The Unspoken

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An Open Letter to All Graduating Medical Students

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"An open letter to all graduating medical students" by Steven L. Kanter, MD

The months of May and June are exciting times at many medical schools around the world as faculty prepare to anoint the next generation of physicians with a formal medical degree, and students prepare to make the transition to doctor.

I wish to celebrate this juncture with the following letter.

Dear Graduating Medical Students,

Congratulations! I write to you on the occasion of your impending graduation from medical school to say, with great pride and joy, Welcome to the profession of medicine!

You have worked hard during your years in medical school and you have accomplished so very much. And I know that your many successes are due, in large measure, to your own efforts.

But let me remind you that success, for many of you, is also due in part to your parents, your spouses and partners, your children, your relatives, and many friends - who have done so much for you. Their support and guidance have been vital to your high levels of achievement, and in the coming years, their love and friendship will be among your most valuable assets.

Furthermore, your success is also partly because you are the heirs to the long-standing traditions of those who have gone before you - individuals who were not only skilled and effective doctors and scientists, but who also had a strong sense of community and possessed broad humanistic aims for our profession.

Yes, you are part of a rich legacy.

You are graduating from medical school during a period of rapid change in medicine. Discoveries in biomedical science are occurring at a pace never seen before in the history of either medicine or science. Every day there are newspaper articles, editorials, and commentaries calling for broader and more sweeping reforms in the delivery, financing, and organization of health care.

Other health professions are pursuing, via legislative and other means, a broader role in caring for patients, particularly in primary care. Some say hospitals are becoming big intensive care units, and we all know that more conditions are being treated in ambulatory clinics and same-day surgery centers. Some even question the diagnostic value of time-honored physical examination skills.

If you sense within yourself feelings of doubt, anxiety, and uncertainty, I want you to know that you are not alone and that it is normal to have these feelings during this time of rapid change in the health care environment, amplified by a significant transition in your own lives. But I offer this thought: taken together, these big changes place before you extraordinary opportunities.

As I hear my own students express feelings that reveal excitement and enthusiasm blended with angst and apprehension, I talk with them about ways to convert the energy generated by those feelings into the confidence and actions that are needed to solve medicine's most pressing problems.

I remind them about the full range and depth of their considerable intellectual and other talents, and how they have a special opportunity to combine those talents with their medical education to contribute greatly to society. I tell them that their medical education has enduring value, that no one can take their education away from them, and that during times of hardship-be it a waning economy, political unrest, or natural disaster - its value can only increase.

During many discussions with many students over many years, I have been asked the following ten questions over and over again - perhaps expressed in slightly different ways, but nonetheless converging on these ten themes.

Since you are likely to have the same questions, I will recount them for you now - of course, with my answers and advice.

Number 10: What are the fundamental goals of medicine in today's world?

My answer: The fundamental goals are the very same goals that have been important for centuries: to promote health and well-being, to relieve suffering and pain, to rescue people from sickness and disability, and to save lives. In this time of broad-based change in medicine, it is more important than ever before to anchor our actions in fundamental goals, basic principles, and core values.

Number 9: What is the greatest privilege of being a doctor?

My answer: That a fellow human being will grant you his or her trust. It is trust that lets you hear the intimate details of a person's life, that allows you to lay on hands to examine his or her body, and that enables you to be present at the most personal of moments. Sometimes, you will be entrusted to be the first person a newborn baby sees as she opens her eyes. Sometimes, you will be entrusted to be the last person a gravely ill man sees as he dies. By virtue of your medical degree, you are granted the profound privilege of trust. You must do everything to promote that trust - and nothing to subvert it.

Number 8: Do I really know enough to have an MD degree? 

My answer: Well, you may not want to ask that out loud after you graduate. But, at the same time, don't worry, this is a justifiable feeling. And it can help you if it motivates you to continually learn new things about the art and science of medicine.

Number 7: Is it true that a physician must be a good teacher? 

My answer: Yes. You must teach your patients how to get well, you must teach the members of your community how to stay well, and you must teach your colleagues all that you learn. And if you have responsibility for medical students, please take good care of them.

Number 6: Has medicine basically become the business of health care? 

My answer: Those who choose to conceptualize medicine only as a business, physicians only as providers, and patients only as consumers, reduce health care to being only a commodity. And that limits the possibilities we might achieve. Those who choose to conceptualize medicine fundamentally as a profession - founded on competence, compassion, and commitment - not only ground our work in a strong philosophic and moral tradition, but also endow future generations of physicians with the capability to grow and develop in important new ways.

