Medicine’s Delicate Balance of Compassion and Science

Dr. Joshua Hauser’s Inspiring White Coat Ceremony Keynote on Medicine’s Delicate Balance of Compassion and Science.

Thank you for having me. To Cheryl McPherspon who invited me and to many others here who helped with arranging things, thank you for welcoming my family and me so warmly. It is a treat for me to have my wife, Juliet and two children, Jonathan and Emily, here listening to me today. Whether it is a treat for them….we’ll see.

To the medical students assembled today, congratulations on being here. You have chosen a profession that is endlessly fascinating, occasionally frustrating and always fulfilling.

To the families of the medical students, you have much to be proud of and you have much to offer your children in the coming months and years and decades: the experience and wisdom of parenthood and the stability of having known each other for decades.

To those of you who are the spouses and boyfriends and girlfriends and friends of any sort to the medical students, some here, many I imagine not, you also have important things to offer: you will be companions during the latest of nights and earliest of mornings and during the many joyous and sad times. Your support will mean more than you can know.

This is not an abstraction: I say these things as a son and a husband more grateful than I can ever say to my own wife and parents and now my own children.

I would be remiss in not noticing that this is a little bit of a challenging time to give a speech of any sort: on Monday, at a Martin Luther King Day celebration in Chicago, I heard excerpts of some of Dr. King’s speeches; the next day, I and I’m sure many others in this room heard the inspiring inaugural address of President Barack Obama. President Obama’s address was followed by a benediction from Reverend Joseph Lowery who marched with Martin Luther King and whose quiet passion moved many of us to tears. Whether you are a Democrat or Republican, from the United States or Grenada or another country, this is a time of great challenge, change and hope in our world.

I mention this not to make this talk into a political address, but to reveal a little of my own anxiety at giving it at this time and to plant in all of our minds the importance of the social and political context in which we find ourselves. More on that later.

Finally, as someone who never went through a white coat ceremony myself, I must confess to feeling a little like a pretender here today.

I am, however, someone who has worn a lot of white coats and still does. Each of these has certain associations for me – the one I wore as a medical student whose pockets sagged under the weight of the books and instruments and was always too clean and a little too white; the one I wore as an intern and resident whose pockets bulged with endless to do lists (not always completed) and which never did seem to get very clean or white enough; the longer one I wear now as a palliative care physician with more than a few stains from the Chicago slush kicked up on the four block walk between my office and the hospital.

I still have some of those early white coats in my closet. During my time in medical school, we got one official one at the start of first year (not in a ceremony, but in a bag) and then it was a little bit of a friendly competition between us to see how many we could get from the different hospitals we rotated through. We were supposed to return these at the end of each rotation and we rarely did: given our tuition costs, I calculated that we were actually paying 10s of thousands of dollars for each of them and that lessened my guilt over taking them.

One of these coats from my days as a medical student recently had a second life on the shoulders of my son, Jonathan, who wore it for a play. He wore it not as a doctor but as a mad scientist – a use that might have surprised the original owners of the coat at Mass. General Hospital but made the current owner, me, very proud.

As I was preparing this address, I did a few things.

First, I tried to think back to my medical school admissions essay: that must have had something about my hopes as a future physician; that could help put me in the shoes of those of you here today. Unfortunately, when your filing system consists mostly horizontal piles and cardboard boxes, as mine does (my wife is smiling broadly right now), finding such a thing is a bit of a challenge. No worries, I thought, there must be an electronic copy….there no doubt is, locked on something called a three and half inch floppy disk that we used to insert into the original Macintosh computers that came out just as some of you were entering not your pre-med years, but your pre-school years. And some of you had not entered any years at all. For those of you who are curious about these computers or like me, nostalgic about them, they can often be found on eBay, reconfigured as fish tanks or planters.

But here’s what I imagine I wrote about and here’s what I imagine many of you wrote about: wanting to be caring and compassionate and wanting to combine a love of science and a love of people. Those are noble values for all of us and I mention them not to diminish them, but to celebrate them.

I want to use my time here today to project ahead with you past your years in medical school and in residency and think together about the values and the habits that I hope will sustain you as they have me in this profession. This is important because while it might seem like a long seven or eight of nine years of medical school and residency, it is actually a relatively small percentage of the 30 or 40 or 50 or more that you will spend as a physician.

The second thing I did as I started preparing this address was look at how others have thought about the white coat ceremony. This is a habit that I have developed over the years (and one that you will soon develop if you have not already): whenever I have a new project or a new talk or a new paper to write: Look in the literature: Go to Medline, go to Google, go to your own piles of papers and see what others have had to say: it will help frame your own thoughts, it will give you perspective and, of course, it can be a great procrastination technique.

This second activity had a curious parallel to my first activity of trying to find my med school essay. In the same way that I could not find that essay, I could not find much that resonated with me in some of the published literature about the white coat ceremony.

Here’s what one commentator said. You will see in a moment why I do not identify him.

“The short white coat can be a highly useful tool allowing patients to identify practitioners in a liminal state. However, by officially sanctioning the white coat as a sign of the psychological contract of professionalism and empathy, the medical establishment may be responding to abrogations of its own authority and is teaching students that they are respected for their sartorial behavior separate from their behavior as individuals.

Conclusion: The White Coat Ceremony fosters a sense of entitlement whereby authority based on title and uniform, and authority based on trust, are poorly distinguished.”

“Authority?” “Liminal state” “Entitlement” “Abrogation” “Sartorial behavior”

It all sounded a little abstract to me: more like an undergraduate philosophy class than something relevant to medical students and physicians. And that part about “sartorial behavior” sounded like it had something to do with a tuxedo or a ball-gown. Perhaps something from an inaugural ball.

So I turned to another source, Robert Veatch, whom I know comes to St. George’s to teach ethics. Dr. Veatch is as impressive a thinker and writer as there is in bioethics and he is not someone who shies away from controversy. He wrote one of the first textbooks of medical ethics I ever read.

Here’s what Dr. Veatch wrote:

“The white coat ceremony may be an impressive ritual for the beginning of medical school. It may add an ominous drama to the first days of a student’s new career. In the process, however, the ceremony raises serious ethical questions. It is doubtful that any code recitation has any legitimate meaning when that code is imposed on a group of students too new to their profession to understand its meaning or even whether its content is controversial. It is doubtful that any code recitation is legitimate if the vast majority of students, when they are better informed and have had more time to think, would really prefer some other commitments. It is doubtful that a “bonding process” is tolerable if its real function is symbolically to remove students from the culture from which they have come.”

Well, no more “liminal states” or “abrogation,” but Dr. Veatch’s words gave me certain pause and I want to tell you why.

First, I hope that this day isn’t too ominous for most of you. I imagine it might be daunting, but I hope it’s not ominous.

Second, I commend Cheryl and others here for having a ceremony that “raises serious ethical questions,” especially when these come from an esteemed visiting professor such as Dr. Veatch: raising questions is one of the ways we all learn and one of the ways we all do better, whether as ethicists or physicians or both. And besides, I bet Dr. Veatch was being a little hyperbolic in his prose.

Third, and most importantly from my perspective, I also hope that this white coat is not representative of an attempt by St. George’s or medicine as a profession to “symbolically” “remove” you from your own culture. The best experiences of medicine for each of you will be when you are able to combine aspects of the “culture of medicine”, however defined, with aspects of your own cultural backgrounds. As a physician with two feet in the culture of medicine, I also have those same two feet planted in a cultural background that pre-dates my becoming a physician. You may want to ask my wife or friends, but I don’t think medicine has removed me from the culture from which I have come.

The third and last thing I did after turning (unsuccessfully) to my medical school essay and some of the literature on the white coat ceremony was ask some people closer to this experience than I am right now. I asked a group of third year students about what the speaker at their white coat ceremony spoke about two years earlier. And what they would recommend for me. There was some hesitation since they couldn’t quite remember at first (not a good sign I thought) and then one of them said: “Progeria.” And the others nodded and smiled. A few even rolled their eyes. Ah…premature aging, I thought, that actually did have a devious kind of relevance…

“So I should talk about a disease?” I asked.

This time there was no hesitation: “No.”

For those of you who came hoping to hear about a disease, whether progeria or any other illness, you have your Northwestern colleagues to thank (or blame).

So, no diseases, relatively few bioethical concepts, and a respectful disagreement with Dr. Veatch about the white coat ceremony removing you from the cultures from which you have come.

What I do want to talk about is my experience of the symbolism of this white coat. As I do this, my larger goal is to help all of you project 10 and 20 and even more years into the future to see what will sustain you in this profession.

I will take as a foundational element of medicine and becoming a physician that caring and compassion and science are all a part of why we are here today.

You will find that the subjects of your caring and compassion will change: sometimes patients, sometimes patient’s families, sometimes colleagues and friends and your own families.

You will also find that the underside of caring and compassion will sometimes be just below the surface: you will have moments of anger and frustration and fatigue at all of those groups of people. That’s OK, as long as you have a technique to deal with these moments. I will not suggest any today, but I ask you to recognize that these moments will happen; and when they do, seek the wisdom and the shoulders of friends and mentors. Remember what I said in the beginning about families and spouses and friends? These times and feelings are expected and will only fester if you do not find ways to share them.

The subjects of your science will change too: whether by organ system or by year of schooling. Make science a refuge when caring and compassion seem too hard and too taxing. But don’t let it replace caring and compassion. Make compassion and caring a haven when the science gets to be too overwhelming and the nerves in the brachial plexus start to blur and you eyelids start to fall. But don’t let compassion and caring replace the science.

When I was in medical school and got sick of pathophysiology or anatomy, I tried to read something in ethics or politics or something that seemed more about the “caring” side of things. Or I just hung out with friends – that’s a form of caring (and being cared for). When I was tired of hanging out or when the ethics reminded me too much of a strange high-school philosophy teacher I once had, I opened that pathophys book again.

Let me use another example to define what I mean:

I am a palliative care physician and an internist and my clinical work focuses on quality of life, symptom control and support for patients with serious illnesses and their families. Many of the patients whom I care for are dying and they and their families are facing hard choices and harder days. One of the things that I love about palliative care is that there are often very specific medical things to do and think about – what is causing this patient’s shortness of breath? What opioids am I going to use to treat this type of pain? And there are also opportunities to help patients and families deal with something that I sometimes call “the big picture.” The big picture is a little bit of a colloquialism but here are examples of it:

What does this illness mean?
What am I going to do now that my husband is dying?
How am I going to decide whether to continue the ventilator?

These types of questions require a lot of caring and compassion from each of us as physicians, nurses and every type of health care professional. Sometimes, though, it is equally important to focus on the biomedical and more concrete question of the physical pain that a patient is experiencing. Indeed, as others have observed and I have witnessed, all the talk of meaning and faith and togetherness in the world doesn’t mean much if you are in intense physical pain.

In palliative care, symptom management is the science; helping patients and families cope with illness and dying is the caring and compassion part. For every patient and family and for every physician in palliative care and in any field, the best kind of care and caring will combine both of these instincts: the compassionate one and the scientific one. An exclusive focus on either will help neither patient not family nor physician.

