Sometimes I am asked why I climb, or how my passion for the mountains intersects with my professional activities as a doctor.
It’s a bit complicated… but, perhaps some answers lie here: My address to the UW Medical School Graduates of 2019. Audio and text included below.
UW School of Medicine Oath & Hooding Ceremony
May 24, 2019
Dean Paul Ramsey, MD
Dr. Paul Pottinger is Associate Professor of Medicine in the Division of Allergy & Infectious Diseases. As an undergraduate, he studied history and literature at Harvard, then earned his MD at Yale. He moved to the University of Colorado for internal medicine residency and chief medical residency. He also studied parasitology at the London School of Hygiene and Tropical Medicine, and set his heart on a career in Infectious Diseases. He matched at UW for ID Fellowship in 2002, and fortunately for us, has stayed ever since.
Currently, he directs the UW ID fellowship program, the UW Medical Center Clinical ID Section and ID clinic, and the Antimicrobial Stewardship Program. His other leadership activities include chairing the ID Society of America Education Committee, and directing a parasitology course for doctors in East Africa. He is a Fellow of the IDSA and the American College of Physicians. He has received the Beeson Housestaff Teaching award, Outstanding CME Teacher of the Year award, UWMC Teamwork Leadership and Caring award, Chief of Medicine Service Award, and has been elected as a “Seattle Top Doc” by his peers in the city. When he is not at work, Dr. Pottinger enjoys mountaineering.
Students have interacted with him during their Invaders & Defenders Foundation Block, and also in the hospital setting during clerkships in ID and general internal medicine. Dr. Pottinger is well respected by the medical students, and was voted by the graduating class to speak today in the Physicians Oath and Hooding Ceremony. Please join me in welcoming Dr. Pottinger.
Paul Pottinger MD
Thank you so much for inviting me. I am very honored. When I got the call, I could scarcely believe it… how could I possibly be old enough to speak at graduation? I still think of myself as a medical student—I still feel that rush of excitement coming to work, just like the first day of medical school. The smell of the hospital disinfectant, or the smell of a gangrenous foot… intoxicating!
Thinking back to my own med school graduation, 21 years ago…. We invited Dr. David Kessler to speak. Dr. Kessler was our new dean, fresh from directing the FDA where he had forced Big Tobacco to start paying for healthcare costs associated with smoking. He had lots of good things to say about that… at least, I assume he did. I honestly cannot recall a single thing he said! Not one word! I polled my classmates on Facebook: Nothing. How sad is that? It’s not his fault, I was so excited to get my diploma and move halfway across the country with my wife, and start a new adventure, and my mind was not on his speech. But, let’s see if I can conjure up something more memorable. And for those of you already bored and on your phones, suggested hashtags for this ceremony include: #UWSOMRocks, #I’maDoctorSoBringItOn, and #OMGourcommencementspeakeristhrowinghashtags.
Spoiler alert: If you’re impatient to hear my conclusion, the punchline is that each of you is amazing, you are now poised to begin incredibly interesting, important careers that will make life better for everyone. But, please let me work up to that.
In fact, I think I need to work up to it. There’s so much negativity out there regarding medicine, isn’t there? We’ve all heard it: This is a “tough time” to enter the profession… doctors work harder, they earn less, they’re controlled by forces beyond their influence. At least, the memes on social media say so. One of my favorites goes, “Being a doctor is easy, it’s like riding a bike… except the bike is on fire, you’re on fire, everything’s on fire, and you’re in hell.” Funny… but, not funny at all.
I’m talking about burnout, of course. Burnout can be defined as chronic stress leading to a lack of fulfillment in our daily duties. It’s an occupational hazard for many Americans… but no one more so than doctors. In a recent survey of more than 15,000 physicians nationwide, about 45% reported feeling burned out on the job, and only 25% said they felt very happy at work. This remained constant across all specialties surveyed. I’ll say it again: Roughly half of American doctors feel burned out! That’s a healthcare crisis if ever there was one. Why am I telling you this? You haven’t even started residency yet! Because burnout is preventable—and treatable—if we approach our work mindfully and take charge of our careers, and respond actively to the inevitable stressors that attack us from all different sides.
