BEGINNING DOCTORS

...It is not entirely by chance that over the years many pediatricians have assumed major roles in the federal health apparatus...

...I would want to know that you have stayed true to your vocation...

...But please note, I do not expect you to know it all, for that is impossible for any of us...

...For our vocations include some level of responsibility for the poor as well as for our more-affluent citizens...

...But given the distance in our ages, I have wondered what ! can say to you that would not sound like banal dich6s, what you could possibly hear and use as you take this first, symbolic step toward your goals in medicine...

...For if the first time is not the best time, it is surely the best-remembered time...

...And notice that the licensure or permission comes now, before you take any examinations to practice medicine...

...But the life cycle of development and maturity should be as much a part of the diagnostic analysis of all physicians as it is for pediatricians...

...Notice that if you do decide to send me to someone for consultation, I will continue, if you are my primary-care physician, to expect you to retain control of my medical care, to coordinate what any number of specialists may recommend...

...Commonweal | 7 October 23, 1998...

...Notice that the metaphor of vocation is not completely poetic...

...I would want you to listen to me, to hear my concerns--real or imagined--and to acknowledge and understand them...

...By this societal permission or licensure, you are expected, indeed required, to adhere to the tenets of the ancient Hippocratic Oath, to remain true to your vocation...

...H ust a word now about what I have done in the course of my career...

...Finally, I want to give you a very definite prescription...

...Only your status as a medical student permits you to dissect a cadaver, otherwise you could be put in jail...

...But the task of learning how to relate to your patients, how to develop caring for your patients--both those you enjoy and those you don't much like--will be an equally if not more difficult task to master...

...As an Irishman, I enjoy a good fight, especially when it is a fight over something I value as important and just...

...the content of a physician's relationship with a patient is no more discoverable by law than a priest's knowledge of a penitent...

...First, I realize that I am more than a trifle envious, for I know things you can only imagine...

...And as I have meditated upon you, me, and my father, I have wondered what, if anything, links us...

...You will find that in these four years you will establish friendships for a lifetime...

...about 25 or 30 percent of us did not make it...

...This decision can be among the most difficult for any physician...

...I would expect you to have learned how to comfort me, to relieve my terror...

...I know that no more than 8 to 10 percent of you will select pediatrics as a field of medicine, but pediatricians have some skills and attitudes that are applicable to all areas of medicine...

...medical education has advanced and, all things being equal, you can expect to receive your degree at the end of four years...

...to know when to ask for help or consultation from colleagues...

...But I also know the pain of having made an e r r o r in clinical judgment, either because I was too stupid or inexperienced or distracted or whatever...

...I recognize that I have the moral luxury, and I do mean luxury, of engaging in a struggle that is much more important than I am...

...I thanked her politely and thought, "Dearie, you have missed the whole symbol...

...All of this you have yet to experience...

...Orthopedic surgeons should know where patients in a long-leg cast live before discharging them...

...For example, you will be bound by a "seal of the confessional...

...one of the three of you will not complete the course...

...I have never been certain that all physicians understand that the developmental process does not end with the right to vote...

...Of all the attributes a physician must develop, an awareness of one's limitations and a recognition of one's responsibilities to each patient are preeminent...

...And he was quite correct...

...Before them, C. Everett Koop, a pediatric surgeon, became one of our most effective public-health spokesmen...

...In return for your performance of these duties and obligations, the larger society will also award you high social status, autonomy, and financial reward...

...And I wondered what would I want from you, when I come to see you with my chest pain or my depression or my Parkinsonism...

...And, of course, neither Medicare nor Medicaid had been invented to pay for care of the elderly and the poor...

...When I graduated from medical school almost thirty-five years ago at the University of Pennsylvania, the science of immunology was in its infancy...

...I know the laughter that comes with the absurd things that can happen during your classes, in clinics, with patients, with colleagues...

...Heagarty, I enjoyed your lecture, but I did notice that when you referred to a child or a pediatrician you used the pronoun 'he.' I want you to know that times are changing...

...But I am certain that the poor, lacking proper medical care, will be with us even then...

...CAT scans, never mind MRIs, intensive care units, and mercifully the HIV virus, were not part of my beginning medical agenda...

...Indeed, I would expect you to fight for me, at whatever your personal cost, to ensure that I receive the care I need...

...But not just pediatricians, all physicians have some responsibility to speak out and to work to solve the public-health problems of the nation...

