“Be bold,” Dean Chip Souba told the members of the Geisel Class of 2014 at last weekend’s Class Day Ceremony. “Be aspirational. Reach for the stars. You won’t regret it. You’re a Geisel School of Medicine graduate.”
The dean was one of several speakers to address the 192 new graduates. To read the full text of the speeches, click on the links below.
Anne de Papp, Class Day Speaker
Chip Souba, Dean of the Geisel School of Medicine
Aris Damianos, Alumni Council President
Paul Charlton, MD Class Speaker
James Geiling, TDI Class Speaker
Marie Onakomaiya, PhD Class Speaker
Anne de Papp, Class Day Speaker
Anne de Papp, MD ('88), is the Global Director of Scientific Affairs for the Women's Health and Endocrine Franchise at Merck.
Hello Class of 2014! I want to congratulate you on reaching this day and thank you for the honor of making me part of it.
Last December I received a very unexpected call from Dean Souba. We had met only once before for a few hours and had discussed the value of industry-academia collaborations. I was excited to hear about the changes he described in the medical school curriculum at Dartmouth and the depth and breadth of all the student activities. I reminisced about my time at Dartmouth Medical School and found it hard to believe that I had started my journey here almost 30 years earlier!
When Dean Souba invited me to be your commencement speaker, I was both tremendously honored and a bit uncertain. I was reassured by the fact that I couldn’t even remember my own commencement speaker, but I was at once humbled when I learned of your past commencement speakers, such as the novelist Abraham Verghese and the humanitarian Paul Farmer and other individuals who have made tremendous impacts on global human health. Dr. Souba reassured me that you would enjoy hearing from a DMS alum—and he told me to give a talk from the heart—so that is exactly what I intend to do.
Over the next 15 minutes, I want to try to explore with you some of the most striking ways that both the science of medicine and the practice of medicine have changed since I graduated from medical school in 1988. I will also tell you a bit about my own personal journey navigating these changes. Obviously, in this short time I can only begin to touch upon some of the significant changes we have all experienced. Although change is an inevitable part of our lives, the changes in health care over the past 10 years, have likely outpaced those in most other fields. The technological advances in medicine and science have been tremendous.
When I started medical school in 1984, the MacIntosh computer had just been introduced, I carried a cell phone the size of a large brick, and the internet, as we know it today, did not yet exist. There was no such thing as an “online” lecture and I attended most of my classes in Chilcott auditorium. I didn’t have an iPhone or an iPad with apps to download Harrison’s [a textbook of internal medicine]. We went on patient rounds with a stack of little white index cards and a miniature Harrison’s stuffed in our white coat pockets.
Shortly after I graduated from DMS, the World Wide Web was launched (1989) and in February this year, Mark Zuckerberg announced that Facebook had succeeded in connecting one billion people around the world. The internet has completely changed the way that patients and scientists interact with the medical profession and each other. Patients today are more informed, more demanding and more connected. The internet has also changed your education, and I marvel at the way students learn today with instant access to information that could only be found within the walls of Dana library 20 years ago.
When I started medical school, patients suffering from AIDS had a very short life expectancy. As poignantly depicted in the movie Dallas Buyer’s Club, patients with AIDS suffered from cachexia, wasting, and universally succumbed to opportunistic infections with little hope for a cure. Today, with the advent of potent antivirals and combination therapy, AIDS has become a chronic disease and individuals with AIDS can expect to live to age 70.
When I started medical school, the U.S. was spending approximately $425 billion on health-care costs, or 10 percent of the GDP, annually. Last year, the U.S. spent nearly $2.8 trillion, with estimates reaching as high as $4.5 trillion by the year 2020. With the signing of the Affordable Care Act by President Obama in 2010 we began to see a major overhaul of the U.S. health-care system. Although the landscape continues to change rapidly, the ability to alter people’s lives with a career in medicine remains a constant.
These are but a few examples of the dramatic changes in both the science of medicine and the practice of medicine over the past 25 years. We now live in a world where we have a vaccine for cancer, we have eradicated polio in India, and companies like “23andMe” are providing online personal genome services. We will talk a little more about that later.
