Change and the values that don't

MARTIN G. MYERS, MD

aFall 1997

[This address was given by Dr. Myers at Northwestern University Medical School's Founders' Day, September 1, 1995.]

WELCOME TO Northwestern University Medical School. It is my special pleasure and honor to speak with you today—you, the students who are our honored guests today. Of course, it may be a while until you feel like honored guests again!

While today is largely a symbolic step on the path to your careers, for the faculty it is a day when you remind us of why we are here.

When Dean Beaty first asked me to address you, I began to worry about what I should discuss with you today—this being my first opportunity to talk to you as a group. I could have no slides, I have no young child to examine with you, and the setting does not seem appropriate to discuss sexually transmitted diseases!

As I contemplated this challenge, I remembered that the speaker at my convocation in medical school was Dean Turner (a classmate of my father's), and at my graduation it was Milton Eisenhower, (president of the university and brother of the former President). I vividly remember the speakers, but to be honest, I can't recall a word they said.

Suddenly I had a great stroke of insight. You won't recall a thing I say today. As I contemplated this oddity—that is, that I was going to work hard to prepare a talk that you will not remember—I began to wonder how many students at the University of Pennsylvania in 1889 recalled the "Founders' Day" address delivered by William Osler. I realize that none of you may have read that talk, or yet know who William Osler was, but let me assure you that it is unlikely that you will complete your professional career without, at some time, reading that marvelous address. The talk I am referring to was entitled "Aequanimitas," which is Latin for equanimity. It defined two attributes central to being an effective physician: imperturbability (not appearing flustered) and equanimity (actually feeling calm as well). What a marvelous talk he delivered. I am sure it was delivered well—probably with just the right amount of levity, hand movements and so on. Nevertheless, I suspect the students that day remembered the speaker but not the talk!

Still, that 1889 essay was a statement of values that continues to be valid today, 106 years later. Isn't that remarkable? Despite all the change that has occurred in medicine over the past century, Osler's values are still meaningful today.

Some things don't change

Have you noticed? Everyone seems to be talking about change and risk and fear of change? Can you imagine this? Someone advised my son (who is a medical student at another university) that this was not a good time to go into medicine—because of the uncertainties, the changes going on. Incredible. Here we stand at the threshold of the era of disease eradication, of gene therapy, and with remarkable new tools to comfort and sustain our patients. Isn't that incredible?!

I think of change as opportunity. So my theme today is just that—that in our profession, change is the rule; that the present rate of change is not particularly unusual; that even amid great change, it is important to remember that our values do not change.

Let me explain my reference to William Osler a few moments ago. Osler was a physician-educator who had a remarkable impact on medical education. He took the medical student from the lecture hall to the bedside to learn from the patient. His early career was spent at McGill University in Montreal; his mid-career was at the University of Pennsylvania; and then he was the first professor of medicine at Johns Hopkins University, where he introduced a new academic order. He then retired to Oxford. Many consider him to have been the "parent of modern medicine" and medical education. He profoundly changed the manner by which we learn and teach medicine.

Here are portions of the talk that Osler gave 106 years ago at the University of Pennsylvania, when he said farewell to the students and faculty before departing for his new position in Baltimore:

In the first place, in the physician or surgeon no quality takes rank with imperturbability, and I propose for a few minutes to direct your attention to this essential bodily virtue.... Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgement in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, rapidly loses the confidence of his patients.

In the second place, there is [the] mental equivalent to this bodily endowment, which is as important in our pilgrimage as imperturbability. Let me recall to your minds. ...Antoninus Pius, who, as he lay dying,...summed up the philosophy of life....[as]...aequanimitas.... A calm equanimity is the desirable attitude. How difficult to attain, yet how necessary in success as in failure!

Osler wrought enormous change in how we teach disease pathogenesis, how we learn to take a history and how to examine a patient. Yet he articulated many of the attributes that we consider that the ideal physician should possess even today: imperturbability, equanimity, compassion, dignity, the love of learning.

I selected change to discuss with you today, because of the extraordinary change that everyone says is occurring all around us and within our profession. Everyone seems to be worrying about change these days.

Today, we observe and celebrate great change for each of you as we mark your passage to student physician. You will probably feel uncomfortable for a while when someone calls you "Doctor." I have to tell you; the title will continue to startle you until you get accustomed to it. There will even come a time when you will stop telling people that Doctor is not your first name.

The alphabet soup of change

Consider the concept of managed care, the health care market place, capitation, the very concept of "health care workers" (I really don't like that term). Then there is PHO, MSO, PPO, HMO, IPA and the alphabet soup.

And there are all those new technologies we must understand and that are so expensive—like gene insertion, genetic immunization, magnetic resonance and positron emission, post translational regulation, cell trafficking, sense and anti-sense! Whatever happened to the simpler times? The "good old days"?