Number 5: Is it true that I will never again need to respond to the question, How many ATPs are generated by one turn of the Krebs Cycle? 

My answer: Well, maybe, maybe not. But remember, it is a deeper and more thorough understanding of the science underlying disease that leads us to new and better therapies. To illustrate, consider what would happen if, right now, we could wave a magic wand and provide health care to everyone who needed it at no cost. We would solve some problems, but not all. People still would suffer the mental anguish of schizophrenia, people still would suffer the physical limitations of multiple sclerosis and arthritis, and people still would die prematurely from cancer and trauma. Better health care requires more than just being able to get patients to their doctors, and requires more than patients being able to pay for their care: ultimately, better health care requires better science.

Number 4: Will I make a mistake that will hurt a patient? 

My answer: Yes. You are human and human beings make mistakes. The approach to preventing medical errors known as Name them, blame them, shame them does not work (my generation and those before us have proven that). It is up to your generation to pursue approaches that do work. You must advance the science of improvement, you must create systems in which error is least likely to occur, you must formalize better approaches to apologizing to patients when error does occur, and you must develop better mechanisms to compensate patients who will live with the consequences of error.

Number 3: Is it important to do what is right within the context of containing cost? 

My answer: No. It is important to contain cost within the context of doing what is right!

Number 2: Is it true that I will have rhinorrhea and/or diarrhea through most of my internship? 

My answer: Yes. But remember: your personal well-being is key to your success. Exercise often, get adequate sleep, and maintain good nutritional habits. Remember to be good to yourself.

And the number 1 question that every graduating student asks, as we part ways, is: Don't you think it will be great? As soon as I graduate, I won't have to say to each patient, Hi, I'm the medical student on the team. Finally, I will be able to say, Hello, I'm Dr. Jones, your health care provider. 

My answer: Don't sell yourself short. You will be much more to your patients than just a health care provider.

Now, don't get me wrong. It is very important to understand the physician's role as a health care provider. But it is even more important to understand that providing health care is only one aspect of being a physician.

As physicians, we are, as Cassel has said, healers, helpers, carers, advocates for the sick, and advocates for the health of all - and we do this as we strive to be ever wiser scientists and humanists. So, don't tell your patients you are their health care provider. Take the privilege you have worked so hard to earn - tell them you are their doctor.

Well, I hope that my answers to these questions are helpful to you as you prepare for the next phase of your professional lives. As you begin this new part of your journey, I am confident that I speak for all medical school faculty around the world when I say to you that our confidence in you is great and that our hopes for you are alive with promise.

We are so very proud to have been your teachers. You have taught us as much as we have taught you. You have touched our hearts with your enthusiasm for medicine. And you have touched our souls with your abiding desire to serve humankind.

Remember that you take with you such an amazing gift to offer to society. Some of you will advance our understanding of medicine by discovering new knowledge, some of you will ensure our future by teaching others, and some of you will attend to the very meaning of life, one patient at a time.

An Open Letter to New Medical Students

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"An open letter to new medical students" by Steven L. Kanter, MD

 

At many medical schools around the world, the months of August and September mark the time when students complete the rite of passage from applicant to medical student. These rites most often include orientation sessions, social activities, and greetings from school officials.

One topic that permeates these sessions is professionalism. Through implicit themes and explicit messages, deans and faculty begin to educate new students on the very first day of medical school about the principles of professionalism, including excellence, humanism, accountability, and altruism.

Over the years, I have heard many presentations and read many articles about these principles and other aspects of professionalism, but rarely, if ever, have I heard or read a compelling discussion about when someone actually becomes a member of the profession of medicine. That is to say, at what point during the continuum of medical education and practice does an individual make the transition from being a lay person to being a member of the medical profession? It is in this spirit that I write the following letter to all those who have the privilege to matriculate as medical students.

Dear New Medical Student,

I know that you have worked extremely hard for many years to gain acceptance to medical school. I also know that your medical school has worked equally hard to screen and interview many applicants, each of whom wanted to occupy the place you now hold. So, congratulations and welcome!

Now that medical school has begun, I am sure that the deans and faculty of your school are talking to you about the unique privileges and critical responsibilities that accompany being a medical student – and ultimately being a physician. As you listen to them, and as you begin to reflect on what it means to be in medicine, I invite you to consider the following question: When will you become a member of the profession of medicine?

Each year, during the first week of class at my medical school, I go before the new first-year students and pose this question to them. Some students respond that it occurs when one becomes a practicing physician. Some say it happens when one receives a license to practice medicine. Others contend that it takes place when one enters a residency program, and still others call out that it happens when one officially receives his or her MD degree.