I chose medicine because it was (and still is) an honorable and privileged profession. After all, what other profession allows an individual the opportunity to intimately impact people’s lives, to physically and mentally touch and heal them? This is a unique privilege that only the practice of medicine has to offer.
Six weeks ago I unexpectedly found myself at the end of a surgeon’s knife, needing a semi-urgent decompression of the cervical nerve roots to my right arm. For anyone who has ever been a patient, you understand the feeling of vulnerability and the complete dependence and trust you place in your physicians’ hands. Despite all of our wonderful technological advances, I implore all of you not to forget the power of gentle healing hands, kind words, and the importance of respect for others.
Medicine is a way to combine the love of science and physiology with the role of an educator and healer. My first job out of fellowship, was my “dream job.” It was a fully salaried position at a teaching hospital with a university affiliate. Had the medical climate in Philadelphia not changed, I think I would still be in my original position. But it did change, and I changed with it. I was fortunate to have a superb mentor during my fellowship years, someone who really took an interest in my career and helped me develop it. Years later, this same individual (who remains in academic research today) helped me make my decision to leave my academic position. Like all good mentors, he pushed me beyond my comfort zone. It was difficult to admit to myself that I wanted a change and was giving up my lifelong dream of a career in academic medicine. But with change comes opportunity, and I embarked on a new career in the pharmaceutical industry—a career that I knew nothing about!
From my very first day in industry when I watched a robot delivering the mail I realized I had entered a whole new world. I have never been terribly tech savvy nor computer savvy. I really didn’t know anything about business or finance—I didn’t even balance my own checkbook. But what I witnessed was new and exciting to me. Above all, the emphasis was on the science and the integrity of the research, both basic and clinical. I was impressed by the individuals I met within the pharmaceutical industry and the global impact on medicine and science they seemed to be making.
My experience in industry has given me a new appreciation for cutting-edge science and drug development. A good example is our growing understanding of human genetics, which has aided tremendously in drug discovery. Drug discovery is no longer serendipitous; rather, it is targeted and the targets are provided by human and animal genetic proof of concept. I want to share with you three different drug development programs that I have worked on that are based on our understanding of human genetics.
Almost all of you are familiar with the post-impressionist artist Toulouse Lautrec. But did you know he was thought to suffer from a rare hereditary bone disease called pycnodysostosis? In fact, when the gene for pycnodysostosis was discovered in 1996, it became clear that this rare sclerosing bone disorder resulted from a gene defect in a lysosomal protease called cathepsin K. Cathepsin K is a protease highly expressed in osteoclasts and is responsible for collagen degradation in bone, a critical step in bone remodeling. Absence of this protein leads to a high bone mass phenotype, which was subsequently reproduced in genetically engineered “knockout “ mice. This genetic evidence justified the discovery and development of human cathepsin K inhibitors, now in phase III drug development for the treatment of osteoporosis.
Similarly, I am sure that many of you are familiar with the character of the Blonde Giant in Steig Larsen’s famous novel, The Girl with the Dragon Tattoo. Those of you who have read this trilogy will know that this albino giant was insensate to deep pain. However, this is not purely a fictional condition. The author, who is Swedish, was aware that mutations in the nerve growth factor (NGF) beta gene first described in 2004 in a Swedish family are associated with syndromes of pain insensitivity. This genetic proof of concept again formed the basis for the development of NGF inhibitors, or antibodies to the receptor for NGF, with the hopes that we could block the pain in painful human conditions such as osteoarthritis. Without this genetic evidence, researchers might never have pursued development of drugs to try to mimic this naturally occurring phenomenon.