Now, what do I want to add to this foundation of caring and compassion and science? What have been more recent values and habits that I have embraced? Here are five:

Curiosity
A Tolerance of uncertainty Humor
Passion
And Service

I’ll begin with curiosity

Practicing medicine is fundamentally about entering into other people’s lives. Sometimes it is through talking such as in a relationship with a psychiatrist or an internist; sometimes it is literally entering into someone’s body in the case of a surgeon. Each of these requires skills that can take many years to master: what to ask and where to cut. Said in that way, it couldn’t sound more simple, but it’s not: how we ask, how we listen, how we react is everything and means the difference between connecting with a patient and perhaps a diagnostic clue and missing a diagnosis or a moment of connecting, just as for the surgeon, how and where and at what angle he or she cuts is the difference between a successful operation and a complication. All physicians, whether internist or surgeon, gynecologist or pediatrician, psychiatrist or emergency medicine physician, require motivation in the form of curiosity: a curiosity that motivates you to want to know about someone’s life to dig deeper into their situation or to perfect an operation.

The stories you will hear will amaze you, will surprise you, will sadden you and will inspire you. You will get to hear things about people that they have told no one else: things they are proud of, things they are ashamed of, things they wish they could change.

And you will be entrusted with a lot of secrets. Please treat these with the respect and dignity they deserve.

Why be curious? There are at least two reasons:

One, it can help you diagnose illness. This is most obviously true in the case of psychiatric illnesses, but it is also true for many medical illnesses. It still amazes me how often I find out things about patients’ relationships or spirituality that are mediating the pain that they are feeling. That helps me to help them with their pain. So, it can help patients to be curious.

Two, it can help you. The stories patients tell us teach us things about them, make us reflect about ourselves, make us laugh and make us wonder and keep us engaged in this work. And that helps sustain us. The 84 year old patient with COPD and pneumonia becomes much more engaging to you (and you to him) when you find out that he spent his early 20s on a Navy ship in the Pacific before coming back to the States to open up a barber shop. And what’s amazing is that this information does not require lots of digging through medical records, does not require many tests. It just requires the instinct of curiosity and the patience to listen.

Let me give you a more recent example from my own life as a physician: I recently saw a man in his 30s with Crohn’s disease and terrible abdominal pain who also struggled with depression and addiction. He was a patient who was suffering and one who angered a number of his physicians, including the one speaking you to you today. He angered us because he was demanding, because we couldn’t seem to help him, and because he was never satisfied with our attempts to be compassionate. We were not proud of our anger, but we recognized it.

Each morning we would dread going in the room and we’d be pissed off when we came out. One morning on rounds, I decided to take another tack and asked him about the tattoo on his neck – it looked familiar to me but I wasn’t sure why. He reminded me that it was the symbol of a 1980s punk band, Black Flag, that I used to listen to. He was a fan of them; in fact, he was a musician himself. And so we spent a few minutes talking about punk music. And all of a sudden we had something to talk about other than his pain. Did it cure his pain? No, but it did make it easier to talk to him; it helped us connect and it even brought back memories for me.

So, be curious: ask patients what they do for work, what they do for fun, what that tattoo means, what symbol dangling from their neck is all about. It actually doesn’t take a huge amount of time and it will make you a happier physician.

Let me move on to my second value: A tolerance for uncertainty

Being sick means dealing with many kinds of uncertainty: over diagnosis, over prognosis and over the fundamental question “Why has this happened?” If you think it will be hard not knowing the diagnosis or what to do as a student or a physician caring for a patient, try to take the next step and imagine how a patient will feel in this same situation.

You will need to join your patients in this uncertainty. You will spend years here and decades beyond here trying to be certain about as much as possible – and that is a good thing. But as carefully and thoroughly as you try to figure out what can be known, what is certain, there will always be things you will be uncertain of. Be there with and for your patients in this feeling. The uncertainty of many illnesses will not change even as diagnostic procedures and treatments improve; it is only the topics of our uncertainty that will change.

Patients don’t necessarily want all uncertainty to be erased, but they do want someone to be present with them in that uncertainty. If you cannot tolerate uncertainty, if not knowing exactly what is going on unnerves you, you will not be able to truly be with your patients and your colleagues.

My third value or habit: Embrace humor

Palliative care is not supposed to be funny. Neither are many other medical specialties. They are supposed to be serious and somber. So why can I turn on a TV and find shows like Scrubs, Grey’s Anatomy, House and find myself laughing? Think for a moment: How does a network decide a show will continue? It is a very basic calculation: if there is a market, it will happen. And so, people want to laugh about illness (or at least laugh at doctors). And who watches those shows? Medical students, of course, but you are vastly outnumbered by patients and families. And if they thought that being humorous about medicine was taboo, they would stop watching and the shows would stop airing.

It is precisely because of the awe and awesome-ness of illness and of the situations that we bear witness to that humor is so necessary. If you are open to humor, if you use it wisely with patients and colleagues and peers, it will help you. It may help you connect with a patient, it may help you connect with a colleague, it may help you have a better day – and that is worth a lot.

What do I mean?

Several months ago, I was caring for a man who was dying from heart failure. I met him in the last days of his life on our palliative care unit after his family had decided to withdraw the ventilator that was sustaining him. On morning rounds with our palliative car team, we visited him and his family at the bedside. He was an African American man in his 80s and although he was unresponsive, he looked peaceful and dignified in that bed. He was breathing slowly and his face was relaxed. He was large and muscular with gray hair around his temples and he had the look of someone whose heart failure had come on relatively suddenly: he was not as thin and wasted as many patients with chronic heart failure are.

I asked his family what he had done for work. They told me that he was a preacher at a Church on the South Side of Chicago. He had done that for decades and had many devoted congregants who had seen him in the hospital. We talked about this and his son who was there talked about how he would be taking over for him and the large shoes he would have to fill.

And then I happened to glance at his TV. He was in one of the new rooms on our unit with a huge 42” plasma TV on the wall. Does anyone here have any ideas what is on mid-morning TV in the city of Chicago? There, with the sound off, above the bed of this very dignified preacher, was that day’s episode of the Jerry Springer Show with the title in bold red letters across the bottom of the screen: “Midget madness” and two dwarves in shorts prancing around a makeshift wrestling ring. The combination of this incredibly dignified preacher and this incredibly exploitative TV show still makes me smile as it did that day. As we left the room, we all laughed as a team. Not in a disrespectful way, but a happy way – it was a moment of levity and strangeness in the face of the tremendous sadness of his dying. And I know that it was partly that glance at that show on TV that makes me remember that preacher.

So, don’t be afraid to find humor in the care you give.

Being curious, tolerating uncertainty and embracing humor will all help you respect one of the fundamental currencies of medicine: the stories of the patients and families you care for. These stories are what patients give to you. Your listening is what you give back to them. But don’t just listen: listen with curiosity, with a tolerance for the uncertainty of the situation and with an eye and an ear to humor. As you progress, add these habits to the caring and compassion that brought you here.

Let me end with two other qualities which have helped sustain me and I hope will sustain you: passion and service.

Simply put, have a passion

It can be for discovery, for taking care of patients, for teaching, for something else; just make sure it is yours and make sure you feel strongly about it.

What do I mean make sure it yours?

When I was medical student and spent some time as a pre-medical advisor, I met a student who wanted my help with his medical school application. He wasn’t sure what to write his essay about. So I said to him, “write about something you feel passionate about.” I remember this moment to this day even though it 20 years ago. I was sitting across from him in the dining hall and he paused and looked at me and he said: “What would that be?” I smiled and told him that if I were to tell him what it was, it would no longer be his.

Let me share something on this from my own life: I feel passionate about teaching. Being a better teacher to students and colleagues, to patients and families, drives me each day. I am not the only one with this passion and all of us will have a setting to realize this passion if we choose to. One of the gifts of being a physician is that you get to teach others all the time. Oh that’s just something for physicians who stay in academic medicine you might say. That is not the case: This is true for every physician almost every day of their lives. You will teach patients and families and peers and you will teach your professors. It is the rare professor who does not learn many things from the students whom he or she teaches. If teaching is your passion, indulge it fully and find ways to do it well.

Others of you may develop a passion for a type of research or for a type of procedure or for a population of patients. Some of you may already have. Nurture and sustain these passions and find opportunities to express them.

Finally, A commitment to service

I will end with service since it is very much on my mind during the US presidential transition. It verges on a cliché, but it is something that many of us feel deeply: Medicine is fundamentally the opportunity to serve patients.

But I want to use this opportunity of this white coat ceremony ask you to try to do something beyond the act of taking care of patients, teaching each other and even doing research that is an act of service. This needn’t be big, this needn’t be time-consuming, but I urge you to make it something.

Let me give you two examples from my own life to illustrate what I mean.

When I was a primary care physician, every election season I would ask my patients if they were planning to vote and urge them to do so if they were not. I would say “I don’t care who you vote for, but I care that you vote.” We would both smile knowing that was not completely true: I did care who they voted for, but it was also none of my business. If I got one person to vote who wasn’t planning to, I liked to think I did my job in this domain. Involvement in the political process is a form of service. It can take many forms. Asking your patients to vote is easy, free and doesn’t take much time.

Tere are of course, myriad other ways that you can devote time or money to the political process in every town and state and country in the world. Consider finding one of these that fits with your values.

There is also very direct service you can provide as a physician. This can be in underserved communities, this can involve seeing patients, helping raise money, serving food or being a companion. For more than a decade, I have worked one or two evenings a month at homeless clinics in Boston and Chicago. I see patients there whose strength inspires me; whose suffering moves me and sometimes, whose behavior angers me. Luckily, this last category is a small one. Mostly, this activity allows me to help patients with very basic things: a cough, high blood pressure, a pain in their back or an ache in their neck. Or the need to be heard: To have someone listen to their story, ask a question or two and, once in a while, give advice or validation.

Each of us has been given an incredible and rare gift to be a physician. And for me this is one form of giving back to others.

This is just one example of service: there are many others in many settings with many different types of people and patients. I told my patients that I didn’t care who they voted for when I asked them to vote and I confessed to you that I wasn’t being completely honest with them. But I will be completely straight with you when I urge you to involve yourself in some kind of community service, large or small, medical or non-medical, directly with patients or not.

You may not feel you have time at every stage of your career and you may not, but you always have time to develop the habit in yourselves to ask: “What ways, beyond my immediate school tasks, beyond my immediate job, am I helping to serve others?” It will sustain those around you and it will also sustain you.

I have tried to outline a set of values and habits that can build on the compassion and caring that brought you to this point: an abiding curiosity, a tolerance for uncertainty, an embrace of humor, a commitment to be passionate and a reflex to serve.

All of these will ebb and flow in your lives as students and physicians. Do not try to do everything at once, but do try to remember these characteristics in the work that you do over the next decades.

This coat that you are now wearing will give you opportunities to enter people’s lives, hear their stories, and help them in small and deep ways. As I said, I hope it represents more (and less) than the “ominous drama” that Dr. Veatch hypothesized. I hope instead that it is a reminder of the diverse ways that you will make a difference.

