White Coat Ceremony January, 2011

Keynote presented by Sidney Goldstein MD
Professor of Medicine Wayne State University College of Medicine
Division Head Emeritus, Division of Cardiovascular Medicine
Henry Ford Hospital, Detroit Michigan

The Challenges Facing New Doctors
instruction and the license to do what you are about to be trained for in civilized society. Medicine men, faith healers, curanderos in more primitive societies may perform similar roles in attempts to treat other humans but without the centuries of science that you will have been exposed. When you graduate and as you move about in your community you will be perceived as being unique. Your friends will presume that you know about every malady in the book and at cocktail parties or in normal discourse you will be queried about all sorts of real and fancied disease that you will be presumed to know about and have formed an opinion. You may even be driven to use the ploy that I have used on occasion, that I am not a doctor of Medicine but of Anthropology. Your friends, your colleagues, and particularly your patients will view you with a special aura and presumption of omnipotence and an expectation that you are a harbor of sensitivity and understanding and humanity. But in reality you are merely a mortal with all the pluses and minuses that go with being a mortal.

You will embark in a study, which will teach you about the most inner workings of the human beings and ultimately give you the ability to apply your knowledge to the treatment of their illness, whether real or fancied. You will learn about the most intimate nature of their being. You will learn all of this from your physical and mental examination and will be challenged to share with your patient the realities, the facts, the ignorance, the hope and despair that may be part of their illness. You will know more about their biology and thinking than even they will know of themselves and you will be challenged to integrate this knowledge in terms that provide understanding and solace to your patient.

The role that you choose in medicine at the conclusion of your studies will be varied. You may be practicing medicine in rural America, in a radiology reading room in Australia or you may even become a Governor General of a Caribbean Island. Or even perhaps you may become a television personality like the cardiac surgeon Memet Oz and advice about the best dermatological preparation to maintain your youthful skin. But you will always be a doctor. I remember one day during and acrimonious discussion with my non-physician administrators when I expressed my frustration in regard to the discourse to one of my medical colleagues. He turned to me and said, no matter what the outcome of your discussion, your role has been critical because you bring the patient to the discussion. As health care becomes more complex throughout the world decision for better or worse are being made by individuals who are not doctors and have never seen a patient or dealt with their problems.

The dimension of what we have learned in medicine has expanded in the last century beyond any resemblance to what our professional ancestors were aware of. Yet amazingly enough the issues through the centuries remain similar. In the short expanse of my own experience, the changes that have occurred defy the imagination of even the most prescient scientist of the mid twentieth century. In retrospect, physicians and surgeons in my childhood were not much farther removed from the understanding of disease and therapy than the medicine man of the primitive world. If you can imagine, they didn't even know what a Cardiologist was. Yet they provided care and understanding to their patients such that they were understood to be a cut above primitive medicine men. Our profession with some difficulty over time has become highly esteemed as a valid and effective response to both organic and mental illness. Our predecessors knew about surgery but nothing about organ transplantation, they knew about infection but not of antibiotics, the first antimicrobial therapy was developed less 50 years ago, they knew about the rudimentary spread of disease but little about the genetics of disease, they knew about hardening of the arteries that they observed in the autopsy room but nothing about the pathogenesis of atherosclerosis and of its prevention which is now within our grasp and they knew of mental disorders but little about its treatment with drugs or guidance. The transformation of medicine just in the last half century has created options for therapy never before conceived.

In the next few years you will learn about how the body functions, how we locomote and emote, ingest and digest, inspire and expire and ultimately understand how the body functions. Your studies will teach you how to invade every body orifice and understand how to reach physically the inner most parts of the human body. Where there is no biologic orifice, you will learn to create an opening in order to investigate and treat disease. You will certainly learn how to cut and sew the tissues of the body in order to maintain the integrity of the human being your patient. But new technology will allow you to picture the human body in dimensions never previously conceived. With MRI and fast CT scanning you will be able to picture the tissue of any organ and understand its function. You will be able to image the brain and map the processes that cause joy and sadness, lust and disgust caused by the biochemical transformation deep within the brain tissue.