Lastly, nature has created other mutants such as the Belgian Blue cattle and the Bull Whippet dog. The Belgian Blue has a natural mutation in the myostatin gene which codes for a protein that inhibits muscle development. The absence of this protein is associated with tremendous muscle hypertrophy. These cattle are known for their double musculature due to an increase in both the number and types of muscle fibers. Similarly, pictures of Wendy the Whippet can be found on the internet, describing her as the “Schwarzenegger” of dogs. This dog is an example of a naturally occurring mutation resulting in the absence of this normal muscle inhibitor. Interestingly, the homozygous condition leads to such overmuscling that these dogs are not fast runners, but the heterozygotes have a distinct athletic advantage over their normal littermates. Not surprisingly, a new “mighty mouse” has been created through manipulation of the same myostatin pathway. A mutation of the human version of the myostatin gene was first described in a German child in the New England Journal of Medicine in 2004. Interestingly, his mother was a successful competitive sprinter.
The discovery of this pathway has led multiple pharmaceutical companies to pursue the development of myostatin inhibitors for the treatment of muscle wasting conditions and muscular dystrophies. As our population ages, the development of sarcopenia (translated literally as a “poverty of flesh”) creates a huge unmet need for therapies to build muscle mass in the elderly. I could go on and on with these wonderful examples, but it is clear that the future of medicine and drug discovery lies, in part, in a better understanding of the genetic basis of human health and disease.
So where do we go from here? What will be the further advances in the science of medicine during your careers, and importantly, how will society adapt to these changes? In the long term there will be huge advances in stem cell research and tissue engineering that promise to dramatically alter patient lives and patient care, but I think genomic medicine, meaning clinical care that is based on genetic information, is a very near-term reality. With a growing public awareness of genes and the promise of personalized medicine, you are all likely to be confronted with some of the practical issues and ethical dilemmas this new era will raise.
There are already a number of genetic tests available to physicians that can help determine the responsiveness of a particular patient to a specific drug. One example is a platelet inhibitor called Plavix (clopidigrel). Patients with a naturally mutated and inherited form of a key metabolic enzyme are generally not responsive to treatment with Plavix and can be better treated with other agents. There are currently over 100 FDA-approved drugs in the U.S. that contain pharmacogenomic information in their labels. Rather than relying on the old method of trial and error, a specific genetic test can now be done to determine drug responsiveness and risk of adverse events.
Genetic tests will also more commonly be used for diagnosis—after decades of relying on the annual pap smear with cytology to screen for cervical cancer, many women may soon rely on a specific genetic test for human papilloma virus. Gene therapy is another example. Once a subject of science fiction and horror films, such as Will Smith’s I Am Legend, gene therapy has now become standard of care for rare genetic diseases such as severe combined immunodeficiency (SCID), and may offer future cures for diseases like cystic fibrosis and even cancer.
In 1999, progress in this field was slowed following the tragic death of a young man, Jessie Geisinger, at the University of Pennsylvania during a gene therapy trial. Critics have continually raised concerns over the risks and ethics of gene therapy. Society and scientists have also recognized the potential misuse of gene therapy for genetic enhancement and so-called “designer babies”. Genetic technology could just as easily be used to select for cosmetic traits as it is used to eliminate disease traits, and this has important ethical implications. Most recently, concerns have been raised with allowing patients to access their own genetic code, referred to as “direct to consumer personal genome services.”
Last November, the FDA issued a cease and desist order to Anna Wojcicki, the CEO of “23andMe”. For approximately $100 (plus shipping and a $9 monthly members fee), the company offered the public an opportunity to look for naturally occurring hereditary mutations, that might predispose people to diseases like Alzheimer’s, Parkinson’s, or a variety of cancers. The FDA issued the cease and desist order because they felt that “23andMe” was marketing a medical device without their review and approval and raised issues of both analytical and clinical validity and clinical utility. The website for ‘23andMe’ currently states, “ We remain firmly committed to fulfilling our long-term mission to help people everywhere have access to their own genetic data and have the ability to use that information to improve their lives.”
Clearly, these are exciting new technologies that bring together bioinformatics, genetics, and medicine and have the potential to alter the course of human health. How physicians and scientists and society as a whole will chose to use this technology remains to be seen. All of these approaches have a chance of revolutionizing medicine during your lifetimes.