...Perhaps because they see themselves in a real sense as in loco parentis for children, at some point most pediatricians become frustrated with solving problems for each individual child and decide they should try to solve the problem for all children...

...ow most of you will not spend your lives in the vineyard of the urban ghetto, in city hospitals battling for the resources to provide basic care for the poor...

...I sometimes find myself wondering which of the children for whom we care in Harlem will become the next Arthur Ashe, Andr6 Watts, or Alice Walker...

...You will be expected not to take advantage of those for whom you are responsible, and in some sense you will be expected to place your patients' welfare above your own self-interest In return for these duties, the larger society will give you a license to do things, to perform acts that others may not...

...Or my delight and pleasure with the first valentine I received from a little tenyear-old girl...

...I remember he also said, "Medicine is a stern mistress...

...I have just enough wisdom and resignation to come to accept the fact that many, if not most, of you right now know more about T cells and B cells and complement than I shall ever know...

...For, with age, I have come to understand the necessity of the virtue of humility...

...One of the considerable charms of providing medical care for children lies in the privilege of watching the wondrous process of human growth and development, a process that brings with it the optimism of potential, of possibility...

...Third, sometime in the course of their professional careers, most pediatricians find themselves wandering into the nevernever land of public health, that is, policy and politics...

...BEGINNING DOCTORS A word from the wise Margaret C. Heagarty II ~ am greatly honored to be asked to say a few words on what, with time, you will discover is one of the more memorable occasions of your lives...

...When I finished a young woman came up to me and said, "Dr...

...But if you become my physician, I expect you to be concerned as much about where and how I live as about which medication or surgery I need...

...You begin medical studies at a time when the entire healthcare system is in flux, when new challenges ranging from the aging of the nation's population to the HIV virus to managed care will bedevil you over the next thirty-five years...

...Anything less would be a betrayal of the vows of your vocation...

...I have come to understand that if I cannot accept and forgive my own humanity, I will never be able to forgive and accept the human frailty of my patients...

...The occasion marked the initiation of a new class of beginning medical students, their taking the Hippocratic Oath, and their investiture with the physician's traditional "white coat...

...there is a very delicate balance between asking for help as against rejecting a patient out of insecurity or an unwillingness to make a difficult clinical decision...

...He did have a doctor's bag and he did make house calls...

...When I began at the University of Pennsylvania there were only about ten of us with two X chromosomes in a class of 150...

...For example, I remember, with considerable clarity, an opening lecture by a dean more than forty years ago when I began medical school...

...And since I had just graduated from a Catholic women's college run by the nuns, I thought this was pretty risqu6 stuff...

...And if you do this, you will find, as I have, the satisfaction of remaining true to what you are setting out to do today...

...Today you take your first vows as a member of this profession...

...I believe you, as I and my father, have decided to become physicians out of some sort of idealistic need or calling to serve our fellow human beings...

...It begins, in fact, the minute you enter the anatomy lab...

...My father was a physician, a country doctor who spent his life caring for the coal miners of West Virginia...

...And that fundamental core can be found in an old-fashioned word, "vocation...

...First, the notion of development, of change, is ingrained in the genetic code of all pediatricians...

...Young physicians sometimes see these matters as issues to be delegated to social workers or bureaucrats...

...And those ten of us girls were clearly one or two standard deviations off the then social norms for women...

...So, a little respect for us old girls, if you please...

...Or the intellectual satisfaction of making the diagnosis of pyloric stenosis--an obstruction of the duodenum found in inMargaret C. Heagarty, M.D., director of pediatrics at Harlem Hospital Center in New York City, is professor of pediatrics at the College of Physicians and Surgeons of Columbia University...

...For I am of the age when it is likely that very soon I will need to rely upon you or someone very like you for medical care...

...At sixteen, I learned to drive on a World War II jeep, accompanying him around the hills and hollers of West Virginia as he made those calls...

...But as it comes your way, you should savor it...

...But while medicine demands a great deal of us, I also know the joy of it: the joy of mastering the intellectual content of the field, the bonds with colleagues, fellow students, as we struggled together to get through anatomy or cellular biology or surgery...

...fants--that can be cured rather simply...

...Fortunately, those days are long over...

...I would want you to understand that as a patient, I am, by definition, at the minimum anxious, if not scared to death...