As you do this work of medicine, you will discover some number of patients and families, role models and mentors who will both inspire you and help keep you grounded. Savor and celebrate those people because they will remind you why you chose this profession and why you will go to work the next day. And turn, always, to your friends and peers and colleagues, because they will help balance you as they already have.

Good luck in your years here at St. George’s and good luck in the years and decades beyond, wherever they take you. And thank you again for inviting me here today and giving me the very special opportunity to share some of my reflections on what makes this profession such a special calling.

Keith B. Taylor Global Scholars Program White Coat Ceremony Keynote

Dr. John Powell-Jackson’s Heartfelt Keynote Address to the Fifth Class of the Keith B. Taylor Global Scholars Program

Deputy Vice Chancellor Mahoney, Vice Provost Randall House, Lord Walton, Senior Faculty Members, Distinguished Guests, White Coat Students, Ladies and Gentlemen.

First I would like to thank Dr Martin Stransky for his kind words of introduction.

It is an honour and a privilege to address you today on what is an important and memorable occasion especially for the White Coat Students.  You are the 5th Class to enter the Keith B Taylor Global Scholars Basic Science Programme; this class numbers 104 students and you come from 21 countries.

The programme is a unique international collaboration between St George’s University School of Medicine and Northumbria University.  It is named after the late Keith Taylor who was Vice Chancellor of St George’s University from 1991 – 1998. Before that he was a Professor of Medicine at Stanford spending 30 years studying the way the body absorbs vitamin B12.  At St George’s he helped create a dynamic research centre, WINDREF and he was instrumental in transforming a fine Medical School into an International University.  He would have enjoyed this occasion and you would have enjoyed meeting this wise and kind physician whose name will always be associated with International Medical Education, a subject close to his heart.  On his behalf I would like to congratulate all the White Coat Students for reaching this important milestone in your careers.

Now, I want to tell you the stories of two of my medical heroes.  One is an Australian, the other a Canadian.  The first illustrates the role that science and a little luck plays in medical discoveries and the second the way in which the practice of medicine is an art.  I hope they inspire you as much as they have inspired me.

Let me set the scene.  Peptic ulcers, gastric and duodenal ulcers were rare until the start of the 20th century when they became ever more frequent, affecting up to 1 in 10 of adults.  The popular belief was that they were related to an excess of acid production in the stomach brought on by stress, faulty diet, and genetic factors but the cause was unknown.  Treatment, in my day as a medical student, was bed rest, antacids and sometimes referral to surgeons for partial gastrectomy.  Ulcers tended to occur in middle life when people were at their most productive so there was an economic impact nationally as well as individual suffering.  In the 1970s drugs were introduced that reduced acid secretion in the stomach and allowed ulcers to heal.  But when the drugs were stopped the ulcers came back.

Along comes Barry Marshall.

Barry Marshall was born in Western Australia in 1951 and after graduating from medical school in Perth became a junior doctor in gastroenterology in the early 1980s.  He wanted an interesting research project and came into contact with a colleague Robin Warren who as a pathologist had observed small curved bacteria in stomach biopsies taken from patients with acute gastritis.  Neither knew the significance of these findings.

Then, quite by accident, one of the patients whose stomach biopsy had contained the unidentified bacteria reported that following a course of antibiotics for a chest infection, his indigestion had improved.  Barry Marshall promptly performed an endoscopy to inspect the stomach wall and found the bacteria had disappeared.

Since the patients’ symptoms and the bacteria in the stomach had vanished after antibiotics, he drew the obvious conclusion that the organisms might have been the cause of those symptoms.

This revelation sparked a flurry of excitement and activity.  Over the next 12 weeks Dr Marshall performed gastroscopies on many more patients and found a high prevalence of bacterial infections in those with gastritis and in every single patient with peptic ulcer.

The next step was to grow the organism on a culture dish but this proved surprisingly difficult.  Usually cultures are incubated for 48 hours after inoculation but nothing grew.  The 35th attempt was interrupted by an Easter break and unintentionally the dishes were incubated for an extra three days.  When the microbiologists returned from their vacation the culture plates were studded with small colonies of helicobacter.

It is at this point, in the summer of 1984, that Barry Marshall became a real hero.  He had to prove or disprove the idea that bacteria found in association with an illness were actually the cause of that illness.  In the great tradition of self experimentation he swallowed a cocktail containing large numbers of organisms which had been obtained from the stomach of a man suffering from indigestion.  Within a week he developed abdominal discomfort, vomiting, dyspepsia and to his wife’s and his friends dismay severe halitosis.  His breath smelt putrid.   A colleague found his stomach lining red and inflamed and a biopsy showed inflammatory cells with bacteria adhering to the surface.  After taking a course of antibiotics his symptoms quickly resolved.

Case proven you may think.

The initial reaction of doctors worldwide was utter disbelief.  Why had this connection never been made before?  Pathologists must have seen bacteria in stomach biopsies but ignored them because the prevailing wisdom suggested organisms could not survive in an acid environment.  Marshall had proved them wrong.  He stuck to his guns, absorbed all the criticism convinced that he was right.

It was another 10 years before this research was adopted into mainstream medical practice.  Nowadays gastroenterologists routinely look for helicobacter and cure peptic ulcers with antibiotics so that they don’t recur.  Gastric Surgeons rarely need to operate for ulcer disease and the outcome for patients has been transformed.

In 2005 Barry Marshall and Robin Warren were awarded the Nobel Prize for medicine for their work.

Here is an example of healthy scepticism and an inquiring mind plus an element of luck producing an important medical discovery.  Dr Marshall was able to think the unthinkable that peptic ulcers might be an infectious disease.  It raises the question that other diseases such as multiple sclerosis and ulcerative colitis may have a biological cause making them amenable to curative treatment.  Here are some opportunities for your generation.

I want to move on to my other hero, a Canadian by birth who became a Professor of medicine at the early age of 25 and spent most of his working life in the USA and England.  He wrote a textbook of medicine single handed and was the outstanding physician in his day and generation.  His influence was irresistible partly due to his intellectual gifts but also the magnetic charm of his personality.

His name was William Osler.

As a boy he thought of going into the church following his father but his love of natural history and science led him to medicine.  For this he was well fitted having a sympathetic nature, a genius for friendship and capacity for teaching and organisation.  He went to a private medical school in Toronto thence to McGill University in Montreal where he qualified.  After postgraduate studies in Europe he returned to McGill where he became Professor of medicine.  From McGill he went to Philadelphia and six years later founded, with others, a new medical school in Baltimore, The Johns Hopkins which he soon made famous.  In 1905 he was invited to become the Regius professor of medicine at Oxford, a post which he held until his death during the Spanish influenza pandemic in 1919.

What were his contributions and why was he so revered?

He made some interesting observations on some rare diseases that you will all learn about in the next few years.  These facts do not explain his unique influence.  Of greater importance were his insistence that medical students learn at the bedside and young doctors live in the hospital as interns and residents.  He started up formal journal clubs, loved books and libraries and advocated that learning should be life long.

However his outstanding characteristic was his humanity.  There is a well known story of him giving his cloak to a beggar one night who in return bequeathed his liver, rendered cirrhotic by alcohol, to his good friend William Osler.  His home was known as “The Open Arms” and his hospitality was boundless.
Incidentally Lord Walton was recently the Warden of that home at 13 Norham Gardens in Oxford and visitors are welcome to view the library and memorabilia.

Nothing pleased him more that teaching students such was his enthusiasm, knowledge of his subject and sense of obligation.  He said farewell to his students and colleagues in Philadelphia with these pearls of wisdom, which are equally relevant today.

“In the physician or surgeon no quality takes rank with imperturbability.  Imperturbability means coolness and presence of mind under all circumstances, calmness amid the storm, clearness of judgment in moments of grave peril, immobility, impassiveness.  It is the quality which is most appreciated by the public though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry and who is flustered in ordinary emergencies loses rapidly the confidence of his patients.”

Osler goes on to say “as imperturbability is largely a bodily endowment I regret to say that there are those among you, owing to congenital defects who may never be able to acquire it.  Education however will do much and with practice and experience the majority of you will attain a fair measure”.

“Secondly there is a mental equivalent, equanimity or evenness of mind which is as important as the bodily endowment.  You cannot hope to escape entirely from the cares and anxieties of professional life.  Stand up bravely even against the worst.”  In other words keep a steady temperament, avoid getting over excited or too despondent when things go wrong.

William Osler certainly possessed the gift of equanimity such that he bore success with humility, the affection of his friends without pride and when the day of sorrow and grief came with the loss of his only son in World War One he met it with courage.

I wish you all well on the journey which is just beginning.  It will be exciting and fulfilling and I would relish the opportunity to join you.  Remember that universities are not places just for acquiring knowledge; they are for learning how to think and reason.  The friends you make at medical school over the next 4 years will endure for life.

I will leave you with a final quote from Osler.  “My belief (is) that the real work of life is done before the 40th year and that after the 60th year it would be best for the world and best for themselves if men rested from their labours”.

I will take his advice and do just that.

Thank you for your attention and good luck to you all.

Dr. Judith Balcerski Congratulates Inaugural Nursing Class

Keynote speaker Dr. Judith Balcerski, a registered nurse who served as Dean of the Barry University School of Nursing for 33 years, congratulated the “brave and privileged individuals” of SGU’s first nursing class.  

My greetings to the dignitaries, administrators, and faculty members.  Special greetings to the parents, family, friends, and especially nursing students.

Congratulations on being the first nursing class at St. George’s University.  You are both brave and privileged to be here beginning your nursing education! You are entering nursing in the company of many outstanding women and men:
The Knights Templar ministering on the battlefields;
Catherine of Sienna, one of the first nurses of the 12th century, the patroness of nursing;
Clara Barton, the creator of the Red Cross;
Florence Nightingale who led her colleagues in a sit-down strike to improve the care of soldiers;
Mother Teresa, Nobel peace winning nurse;
women and men who rode horseback into battlefields and who served in field hospitals;
women and men who conduct nursing research to dispel myths and extend lives;
women and men who deliver and care for infants;
and women and men who sit with the person who is dying.
These heroic nurses brought nursing to where it is today.

One definition of nursing is that it’s a Science and an Art.  I am going to add that it is also Sense and Heart.  Science, Art, Sense, Heart.

The science part is clear because you will be caring for persons with bodies and minds.  Nursing care is based on evidence rather than myth.  You will learn the evidence of science in your anatomy, physiology, chemistry, microbiology, sociology, and psychology courses.  You will also study nursing science and read nursing research.  When you practice nursing according to evidence based science and research, rather than myth, you will be successful.  Nursing is a science.

Nursing is an art because you will be caring for people.  No two individual’s responses to illness are alike. While you must learn procedures in your nursing courses, frequently you will have to be creative in how you design nursing care for each individual.  Your patient may not eat.  Be creative.  Your patient may not sleep.  Be creative.  Your patient may refuse a treatment because of fear.  Be creative.  How will you learn to be creative?  Painting, sculpture, jazz, and poetry are creative accomplishments.  Studying art, music, and literature in your required courses helps you to learn to be creative.  You will then be more able to propose creative solutions to confounding nursing problems.  Nursing is an art, a creative art.