It is a thrill for me to be here today and see some of my old friends and colleagues. I hope my comments have inspired and motivated you.
Before I leave you, I want to give you three pieces of advice. First, don’t be afraid to change. Embrace change in your life and your career and push yourself beyond your comfort zone. Remember, Darwin said “it is not the smartest and strongest who survive but it is those who are most adaptable to change.” Although I occasionally still feel envious of the individual in a long white coat with a stethoscope in hand, I tried something new that I never envisioned for myself and I have found tremendous professional satisfaction. After all, this is what life is about, new experiences and new opportunities, and as you progress through your future training you will realize that these opportunities are just beginning.
My second piece of advice: find a good mentor. Don’t work in isolation—but recognize the value of learning from others and the value of networking. Listen to criticism, but do not surrender to it. Be open to feedback, whether good or bad. In recognition of your benefactor, Theodore Geisel, you should know that Dr. Seuss himself had his first children’s book rejected 27 times before it was published. So persevere and follow your dreams. Be honest with yourself and accept the challenges ahead.
Lastly, be open to life-long learning. Science and technology are changing rapidly and you will need to keep up. Don’t be afraid to admit your knowledge gaps and seek to fill them. The actual practice of medicine can be very dogmatic but the science is not. Innovations are often born from creative minds (like Anna Wojcicki), so as we like to say in industry, “think out of the box” and make your voice heard. Be conscientious, competent, and compassionate in everything you do. Finally, don’t underestimate the impact you can make in the exciting world of science and medicine, whether it is on the level of an individual patient and their family or on a larger public health scale. I want to leave you by reading a short passage from one of my favorite children’s books—a book all the parents in the audience will know and one I read often to my own two children when they were young. This is from Dr. Seuss’s book “Oh the Places You’ll Go” published in 1990, one year before his death.
It begins:
Congratulations!
Today is your day.
You’re off to Great Places!
You’re off and away
You have brains in your head.
You have feet in your shoes.
You can steer yourself
any direction you choose.
He warns—You’ll get mixed up, of course,
as you already know.
So be sure when you step.
Step with care and great tact
And remember that Life’s
a Great Balancing Act.
So be your name Buxbaum or Bixby or Bray
You’re off to Great Places!
Today is your day!
Your mountain is waiting,
So…get on your way!
Remember, Dartmouth has given you a wonderful foundation to go on and accomplish so much. I leave you now with all my sincerest best wishes for your very promising futures.
Thank you.
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Aris Damianos, Alumni Council President
Paul Charlton, MD Class Speaker
James Geiling, TDI Class Speaker
Marie Onakomaiya, PhD Class Speaker
Chip Souba
Chip Souba, MD, ScD, MBA, is dean of the Geisel School of Medicine at Dartmouth
Today we send out 150 leaders who will make the world a better place. Congratulations! As you set sail on your careers in medicine, science, and public health keep in mind that you are the leading actor in the play called your life. You get to write the script and choose the kind of person you will be as you live out your life.
In the end, you will be defined by your commitments. For example, when a physician commits to providing her patients with the best care she knows how, she is taking a stand for the inviolability of the doctor-patient relationship. When a teacher commits to making available the best education possible, he is taking a stand for his students. Your joy in life will be a function of the degree to which you take a stand for improving the lives of others.
Fear will be your greatest enemy and you must conquer it. Otherwise, it will drag you down, tempt you to settle for mediocrity, obscure your commitments, and shake your trust in what you truly care about. As Frank Crane said nearly 100 years ago, “You may be deceived if you trust too much, but you will live in torment unless you trust enough.”
A future worth living into is one that you create in response to the question, “What is it that I am committed to that is bigger than I am?” In other words, what future are you committed to creating that goes beyond any personal gain? Keep that question front and center and revisit it regularly. We need you to take on the challenges that confront our health-care system today. And you can't solve problems by using the same thinking that was used when those problems were generated.