When asked why they feel burned out, most doctors cite unhealthy work-life balance. They are proud to be doctors, but they’re stressed by the bureaucracy of modern care: dealing with insurance, struggling with unwieldy electronic medical records, etc. And, I admit, those things stink. They really do. But, we have an obligation to take charge and make it better! Dr. Melinda Ashton wrote a beautiful article in The New England Journal of Medicine last year called “Getting Rid of Stupid Stuff,” in which doctors took back their EMR and made it work for them. We can all do things like that, if we are willing to invest the time and sweat equity.
However, I think our frustration with bureaucracy is symptomatic of a deeper problem: In my opinion, our national social contract seems broken, doesn’t it? Throughout American history, medicine has operated in the same fundamental way: “I’m sorry you’re sick! Thank you for coming to see me. Please pay me, and I’ll try to make you better.” It’s so foundational that we may forget that this arrangement is—of course—backwards. Instead of focusing on health, we focus on disease. Instead of preventing illness, proactively guiding our patients onto a wellness pathway, instead we respond to sickness, passively, when it shows up in our practice.
This is sub-optimal. Although doctors work incredibly hard, our society looks sicker and sicker! Last year, life expectancy began falling for American men for the first time in modern history. It’s not supposed to do that. Women’s life expectancy held steady at 81.1 years, but men have fallen two years in a row to 76.1 years. We’ve actually made progress with deaths due to cancer and cardiovascular disease, but other disorders are stubbornly on the rise among men, including opioid addiction, chronic liver disease, suicide, Alzheimer’s disease, and septic shock… and not among all men, but especially with certain ethnic or racial groups, including men who self-identify as non-Hispanic African-American. To be clear: In spite of centuries of medical progress, human mortality remains 100%! But, a falling life expectancy, especially impacting one group of our society, is symptomatic of multiple public health and public policy failures.
Perhaps this is driven in part by the lack of trust patients have in us. This is alarming. Like never before, patients are skeptical of our advice, they question our motivations, our expertise, even our qualifications to take care of them. Survey data are alarming: in 1966, 75% of Americans trusted our national medical leaders, compared with 34% today. Only 25% of Americans now express confidence in our health system, and 58% say that doctors in particular can be trusted. 58%! The consequences are very real: just look at our routine immunization rates, which are much too low.
Who can blame them? Fake news and fake memes spread like wildfire, much faster than credible information. It takes a discerning eye to tell real news from fake. Likewise, it can be hard to appreciate the subtleties of medical decision-making, the difficult process of balancing risks and benefits from the dogma spouted by a handful of angry zealots. Trust has to be earned, of course, and in my experience doctors earn it every single day, in the clinic, at the bedside, publishing articles, lighting up social media… having conversations with patients and their families, often in difficult situations. We earn trust through our compassion, yes, but also through our honesty, our willingness to say that we are uncertain about the future. We earn trust when instead of promising outcomes, we promise to stick with our patients, that they will not be alone, and that we will always be truthful with them. We earn trust when we are willing to be vulnerable, and to be human. That’s what all of us want in our doctors, isn’t it? Now, patients will not always do what we recommend—they probably shouldn’t take our advice on blind faith—but they should always TRUST that we have their best interests at heart. Without mutual trust, doctoring is frustrating, demoralizing, and ultimately impossible. Doctoring is all about communication, and communication is all about trust.
The good news is that we’re already doing well on an individual basis… the USA ranks near the global top among patients asked how satisfied they are with their last doctor visit. The implication: “I like my doctor, but other doctors suck, and I don’t trust the healthcare establishment in general.” Clearly, somehow, we need to do better.
But first, we need to take care of ourselves. In my generation, that was not emphasized nearly enough during medical school. I think things are changing, for the better. Some paradigms still need to change. For instance, if I ask you for the first rule of medicine, what would you would say? The first rule of medicine is, “First…”
Graduates: “Do no harm.”
YOU SHALL ALL PASS!