To Science and Art I add Sense.  Good sense will benefit your patient and yourself.  When you make a mistake, (because we all have and you will), good sense will give you courage to tell your instructor or the Sister immediately, so that a remedy can be taken and harm prevented.  When your patient suggests there is a better way to do a procedure, good sense will support you as you consider the suggestion seriously.  Good sense will sustain you when you are tired or frustrated and need to step away for a few minutes to take a deep breath to refresh yourself.  When you are corrected by a supervisor, instructor, or physician (and you will be) good sense will permit you to listen to their concern with an open attitude.  Nursing is sense, good sense.
To Science, Art, and Sense, I add one more attribute: Heart.  Heart is why you came to nursing.  You already have heart for persons who are ill.  You want to help them get well, or have less pain, or sleep more restfully, or have a peaceful passing when a cure is impossible.  Heart is the feeling at the end of every day, that you have contributed something very important to someone’s life.  Heart is what presses you to care for someone different from yourself: of another culture, skin color, intellectual capacity, or social level; to care for a criminal and the queen equally.  Heart supports you to care for persons who are impatient, rude, unclean, or manipulative because they are ill and need your care.  Heart compels you to care for an elder woman with Alzheimer’s as if she is your grandmother, a drug addict as your brother, an infant with Down’s syndrome as your child.  Nursing is Heart.

Finally, remember these four:  nursing is Science, Art, Sense, and Heart. SASH.  Remember nursing as a sash, a mantle across your shoulders of science, art, sense, and heart.

If I could make an assignment it would be to require you to read the biographies of outstanding nurses.  Ask nurses you meet to tell you their heart experiences.  As strange as it may sound, read the obituaries of nurses recently passed in your own country. Search these stories for nursing heart.

Starting with this induction ceremony today, write your own stories.   Keep a diary of the heartfelt experiences you have during your journey in nursing education and nursing practice.  Your heart stories will fill your soul and spirit with a return immensely greater than a grade A on a paper, a promotion to a higher position, or even the gratitude bestowed on you by a patient.  It will make you profoundly proud to be a professional nurse.

Congratulations on this beginning, and may God speed you on your journey.

369 Take Oath at School of Medicine White Coat Ceremony

dr william s andereckSt. George’s University School of Medicine (SGUSOM) officially welcomed a new class of 369 medical students from 43 countries at the SOM White Coat Ceremony held at Charter Hall on Sunday, August 24th.  The class of 2012 received words of inspiration and warm welcomes into the medical profession and the SGU community by SGU Alumnus and Master of Ceremonies Dr. Randy Becker, Chancellor Charles R. Modica, Prime Minister Hon. Tillman Thomas and Keynote Speaker Dr. William S. Andereck.

A familiar yet central part of the White Coat ceremony showcases students swearing a professional oath, promising to act with integrity and in an ethical manner during their training and career in medicine.  As Medical Director of California Pacific Medical Center’s Program in Medicine and Human Values, Dr. Andereck’s distinguished career in medical ethics served as inspiration to this new generation of medical students, further substantiating the importance of serving their patients with honor, dignity and humility.

“To help, not to harm,” the essential duty of the physician for over 750 years, was the essence of Dr. Andereck’s address, asserting that the principles of competence, compassion and commitment are the cornerstones of the practice of medicine.  When implemented as one, he explained, these essential principals produce not only highly skilled professionals but physicians who possess compassion and humanity.  Clinical competence, for example, must be well balanced with respect and a sincere concern for one’s patients.

Dr. Andereck discussed the swing of the medical pendulum as it moved from one extreme to another. Initially, it was thought that patients do not need to play an active role in their medical care. Critical aspects of care such as diagnosing the nature of the problem and treatment options were very much the decision of the attending physician. This was well illustrated statistically when in 1960, 90% of doctors interviewed said that they will not always tell their patients what is wrong with them. However, just 18 years later, with growing emphasis on respect for the individual and taking into account their goals, values and aspirations, an overwhelming 99% of physicians said that they will fully disclose the patient’s diagnosis at all times.

Today, the challenge for the modern physician is to find the right balance between individual needs and public health needs. Here is where a fourth principle – justice – is to be fully embraced in their professional life. The modern doctor is faced with not only the care of his patient but with the responsibility to treat the poor with the same skill and attention as the rich. Moreover, they must also successfully face the challenge of the statistical patient as they seek to balance scarce resources with the needs of the patient. More and more physicians are called to administrative roles and must be prepared to take a holistic approach to medical care.

Parents of the incoming class were specially commended for already instilling in their sons and daughters these cornerstone principles of medicine along with the qualities of compassion, humility, industriousness and willingness to work hard. These are not just virtues of medicine, but virtues of life.

Since 1979, Dr. William S. Andereck has combined the private practice of internal medicine in San Francisco with his ethics work and a busy clinical practice. As Medical Director of California Pacific Medical Center’s Program in Medicine and Human Values, he oversees a vibrant and rapidly growing center which provides ethics consultation, educational programs and policy development services within a large community hospital located in San Francisco.  He has also chaired the hospital’s ethics committee since its inception in 1985.  At present he is a trustee of the California Medical Association.

Dr. Andereck’s community interests include a long-standing affiliation with youth soccer and a ten-year term as Director of the San Francisco Zoo.  He and his wife Helga have three children.

John Madden White Coat Ceremony Speech

SGU alumnus Dr. John Madden, Associate Dean of Students, United States and Director, Office of Student Development and Career Guidance, was the Master of Ceremonies at the August 2008 Keith B. Taylor Global Scholars Program White Coat Ceremony.

Voltaire once said “Those who are occupied in the restoration of health to others by the joint exertion of skill and humanity are above all the great of the earth.  They even partake of Divinity; since to preserve and renew, is almost as noble as to create.”

While I know some Trauma Surgeons that have taken Voltaire’s Divinity concept quite literally, I think he otherwise has the right idea; a physician is engaged in a wonderful profession- maintaining someone’s health or attempting to restore an ill or injured patient to a healthy state.

I am an emergency physician in Delaware and also an Associate Dean of Students for St. George’s.  I work at a very busy ED where we see over 150,000 patients a year. It is a Level I trauma Center for both adults and pediatric patients. I trained at Jacobi Hospital in the Bronx where I was taught that the emergency department was the safety net in health care; when there is no where else to go for care, you go to the ED. We are the 7-Eleven in medicine- 24 hours a day, seven days a week, 365 days a year.  We care for the sick and injured, young and old, with or without a shirt or shoes on, whether they are intoxicated, abused, victims of crime, those that committed those crimes, those who think they are ill but are not and even those without the ability to pay or a place to call home.  We care for those who have experienced perhaps the most significant crisis that they will ever experience in their lives.

I wouldn’t have it any other way.

I have also been privileged to only work at places where physicians in other hospital emergency departments send their patients because they lack the ability, or in rare cases the compassion, to care for certain types of patients.

We’re here to witness you symbolically join this noble profession of medicine by donning your white coat and reciting an oath.  Today you become part of a tradition that goes back over twenty five hundred years; the physician as a servant of the sick.

During the next several years, here in Newcastle, in Grenada, in your clinical training in the US or UK and during your residency, you will hear your teachers discuss “Core Competencies.”  There are 6 Core Competencies, all of which are vital to your education;

  1. Patient Care
  2. Medical  Knowledge
  3. Practice Based learning & improvement
  4. Interpersonal and communication skills
  5. Professionalism and
  6. Systems Based Practice

Except for medical knowledge, these competencies don’t mean much to you right now. You will become adept at all of these during different phases of your training, but they all start right here – today!  A friend of mine once told me that medicine attracts the best and the brightest from college, but I am quite sure, and lucky for me, that being the brightest in organic chemistry does not make one a good physician.  It is the respect and compassion you show towards those with whom you come into contact, be it patients, fellow students, school officials or the staff that clean your classrooms and it starts right here – today.

Medicine is a team sport.  The physician doesn’t save lives, the team does. Often members of the team never lay eyes on the patient- they may be reading an x-ray many miles away or even on another continent and notice a small growth on an imaging study, or a lab tech that identifies the pathogen infecting the patient that prompts you to change the antibiotic you are giving the patient. We’re all in this great profession together.  Treat each other with respect now and you’ll treat your patients the same way.

You have many hurdles between today and your graduation.  Take it one step at a time- your first hurdle may be a biochemistry or an anatomy exam while your roommates hurdle might be microbiology.  Help each other get over the hurdles and cross the finish line together.  Thousands of Saint George’s students have preceded you.  They had the same concerns and uncertainties that you probably have right now, but they have graduated and as physicians have touched hundreds of thousands of lives.  Your ability to touch these lives starts right here and now with the help of your faculty and fellow students.

I wear a white coat most of the time when I work.  I might change into a hospital gown when I am treating someone who is actively bleeding or needs to be sutured or perhaps even has the potential to vomit on me.  Anyone who has tried to collect a urine sample from a baby boy or even changed their diaper quickly learns how to keep a safe distance.  But after a serious trauma case or a cardiac resuscitation, I’ll put the white coat back on when I go to speak with the family to tell them either the good news or perhaps the news they have been dreading since being summoned to the emergency department.  I put the white coat on so that can see immediately that the physician speaking with them is part of the profession of medicine.  The white coat is the robe of our profession.  Wear it proudly!

The Not so Quiet Art: Medicine in the 21st Century

Keith B. Taylor Global Scholars Program White Coat Ceremony Keynote Speaker Professor Sir Miles Irving, Professor of Surgery at the University of Manchester and Consultant Surgeon at Hope Hospital Salford for 25 years, explores the ethical responsibility and generosity of spirit which is at the core of the medical profession.

Provost Macpherson, Vice Chancellor, Dr Rao, Distinguished Guests, Students, Ladies and Gentlemen.

It is indeed an honour to be asked to deliver this keynote address at your white coat ceremony here in this magnificent Arts Centre in Gateshead on the banks of the River Tyne next to the ancient city of Newcastle.

Enoch Powell, a famous British politician of former years, once advised me “always lecture with a full bladder, then you will not go on too long.” I want to add my own variant of this advice “lecturing five weeks after a knee replacement produces exactly the same benefits without the risk of any embarrassing accidents”.

Newcastle has a long history of the teaching and practise of medicine as– evidenced by the ancient company of barber surgeons that existed in the seventeenth century and their beautiful surgeon’s hall, now sadly long demolished. In my own specialty of surgery the names of the Newcastle surgeons  Rutherford Morison and Grey Turner  stand out in the fields of abdominal and oesophageal surgery whilst Rowbotham was one of the world’s pioneers in the scientific approach to the management of head injuries. In paediatric medicine the famous, and still ongoing ,“Thousand Families Survey” was initiated in this city by Sir James Spence  and in the field of maternity care Newcastle was the first to establish flying squads for women who developed complications whilst  giving birth in their own homes.

This fine tradition of scientific medicine continues to this day with Newcastle playing a leading role in many areas particularly genetics and  stem cell research and the problems of ageing.

