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College of Medicine Dean Dr. John Fogarty Remarks White Coat Ceremony, Class of 2012

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FRIDAY, AUGUST 15, 2008, 6:00 P.M.

Thank you - it is a great honor to address the Class of 2012 on this, YOUR day, acknowledging this significant transition in your professional life as you get ready to incorporate clinical care into your training. The white coat, along with the stethoscope, is one of the most recognizable symbols of medicine. You should wear it with great pride. It is interesting to note that physicians first adopted it at a time of great cynicism about medicine and its craft and practices, many people associating doctors with quackery and charlatans. Physicians needed to ally themselves with science, so they took on the frock of the laboratory scientists. So we today will hopefully symbolize the best of the blend of science and clinical care.

The color white is also significant since it symbolizes hope and health in contrast to the old hospitals where only the very poor went for care and conditions were not conducive to recovery.

But I wonder why I am the one who was asked to address you today since I hardly ever wear a white coat and had to purchase one for this day. And what do I have to say to you as you sit excited about your future as you are at your most enthusiastic and idealistic stage of your career. Over the years, many physicians -- particularly psychiatrists, pediatricians, and family physicians -- have given up the white coat, perhaps thinking that as a symbol of authority, it might create a barrier for effective patient care.

My hope today is that you will take on the best of the symbolism of the white coat and be the kind of physicians we all aspire to be.

I come from a military career steeped in oaths and traditions, a wearing of uniforms and symbols of status and hierarchy. I wore a uniform for over 28 years (perhaps that's why I hardly ever wore a white coat). I have attended or participated in countless change of command ceremonies, promotion, awards and decorations programs, and Army school graduations and retirements. Each is a reflection of traditions of service and passages to new stages of careers.

Your excitement today reminds me of the pride and excitement I would see in the soldiers at Fort Benning (the home of the Infantry not too far from here) as they completed basic training. The trainees had been tested to new levels of physical, emotional, and mental fitness; some of them had to dig down and find reserves of strength and commitment that they did not know they had. I know many of you have been tested and challenged this first semester. Many of you questioned whether you had what it took to be a doctor. The basic training graduation signified entry from the basic trainee to a real soldier. As you put on the white coat, this ceremony signifies your passage to the essence of doctoring -- which is caring for patients.

The art and history of medicine provides an interesting view into the essence of being a doctor and how medicine has changed in the last 100 years. One of the most enduring works of art is 'The Doctor" by Sir Lewis Fields, showing the caring doctor at the bedside of an ill child, concerned but helpless.

There was little to offer the child and family other than compassion and watchful waiting to see if the crisis would pass and the child recover, or not and the child would die. There are equally compelling pictures of Sir William Osler, considered by many to be the epitome of the modern teaching physician, on bedside rounds with his students in the early part of the 20th century, engaged in the discovery of the elusive diagnosis. Neither of these physicians had the antibiotics, diagnostic tools, or heroic procedures we have today; some would even say that they were equally ineffective in their cure of their patients. But if Osler were alive today, the trait he would most likely wish to see endure in all physicians in the 21st Century would be compassion. As he said it so well, “It is more important to know what patient has the disease than what disease the patient has.”

I am very excited to be here at the FSU College of Medicine because this is a special and unique place – your mission “to develop exemplary physicians who practice patient-centered health care, discover and advance knowledge, and who are responsive to community needs” attracted me to this opportunity. Many schools, including the one I just left, have redesigned their curriculums in the past 10 years. Most have had as one of their guiding principles to be “patient focused.” This medical school was founded on and has as one of its cores, that principle. Much of your teaching -- in lectures, small groups or self-study -- focuses on the diagnosis of disease or maintenance of health around the care of patients and patient and family case studies. But what does it mean to be “Patient focused?”

I believe it requires:

  1. The capacity to listen and communicate;
  2. A comprehensive focus on prevention;
  3. Consideration of health and illness of individuals in the context of their families, cultures, and their communities;
  4. Understanding of individual professional and societal values and how they affect clinical decision making;
  5. An awareness of and ability to analyze ethical issues in the context of the patient’s illness and values.

Starting a new medical school allowed your faculty to design from the ground up a curriculum that was comprehensive, integrated, and patient focused. Integrating the basic and clinical sciences by focusing on the patient and systems rather than specialties or disciplines places the emphasis directly on why most of you are here – to take care of patients.