The story of two cancer researchers illustrates the power of context. A few years ago, I was visiting a comprehensive cancer center and had the opportunity to meet with several junior faculty. It was grant deadline time so many investigators were busy at work putting the final touches on their proposals. I happened to be about 10 minutes early for one of my appointments so I strolled down one of the adjacent halls. I walked by one open door where a researcher appeared to be busy at work. Not wanting to disturb him but somewhat curious, I stopped and asked, “How’s it going?” The investigator paused and looked up, annoyed by my intrusion, and said, “Can’t you see I’m writing a grant? I hate this work. And I know I’m going to get the shaft from the panel that reviews my grant. But my chairman insists that I get funded.” I promptly apologized for my interruption and made my way back to my scheduled appointment.
A short time later I met with another researcher who similarly was hard at work. Her desk was covered with reprints, gels, tables, figures, and other important materials. “That looks like hard work,” I said, “and I bet it can be discouraging knowing that the chances of getting funded are so unfavorable.” The relatively young woman stood up from her computer and replied while sipping her coffee, “It is hard work and it requires lots of dedication. I know it’s going to be many hours before I finish this grant and I know the chances of getting funded aren’t in my favor. But it’s a labor of love because I’m discovering a cure for cancer.”
The difference between these two cancer researchers was not intrinsic or circumstantial. As the story illustrates, the context we create can powerfully impact the way we live and experience our lives. Our effectiveness and fulfillment in life is not so much a function of what we’re doing as it is a function of the context inside of what we’re doing. The first scientist saw his circumstances—a seemingly hopeless situation manifested as an outwardly defeatist attitude—as determining his experience. His focus, so it seemed, was on content, and perhaps he lived a content-driven life. In contrast, the second researcher seemed to have more of a context orientation in living her life. Rather than see herself as a victim of her circumstances, she appeared to be more interested in being the author of her own future. Her stand—for curing cancer—was inspiring, to say the least.
Most of us live into a future that is a continuation of the past. We may have hopes and dreams for a different future, one that is really worth going after, but it seems out of reach or too risky. A future worth living into enriches the lives of others—your patients, your students, and your colleagues. Because it is a future that is larger than yourself, it will be authentic and inspiring, granting you the tenacity, courage, and action to deal with the obstacles that will invariably show up along the way. So be bold. Be aspirational. Reach for the stars. You won’t regret it. You’re a Geisel School of medicine graduate.
Godspeed and God bless to all of you. Congratulations!
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Anne de Papp, Class Day Speaker
Paul Charlton, MD Class Speaker
James Geiling, TDI Class Speaker
Marie Onakomaiya, PhD Class Speaker
Aris Damianos, Alumni Council President
Aris Damianos, MD ('88), is a gastroenterologist in Portsmouth, N.H.
I am delighted to share the stage today with a distinguished alumna, my fellow classmate and dear friend Anne de Papp. Anne was the star of our medical school class of ’88, always a step or two ahead of the rest of us. Her notes in class were like beautiful calligraphy. She was flabbergasted that people would actually knit during lectures.
I remember early on in our first year pathology laboratory, down in the bowels of Chilcott, peering into the microscope at slides of bone. Professor Marin-Padilla was circulating among the students. Eager to make an impression, Anne and I both raised our hands. Looking at a slide of the femur, Anne characteristically asked, “are these large, multinucleated pink cells the osteoclasts involved in bone resorption?” Slowly my arm came down, and I murmured that I was going to ask the same thing, when in reality my question was “How do I make this stuff bigger?” And so Anne rose to the top of her profession, and I became a gastroenterologist.
Most of the people assembled today are here to bid you farewell. I have the distinct pleasure, on behalf of Geisel’s alumni body, not only to congratulate you on your remarkable achievements, but to say, “welcome.” Welcome not as students, but as colleagues and peers, as fellow alumni of the fourth-oldest medical school in the nation, and the only one to be indelibly associated with the Lorax. While most of you will be leaving the Upper Valley and scattering across the country, our job as alumni leaders is to help keep you connected through the miles and through the years to this amazing community, to your mentors, and most especially to your friends.