May I say at this stage how impressed I am at what St Georges University School of Medicine is doing to help tackle the massive shortage of doctors in this world of ours. I have long been aware of your existence and the work you are undertaking not least because one of the key individuals in your foundation, Paddy Ross was a colleague and friend  of mine when we were training in surgery at St Bartholomew’s Hospital in London many years ago.

It is now some fifty years since I qualified in medicine from the University of Liverpool and over that time I have seen miracles in the practice of medicine that almost defy belief. Not a week goes by without some new advance in medicine being reported and indeed, though now retired from clinical medical practice I still experience new facets of my profession through its Research and Development activities,  and not least  today when for the first time I am taking part in a white coat ceremony,  which is not a tradition in British medical training. But more of that later.

So what of my title today?  It  is taken from Virgil’s book the Aeniad  which  contains the following phrase;

Scire postetates herbarum usumque medendi 
Maluit et mutas agitare inglorious artes.

Translated into English this reads;

it was his part to learn the powers of medicines and the practice of healing, and careless of fame, to exercise that quiet art.

From the time of Virgil to this present day  I believe the core of our profession remains  this combination of  the powers of medicine  with the practice of healing implemented within a framework which incorporates the features  of the Quiet Art , and which distinguishes the whole from a mere technical exercise.

I first heard of this term when I was given a book compiled by a great Liverpool Physician called Robert Cooke who brought together an anthology of sayings about doctors. This book was given to me by the author in my first year after qualification following my looking after him for several weeks. Here it is, and it has remained a constant support to me throughout the fifty years since I qualified. How so ?

I want you now to picture a famous painting, currently in the Tate Gallery, called “The Doctor”. . It is by the famous painter Sir Luke Fildes, also from Liverpool, who has portrayed a bearded doctor of the 19th century sitting by the bedside of a dying child throughout the night whilst her parents look on anxiously. The doctor  almost certainly did not know what was wrong with the child and even if he did he equally certainly  was not able to do anything about it, but he was there  bringing  comfort  at the time of greatest need of the child and her parents.

It was undoubtedly stimulated by the fact that Fildes had himself  suffered the death of  a son and indeed it  is said that the picture is a tribute to the doctor that looked after his son.

I always thought that this painting portrayed the final moments of the child as shown by the obvious distress of the parents but in reading further about it I understand that the glimmer of light from the approaching dawn is meant to show that in fact the child was getting past the crisis and was to recover.

What did the public of that time think of such doctors who had little to offer but kindness and compassion. Robert Louis Stevenson the famous author of the book Treasure Island  wrote the following:

There are men and classes of men that stand above the common herd: the soldier ,the sailor, and the shepherd not infrequently ,the artist rarely, rarelier still the clergyman; the physician almost as a rule. He is the flower(such as it is) of our civilisation; and when that stage is done with, and only to be marvelled at in history, he will be thought to have shared as little as any  in the defects of the period, and most notably exhibited the virtues of the race. Generosity he has ,such is possible to those who practise an art, never to those who drive a trade; discretion tested by a hundred secrets; tact tried in a thousand embarrassments ;and what are more important, Heraclean cheerfulness and courage. So that he brings air and cheer into the sickroom, and often enough ,though not as often as he wishes, brings healing.

Heady stuff,  but only one example of many similar pieces written around this time. Nowadays he would of course have included women doctors in his description. It is interesting to note that of all the attributes that Stevenson values in the physician the one he mentions last of all is healing. That’s not to say he does not value healing; the parents in Fildes’ painting want healing of their child more than anything else, but Fildes, who you recall had himself   suffered a death of a child was depicting all those other attributes mentioned by  Stevenson. I consider that these are  the Quiet aspects of the Quiet Art. I hope that what follows will persuade you that these Quiet aspects of medical practise are as important today, in this era  of high technology medicine, as they have ever been.

Even as Stevenson and Fildes were writing and painting ,the effects of the scientific enlightenment were beginning to bear fruit and allowing our profession to emerge from what Sir Frederick Treves the famous London surgeon described as the medical dark ages.

Treves was an exemplar of that combination of medical science and the Quiet Art for not only did he have the skill and knowledge to save the life of the king by draining an appendix abscess  on the eve of his coronation, but  also in a truly humanitarian  act rescued the  Elephant man from poverty and captivity in circus shows and looked after by  giving him accommodation in the Royal London Hospital.

So is it different today when we have the most powerful array of effective treatments that has ever existed and which backed by sound evidence expands at an almost exponential rate?

Our 21st Century patients have high expectations of what we have to offer and expect the highest standards of care.

However there is a paradox at the present time in  that whilst we deliver increasingly effective medical care , in the Western World  there is an unprecedented interest in, and use of complementary therapies ,for which there is no scientific evidence.

Does this represent a reaction to the fact that in delivering our successful high technology treatments the medical profession of today may be tending  to ignore the Quiet aspects of our practice  with the result that, as suggested by the title of my talk today, Medicine in the 21st Century is not as Quiet an Art as it should be.

If this is the case then we, as a profession, will be missing out on just those aspects of our work that make our occupation so enjoyable and memorable.

Every experienced doctor will tell you when he or she looks back on their professional lives that  the rare moments of triumph of diagnosis and treatment are always  recalled with pride and relish as great occasions, whilst those terrible cases that go badly wrong are remembered  with sadness and often guilt. However, the vast majority of routine cases that go well are rarely remembered.

However , the really  memorable  moments one recalls  are often  those  when  one is using the attributes common to all good doctors when  practising the Quiet side of our art.  For example when one is alone with a patient at a time of difficulty, bringing reassurance through the holding of a hand  and patiently listening or alternatively joining in the moments of fun, laughter, and at times hilarity.

Careers in medicine are gilded by such memories of  patients  and events. I once recall sitting with  an elderly nun  who was accepting with amazing calm and equanimity  the fact that she had an inoperable malignant disease and that her life was coming to its end.. As our conversation drew to a close  I commented that I knew that nuns  took their religious name from that of a saint yet I had not heard of a saint Thecla which was her professed  name .Sister Thecla  looked at me, smiled sweetly and said “no, not yet, but soon”.

Even awful times  can have their  lighter moments  and episodes of bravery . Some thirty five years ago when terrorists  were regularly bombing  London  the criminal high court of London ,known as the Old Bailey  was attacked and some 160 people were injured. I was the duty surgeon at St Bartholomew’s Hospital ,Britain’s oldest hospital now approaching its 900th anniversary , which was situated very near to the Court. Amongst the injured was  Judge Caesar Crespi, a rather large man  who was heavily overweight and who was caught in the blast just as he was being evacuated from the building. He was brought to the hospital still in his gown and legal dress ,bloodstained and awry. As I triaged him at the hospital entrance he greeted me with a booming voice saying, doctor, I tried to save the Old Bailey by putting myself between the bomb and it.

A few weeks later  the hospital was full of the victims of the Tower of London bomb explosion  and  I recall the singular  horror of a young visitor  from New Zealand   with his leg blown off by a terrorist bomb pleading with me not to cut off his new shirt which” daddy has just bought me”. Years later this memory was lightened when on a visit to New Zealand I discovered the boy had turned into an adult  who was  a skilful  football player.

That the quiet  art is relevant across the whole spectrum of medical practise including research is shown by  Sir David Weatherall, Regius Professor of Medicine at the university of Oxford and a Fellow of the Royal Society, the highest accolade in the scientific world this country can offer, and a medical scientist of the world rank. His book about science and research in medicine is titled Science and The Quiet Art   and has on its front page  the picture by Fildes to   remind us that  medical progress through research and its high technology outcomes  needs to be combined with what he calls the importance of the pastoral role of doctors in patient care to counter the dehumanising effects of purely technological approaches to ill health.

So what has all this to do with your white coat ceremony today?

Well. let me start by saying that I realise that this is a significant and memorable day for you and your family and friends and one you should relish, enjoy and remember.

My introductory comments have been designed to show you that what you are committing yourselves to in today’s ceremony is not just about the practice of clinical science and advanced technology but also about the wider humanitarian side which is encompassed in the words Quiet Art and is almost certainly what Dr Gold was aspiring towards when he introduced the White Coat Ceremony.

So, let us for a moment briefly look at the origins of the White Coat Ceremony.

I must say that I was intrigued when I first heard about it for in all my years in travelling to the USA I had not come across it until very recently.

You however will all know that it is a contemporary medical ritual devised by Dr Gold of the Robert Wood Johnson Foundation. It was introduced some 15 years ago in 1993  at the university of Columbia under the title humanism in medicine.

Then it consisted of symbolically putting on a white coat and receiving a book on doctoring and a pin for the coat saying Humanism in Medicine. Putting on the coat was regarded as a statement that  the doctors to be  are accepting the ideals of the Hippocratic Oath and those of a great profession. From its origin in the United States it has spread quite widely and involved other medicine related specialties.

I have no doubt that some public statement of what is expected of doctors, and the opportunity for them to acquiesce to the values extolled is necessary, be it at graduation or as today at the start of you careers.

One has to ask whether such a symbolic act in which you take part today would have prevented the darker side that has at times afflicted our great profession . History reveals that the medical profession during its existence has embraced some pretty disgraceful practitioners.   For instance records show that the biggest professional group in the Nazi party of Germany was made up of doctors. Many terrorist leaders have been doctors, and in Russia psychiatrists were involved in  the imprisonment  of political dissenters. In recent times in my own country Dr Shipman, a general practitioner deliberately killed a huge number of elderly patients. Within the last few weeks  Radovan Karadzic from Serbia has been arrested and is to be tried before the international court in the Hague for Genocide. He too is one of our profession who at the time of his arrest was practising medicine.

The University of Maryland justify their White Coat Ceremony   by saying that it recognises  the point of entry into the profession of medicine and is a vow to maintain professional  attitudes and behaviours in work and relationships with classmates, teachers patients and the community at large.

I know that I am not alone in wondering whether this rationale presents too conventional a picture of medicine and its practitioners.

For instance the order in which the University of Maryland  has stated  the goals is not one that I would consider appropriate for the 21st century.  Personally , I would have put  them in the reverse  order on the grounds that our  first responsibility is to the community  and patients  we serve.

Additionally I believe that the profound changes that have occurred at an exponential rate in the practice of medicine within the last few decades  require a radical alteration  in the way we think about and manage the delivery of medical care.
Such challenges are not addressed by this conventional view of our profession nor ,I believe, are they  represented by  the conventional view of the white coated doctor a portrayal which reinforces  the more technical side of the profession.

This leads me to explore the symbolism of the white coat, particularly here in the United Kingdom where as far as I am aware the White Coat Ceremony is unique to the University of Northumbria in its relationship with St Georges University.

The fact is, that in this country doctors have a uniquely British problem with white coats. Although many patients, particularly older ones, prefer to see doctors in white coats, doctors themselves are not keen on them .Indeed many abhor them, and they have long been banished from children’s hospitals and psychiatric institutions. A major blow to their use occurred last year when the Government’s Department of Health recommended that they should be forbidden on hospital ward rounds on the grounds of infection control.

To be frank, and to use modern parlance, in Britain White Coats are not regarded as ”cool”.