Right. “First, do no harm.” That’s correct, it’s just incomplete. I think the first rule of medicine should be, “First, do not harm… to YOURSELVES or to others.” If you are unwell then you may become unfit to practice, or worse. Everyone finds their own pathway to wellness… your results may differ, but here are some habits that have helped me over the years, for your consideration.
Please be good to your people at home, whether that’s your biological family, your romantic partner, your friends… By “your people,” I mean the people who care about you—and care for you—outside of work. Being related to a doctor is a great privilege… it’s also very difficult, and we should acknowledge that. Thank them for their support, acknowledge their perspectives, do the right thing, whatever that is, so that when you’re at work you can focus on being at work, instead of looking over your shoulder, fretting about whether things are right at home.
Please acknowledge your mistakes. Yes—you WILL make mistakes. Probably not half as many as I’ve made, I know how smart you are, but it’s inevitable. And that’s the point—to err is human, and doctors are human. No matter how much we know, our knowledge has gaps. Although we want to appear flawless, we are flawed. Obviously. The question is, will you acknowledge your errors—more than acknowledge them, will you discuss them, disclose them, learn from them… embrace them? Errors keep us humble, and provide opportunities for growth—as physicians and as human beings.
Next, please keep a journal. Not to record patient details—amazing though they may be. Instead, journaling is a fabulous way to reflect on how medicine makes you feel—grateful, fulfilled, enraged, indignant, exhausted… the entire spectrum of emotion will be there. But, I predict that gratitude will be the biggest emotion that rises to the top. And if you focus on the things that make you grateful to be a physician, those things will take on a life of their own, and the negative feelings will become easier to sort out. There is plausible evidence that by focusing on our gratitude, we can improve our brain’s chemistry and our heart’s function. And yes, I have references for those who want to see them![i] You will NOT want to keep a gratitude journal post-call…but please, find a way to do it when you can.
Please read books. Not e-books but preferably real, bound, paper, tangible books. Not medical texts, instead read about things totally different from work. Continuing medical education is essential, but your mind will crave something different, too. I like the idea of paper books because the tactility, the smell, the look of printed words on the page, all more evocative than on screen, right? You will spend enough time looking at computers, give your eyes a break.
Please stay physically fit, as much as you can. Exercise regularly (be happy with short workouts when you can get them)… eat mindfully… get to sleep on a healthy schedule—when you can. Your bodies are important. Yes, they will probably take a hit during residency—I was so out of shape at the end of internship, truly. If that happens to you, it’s OK, you’ll get your fitness back later. Working on physical wellness pays all sorts of dividends.
Please Teach. Teaching is a lot of work, take it from me…. But you learn so much about a subject when you teach it, and it’s so gratifying when your students thank you for your efforts. I realize we probably haven’t taught you formally how to teach—sorry about that! Just reflect on the teachers whom you admire and borrow techniques from them… and avoid the bad habits of teachers whom you don’t admire so much. But, either way, do it.
Please volunteer. This one’s a hard sell, I know. After all, working as residents you make so little money it almost feels like volunteering… almost. I’m talking about staying active in your communities outside of medicine, whatever cause calls to you. March for science, march for black lives, march for women’s lives, march for whatever, but for goodness’ sake, please march… or organize, or reach out, or engage in whatever way feels meaningful and fulfilling to YOU.
And above all, please be compassionate with your patients. Compassion matters to them, emotionally and physically.[ii] Patients with diabetes achieve superior glycemic control… patients with acute viral rhinosinusitis have a shorter duration of symptoms… and doctor’s advice is more likely to be followed when her demeanor is compassionate. Now, some of you are surgeons, and I can see you rolling your eyes—I know who you are! You’re thinking, “I cut to cure, and the patient’s under anesthesia! How important can compassion be for me?” Well, postoperative wound healing may be enhanced among patients whose doctors spend more “quality time” with them on rounds. All of you are great doctors, and therefore all of you are skeptical. You’re concerned about potential confounders. That’s good. Suffice it to say, there is an emerging appreciation of the biomedical importance of kindness and meaningful connections with our patients. And the best part: it’s super cheap, and it benefits the physician, too.