Like whatever happened to Housecalls? You remember hearing about those, don't you? That's the time when there was epidemic diphtheria, epidemic scarlet fever, measles and so on. Maybe the "good old days" were not so great.

Whatever happened to the Resident's Ward? Where the students and residents really did make all the decisions and manage the patients. That was the time of every-night call. You could not be married because you needed to live in the hospital (truly as a "resident"). And it was unusual to have women entering the medical profession. Aren't we glad things have changed?!

Was cheaper medicine really better?

The business people sometimes think back to the "good old days" of cheaper medicine when they didn't have to think about MRI's, transplants and other new expensive technological procedures. But would they really want to go back to the days when imaging the head and heart was potentially a lethal procedure? The days when children with leukemia died in weeks, or at best in months, instead of enjoying today's 80 to 90 percent cure rate and so on? I think not.

Where were you on October 26, 1977? Do you recall? Does the faculty recall? You lived through one of the most extraordinary changes in the history of medicine—the last case of naturally acquired smallpox. Smallpox eradication. How about that for change!

Perhaps, then, change is not only anxiety provoking, but often good! In Austria, early in the 19th century, Josef Skoda, Karl von Rokitansky and Ferdinand von Hebra recognized that with careful examination of the patient, pathologic findings could be deduced. What extraordinary change they and their contemporaries brought to the practice of medicine!

For example, this was the situation a young Hungarian medical graduate, Ignaz Semmelweis, faced when he arrived in Vienna from Budapest. At the time, childbed fever was epidemic in Europe and killing up to 20% of women who delivered their babies in lying-in hospitals.

Without understanding the germ theory (which was described 40 years later), he taught us about hands as vectors (Your mothers were right about hand washing, you know!) Again, Great Change. That was the beginning of the end of epidemic childbed fever.

Over the next few years you will learn about poliomyelitis; about Abercrombie, Jacob von Heine, Karl Oskar Medin, Karl Landsteiner, Sister Elizabeth Kenny, John Enders, Jonas Salk and Albert Sabin. Do you realize that a disease that had been rare and sporadic until 150 years ago suddenly became epidemic? Its physical examination was described by Heine; and it was correlated to specific pathologic findings by Abercrombie (this was that same era as Skoda, Rokitanski and Hebra). The unusual epidemiology of what we now know is a common infection that caused paralysis in only a few was accurately described by Medin (during that period of time when the very concept of a communicable disease was revolutionary). Then came the great intellectual leap that occurred with the development of an animal model of polio—for which Landsteiner received the first Nobel award (1902). Then followed the cultivation of the virus in the laboratory by Enders (1948) and ultimately the development of effective vaccines (1954 to 1960). Think of the profound changes each of these events caused.

Speaking of change, where are the contagious-disease hospitals of 50 years ago? For that matter, why did we have contagious-disease hospitals in the first place? It was primarily because of polio. Indeed, your parents (or in some cases, grandparents) have witnessed the eradication of paralytic poliomyelitis from our hemisphere. But remember, it was only about 40 years ago when there were more than 21,000 new cases of paralytic polio in the U.S. alone. This is an extraordinary story; it is the story of the evolution of modern medicine! These were profound changes that occurred in a relatively short time span.

Of course, the rate of technological change has accelerated, but the change in our understanding of disease has not undergone such profound change as it did during the past 150 years. For example, the history of our understanding of HIV and AIDS has great parallels with polio, but the timetable has been much faster because of our prior experience.

Thus, my thesis is that there is great potential value in change, and neither the speed nor the long-term impact of what we are experiencing now are particularly unusual. Change is opportunity!

What an exciting time to be entering the medical profession. Our society has finally figured out so many things: how to prevent disease, how to educate, how to care for the under-served, how to attack social problems—with the goal being to reduce the costs of medical care and greatly enhance the quality of life.

Embracing societal changes, too

Let's just consider for a moment the obvious. As we move to a "capitated medical environment" (that is, where we as physicians assume the financial risk for the health of our patients), the delivery of health care will necessarily cause major societal changes. For example, to reduce our infant morbidity and mortality logically means that we need to reduce the frequency with which infants are born prematurely. That means preventing children from having children. That also means providing prenatal care for the expectant mother, which also increases the likelihood of a normal infant (particularly among those at greatest risk for pre-term delivery). This is so logical as to be absurd but, until recently, our society has been unwilling to permit sex education or to pay for prenatal care, especially for those at the greatest risk for delivering a pre-term infant. Society has preferred to provide care to the pre-term infant. What a "bass ackwards" system we have had to finance health care! Can you imagine insuring the car engine without putting oil in it or without requiring that the oil be changed? In a capitated system, our success will depend on preventing the pregnancy, or when pregnancy is established, assuring the greatest probability of delivering a healthy infant into a nurturing home. What an exciting concept!