On the other hand the symbolism of the White Coat is not entirely without significant meaning in this country. Another book which has brought stimulation and pleasure into my life as a doctor mentions the white coat in its title. White Coat Purple Coat is written by a Welsh respiratory physician called Dannie Abse.

This physician poet talks about  the white coat as the mark of the doctor and the purple coat as that of the poet

Song for Pythagoras

White Coat and Purple coat
A sleeve from both he sews
The white is always stained with blood,
That purple by the rose,

And phantom rose and blood most real
Compose a hybrid style
White coat and purple coat
Few men can reconcile

White coat and purple coat
Each can be worn in turn
But in the white a man will freeze
And in the purple burn

However, although I am sceptical about the symbolism  of  the white coats in  today’s ceremony I believe that the ceremony  has another outcome which will be of equal if not more importance to you in the professional life that lies ahead of you.

I know from reading commentaries on the  White Coat ceremony on the web by some of your colleagues who have been through the ritual  that they too have had doubts about its message and significance. Such doubts are important for they introduce you ,at the very start of your professional lives, to that essential requirement of a good doctor namely a high degree of scepticism and the associated ability to think laterally about your profession, its values and its teaching. This is in marked contrast to cynicism which is destructive because it almost invariably descends into inactivity rather than the creativeness which can be generated by scepticism.

Why is scepticism so important at this early stage in your careers.? The answer is because at this stage of your training you are very susceptible to didacticism not least because of the many good personal  attributes that have led to you wanting to enter medicine as your lifetime profession.

One of your medical student colleagues writing in a medical journal some 15 years ago summed up these attributes when he wrote this about  being a medical student.

I am that most fragile of hobbledehoys, the doctor soon to be; infinitely malleable, ludicrously credulous, brazenly idealistic and just plain scared.

In such a state  the acquisition of the art of being sceptical ,as opposed to cynical ,is one to be cultivated for the history of medicine repeatedly shows that ,in some areas, what one day is taught as infallibly correct, within a short time is shown to be of no value or even dangerous. One of the greatest realisations by our profession in recent years is that virtually everything we do is  a balance between benefit and harm and it is in assessing this fact for each of our patients wherein lies the skill of modern medicine. Indeed to reinforce my scepticism I  about white coats I have to remind you that they themselves can be pathogenic for  there are a group of patients who exhibit   the condition of white coat hypertension, a rise in blood pressure  occasioned  by the sight of a doctor in a white coat.

The Quiet aspects of our profession, including scepticism, are an integral component of good medical practice in the 21st century and can generate therapeutic benefits in their own right.

There is general agreement that doctors in addition to being clinically competent should be well rounded individuals with a range of outside interests. Sometimes these interests can overlap with ones professional practise and be of value to patients. There is sound evidence that music and art have valuable roles in treating certain medical conditions.

You may be surprised to know that a search of the literature shows that poetry too  can have a significant place in medical practice. The medical journal the Lancet  has  recently had more than one article dealing with the role of Poetry on the Ward Round  which, amongst other things, can certainly be  used to address the most difficult and sensitive  situations. Take this poem for instance which touches on the issues of racism, anti Semitism and that most difficult of all problems namely when a doctor develops a profound dislike for a patient and even momentarily may wish not to treat him  or even to do him harm

Dannie Abse,  CASE HISTORY

Most Welshmen are worthless ,
An inferior breed doctor,

He did not know I was Welsh.

Then he praised the architects of 
The German Death Camps-
Did not know I was a Jew.
He called liberals “white blacks”,
And continued to invent curses.

When I palpated his liver
I felt the soft liver of Goering: when I lifted my stethoscope
I heard the heartbeats of Himmler; 
When I read his encephalograph
I thought,”Sieg heil ,mein Furher”

In the clinic’s dispensary
Red berry of black bryony,
Cowbane, deadly nightshade,
 deathcap.
Yet I prescribed for him as if he were my brother.

So the message for  you, tomorrows generation of doctors who will be practising in the 21st century, is to be competent in embracing the powers of medicine and delivering healing but to be so within the framework  of the quiet aspects of our profession.
I you can reach the standards laid down by Robert Louis Stevenson for a perfect doctor remember that they were reached by doctors who like Sir Luke Fildes portrayal  showed devotion and a quiet heroism  but who, incidentally, never wore white coats.

This, underlying timeless approach, whilst coping with all the excitement of the new technologies which will inevitably unfold, will ensure continuing public support (currently running at a level of around 95% trust for British doctors)for our profession in the 21st century.

Before I step down from this podium I want to give you something to raise your morale.
I am well aware that talks such as I have given today are very much ”old  dog to young dog” activities and as such may soon be forgotten. The ideas and values that I have advocated are much more likely to be sustained if they arise, are developed, and are taken forward by people of your own generation.

I therefore have found it highly encouraging that what I have advocated today for your consideration is already being promulgated by your own generation.

When I had finished compiling this talk I turned to a literature search and to my amazement and alarm came across an article (from which I have already quoted earlier in this talk)  written in 1993  and published  in the Journal of the Royal Society of Medicine, by Jason Warren, a medical student from the university of Adelaide , under the title courage and the quiet art: night thoughts of a doctor to be.

It was a profound and challenging article, virtually identical in content and approach to, but far more  eloquent than ,my talk today and also  centred  around  Fildes painting , My reaction was that had the author heard what I have just said he would have had a claim against me for plagiarism.

This all goes to show that you  like him , at the start of your careers ,possess in your minds all the potential to be just as radical and innovative as any else in our profession as long as you let your thoughts flower within an atmosphere of humility and scepticism

I wish all of you commencing your clinical careers a long and happy time in our wonderful profession and hope that  this ceremony  today will  permanently foster  within you the quiet aspects of our  Quiet Art .

14th Annual Geoffrey H. Bourne Lecture Held on February 11

bourne lecture fred jacobsOn Monday, February 11 Dr. Fred M. Jacobs, keynote speaker for the Geoffrey H. Bourne Memorial Lecture, delivered a presentation to the St. Goerge’s University community that echoed the University’s distinct academic and moral purpose. Since its inception, SGU and its faculty have instilled a cultural awareness and sensitivity in the student body that is unique to this institution.

As St. George’s University’s diverse student body continues to expand, with the most recent incoming SOM class originating from 26 countries, Dr. Jacobs’ lecture, which addressed the need for “Cultural Competence in Health Care,” was both relevant and timely.

Dr. Jacobs has long been a public health advocate, working diligently on numerous public awareness campaigns to educate the community on issues ranging from Rapid HIV testing, postpartum depression, flu pandemic preparedness, childhood obesity and the toxic effects of second-hand smoke.

Under his leadership as Commissioner of the New Jersey Department of Health and Senior Services from December 2004 through December 2007, the landmark Smoke-Free Act, one of the most significant public health achievements in New Jersey history, was signed into law.  Dr. Jacobs’ greatest priority as Commissioner was the reduction of health disparities among minority and multicultural populations, for which he established numerous influential initiatives.

As Dr. Jacobs addressed the audience, he drew upon his experience and conveyed the critical need to “develop a system and workforce that delivers the highest quality care to every patient, regardless of race, ethnicity, cultural background or linguistic needs.”  He explained that the demographic changes in the United States anticipated over the next decade substantiates the importance of addressing the disparities in health care, with specific attention to the poor health status of individuals effected by lower income, language barriers and cultural differences.  Minority and multicultural populations in the United States have experienced an increase of potentially avoidable procedures like amputations, treatment of late-stage cancer, unnecessary hospitalizations and untreated disease.

Dr. Jacobs emphasized that improved patient-physician communication on a national level will help combat the major changes in the way health care is delivered and financed.  This can be achieved through the use of interpreters, offering linguistically appropriate health education workshops and materials, employing multi-lingual care workers and offering cross-cultural training for providers.

Dr. Jacobs cited New Jersey’s initiatives, which have been designed and implemented to provide cross-cultural resources to its diverse population.  New Jersey executed the first state law requiring cultural competence education, whereby medical schools must provide cultural competency training as a condition for diploma.  This formal requirement is one step toward achieving a new standard for health care which delivers consistent quality care to patients, regardless of socioeconomic and cultural difference.

Before his terms as Commissioner, Dr. Jacobs spent 35 years in various executive and management positions in the Saint Barnabas Health Care System.  He joined the staff at Saint Barnabas Medical Center in 1969 as Chief of Pulmonary Disease.  He also served as Medical Director of the Intensive Care Unit and was elected President of the Medical Staff in 1987.  Subsequently, he became Senior Vice President followed by Executive Vice President for Medical Affairs.  He is now the Executive Vice President and Director, Quality Institute, Saint Barnabas Health Care System.

Dr. Jacobs received his bachelor’s degree from Colgate University and his medical degree from the University of Miami School of Medicine, where he was elected to the Alpha Omega Alpha Honor Society. He trained in internal medicine at Maimonides Medical Center and Mt. Sinai Hospital in New York City.  He completed a pulmonary research fellowship at the University of California, San Francisco Medical Center and a Chief Residency in pulmonary disease at Kings County Hospital Center in New York. He is board certified in both Internal Medicine and Pulmonary Disease. In 1990, Dr. Jacobs graduated from Rutgers University School of Law in Newark, New Jersey. Dr. Jacobs has also held many faculty positions, and is a Fellow of the American College of Physicians, the American College of Chest Physicians and the American College of Legal Medicine.

For Dr. Fred Jacobs Complete Keynote Address…

The Geoffrey H. Bourne Memorial Lecture is dedicated to the memory of Geoffrey H. Bourne, Phil, DSc (1909-1988), the first Vice Chancellor of St. George’s University (1978-1988).  Dr. Bourne was an educator, scientist, writer and visionary.  His professional life was spent largely in England and the United States, where he was Professor and Chairman of Anatomy at Emory University, Atlanta and then Director of the Yerkes Regional Primate Center at Emory.

As Vice Chancellor, Dr. Bourne played an outstanding role in the early development of St. George’s University, guiding its growth with a determined and steady hand.

The Inaugural Keith B. Taylor Memorial Lecture joins with the Ninth WINDREF Lecture

Professor Sir Andrew HainesOn Sunday, February 10th, SGU welcomed Professor Sir Andrew Haines to its new Charter Hall to educate and inspire an audience of faculty, staff and invited guests. Sir Andrew Haines, an internationally respected researcher in epidemiology and health services research, delivered a lecture on “Climate Change, Energy Use and Health in the 21st Century.”

Sir Andrew Haines’ presentation addressed the grave environmental and humanitarian effects which stem from the use of non-renewable energy; the result being the sharp acceleration of Greenhouse Gases (GHG), most notably carbon dioxide and methane. The umbrella effect, universally known as global warming, is seen in the rise in air, land and water temperatures.  Sir Andy discussed the dramatic consequences of global warming which include extreme weather variations like droughts and floods, a rise in sea level which results in displacement of population, threats to food production, increase in infectious disease due to overcrowding, rise in carriage of bacteria and fungi, and increased health risks including mental health and malnutrition.