These “self-care” activities—nurturing each other, journaling, reading, exercising, teaching, volunteering, being compassionate—maybe they’re good for us because they require active participation, they put us in the driver’s seat, allow us to think and behave proactively… they put us in control. In my experience, doctors do NOT like to be controlled! I certainly don’t—just ask my lovely family.
Of course, self-care will only get us so far. I admit that patients may seem frustratingly disconnected from their own best interests… whether it’s preventing obesity, or addiction, or vaccine-preventable infections (don’t even get me started on that one). To be clear: These are difficult problems. Prevention sounds easy—it isn’t.
My point isn’t that I have the answers here. I do not know what’s best for our nation to take us to the next step—single payor coverage, expansion of Medicare, expansion of Medicaid, universal basic income, more regulation of private insurance, training more doctors… I don’t know. What I DO know is that it’s high time for us—as a society—to have a conversation about what we want healthcare to look like, and who we want to become as a nation. What SHOULD healthcare BE? Should it be a human right, accessible to all, regardless of income or skin color or gender? (That’s the right answer!) Should it be a way to enrich insurance company stockholders, like we do now? Some hybrid of both those things? To move forward, as a profession of doctors and as a society of human beings, we should have that conversation in a meaningful way—which is totally not happening now.
As our future physician leaders, YOU are poised to lead that conversation. Please do—with your legislators, your hospital CEOs, with your communities, even—yes—with your patients. As physicians you are experts in healthcare. Like it or not, your opinions carry weight—real weight. Leverage that. Here’s an example: According to CDC, about 10% of Americans still smoke cigarettes; they know it’s bad for them, but quitting is hard—very hard for most. When successful quitters are asked how they did it, they cite a variety of factors… but a strong message recurs time and again: “My doctor never gave up on me. She told me how important quitting is, she helped me, and she believed in me.” That is such powerful stuff, the power of a doctor’s words, a doctor’s empathy, a doctor’s actions. That power lives in each of you, not only in your bedside counseling, but also your potential as advocates of broad social change. You will be told that things are the way they are for good reasons, or that change would be nice but it’s impossible, the system is too big to fix. You’ll encounter a thousand discouragements. But that does not mean they’re right, that you have to just sit there and take it. Can one individual’s actions lead to meaningful change? Of course… change ultimately arises from individual actions, that’s how we’ve always moved forward—TOGETHER, as a team of individuals resolved to unite, to stand up and do something amazing.
So, please pick an epidemic that calls to you, and dive right in. We have many to choose from: Tobacco use… alcohol overuse… violence against women and children… handgun violence… opioid addiction… suicide… inaccessible reproductive healthcare… malnutrition—both over and under nutrition… vaccine-preventable infections… bullying… sexually-transmitted diseases… untreated psychiatric illness… homelessness… the impact of climate change on disease… the implications of ecosystem collapse for our drug discovery pipeline… and, sadly, many more. These epidemics arise, ultimately, from ignorance, from indifference, from division. From the “otherness” that threatens our society, in which we see one another through the wrong lenses—skin color, gender, sexual orientation, whatever, as reasons to split apart instead of sources of rich diversity that make us stronger and bind us into something unique.
I’m talking about healthcare disparities, of course. Disparities are insidious… outrageous… unacceptable. Yet, they happen worldwide, and in our nation, and—yes—in our own city. My friends, solutions to these divisions can arise from many professions, but doctors are placed at the center of that uniquely American paradox—the oxymoron, really, that defines our nation, and it’s stamped on the coins in your pocket: “E. pluribus unum:” From many, ONE. A doctor’s work is all about that ONENESS, bringing patients, families, communities together for mutual benefit. That’s what I see here today, in you: an eagerness to create safe spaces where patients are treated, not judged, regardless of their origins… or what they’ve done in the past. More than that, I see your willingness to become role models, to lead, to take the initiative and make a difference on a bigger scale.