Because of the explosion in medical knowledge and technology in the past 50 years, many students have become more disease focused to survive, rather than patient focused. Perhaps we are here today to make an effort to avoid that. Lewis Thomas expressed his concern about the widening gap between the doctor and the patient when he said: “Medicine is no longer about the laying on of the hands, it is more like reading the signals from machines.” And “if I were a medical student today, I would be apprehensive that my real job, caring for sick people, might soon be taken away, leaving me a different occupation, looking after machines.”

These are not new ideas. At ceremonies such as this, we recall the words of the ages to remind us of the values, guiding principles, and tenets of our profession. The white coat reminds physicians of their professional duties, as prescribed by Hippocrates, “to lead their lives and practice their art in uprightness and honor.” Maimonides in the 12th Century said: “May I never see in a patient anything but a fellow creature in pain. May I never consider him a vessel of disease.” Unfortunately today, we know that pain is inadequately managed even in our best hospitals and there are far too many errors in this complex world of medicine that you are entering which leads to suffering, prolonged hospital stays, and loss of life.

Mark Twain was suspicious of doctors – once when he was awarded an honorary degree he said, “I am glad to be among my own kind tonight. I once was a sharpshooter, but now I practice a much higher and equally as deadly a profession.”

Today, in many ways, we have a disease cure system, not a health care system – a recent survey of average citizens suggested that most believed that physicians do not care about their patients as much as they used to and are too interested in making money. What do they see in the doctors who care for them that make them feel this way?

The special profession you are entering is a wonderful mosaic of stories, people, and experiences of the human existence. As you learned in your medical interviewing course, you will do well if you just remember one thing: Listen!

Osler said, “Listening, not imitation, is the sincerest form of flattery, it is unspoken caring” and advised “Look wise, say nothing and grunt. Speech was given to conceal thought.”

Epictetus said, “We have two ears and one mouth and should use them in that proportion.”

As you listen, you will have the kind of wonderful experiences that I have had in the past 30 years in sharing the thoughts, fears, joys and ills of your patients, to understand them in the context of their families, and their illness. I would like to share just a few with you.

The young - the child during a routine office visit who brings me a picture she did in class for me --for her doctor -- and hopes I display it on my office wall.

The old - The 93 year old retired MC General who called me after he was discharged from the hospital with a complicated pneumonia, thanking me for not giving up on him and pushing him to recover.

The sick - the older gentleman knowing he was dying from bladder cancer who bought his wife a puppy so she would have a companion after he died. A special friend who I actually lit his cigarette for him in his final days.

The well - the middle aged woman scheduled for a routine health maintenance exam who really did not want to go into all that but just wanted to discuss and get advice on how to train for a marathon.

The fearful - the 50 year old man returning to the office after a 5 vessel coronary bypass operation. I had seen him for the first time a month before and we were beginning to address his risk factors and lifestyle when he had his heart attack. Needless to say, he was scared and shaken by his experience. He remembers little of his hospitalization, but does remember my visit to the ICU after the operation.

The joyful - the Christmas cards I still get with pictures of the children I helped deliver.

The newborn - helping a young family deal with an unexpected congenital defect after a normal delivery.

The dying - all of the patients who have taught me so much about the gift of life and their faith in dying.

What are the attitudes and skills that I would recommend that you develop as you go forward?

  1. Be a doctor – listen, care, and communicate with your patients.
  2. Talk to your patient in the way that best fits for them – all patients are not alike.
    They have unique cultures, fears, and needs. It is up to the doctor to adapt to the patient not the other way around.
  3. Be accessible, be available, and give the patient the time they need.\
  4. Know your science and your limitations. Compassion without competence is mistaken kindness. Be a lifelong learner and learn with your patients and from your patients.
  5. Care for yourselves and your families – enjoy the journey and don’t always focus on the destination. As a group of people who pay homage daily to the concept of delayed gratification, it is critical for you to enjoy the trip along the way. The station is only a dream – it outdistances us constantly.

As Francis Peabody in his famous essay “The Care of the Patient,” delivered at Harvard Medical School in 1926 said, “the essence of the practice of medicine is that it is an intensely personal matter… the treatment of a disease may be entirely impersonal, the care of a patient must be completely personal.” He noted that the most common criticism by older physicians of young graduates was that they had been taught a great deal about the mechanisms of disease but very little about the practice of medicine, or that they were “too scientific” and did not know how to care for patients. His essay and a commentary was republished in JAMA in 1984 and his words are just as true today as they were in the 1920s when he spoke them. “The secret of the care of the patient is in caring for the patient.”

If you simply remember that in medicine, the goal is, “To cure sometimes, to relieve often, to comfort always,” you will do well.

I congratulate you on your passage to clinical experiences and wish you well in your journey.