Year Two Luncheon

As we move ahead in our careers I think we all find ourselves saying things like, "back when I was a med student" or "back when I was a resident..." I thought I would avoid that. But, since I am talking to future graduates and since I should be talking about transitions I think a couple of vignettes will fit...

So... back when I was a med student about to start a third year rotation (which will go unnamed) a few of my classmates and I gathered for our pre-rotation test patient encounter: I was the first student selected to enter the tomb, I mean, room. So we were all dressed up very nicely, professionally, I in my dark green dress pants, a pressed oxford shirt and a basic solid color tie. I went through, a bit awkwardly, eliciting a history and then examining this "paid patient" and tried my best to pretend this was the real thing. Then I proceeded to the adjoining room where I was greeted by the director of this rotation and a video camera. I presented the patient's story, my physical exam findings, and the differential as the attending and video camera glared at me. I answered a few questions about the case. The video camera was turned off. Then, the part we probably all hate... the live critique: "Vitterito, your patient history and physical were very good. Your differential was adequate for someone about to begin this rotation. However, you are wearing inappropriately colored socks. That was the critique. In the next split second, I am sure a few really nasty thoughts went through my head. Wasn't this person aware that I worked in the business world for 8 years and knew how to dress myself? Hasn't this person heard the saying, "clothes don't make the man"! Nonetheless, I proceeded out to the line of my peers waiting to go after me, with a beet red face, dilated veins on my forehead, and a sea of sweat beads pouring down my face. I am positive some of them had a bit more fear going into their assessment after they saw me.

I am honored to have been invited to share some thoughts about the transition. I have to admit in some ways the idea of talking about my transition is a bit self-aggrandizing as I have the luxury to stand here and proselytize about my experiences and thoughts.

Quality of care is probably one of the hottest-phrases in medicine these days. Quality of medical care often focuses on the precision of diagnosis and technique and the success or failure of treatment. Increasingly more research has focused on other aspects common to the medical care environment: including patients in decision making, the quality of the patient-physician relationship, and promoting a multidisciplinary network to support patients' additional burdens which may impact overall well-being.

Improving medicine goes beyond finding new cures or decreasing side effects. Providing care extends to better ways of offering palliative care, better ways to involve patients in decisions, better ways to assist patients with their other needs - social supports, financial supports, etc. An analysis of survey responses by parents in neonatal units showed that having adequate social supports, having consistency in care teams, and sharing in decisions about care were significantly related to their perception of high quality care. It is probably not too much of a stretch to think this applies to all fields of medicine.

Everything you do in your first two and then your last two years (in the traditional sense) of medical school focuses on acquiring and strengthening your medical acumen and developing reasoning skills so you can deliver care with accuracy and precision. If you are asked what do you prefer... a doctor with wonderful bedside manner and so-so medical skills or a doctor with a miserable bedside manner and phenomenal medical skills, what would you answer? I tell you my answer is simple: I WANT BOTH.

What a thrill it was for me to find this in a pediatric urologist with whom I did an inpatient elective, who demanded excellence and respect both in the OR and at the bedside, a quality I called "personable professionalism." Hopefully, that is what you are training to become.

Personality is probably not just an inborn success or error of [psychologic or neurologic] development. Threads of knowledge build the fabric of your medical education, but there is another part, an important part that can be, I think, ¼ taught, ¼ imitated, ¼ developed, and is ¼ innate: I call this, your "patient personality." In today's medical market we have to focus on maintaining high standards of all aspects of care despite increasing demands and rapid advances in technology. Make what you can of your next few years in training. You can learn what is important to patients, those human beings that you treat and you must respond to those needs. Compassion, honesty, transparency, and patient-focused care drive good quality [of care].

Remind yourself often that there is another aspect to the human bodies you will be treating; something perhaps not as concrete or tactile as that broken bone or those out of whack hormones... you are treating another being. You have to remember this!

Nine years ago I think it was when I sat here about to
make this transition, that a speaker said he was envious

Joseph Vitterito, M.D., DMS '00
Neonatology/Pediatrics
Dartmouth Hitchcock Medical Center

of us. He pointed out that we were closer to the latest and greatest in medical knowledge than he had been in years. He stated that time should be the period of greatest inspiration and we were about to be faced with things that will make the greatest impact... a crossing in our careers. I don't entirely agree, I need to challenge that thought. There are so many crossings ahead you will face. I think of those times that have had an impact on me:

• Every time I see any patient
• Every time I start on service
• Each birth I attend
• Or the day I see a birth of a baby and then see that same baby die
• The time I worked with a young patient who chose to admit himself to the hospital in order to die among his care team
• The day I help someone face what we think is a bad prognosis
• The day I give good news
• [Every day I come to work; in fact, this is such a great profession I never even really think about it as "going to work."]

I am constantly reminded of the importance of communication and compassion in my practice. But it was just 9 weeks ago I had the biggest affirmation of their magnitude: I went to work for a second time with the doctors of a neonatal unit in Kosova. There was a baby born with congenital heart disease, something correctable with surgery, but a surgery unavailable in that area. I was introduced as a doctor from the USA. The baby's mother thought I was going to be her son's healer, something for which I was powerless. I don't want to give the wrong impression in this next statement so let me clarify a few things. The unit there is very very busy. And babies die at such a higher rate than here. And the people there are some of the warmest souls I have met. But this baby was left on the warmer, dying before my eyes alone. And chaotic business carried on as usual around him. So I discussed different comfort measures with the team. And then the most remarkable thing happened for me personally... the chief of the neonatal unit wanted me to lead the discussion with this mother about end-of-life issues. She wanted to witness exactly what I would say and how I would elicit the needs of this family. After understanding the complete state of her infant son, she wished to take him home so he could pass away in his own crib. And we arranged for that.

The moral here is twofold... (one) you can never stop learning, and (two) what you have received thus far out of your training here at DMS can transcend many boundaries. I tell you this because what ended up being most important to these doctors, this mother, that baby [infant human being] at that moment and in that situation was not technical expertise, but compassion and communication...two basics.

I made a harsh promise with myself before I started residency that "the day I stop shedding a tear at the death of a patient is the day I stop practicing medicine." I forbid becoming complacent.

So what's my overall message to you? Continue to open your minds and hearts as you continue to enrich your brains, your ears, your eyes, and your hands. The other stuff is important.

I encourage you to take advantage of these next two formative years and pay attention to the other parts of becoming a physician. These things don't help you pass boards, but they'll help you pass muster with patients.

Allow me now to indulge you with one more, "back when I was a third year:"

Back when I was a third year, my very first day on family medicine rotation in Rhode Island... First patient is a 50-something year old single woman. It was time for her yearly "exam." So there I am in my white coat, stethoscope in hand. We have a nice initial encounter, review of systems, full/complete history. I leave the room as she prepares for the exam. I come back in after knocking and sit down in proper position for the exam, my attending gazing over my shoulder. I start the exam explaining the procedure. Just shortly after I start the exam, she pushes the sheet down and yells, "What the heck are you doing down there?!!?" Again, beet red face, sweat pouring down my brow, veins showing on my forehead. Then she laughed and broke the ice. At least I had the right color socks on that day.

Thank you and congratulations.