Sir Andy explained that while industrialized countries like China and the United States are the largest producers of GHG it is the underdeveloped countries that are most vulnerable to the environmental and health risks that ensue.  The burning of fossil fuels and deforestation cuts absorption of carbon dioxide and have irreversible effects.  Through immediate conservation measurements which include drastic cuts in non-renewable energy in exchange for renewable sources of energy such as wind, water and sun, we as a community, nation and universe can meet the challenges ahead.

Sir Andy became Dean (subsequently Director) of the London School of Hygiene and Tropical Medicine in January 2001. He was previously Professor of Primary Health Care and Director of the Department of Primary Care and Population Sciences at Royal Free and University College Medical School, and worked part time as a general practitioner in North London. He was also formerly Director of Research and Development at the NHS Executive, North Thames and a member of the Council of the Medical Research Council. He has worked internationally, including in Nepal, Canada, Jamaica and the United States.

Sir Andy’s research interests are in health services and epidemiology.  He has undertaken a number of major intervention trials in primary care settings and has also studied the impacts of climatic factors on health. He has published widely on these topic areas and has more than 150 papers in leading peer reviewed journals. He is a frequent contributor of editorials in the British Medical Journal and the Lancet. He has also written seven books and numerous reports and letters. He has an impressive funding track record for research and institutions, and serves on a number of international and local health related committees.

Sir Andy was a member of the UN Intergovernmental Panel on Climate Change for their second and third assessment reports. He also chaired a Task Force on Health Systems Research for World Health Organization (WHO) which reported in 2005. He sits on many national and international committees including the WHO Advisory Committee on Health Research. He was knighted in the 2005 New Years Honors list for services to medicine, and has recently been elected as chair of the UK Health and Social Care Policy Committee.  St. George’s University is grateful to Sir Andy for his participation in this year’s WINDREF Lecture.

The Windward Island Research and Education Foundation (WINDREF) was established in 1994 to advance health and environmental development through multidisciplinary research and education programs.  WINDREF strives for program excellence by promoting collaborative relationships between internationally recognized scholars and regional scientists and by adhering to the highest ethical and academic standards in all research endeavors.

Keith B. TaylorThis Memorial Lecture is dedicated to the memory of Keith Breden Taylor, DM, FRCP (1924-2006), former Vice Chancellor of St. George’s University. During his tenure from 1989 to 1998, Dr. Taylor worked tirelessly to implement his vision that St. George’s University should grow into an international university. He achieved that by creating a Panel on Research and Scholarly Activity in 1992; then founding a research institute, WINDREF, in 1994 which allowed the development of a graduate studies program; by instituting the School of Arts and Sciences in 1996 which broadened the academic opportunities for students in the region; and, first and foremost, by insisting on an international scope for each and every development at the University.

Published on 2/12/08

Dean Rodney Croft Addresses KBTGSP Students at White Coat Ceremony

SGU Dean Rodney Croft Delivers Keynote Address, emphasizing the critical link between art and medicine.

Deputy Vice Chancellor Mahoney, Sir Malcolm McNaughton, Senior Faculty Members of Northumbria University and St. George’s University Grenada, White Coat Students, Ladies and Gentleman, I would first of all like to thank Dr. Peter Beaumont for his warm welcome, his interesting reflections as an alumnus of St.George’s University School of Medicine and his most kind words of introduction.

It is both a very great pleasure and indeed an enormous privilege  to have been asked to give the keynote address here today on what is for all of us, but especially the White Coat students, a most auspicious and memorable occasion.

As Dean of Clinical Studies in the UK for St. George’s, let me add my heartiest congratulations to you the White Coat Students who are about to enter the St. George’s Keith Taylor Global Scholars basic science programme at Northumbria University.

This is a very significant programme, not only because it is associated with a renowned UK University, Northumbria, but also in the true tradition of St. George’s School of Medicine, it is for a significant number of you directed towards training medical students who either come from developing countries or towards those who wish to subsequently practise in such countries: a dream shared by our late Vice-Chancellor Emeritus Keith Taylor. It is good therefore to see so many countries, fourteen in all, represented amongst the student body here today who number almost one hundred.

Today’s students are the third class to be admitted. I am pleased to inform you the first two classes did very well in their end of first year examinations which is not only a great credit to the students, but also to their teachers who include both Northumbria and St.George’s University Faculty.

So the previous students, guided by their teachers present here today, have set a very good example to follow; a challenge which I am sure today’s new White Coat Students will meet.

I also wish to congratulate you on the serious but celebratory Professional commitment you will shortly make to your forthcoming medical education and future as doctors to be lead by Mr Simon Crocker the UK Departmental Chairman of Obstetrics and Gynaecology and witnessed by all present.

Everyone here knows that you young men and women about to be donned with your white coats are in an extremely privileged position: I say that for the very simple reason that there are thousands of your contemporaries around the globe whose dream is to become a doctor but because of various adverse circumstances are denied this privilege. They would love to exchange places with you today because they know only too well you are joining the most noble of professions, medicine, totally committed to the curing and easing of pain and suffering in our fellow men, women and children.

However, do remember, with privilege comes obligation and it is your obligation to your newly adopted profession, to your teachers, your parents, guardians, sponsors, fellow students, but most importantly to yourselves to remain loyal to your Professional Commitment and to succeed in your professional mission. This will of necessity require long periods of intense study and hard work, but like all good medical students I have no doubt you will play hard too!

Remember also that in the rapidly expanding technological world  of medicine, patients not only require men and women of science but also doctors who have humanistic and empathetic skills.

In the Christian religion St. Luke is both the patron Saint of Doctors but also of Artists.
This serves as a very apt and constant reminder to us all that art and medicine are inextricably linked and prior to you beginning your clinical studies in two years time you will be taught during the Medicine in Society course in Grenada the crucially important practise of taking a clinical history from a patient when the humanistic bond between doctor and patient is first forged and which thereafter continues throughout a patient’s care.

Patients live their symptoms on a daily basis. A good doctor trained in taking a focused clinical history becomes a decryptor of a patient’s symptoms and if you learn this art together with your scientific knowledge, you will often by the end of taking the clinical history alone, have a good idea of the diagnosis. What you certainly also will have achieved is the firm foundation of the humanistic bond between patient and physician.

Always remember too, attached to every medical investigation or clinical procedure there is a concerned patient, together with their relatives and friends. The result of each blood test, ECG, X-ray, each CT, MRI scan, the outcome of each non-invasive and invasive procedure all has a very personal identity and ownership: all belonging to a specific individual and often anxious patient.
Knowledge of the science of Medicine is crucial but dealing compassionately and empathetically with patients and their relatives is truly the art of medicine.

St. George’s University School of Medicine has an established association with the Arnold Gold Humansim awards scheme in the United States and each year on the day before graduation in New York, Humanism awards are granted to a number of students who have been judged by their fellow student peers as being outstanding in exhibiting their humanistic qualities.

So teaching the Art as well as the Science of Medicine is rightfully a great priority for St. George’s.

Indeed for most of you, if not all, it was such a humanistic feeling of wishing to change and improve the lives of the sick and infirm,  thereby also positively affecting their families and friends that motivated you to seek a career in medicine, so never forget this in your basic science years.
During your training there will be periods of stress and perhaps even doubt, but that is when you can call upon your student colleagues, teachers, support staff at Northumbria, then when in Grenada Dr Rao Dean of Students and his staff and also the staff of the Department of Educational Services, and of course your family and friends for help, support and advice. But you must also draw on your own inner strength and when doing so remember the humanistic values and goals you strove to achieve; recite again to yourselves the words of the Professional Commitment you will shortly make and recall the memories of today for I am sure it will serve you well. During your clinical training too, there are many people in the UK and US to advise you along the way, so you really are never alone.

Another obligation you must fulfill is that as trainee doctors you are fully accepting the important professional duty and responsibility to treat all with whom you come into contact, irrespective of race or creed, with due manners, courtesy and respect.

You will of course during your student and indeed subsequent postgraduate careers have many examinations to take. These are obviously serious and nerve wracking occasions but can sometimes have their amusing side too. I never sat a multiple choice question paper in my career; then it was all essays and vivas. I read my basic sciences at Cambridge University and on the appointed day arrived trembling at the Anatomy museum for my Final Anatomy viva. There was a wonderful man called Mr Merryweather who looked after the Anatomy museum and who arranged when we entered the museum for our vivas and which table we had been allocated where our examiners were seated. I must have been looking somewhat pale and anxious as when he helped me on with my short student academic gown which we wore in those days, he leant over my shoulder and whispered in my ear “Don’t worry Mr Croft from Selwyn College: please remember sir just like you and me, every morning your examiners sit on the lavatory!  Good luck sir!”

So you can imagine my thoughts as I approached my two white coated examiners sitting down behind a green baize table.
However my heart sank as one of the examiners was Professor Shute, the organizer of the one year Comparative Anatomy course which we had occasionally attended, but certainly not excessively revised!

Nevertheless, one fact of comparative anatomy I do remember to this day is that the three parts of a crocodile’s jaw are represented by the three tiny bones, in the human middle ear. Now without a shadow of a doubt, I can assure you all that this fact has proved most useful to me on a daily basis during the whole of my surgical career!

However the younger man, Dr Message began by asking me some origins and insertions of muscles on a humerus which was fine. Then we moved on to a skull with the origins and insertions of the medial and lateral pterygoid muscles which I was then asked to repeat with the skull turned upside down: (nice touch I thought!). Finally he zeroed his pencil point at a tiny area on a neuroanatomy slide: I proudly announced it was the nucleus of the ementia teres…and I knew I was right; that was the detail we were expected and had to know in 1965.

He then invited the Professor to take over, who then asked “Are you interested in comparative anatomy?” “Of course sir, absolutely fascinated” I stuttered. “Good, so come over here” he retorted. He took me to a large trestle table covered with skeletal remains ranging from a sabre tooth tiger’s skull to a dormouse and asked me what in retrospect was a reasonably simple question “please show me a non-mammalian skeleton”. I panicked!…mammals, they suckle their young: my thoughts instantly turned to breasts: no you fool that’s soft tissue: he said non-mammalian, that’s without breasts and I have to choose a non-mammalian skeleton from this hoard!

The time for these thoughts to whizz through my head was probably momentary but with my adrenaline levels in the danger zone it seemed like an age and my heart raced and thumped and a rivulet or two of perspiration ran down my back. Then, right at the far side of the table I saw a strange looking skeleton and on one of its rather narrow ribs in extremely faded Cambridge ink I could just about discern the word “Penguin”. I was confident the myopic Professor would not be aware of this. “Oh there sir” “Excellent” he replied, “what is it?”
Very conscious of occupying the remaining viva time to my advantage I said “I’m not immediately sure sir, may I describe it?”

He acquiesced, so I slowly took the Professor through the large protruding beak, but small skull, the large elongated thorax and abdomen, the very short legs but enormous feet, couldn’t possibly have been webbed could they?, but extremely underdeveloped upper limbs, so can’t have been wings.…”So?” the Professor abruptly quizzed. “I’ll hazard a guess” I replied, “it couldn’t possibly be a penguin could it, sir?”  “Excellent Croft”, he exclaimed, “no need to ask you anymore comparative anatomy” and he strode off heading towards an occipital neck dissection. I intentionally lingered slowly behind him as I adjudged my viva time was almost up. It was then that I felt a gentle tap on my right shoulder, I turned: it was the younger Dr Message who then whispered in my ear “I can see the word penguin too!”