Sounds like a lot of work, right? I mean, becoming great physicians is exhausting enough, and now I’m asking you to bear this additional mantle of responsibility as change leaders? Well, yeah, you’re right: it will be hard work. But, if you don’t do it, who will? Our generation is with you, we’re trying, and we have your back. But, this is your time, your opportunity to lead. Looking out at you, here today, I know that’s exactly what you’re going to do.
By the way, I’ve mentioned domestic opportunities for change, but to be clear: you may find your calling working internationally. For me, that’s a huge source of personal growth and learning, when I teach overseas every year. If global health calls to you, please do that! My point is that we can also be fulfilled here, at home, in our daily practice, in our daily lives.
So, getting back to that punchline, I will say it again: You are now poised to continue the greatest adventure imaginable. Take it from me—I’ve had a few adventures in my time! But none of them compares with this—the career… the calling… the life of a healer. I remember how intimidating and exhausting residency was… but in all sincerity I am envious that you get to experience that journey now, that’s how exciting it’ll be. And I’m sure I speak on behalf of all of us to say that we remain enthusiastic about medical education, not because of the sounds or the smells, but because we get to interact with brilliant, optimistic, dedicated students like YOU.
Alright. To close these remarks, I need your help. Together, we will borrow a technique pioneered in pediatric anesthesiology. It’s called “guided imagery.” I am neither a pediatrician nor an anesthesiologist, but I can do this! And, so can you.
For the next few moments, please consider holding hands with the people seated next to you, whether friends or strangers… yes, faculty, that includes you, too. Swapping viruses is OK. Thank you.
Now, honored guests and family members, please close your eyes. Focus on the moment when you learned that your loved one was accepted to UW medical school. That pride and admiration, the joy that you felt when you realized that this person you have known for so long—perhaps since birth—was going to become a doctor. Focus on that happy emotion, and send that positive energy out into the room, share it, amplify it for everyone to feel.
Please keep your eyes closed… and faculty members, please close your eyes, too. Faculty, please reflect on this class… the first time you met them, perhaps in lecture or a small discussion group, perhaps on rounds, maybe in clinic. Recall the pride you felt when they nailed that differential diagnosis… when they presented expertly at the bedside… when they took a genuine interest in their patients’ lives, got to know them as individuals, not just as patients… and when those patients themselves told you privately what a star the student was, and admonished you to give them an A! Keep your eyes closed and focus on those proud, happy memories and send that positive energy out into the room, share it, amplify it for everyone to feel.
And now, graduates, please close YOUR eyes too. And focus on each of those same moments: When you realized you were going to medical school… meeting your classmates on the first day… sitting for that first exam… interviewing and examining your first patient… presenting your first H&P… nailing that differential diagnosis for the first time… spending time with your patients, listening compassionately to them, making a genuine difference in their lives.
That darkness that you see behind your closed eyelids is not emptiness, it’s a world of infinite possibilities and accomplishments yet to come. When you close your eyes at bedtime—and yes, you will be allowed to sleep during residency—what will you choose to see? When I go to bed I see my family, accomplishing great things… I see the mountains, tall, austere, so alluring… I see my colleagues—and that includes all of you—brilliant, energetic, dedicated… and I see the faces of my patients—both the ones I have saved and the ones I have lost. Each a unique person whose life I have touched in some small way—and who in return has enriched my life exponentially more so. I hope you will choose to see your patients too, and your incredible, inspiring colleagues. Being a part of their lives is a doctor’s unique privilege, a privilege each of you has earned.
Right now, we are all connected to each other, and you are connected to each other as a class… please nurture these connections, and draw strength from them, for all the many decades to come.
Now, everyone take a deep breath in, and hold it… aaaand, slowly exhale. Do you smell that? That’s the smell of awesomeness. It’s the smell of the future… the smell of the UW class of 2019.
Everyone, please open your eyes. On behalf of the University of Washington School of Medicine faculty and staff, please know that we are so proud to have trained you. We are delighted to have you as colleagues, and we are so grateful for all the good you will do as doctors. Welcome to your new profession, and to the next chapter of your already-remarkable lives.
Truly… in every sense… thank you so much.
–Paul Pottinger, MD