So then I ask my students whether they think that something magical happens at some point during medical training, such that an individual suddenly merits membership in the profession. For example, could this happen with the granting of a license or degree? What about the first time you touch a patient? Or, perhaps, the first time you save a life?

We always come to the same conclusion: that there is no better time to begin the transition from lay person to professional than the very first day of medical school. It is so important to start, as soon as possible, to incorporate attitudes and values of professionalism, to integrate in your own mind ways to think and act in a professional manner, and to develop an underlying identity of yourself as a member of a profession. That's right—it is critical that you begin this process now. And, as soon as you do, I believe that you have become a member of the profession of medicine!

Considering yourself a member of the profession of medicine, starting right now, will begin an important process of socialization and acculturation. It will help you begin to think about yourself and to conduct yourself in new ways and to mature intellectually and professionally as you develop an identity as a student-doctor, and eventually as a doctor.

This is important for many reasons—let's consider three. First, it is very likely that sometime in the next few weeks, one of your professors will bring a patient before the class. As a student, you may see it as the order of the day that a patient is brought in to help you learn. But, if you consider yourself a member of the medical profession, you will begin to sense a larger perspective, and you likely will reflect on your own responsibilities in such a setting.

You may decide that it is important to present a professional appearance to the patient, and so you may wear your white coat that day. You may think about how the patient views you (not just how you view the patient). A patient once commented to me that he saw medical students not only as members of the medical profession but also as representing the very future of the profession. Because patients will often see you as a member of the profession (even though you are not yet a licensed physician), they will share with you the most intimate details of their lives. This is truly a privilege and important to your learning.

As you extend your thinking along these lines, you will begin to think more about the patient in the context of his or her own life. For example, the patient may not be confident in his or her decision to appear before a class of medical students, but was swayed by the desire to please his or her doctor (who also is your professor). Recognizing this as a possibility may help you include some comforting words as you thank the patient for contributing to your education. For instance, you might decide to say something like, “I realize how much courage and effort it takes to appear at an event like this, and I just want you to know how much it adds to our understanding of other people who have an illness like yours and who work so hard to deal with it.”

When you conduct yourself in a professional manner with patients who consent to come before a medical school class, it validates their feelings that they are contributing to the education of health professionals and thus helping others who have the same disease or syndrome that they do.

Second, considering yourself a member of the medical profession is also important to your basic coursework. Soon, you will begin to study the gross anatomy of the human body and, in most medical schools, you will have the privilege of dissecting a cadaver. If you think of yourself as a professional person, it will enhance your ability to understand the relationship between you and your cadaver and it will help you as you think about how to regard a body willed for anatomic dissection.

And third, if you are walking down a road and you see someone get hit by a car, and you believe that you are a member of the medical profession, then you have no choice but to go to that person's side and do what you can to help. A lay person may do that – perhaps should do that – but is not obligated to do that. You are. I realize that you may not feel qualified at this stage to do much, and it is certainly important to do no harm. However, I believe that there are many things you could do to help in a situation such as this. For example, even as a new first-year student, you could call for help, make observations about what transpires that could be useful to qualified personnel who subsequently arrive on the scene, and comfort the individual.

So, congratulations again on securing a seat in your entering class. You will hear a lot about professionalism—its definition, its principles, and how your school will measure it—but please consider what it means for you to be a member of the medical profession, beginning right now. It will influence how you think about yourself, how you approach the task ahead of you, and how you interact with patients, colleagues, and others.

Remember that nothing magical happens at the time a degree is awarded or a license is issued or a ceremony is held. These are milestones that mark achievement, but they will not suddenly and miraculously convert you from a lay person to a member of a profession. It is up to you to begin a process of reflection as your underlying identity evolves from undergraduate student to medical student, from lay person to professional person, from learner to health professional.

Thinking about yourself in this way is hard work and takes time and will continue throughout your professional life. But the rewards of being a member of the medical profession are some of the greatest a human being can know.

Welcome to the profession of medicine!

Limits

What constitutes a bad day to me is as listed below:

• Making a provisional diagnosis of an exacerbation of pneumonia in an elderly patient and finding out through investigations that she's actually got heart failure (how did I miss that?!)
• Cannulating an elderly patient with really tiny veins and getting it -- And then missing it (what a difference a second makes...)
• Ending a shift in ED feeling like you really haven't got much right today

Don't get me wrong, I am loving my Emergency rotation.