...I know how it feels to have a little old lady take my hand and say, "Oh doctor, I always feel better after I've seen you...

...Commonweal | 6 October 23, 1998 Finally, I would want to be assured that you would do what is in my best interest, even if the managed-care plan places bureaucratic obstacles in your path...

...But I would want much more...

...This article is based on an address she gave at this year's White Coat Ceremony at the Mount Sinai School of Medicine...

...For much of what you will do as physicians will involve comfort, support, caritas...

...Of course, I would assume that you are medically competent and have managed to keep up to date, more or less, with advances in science and therapeutics...

...More importantly, I do expect you to know what you don't know and to be wise enough to recognize your own limitations...

...Second, perhaps because they cannot avoid it, pediatricians pay a great deal of attention to their patient's social setting and situation...

...My basic message to you is that a vocation, by definition, is more, much more than simply an income-producing occupation...

...After all, the social situation, in the form of parents or family, is integral to the care of the dependent, vulnerable child...

...Internists should know whether widow ladies or spinsters like myself live alone before sending us home after hospitalization, especially now since hospitalization is only for acute care and insurance provides little time for convalescence...

...I can still feel my anxiety, and--terror being the rule of the day then--this silly man actually said to us, "Look to the right of you, look to the left of you...

...But this approach is equally important to all physicians...

...I have spent my time trying to remain true to my vocation as a pediatrician in the setting of health care for disadvantaged children...

...11 of this may sound like obvious generalizations, but as I have thought about you, I suddenly realized that I have a personal and rather pragmatic stake in your future careers...

...there are considerable similarities between medicine and the other classic professions or vocations of religion, law, and education...

...Before Doctor David Satcher became surgeon general, two pediatricians, Antonio Novello and Jocelyn Elders, held that job...

...When he graduated from the University of Georgia about 1928, he did not have vitamins, steroids, hormones, or antibiotics in his doctor's bag...

...How in the world would the patients manage if home is a fifthfloor walk-up...

...The entire population of this nation needs young men and women like yourselves to care for them--the rich and the middle class as well as the poor...

...But I believe that while the scientific knowledge base has broadened and changed, and the structure and the organization of the profession have surely changed--indeed dramatically in the past few years--the basic core of who we are and what we do has not changed and must not, ever...

...With this choice you, as I did, are about to embark upon a tong and arduous novitiate during which you will not only be taught basic scientific knowledge and skills but also the social and ethical norms of the medical profession...

...And with some difficulty, I have had to learn to live with those mistakes, learn to forgive myself my own human failings...

...While the incomes of physicians are likely to moderate in the future as compared to the immediate past, you will become, as I am, valued and comfortable members of the nation's upper or middle classes...

...that a thirty-year-old is very different from a fortyyear-old or a sixty-year-old...

...So when the time comes, I want you to remember that I told you to look around and find someone who looks like me, who is doing what I do...

...And this skill is as important as any a physician possesses, certainly as important and sometimes more important than any high-tech diagnostic or therapeutic maneuver available to you...

...I want you to remember that a red-faced, whitehaired Irish lady doctor from Harlem gave you this command one fall day in 1998...

...In ten years or more, you will have become established in your careers and, as I say, most of you will be situated in comfortable settings, providing invaluable care to your patients...

...And I cannot resist commenting upon another obvious difference...

...And you are to go to them and say that a trifle eccentric lady doctor sent you to help them for at least one half-day a week, pro bono...

...If I weren't standing here lecturing to you, you wouldn't be Commonweal | 5 October23, 1998 in that chair listening...

...I want someone who takes the ultimate responsibility and makes the ultimate decisions about what I may or may not need...

...But he was right about that, for medicine is a stern mistress, requiring the best in us to meet the challenges of providing medical care...

...And let me assure you that I have spent all this time among the urban poor, not because I had to--not out of any missionary zeal--but because of who l am, what I enjoy doing, and what, over time, I have become reasonably competent at doing...

...And that's as it should be...

...In the more than seventy-five years since my father began his journey in the profession, has medicine so changed that we have little to share with one another...

...But you will encounter other types of fights and struggles for patients in other settings that are equally just and important, and your calling will give you the same "moral luxury...

...For the next year or so, the mysteries of anatomy, physiology, and the like will seem formidable to you...

...I do not want my medical care to be provided by a committee...

...To digress, I remember in the early seventies lecturing to first-year medical students at Cornell...