You will learn of how the heart function in a manner that I as student could not even imagine only a few years ago. Consider the fact that as you sit here in this auditorium and your heart beats at about 60 beats a minute, your heart muscle, made up of about 6 million cardiomyocytes beating in unison, is being told to contract and relax by a calcium molecule crossing a cell membrane, so thin that it is permeable to a single ion. And in fact we can measure that ion transfer and modify it with drug therapy and change that protein membrane in order to prevent life threatening rhythm disturbances. Not only that, but as we sit here and think about that calcium ion swinging back and forth across that protein membrane, a scientist somewhere will be studying how to modify that membrane so that the calcium ion moves faster or slower, depending upon the disease state he wants to modify. We can also enter the cell itself, describe its protein structure, how it uses its energy resources in order to maintain or improve its function. We can modify the energy by administering electrical impulses with implantable electrodes or by administering a variety of drugs. And in the laboratory that I work in, new drugs and devices are being studied every day in order to improve the function of the failing heart. And you will be apart of that process, either in its application to your patient or by modifying and amplifying the knowledge of tomorrow.

And yet some would say we know too much. Although Mendel described the genetics of the fruit fly, today we are able to describe the genotype of the human body, their biochemically characteristics them and relate those genes to health and disease. We now are able to treat a number of genetically determined diseases like pulmonary fibrocystic disease. We may be able to actually predict which and how much drug to administer based on the patients genotype. We will be able to predict what disease your patient will acquire and perhaps die of. You can now obtain your genetic makeup from the Internet. And then what--- the ability to predict life and perhaps death. How will you deal with this knowledge as a doctor to your patient? We are now able to predict the occurrence of breast cancer based on particular genotype. We may soon be able to predict premature senility or Alzheimer’s disease without any possibility of being able to prevent it. We can in fact treat a few of these genetically determined diseases. Treatment is the positive part of the knowledge, but prediction of disease without any therapy or prevention is the dark side of our knowledge about genetic diseases. To know the future without knowing a treatment option can be a terrifying outcome of our knowledge. The general availability of genetic information can have serious impact on your world and will impact on your work and your future. Those are questions that we are just beginning to deal today and will be an integral part of your medical relationship with your patient. The confidentiality of your interaction with your patient remains sacrosanct, yet the medical record is fast becoming part of the electronic atmosphere.

And what about paying for health care? How about getting paid yourself for performing your professional responsibility. The increase in health care cost worldwide has led to a world in which health care is economically rationed. Hardly any one in Zambia is getting a heart transplant today but there will probably dozens performed in the developed world. This is not a function of need but a function of economic rationing. I can look out my office window in Detroit and see areas of my city where the infant mortality approximates that of many African nations. What will happen to the millions of poor people including those in the United States who will suddenly be provided with preventive pre-natal and diabetes care suddenly survive their teenage and young adulthood only to face degenerative disease as they age? And yet health care now represents a huge part of every nation’s budget regardless of the country or continent. In a time of plenty this was not an issue but in our recent recession or depression there is just not enough money to go around. Doctors in large part have given little thought to controlling health care costs. It will be up to your generation to return altruism to its rightful place in dealing with societies social and medical needs.

The greatest skill that you will need to acquire will be to learn hoe to talk and listen to your patient. Communicating with them will be your greatest tool. The common complaint that patients bring to my office is that the last doctor I saw never explained my problem to me. This often translates to meaning that they didn't understand or the were not listening. It also can indicate that actually the doctor really did not spend time explaining to the patients what the problem was. Either way it makes no difference. You can never spend enough time talking and communicating to your patient but in today’s medicine, time is in short supply. Medical information is difficult to understand and to explain. As the clinical environments changes, and patient numbers increase the time available to spend with patients becomes shorter, more and more ancillary support staff comes between you and your patient. You will become increasingly remote from your patient as you become increasingly dependent on your support staff in order to get through the day, and they will impede your ability to interact with you patients. Both you and your patients will be short changed and loose out on the satisfaction of than you both gain from being both a doctor and patient.

But on a day to day experience you will be faced with the treating your patients and finishing your day flushed with success or resigned to the fact that you have failed to achieve the therapeutic result that you had hoped for. With each patient encounter, either in surgery, in the medical clinic or in the radiology department you will be faces with challenge of how to help your patient. Medicine provides such a variety of disciplines I am certain that you will find the one that best suits your personality. What ever you choose, as a doctor it will be patient centered, you will be trained in the next few years to understand what it means to be a doctor. Occasionally it will be a successful encounter and you will leave it with the feeling of success, often with only a sense of support, many times with a sense of frustration or even failure. At the end of the day will return to your room, your family, read a bedtime story to you four year old make love to your partner and move on to tomorrow. And I hope that you will return to your role as a doctor with the same enthusiasm the same commitment, the same excitement that you have today and as I will have next Monday when I return to the hospital to see patients in my hospital. Good luck and have a wonderful life and career in medicine.

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