But if there's one thing that I've realised more and more since starting my final year, it's that being a medical student comes with an expiry on your level of usefulness.

When the Emergency Department is bustling with acute incidents and there's so much to be done, at the end of the day, the nurses work faster than you do, so you just end up being in the way.

While the doctors are busy doing doctor-things and you've done your medical-student-things, you need to get things signed off by a "real doctor", guess what? They're occupied.

So you just wait til they've got a free milisecond to sign off that pathology form for the blood you've just taken or the investigations that you've written out to be ordered, and until then, you've hit a brick wall in terms of productivity.

I certainly won't be missing those limits when I'm a fully qualified doctor. I'm looking forward to being able to sign for things in my own right and follow through with the workup of my patients. In short, I'm looking forward to having more control.

However, I am aware that more control comes with more responsibility and as much as I am eager for it, I don't know if I'm good enough just yet.

I know I've got to work hard to be better, faster, sharper... But it's hard work. It's like climbing a mountain and having rocks fall on you as you struggle to get higher. At the end of the day, you just feel extremely battered, but not much better for it.

You might recall that a couple of weeks ago, my friend Keira took me to see a performance at the National Institute of Circus Arts. Inspired by the show, I signed up for a beginner's course in aerial acrobatics.

I expected my first class to be an introductory session, but instead, the first thing we were asked to do was monouvers on a static trapeze. Sure, they were basic moves, but having never seen a trapeze up close before, actually getting on it was an incredible feat itself without taking into consideration that I actually had to move on it! And trust me, the static trapeze was the easy part of the night.

Needless to day, it was a brutal session. By the end of the hour, my muscles burned and I could barely walk straight. I came out of my first class last night with the stark realisation that my body and my will were truly weak. After all, my teachers and classmates made it look so easy! And if their expectations of me were anything to go by, it really should not have been that hard.

They climbed and curled and defied gravity like it was second nature to them. It was beautiful to watch, whereas my efforts would probably have seemed less dainty and more ghastly. Contrary to them, I was weighed down by my lack of strength, coordination, and confidence. I felt the limits.

The parting words of one of my teachers (whom, by the way, I fell on top of during one of my attempts to climb the rope) were this: "Don't give up... You can do this. You have the strength, you just haven't figured out how to use it yet."

They say that the key to gaining competence is to just keep at it. But what do you do when you're just plain tired?

What do you do when your muscles ache and your mind has turned to mush and you just cannot squeeze even an atom's worth of effort any longer? What do you do when you're just not good enough?

Trying to be better is a simple concept to grasp, but the actual feat is far from easy.

And, in my opinion, despite loving the climb, being at the foot of the mountain and knowing that you have such a long way to go is not much fun.

Just Like Me

"Just think, though... The best doctor you've ever known started out just like me!"

Thankfully, my patient laughed.

In all honesty though, I often forget that although the struggle to perfect your medical skills is something that all medicos have in common, a lot of the time, that's where the similarities end.

Every time I meet a fellow medico, I have this innate (and extremely naive) notion that I'm meeting a kindred spirit. After a few minutes of conversing with them though, I may be proven wrong and this can at times be disappointing.

Medicos are people, and people are different. Although some have said that the practice of medicine attracts a certain kind of personality (or, in my opinion, a certain kind of crazy), there is in fact a lot of very different people in medicine.

Our values are different, our motivations are different. Our opinions and approaches are different. Our priorities are different. And often, our perception of our patients and the profession in general are different.

In a perfect world, this would be okay.

However, in reality, it is often hard for a person altruistic in nature to relate to a person egoistic in nature and vice versa. And although this is true in all facets of life, I can think of no other profession in which these two personalities collide to the extent that they do in medicine.

Medicine has the capacity to fulfil the needs of both these archetypes and therein lies the attraction.

It is easy to put down the surgeon who is in it for the money or the psychiatrist who is in it because his best friend committed suicide and say that they've got it all wrong. But labels and stereotypes are poisonous and they pollute our thoughts and behaviour, and ultimately pitch us against each other when it is in our best interest to stand together.

Mutual respect is an easy thing to say, but amidst our pride and respective prejudices, it can often be quite a challenge to implement.

At the end of the day, nobody will appreciate the full extent of a doctor's responsibilities and the risks involved in the profession better than another doctor. Despite our differences, we are comrades in arms and the world needs all of us in every which way we come.

The Great Balancing Act

"So be sure when you step, step with care and great tact,
And remember that life's A Great Balancing Act!"

'Oh, the places you'll go' by Dr. Seuss

Believe it or not, I was first introduced to Dr. Suess when I was 16 years old.