Not quite ten years ago, I was asked to consider the potential impact of the then newly licensed Hib (bacterial meningitis) vaccine if it were to be distributed to all of the young infants in a large metropolitan area. We estimated that, for that community, at a cost of $300,000 to $400,000 per year, invasive infection in young infants due to Hemophilus influenzae type B could be reduced by 90%, which would ultimately result in a cost savings to society in excess of $12 million per year. In retrospect, we underestimated the effectiveness of the vaccine. Indeed, most of you in your pediatric rotations through Children's Memorial Hospital may never see a case of invasive Hemophilus influenzae type B disease, which, until only a few years ago, would have been expected to affect one out of 250 children under five years of age. Indeed, just this past month, the CDC published an initiative to eliminate invasive H. influenzae disease in North America. My father witnessed the reduction of the mortality of meningitis from 100% to 2% with antibiotics; I have seen the remarkable impact of vaccine on reducing morbidity; you will see eradication. Now that is change!

I believe that one of the great strengths in the health care system of the future is that there will now be powerful financial motivations for society to prevent disease. Your success will be dependent upon your finding ways to deliver vaccine more effectively; finding ways of preventing children from having children; limiting access to guns; preventing substance abuse.

Change is occurring all around us: it is the very essence of what medicine is about. However, to manage change effectively, we must shape the change. It is fun to look back at change in the past (like with smallpox or childbed fever) and then to trace the evolution of the present. Isn't it too bad that it hasn't proven possible to project the lines of advance into the future?

To truly affect change, we must know where we want to go. We need to know why we are going there. And, we need to know how best to get there. In short, we need a roadmap.

I believe that the road map to manage change requires three things: a keen sense of mission; clearly focused values; and continually trying to develop those attributes that make you more effective as a physician. I believe these constitute the roadmap.

First, you need a keen sense of mission: Do you remember when and why you decided to become a physician? For me, it occurred when I was accompanying my father on housecalls; the motivation was simple and naive. I would be willing to wager that that point is as clearly focused for all the faculty here as it is for you and me, and that your personal mission will not change very much over the coming years and decades.

Thus, the basic mission that brought you here today is common to all of us even if we are a little embarrassed as adults to admit to being so "sentimental."

Do you realize that this motive was written down some twenty five centuries ago? It is written on your program—on the inside of the back cover.You will shortly repeat this Declaration of Geneva, written in 1948 and amended in 1968 and 1983, as have all of your predecessors on this stage. Oh, some of us may have pledged a different version, and you won't have to pledge "by Apollo, the healer, by Aesculapius, by Health, and all the powers of healing" like I did, but all in all it's pretty much the same pledge. When you do this again, four years from now, you will perpetuate a tradition that goes back to ancient Greece, Persia and Egypt. By tradition you will be admitted to the Doctorate of Medicine by pledging to "consecrate your life to the service of humanity."

As physicians, we have a clear mission, and it has been well stated. Remember it during these periods of great change.

Second, have clearly focused values: As you look at the "Hippocratic creed," you will see a number of important words: respect, learning, conscience and dignity, confidentiality, honor, duty, knowledge. To these I would add the summary word—integrity. As physicians we have focused and clear values; they, too, have been well stated. Remember them especially during periods of great change.

Third, continually hone those attributes that enhance your skills as a physician. In addition to your mission and values, I suggest that you need to constantly attempt to enhance the attributes that you admire in others, so that you become more effective at achieving your mission and maintaining your values. To do this you will need to learn to be able to use all your faculties.

Listen. My father's best friend became deaf, but he listened better than any physician I can recall. Watch and observe your patients—learn from them. Smell, touch and feel. (Then, of course, wash your hands.) Practice imperturbability and learn equanimity.

In 1895 Osler said: "Tis no idle challenge which we physicians throw out to the world when we claim that our mission is of the highest and of the noblest kind, not alone in curing disease, but in educating the people in the laws of health and in preventing the spread of plagues and pestilences."

As physicians, you will have the opportunity and, therefore, the responsibility to direct change. Act quickly, assume risk, be responsive, plan strategically and deal effectively with those who are paralyzed by the fear of change.

While you utilize the science of medicine, also practice the art. When you have the opportunity to help someone, and they attack you, help them anyway. When a patient fails to meet your expectations, and you feel the frustration of impatience, help them again. When secrets are confided to you, and they scream to be told, keep the confidence. When your patient is frightened and you are too, be imperturbable. But hold their hand if it will help.

As change occurs, remember the roadmap, remember your mission, remember your values; they will help you.

There is great value in change, but it is important to recognize that your mission and values do not change.

Welcome to each of you from your faculty, and Godspeed on your journey.

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