In many ways, you graduate from a very different school than Anne and I attended. The hospital of course was just across the lawn on Maynard Street. Forget Tanzania or Kosovo; for us “global health” meant a subinternship at in White River Junction. We had no computers or smartphones, just our pockets bursting with handwritten formulas, algorithms, and notes, our “peripheral brains” precariously held together by rubber bands and fat paper clips. And let me tell you as an aside, as a clinical gastroenterologist, that technology really is a double-edged sword. Believe me, the last thing you want to see as a gastroenterologist is a patient reaching for his iPhone and saying, “Hey, doc, let me show you a picture.”
Much has changed over the past 26 years, since Dr. de Papp and I received our green hoods on this very spot, but the core mission of Geisel has not: to provide a transformative student learning experience, and to produce outstanding clinicians and scientists. Today the Geisel Alumni Council is a broad representation not only of the traditional MD track at Dartmouth, but also of our master’s and PhD programs, be they in the basic sciences or public policy. Our alumni body boasts over 3,500 MD graduates, in 44 specialties and 95 subspecialties, all eagerly awaiting your phone calls and emails for career advice. We are proud to have over 1,000 graduates of our TDI and other master’s programs, as well as over 500 PhDs. To borrow the phrase of another Dartmouth alum, we applaud those of you who have taken the road less travelled, and thank you for enriching our community.
Medicine has unquestionably been transformed by dramatic advances in technology and pharmacology. It’s hard to imagine that there are people here in this audience today who were born before penicillin was even discovered. It’s mind-boggling to think of where we will be, where some of you will help take us, in the future. But no matter what your path, be it in patient care, in policy, or in research, the most important tools of all are the tools that we have, in fact, always had, as far back as antiquity. Our eyes, not just to observe, but to really notice what is most important around us. Our ears, so that we can really listen, listen to our patients, to our colleagues, and especially to our loved ones. And our hands, since the power of the human touch can never be replicated, not by Apple, or even by Merck.
And I tell you this, not as someone who everyday hears “Whoa, doc, where you going with that finger,” but as one who has been humbled and privileged to have my own hands grasped in gratitude. We trust that you will use all of your resources well on the road ahead, wherever that road takes you. And know that your fellow alumni will be with you every step of the way. Congratulations and welcome.
Anne de Papp, Class Day Speaker
Chip Souba, Dean of the Geisel School of Medicine
James Geiling, TDI Class Speaker
Marie Onakomaiya, PhD Class Speaker
Paul Charlton, MD Class Speaker
I want to open with a thank you. A thank you to all of our families for their support and their sacrifices. This whole medicine process hasn’t been easy for us, and it hasn’t been easy for you. We didn’t get here on our own. Thank you for being with us along the way.
During one of our first days of class after starting medical school, Andy Welch—Geisel’s director of admissions—came to the front of the auditorium to welcome us and introduce our class.
He told us that 22 members of our incoming class, or one out of every four of us, were born outside the United States.
Ten had already completed other graduate degrees.
We had a Fulbright scholar, a member of a national chess team, athletes, musicians, and many people involved in global health.
Our class was filled with people who work hard, who care deeply about others, and who are going to make the world a better place.
We came to Dartmouth from different backgrounds, with distinct life experiences and unique interests. We brought our own cultures and subcultures from around the world. Our diverse backgrounds shaped Geisel and made the Dartmouth community stronger.
Similarly, our time at Dartmouth has shaped us.
Nadia, for example, proudly representing our Southern California cohort, had never experienced frost on a car windshield before starting at Dartmouth. The first frosty morning of our first year of medical school, she reports sitting in the front seat of her car for what she says was a rather long period of time, contemplating what to do about that white stuff obscuring her windshield, until a native New Englander walked by and asked if she needed help. And now that Nadia is an expert in all things frozen, and she knows how to survive long New England winters, she is heading back to L.A. from where she never plans to experience a snowy winter ever again.
