This past Monday, I had the honor of delivering the keynote address at commencement ceremonies for my alma mater, the University of Medicine and Dentistry of New Jersey – New Jersey Medical School. What do you think are the biggest challenges facing the next generation of young physicians and dentists? How can we better bridge primary care and public health?
It is an honor to be your commencement speaker.
It’s astounding to think it was just 20 years ago when I was in your seat. My medical school graduation was one of the most momentous days of my professional career. Personally, I was humbled by the honor of having my grandfather travel from a rural town in Puerto Rico to see his granddaughter become a doctor. As for many of you, this accomplishment was not just my own, it was - and still is - my family’s accomplishment as well. Professionally, I saw it as the beginning of a journey I had always dreamt about. It was real and I had the paper to prove it!
One of my internal motivations has always been hearing my mom’s voice in my head saying “don’t forget where you came from and make sure you give back to the community”. I’m certain that many of you may have that same tape running in your head because we all come from somewhere and we all get to where we are with the support of others. And even if we don’t share similar upbringings, we share the fact that we had the privilege and honor of being from New Jersey Medical School.
Newark, New Jersey and its people have become a part of you - same as you have become a part of the lives you have touched in this city. The patients and families I cared for and learned from here helped to shape my views when I went to Washington, DC to work in a community health center. They also helped to inform my decisions when I went into public health in NYC and now in Baltimore City as health commissioner.
And so MY first point to you is to “remember where you came from and make sure you give back to the community” wherever that community may be.
In preparing for this speech, I searched the internet for just the right quote to impart words of wisdom and I pretty much gave up until I came across a quote that reminded me of what my mom said. It’s a quote from the 18th century German philosopher, Immanuel Kant:
“Always recognize that human individuals are ends, and do not use them as means to your end.”
By remembering that individuals are ends, we then come to the second point: Each of our patients has something to teach us. All too often this point in medical school has been made within the context of learning about the body and natural course of disease. As you progress in your careers, my hope is that this point will take much greater dimension to learning and integrating how social determinants of health – things that impact where we live, work and play - affect the patients you see and the way you practice medicine.
As physicians we have the privilege of being let into our patients’ lives. Some times by choice and other times in spite of their objections. This privilege should never be taken for granted. With this privilege comes the responsibility of bearing witness to the social conditions that affect individual health outcomes, as well as community health outcomes.
One of the most important things we can do is not ignore the power of the white coat. I encourage each of you to be more than just physicians. I challenge each of you to be physician advocates. To be outraged by the health inequities that are driven by social determinants of health such as education, housing, access to healthy foods and transportation. There are opportunities that will be afforded to you by virtue of the power of the white coat. Use this to the advantage of your patients.
According to the Institute on Medicine as a Profession:
Physician advocacy extends beyond the provision of good clinical care and advocacy on behalf of individual patients to include collaborations with people and organizations that combat interpersonal, structural, and systematic inequities and abuses in our society. Advocacy is the bridge that links patient care with efforts to address social determinants of health, institutionalized prejudices, and structural dislocations that patients and communities face. Physicians are especially qualified to advocate upon behalf of social change. The prestige and credibility that they command may serve as valuable resources in advocacy efforts.
When I was just out of training I worked in a community health center in inner city Washington DC. Day in and day out I saw children that were being lead poisoned by their housing environment. It was frustrating to be treating outcomes that were so easily avoidable. I was at a loss of what to do until I did what we as scientists have been trained to do – document what we see.
I created a very simple database that tracked the addresses of children with elevated lead levels. This simple tool demonstrated that there were identifiable units that were serially poisoning the children of our community. Just as I finished the first phase of the database, I was connected to a young lawyer in the Department of Justice who came to our clinic working on another project, but who was also interested in housing justice.
To make a long story short, he was able to use the database to make his case against delinquent landlords even stronger and levy heavier fines against those landlords. In the end, then-Secretary of Housing Andrew Cuomo came to our clinic to highlight the work that had been done.
The power of the white coat lies in the ability to apply your diagnostic skills to identifying trends in a community. It lies in your ability to translate medical data into everyday language that illustrates that acuity with which things such as housing policy, educational policy and even land use policy affect communities such as the one we have served here in Newark.
As John F. Kennedy said, “the goal of education is the advancement of knowledge and the dissemination of truth”.
Births and deaths and the dignity with which they occur remind us of why it is we do the work we do and that there is urgency to creating a healthcare delivery system that makes healthy choices the default choices.
You will be among the first group of doctors finishing their residency training when the majority of the provisions within the Affordable Care Act go into effect in 2014. None of us know exactly what this beast will end up looking like, but one thing is certain: It won’t be what it is now.
The question is “Will it be what we want it and need it to be?”
Not one of us should have the delusion that an insurance card will be a game changer when it comes to addressing health disparities and health inequities. But we should all have the courage to advocate for a healthcare system that values preventative care, makes it easier for doctors to do the right thing with the use of electronic health records and provides a quality feedback loop at the systems level so that we can know when what we’re doing isn’t giving us the outcomes that we anticipate.
As I end, I am reminded of a visit I made to South Africa shortly after apartheid had fallen. I had the privilege of visiting Kwazulu-Natal, the birthplace of Community Oriented Primary Care. COPC is a way of practicing primary care that incorporates the social determinants of health. It was started in the 40’s by Sidney and Emily Kark, first in Israel and then in South Africa. It gave rise to the community health center movement here in the 1970’s.
During that trip I also had the privilege of spending time with young doctors who were studying at the newly formed school of public health. To this day, I have never forgotten what one young doctor said to me about her class - “We are excited to heal our country”. I hope that you too are excited about healing your country and your community.
We come to medicine out of love – love for science and the purity of reason; love of our fellow man and the wellness of communities. Be the best you can be at whatever specialty you choose because your patients deserve it. Be advocates - whether you are an interventional radiologist or a general pediatrician – because your patients and their communities need you. Understand social determinants of health and how they affect your daily practice and the outcomes you can attain with your patients. Also be mindful of the fact that where we live, work and play oftentimes play as big a role in making us sick as they do in keeping us healthy. But most of all strive for health equity.
Thank you and Godspeed.