Anna, who was 18 at the time and my very first soulmate, read to me her favourite book, 'Oh, the places you'll go, and I loved it.

Since then, I have found the wisdom of Dr. Seuss to be very relevant to my daily life.

From my observation, life is a circus - Not only is it A Great Balancing Act, there is also plenty of juggling involved. And sometimes, there are clowns (both of the funny and scary variety).

At the moment, I am juggling the end of my formal medical enrolment with the beginning of my medical career. This involves keep up with my medical studies in term of the university's curriculum and assessment requirements, along with all the on-the-job learning that I do on my clinical placement everyday from before dawn to beyond dusk, and at the same time, address the requirements of my internship applications for next year which includes months of researching different hospitals and training programmes, CV and Cover Letter writing for each hospital, obtaining spectacular references, and lastly but most importantly, wow-ing the interview panel with my dazzling charms and sparkling personality. If I can manage it.

Trust me, it's not easy.

Where do I find the time? The short answer is, I don't. But life goes on regardless.

In the end, I do the best I can, the only way I know how.

For internship, I applied to 25 training programmes and have so far completed interviews for 10 of those places. It took a lot of time, planning and effort, and at random points in the process, I was utterly mentally, physically, and emotionally drained. Some of my interviews were hours and hours of away from each other, after which I still had to go to work the next day, and for the past three weeks, I've had multiple interviews per week, some of them back-to-back.

But this is the price we pay. Our time, effort, and energy is the sacrifice we make in order to increase our chances of getting to where we want to be next year. Having said that though, even after all that, nothing is guaranteed.

For now, there is a still moment of silence before the next round of interviews come-a-calling. I'm hoping that by then, I'll already have a job offer in hand. If not, the saga continues.

And, of course, in and amidst all this internship drama, I've actually got to focus on completing my personal learning objectives to ensure that I make an excellent intern next year.

All I can say is, I can't wait to finally have a job secured so that I can start focusing once more on what really matters, and that's getting the job done right.

Also, by the way, it'll be nice to finally get paid.

On purpose

It's been a long day... And not a particularly easy day, either.

Still, long days or not, easy or not, I love my job.

A number of things plague my mind tonight.


One of my patients informed me today that she was dying.

Not knowing how to reply, I did the only thing I do know. I was honest.

I told her, "We're all dying. It's just a matter of how and when."

And then I said, "No matter what happens though, my job is to take care of you and make sure that your time here, however long, is as comfortable as it can be."

Thankfully, she smiled and replied, "Good answer."

~~~

One of my Palliative Care patients was in dire straits yesterday, but following our treatment regime, she has improved markedly, and I've been very, very happy with this.

However, despite having COPD and a chest infection, she still continues to smoke.

Rightly or wrongly, it feels like we are fighting to give her a better quality of life (however long she's got), and she's fighting against all our efforts.

It's against my nature to give up on my patients. Palliative Care or not, she's still alive now, and I firmly believe that her life CAN be better. If her lung function improves, her appetite may as well, and really, that's the only thing that's holding her back.

She has not got a terminal illness as far as her records show (no more than the rest of us, anyway - Life is a terminal illness, after all), she's just got really crappy lungs. But that's not killing her - the smoking is. Slowly, but surely, and most certainly torturously.

I know I'm new and inexperienced, but I just think that if she were managed better, she COULD come out of this, despite her many near-death episodes.

Unfortunately, my opinion in this case means nothing because as things stand, I have more faith in her potential recovery than she does, but she's the one calling the shots.

~~~

A young man showed up today after having his first episode of generalised tonic clonic seizure.

He is my first patient of this variety, and I couldn't help but recall the words of my Neurology mentor.

"Before referring to Neurology, ALWAYS check the tongue."

And I did. And sure enough, he had bite marks on his tongue; an observation I included in his notes as any conscientious medical student would.

Naturally, I did feel proud when the admitting physician said that my notes were "perfect".

In medicine, it's those kinds of moments that get you through the day.

We spend so much time swimming against the tide, fighting the odds, and being thrown around by waves of uncertainty and by so many factors beyond our control that we will pretty much take any victory that comes our way.

Even if it comes in the form of perfected paperwork.

I have now come to the end of my day, and I'm exhausted.

Every patient I see is unique and important and I care for them in different ways.

In a way, they've all had a piece of me today. And today, I'm feeling it.

The stretch, the weight, the tension...

Regardless, I wouldn't give up my job for anything.

It's what I'm here for. It's my role.

It's my purpose.