had fallen down stairs several days before and had been in a nearby hospital's intensive care unit on life support with a massive head injury. He and his grown children had been at her bedside and had watched her go peacefully the night before. He had recently retired and they had been enthusiastically planning their new lives together and now she was gone. I asked him why he was in clinic today and he said he just needed to keep moving, doing the errands, chores, and visits that had already been scheduled. He didn't want quiet time alone. I asked him how he and his children were doing and he felt well surrounded by their love and support. But they wouldn't understand how, even in his grief and profound sense of loss, he was also mad as Hell at something, or someone, or at God. How could life be this unfair, how could she be taken away from him?
I listened quietly. My patient felt like screaming but didn't know how and thought it was somehow not appropriate. I asked him what he was going to do over the next two weeks to take a break. He said he had been planning to join a friend of his for a week of fishing as he does this time each year, but wasn't going because of the circumstances. He confirmed that the fishing trip would be after his wife's funeral and memorial service. Feeling less courage than I projected, I carefully but firmly asked him if he wanted to go fishing. He looked at me as if I had pulled a blinder off, and after a few seconds, said a definitive "Yes." I said, "I want you to go fishing. You have my permission to go fishing. And when you're out there in the woods where no one can hear, you have my permission to slam your fishing rod against a tree and scream at the forest, at God, or at the squirrels." He smiled with relief and tears in his eyes, I examined him, and we confirmed that he did not have a recurrence of his melanoma. The visit was about 30 minutes over the scheduled time. As we left his room, I looked at my intern and said, "That experience has nothing to do with melanoma and everything to do with medicine." This is the kind of opportunity that the practice of medicine will give you. My wish for you is that you never let the scheduling, financial, and political obstacles you will encounter keep you from recognizing and sharing the pearls to be found in the relationships with your patients. My patients help me to be a better person, a better husband, and a better father.
As your practice grows, you will find your balance professionally. It is less likely that you will feel balanced in your personal life. Many of you will marry and have families. I can say without reservation that starting a family and having children will change you forever. Those of you who have parents and family here today should look carefully into their eyes. You will see an unconditional love and pride in their eyes that seems to defy reason, and it does. The wonderful thing about it is that when you are in their shoes years from now, that feeling will become crystal clear to you. My wife Kathy and sons Adam and Stephen fill my soul. Adam, who is in the audience today, knows that there is a golden chain with unbreakable strength that connects our hearts forever. Do not let your families slip away because of the great demands of medical practice. Do anything you can to achieve this balance in your family life. It will complete you as a person. I have never met a retiring physician who wished he or she had spent less time with loved ones.
I want to end with a recurring dream that I have and that I hope to have always. I dream that I'm walking away from presenting at a national meeting or from an honor such as this, feeling light-headed and with a well-stroked ego, and a small, elderly, slightly disheveled smiling woman comes up to me. With complete sincerity in her question, she asks "Are you important?" The result is always the same. I see with humble clarity that we all enter and leave this world in the same profoundly simple way. I answer, "Yes, I am very important, just like you." We go arm in arm and the dream ends. She is my balancing post.
Ladies and gentlemen, it has been an honor and a privilege to speak to you this morning. Now go forth like the wind, seek your own wonderful collisions, and discover your own stories. Thank you for listening.