We were shaped by this new medical profession—a profession of high expectations. A profession that will take from us as much energy and time as we are willing to give it. A profession where the best that we can do still sometimes feels like it isn’t good enough. All of us have had to find ways to deal with contexts where we feel inadequate, where there is so much more to know, so much more that we could have done, should have done. As Marshall Ward said in his remarks last year—the challenge is to find a way to capitalize on this feeling as a positive force for improvement, a welcome driver of excellence, rather than a source of stress. It is a big challenge.
We have had lots to be grateful for along the way—accidents survived, engagements and marriages and babies welcomed, articles published, potlucks enjoyed, study group friendships forged, and—most of all—having survived to get this darned diploma!
And beyond our induction into this broader medical profession, we were specifically acculturated to some very unique values and ideas here at Geisel:
- Through TDI, we were acculturated to important work on practice variation
- Through Gil Welch, to statistics and informed medical decision-making
- Through mentors such as Arnold Katz and Stephen Plume, who epitomize the lifelong commitment to enquiry and learning.
- Through Steve Bensen—who showed us that you can be a doctor and still be cool.
- And, perhaps most importantly, we have been schooled by Brittany Raffa, who showed us that life might be a little more fun if more of us dared to live with a little less filter.
These are now things that are a part of us: We know the benefits of a tightly knit community.
We’ve experienced the commitment to thinking critically about innovative ways to transform American health care.
And we’ve gained the empowerment to go forth into whatever domain of medicine we are passionate about.
And that is exactly what we are starting now. Just as we brought our own diverse cultures into Dartmouth, we now are taking part of Dartmouth’s culture and spreading it. We are headed into all sorts of specialties of medicine in all sorts of training contexts. We will be using our skills in very different ways.
As we do so, we are Dartmouth’s ambassadors. We have the opportunity and the platform to be using the awareness we have gained over the past four years to make our residency programs, work cultures, and future communities better.
We will continue to be shaped by cultures around us. Some of this will certainly be good and positive. But some forces probably won’t be. As we confront attitudes and values and behavior that we don’t want to adopt, we may need to draw on our own core values, our individual purpose, our own answer to the question “why?” We see this in secular sources, see it in religious sources—the idea of a purpose-driven life. I don’t know what each of us would say is our purpose. I’m sure it varies. But I suspect that an aspect of it for many of us is to make things better—to reduce the amount of suffering we see around us, to make the world slightly better in some unique way. And as we face cultures that we don’t want to emulate, I think remaining grounded in our core, our purpose, our “why” will be key.
We are 90 people about to leave Dartmouth, perhaps slightly bruised, slightly battered, but also empowered. Ninety people with good hearts who have the drive, the ability, and the tools to make a difference. How will these 90 people make the world a better place in the future? I don’t know. But I am excited to find out. To all of the wonderful people in the Geisel class of 2014, congratulations and good luck!
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Anne de Papp, Class Day Speaker
Chip Souba, Dean of the Geisel School of Medicine
Aris Damianos, Alumni Council President
Marie Onakomaiya, PhD Class Speaker
James Geiling, TDI Class Speaker
The views expressed here are those of the speaker and do not necessarily represent the views of the White River Junction VA Medical Center, the US Department of Veterans Affairs or the US Government.
Dr. Weinstein, Dean Souba, Dr. Fisher, other distinguished guests, faculty, family and friends, and fellow students. I’m deeply humbled to have been asked to represent TDI’s students at this graduation.
But also, speaking here honors a friend and public health servant, Dr. Arvo Oopik. If you walk through the doors behind me in the 1978 Life Sciences Building, to your left is an auditorium dedicated to him. A ’78 Dartmouth graduate, Arvo was my medical school classmate and a fellow internal medicine resident. A member of the U.S. Public Health Service, Arvo honorably served as a cardiologist for the Indian Health Service. Tragically he died in a plane crash during a 1994 winter storm on his last trip to the Northern Great Plains. So with great appreciation and in deference to a great American and dear friend, I am especially honored to stand here today.
