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,1 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,2 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 all3 – 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.
Steven L. Kanter, MD
1 Berwick DM. The science of improvement. JAMA. 2008;299:1182–1184.
2 Lazare A. On Apology. New York: Oxford University Press, 2004.
3 Cassel CK. The patient-physician covenant: An affirmation of Asklepios. 1996: Ann Intern Med. 1996;124:604–606.