Four years from now, you White Coat Students will have the wonderful opportunity of being able to walk across the stage of The Lincoln Centre in New York in front of an enormous audience to receive to great applause, frequently augmented by yells and screams, your medical diplomas from Chancellor Modica, who will then read the Graduation Proclamation when you legally become doctors in an instant!

But take note, the Chancellor does not suddenly flick a switch to magically turn you from a medical student into a doctor in a flash; this is a gradual transitional process which actually begins here today and which continues every day of your medical student training. So never forget you are learning to become and are inexorably becoming a doctor during the whole duration of your medical student life.

The increasing responsibility this brings will be assisted by your advancing maturity brought about by the assimilation of your medical knowledge, but also by your ever increasing experience of academic and enriched cultural life that you will experience at Northumbria University here in Newcastle, at St. George’s University in Grenada and then in the St. George’s Clinical programme both here in the United Kingdom and also in the United States of America.

Travel alone is a great educator: studying a medical curriculum is an amazing educational experience: combine the two and you have the quite awesome opportunity that St. George’s medical training can give you. An experience which thereby prepares you for the medical global world in which we now live and provides you with an experience which you will carry with you for the rest of your lives.

When the mantle of the White Coat is symbolically placed upon your shoulders and when you make your Professional Commitment, you are accepting the profound responsibility essentially required of both a medical student and doctor and you are all today beginning your journey to medical qualification.

I wish you all God’s speed in your venture.

This journey will require great learning, a process which you will need to continue throughout all of your medical careers. One of the fascinationg facts of medicine is that we are on a constantly moving scientific platform with enormous changes in the prevention and treatment of diseases.
In my lifetime I have seen how many infectious disease patterns have drastically changed with improvement in hygiene, housing and education, with the development of antibiotics and vaccination programmes  resulting in the reduction of most and elimination of some infectious diseases.

But then, for example, due to lack of hospital hygiene and abandonment of principles taught to us by Lister in the nineteenth century, together with inappropriate and overuse of antibiotics, seen nature come fighting back with MRSA and clostridium difficile.
The treatment of sexually transmitted diseases was increasingly successful, until a major revolution arrived in the form of HIV.

In surgery, streptomycin drastically changed the necessity for lung surgery for Tuberculosis. Stomach resection operations regularly performed for decades for peptic ulcer are virtually now no longer necessary because of the development of powerful gastric acid reducing drugs.
New treatments for cancer are being developed all the time: now we hear of the ability of ultra violet light to be able to release coated antibodies to kill cancer cells having reached their malignant target, thereby avoiding the side effects of chemotherapy.

One of my old surgical mentors used to say many years ago “Rodney, all the answers lie on the biochemist’s bench” Then, he was right, but now to that I think has to be added the geneticist’s and the stem cell researcher’s bench.

Many people in the developed countries of the world do not now die of old age but the degenerative diseases of old age. It seems stem cell research will in the not too far distant future be able to halt and even prevent the degeneration of tissues, so theoretically we could live forever. What enormous population problems that would cause together with all the ethical problems and end of life issues with which you all will be involved.

The Professional, ethical and financial debates all these changes will generate will be endless and will be a daunting but nevertheless interesting challenge which you will experience during your future medical careers.

This constantly moving scientific platform is not only a challenge for you but also for your teachers: we too have to keep apace!

Furthermore, if you decide to specialize, choose your speciality carefully. Streptomycin changed the necessity for all the pulmonary surgeons many years ago: The many stomach operations I performed in my career for peptic ulcers are no longer necessary, operations I performed for many years gaining access to major intraabdominal arteries via large abdominal incisions can now be accessed by using a fine arterial catheter placed via an artery in the groin. So if I were beginning vascular surgery today I would perhaps be wise to opt for interventional vascular radiology. There are numerous other examples but remember when the time comes to decide on a chosen speciality do try to envisage how it may look in 20 years time.

An interesting gaze into the medical crystal ball.

So it is not just life-style issues, so fashionable with the present generation, which are pivotal in wisely choosing one’s future medical career.

A significant number of you wish to return to your home countries to practice medicine, many of which are developing countries and you may be in awe of the task ahead of you as on qualification you may think what difference can you make to your fellow countrymen, women and children.

I have no hesitation whatsoever in saying you can make an enormous difference not only to the individual patients you treat but in turn to their families and communities so the beneficial effect is far reaching.

In 1967 when I was a final year clinical student at The Middlesex Hospital Medical School in London, I did my three month clinical elective in a Mission Hospital in Zululand, now Kwazulu in South Africa. This was of course at the time of Apartheid. The hospital was the Charles Johnson Memorial Hospital situated in Nqutu, a tiny settlement on the veldt about 30 miles from the nearest town Dundee. The hospital then had over 600 in-patients, had departments of medicine, surgery, obstetrics, gynaecology  paediatrics and a two large TB wards.

The Doctor in charge was an absolutely amazing man called Anthony Barker who with his doctor wife Maggie, went out to Nqutu in 1945 having served as a ship’s doctor in WWII in the British Merchant Navy. When he arrived there the so called “hospital” was a simple wooden dilapidated disused store containing seven frightened and suspicious patients. Dr Barker and his team over a period of years transformed that dilapidated old store into the hospital I have just described. It continues with its wonderful work to this day. When I was there in 1967 we operated most days; we had outreach clinics at trading stations on the veldt, often held in the stables; one clinic indeed on the Battlefield of Isandlwana which preceded the heroic defence of Rorke’s Drift in 1879 as depicted in the famous epic film Zulu. The way Anthony Barker changed the lives of the Zulu people and the people who were fortunate enough to know him was immeasurable. He really was a truly remarkable man.

There are of course many other examples around the world of such leviathan human efforts to improve the health of the needy; so the message is: it has been done, it is being done, more needs to be done and for many of you on the Keith Taylor Global Scholars programme your turn can come and you can be successful in such a mission.

During my very memorable time in Zululand which means “Heaven land”, I naturally assimilated some of the language: I still to this day remember amatispuni amabili gatatu neylanga….two teaspoonfuls three times a day.

On leaving Nqutu, I returned to Johannesburg prior to returning home to England and was met by the wife of a friend of mine who was the Managing Director of Canada Dry in South Africa. I was in my student rig and was met at the station by this beautiful lady, Grace, wearing a lovely summer’s dress and gorgeous hat. She took me over to a stunning cream convertible Mercedes with the roof down thereby showing off its beautiful red leather upholstery. The chauffeur dressed in his very smart grey uniform with cap and shining black knee length boots was a native African (a Zulu in fact) and as we drove through the streets of Johannesburg with the sun shining, Grace asked how I had managed conversing with the Zulu patients. Having been asked this question by a lady, I just automatically came out with a string of Zulu phrases used in the gynaecology clinics on the veldt including “get undressed” “hurry up please”,(this was related to the inordinate time it took the Zulu ladies to undo their heavy leather pleated skirts) and ”lie down, look up at heaven”.  “Lala pansi begape Zulu”.

Now in 1967 at the height of Apartheid, fraternizing with native African females was I recall a capital offence. The chauffeur obviously totally unaware of my medical connection, turned round and glared at me in total amazement and utter horror to which Grace briskly patted him twice on the shoulder and said “It’s perfectly all right Mhambi, Baba’s a doctor, he was treating patients; drive on!”. Serenity was restored!

All of you White coat students here today have a marvellous opportunity ahead of you with the global medical passport a St.George’s MD affords you. So grasp it, as there are great works to be done and wonderful ambitions to be achieved. Enjoy your student life with your colleagues, teachers, families and friends, especially as it really does go quite quickly!

Again many thanks to St.George’s for their kind invitation to address you on this wonderful and memorable occasion of your White Coat Ceremony here today which I have no doubt will live long in your memories.

Also again, many congratulations to the January 2008 students who are entering the St. George’s Keith Taylor Global scholars programme at Northumbria University.

In conclusion, may your student days and indeed the journey throughout the whole of your future medical careers and lives prove to be for you all, a fulfilling, worthwhile and joyous adventure.
For if it is so and I am confident it shall be, you will then justifiably be able to say at the end of your medical careers and indeed lives,

“My time on earth was not wasted”.

The very best of luck to you all!

Thank you.

Special Public Lecture Series at the KBT Global Scholars Program in UK

ian elvin dr michael chewThe KBT Global Scholars program is designed for students who wish to spend all or part of their professional lives in developing nations or in underdeveloped areas of developed nations. SGU has introduced this special public lecture series to reinforce the international aspects of the KBTGSP.  One or two lectures a term will be presented by professionals well versed in a variety of health related global issues.

On September 20th at the Newcastle Upon Tyne campus of NU, Sport Northumbria kicked off the series with a lecture on sport and health.  Ian Elvin, Director of Northumbria University Sport addressed his audience with a presentation titled “Developing Community Health through Sporting Partnerships: The Global Vision.”   Professor Elvin believes strongly in the power of sport as an instrument of both personal development and social change.  Teaching the rudiments of health can be a real resource for developing communities.   Through his efforts, Sport Northumbria is involved in a number of local and international community sport projects,  providing a unifying platform in areas which include the Caribbean and Zambia.

Now ten years old, Sport Northumbria offers a myriad of competitive and social sport opportunities to the international community of Northumbria University (NU).  Ian Elvin has worked at NU since 1979; he was Program Head for Sport Management before becoming Director of University Sport in 1995.  In this capacity he is responsible for the planning, delivery and management of all sport facilities, programs, clubs and services at NU.

Ian was a Board member of the European Association of Sport Management from 1992 – 2003 and has been Chairman of Sport Newcastle since its inception.  He is also Chairman of the English Student Rugby Union’s Development Committee.

The second lecture was given on October 22nd by  Dr. Michael Chew, a Science Program Officer at the Wellcome Trust – one of the largest biomedical research charities in the world.  He presented a lecture on “Diseases of Poverty: The Good, The Bad and the Ugly.”  Dr. Chew’s life achievements and focus have been devoted to studying those diseases which target people who are living in poverty.  Many of these diseases can be prevented with a community’s dedication to public health issues.

Dr. Chew’s responsibilities include receiving and processing research grant applications in the areas of immunology and infectious disease, advising scientists about their research and careers in this area, and ensuring that funds awarded by the Trust are used appropriately.

Dr. Chew travels extensively, usually to remote and impoverished places, as most of these research projects are conducted in the developing world where ‘diseases of poverty’ such as malaria, TB and HIV are pervasive.  Prior to joining the Trust in 1997, Dr Chew worked as a research scientist at the Institute of Child Health, London, and Imperial College, London after completing his PhD in Parasitology at Imperial College in 1981.

SGU and NU look forward to the continued success of the KBTGSP lecture series which will provide students with information on public health issues much needed in today’s globalized society.

Published 11/13/2007