When Karen Tombs first told me about my nomination and selection, I frankly was really baffled. The old guy, part-timer in the class, should speak as a student? Why me? But with her support and encouragement, here I am.
Then when I asked classmates what I should say, more than one said, just tell us why you’re here, what’s your story, what keeps you energized in medicine today? It's so complicated and frustrating—why do you stick with it? So, in the context of the online advice Lisa sent me for graduation speeches, I’ll touch on three points.
In January 2010, while at a critical care meeting in Miami, we saw over the television scenes from a horrific earthquake not far away. While my heart said I needed to help, I really didn’t see a way personally to assist.
Jump forward eight days and with a dedicated team of ICU nurses from Dartmouth, I was on a plane leaving snowy Lebanon headed into the bowels of a destroyed hospital in a devastated country to try to assuage some pain and suffering. As a former Army doc, I’d experienced many of the same emotions, discomfort, and shock before, but this was on such large scale. It was there, in the heat, stench, and horrors of a hospital and ICU under duress that so many years of training came to fruition. This is medicine at its heart and soul. When your pulse oximeter has been stolen and your blood pressure cuff long gone, you’re left with your senses and your stethoscope. Soon you learn a dressing needs changing by its smell, your thin patient with a cough probably needs TB isolation and indeed, tetanus does exist and why on earth do we have to treat this preventable disease in 2010?
Takeaway number one: get ready. The schooling, the training, the papers and exams, the tragedies thrown your way all bring you to a point where your clinical or organizational expertise will be needed someday. But you have to seek out those options, get out of your bubble, think globally and play in the sandbox with folks outside medicine.
A year after the earthquake I was back in Haiti, and it was there I first entertained applying for this program. I had to get my head around the challenges of providing care in such places and conditions. Certainly there were trepidations—it had been quite a while since I had last sat in a classroom. And for sure I didn’t need any more initials behind my name; D-A-D suits me just fine.
But thanks in large part to his friendship and advice, Gil Welch convinced me to leave my apprehensions at the door and jump in. Fortunately my first exposure was my colleague Robin Larson—a talented instructor, gifted researcher, and superb clinician. In short order she convinced me I had made the right decision.
Now a year later in Gil’s epi-biostats class . . . that’s when I thought I was nuts—talk about outside your comfort zone! Those all day classes and labs every Monday for six months can give you a serious brain cramp. Thank goodness I had the great privilege of working with some extremely talented, often much younger classmates, who patiently supported me and others of my “vintage.”
Where then have we landed after this time at TDI? While we’ve been taught to look critically at the literature, dissect the nuances of a 2x2 table, and evaluate the public health aspects of environmental toxins, we should never forget that at the tip of the spear in these analyses are patients—scared, ill and vulnerable persons dependent on us and our health-care system to give them the compassionate care they need and deserve. Shame on us if we ever lose that focus, that azimuth in guiding our public health efforts.
So that’s takeaway number two: public health has a face, a name, and a family. Whether in Haiti or Hanover, it’s that person on the other end of our stethoscope that needs the literature translated for them as a person.
Yesterday was the 70th anniversary of D-Day, the day when members of the “greatest generation” began to take back our liberties and freedoms absconded by a fiendish leader. We’ve had two D-Day vets in our VA this week—one seeking oxygen so he could make his yearly trek back to Normandy, and the other a medic who actually went ashore that fateful day. And we have at least one World War II veteran in our midst here, Mr. Ramon de Guzman Sr., Adrian Velasquez’s grandfather. Caring for these heroes has been a true honor and privilege since I was a first year medical student. We owe this generation and those that follow in their footsteps of service, the finest support and care our nation can offer.
The VA I serve, your VA, is the largest health-care system in the nation. By many accounts, it’s the best in meeting health-care metrics such as diabetes control, early antibiotics in pneumonia, and post-heart attack medications. Its emphasis on systematically improving health care has also helped foster the careers of some of our own leaders here at TDI through its prestigious Outcomes Group.
But as you’ve heard of late, its mission and service to our veterans has, in my opinion, been derailed by a narrow focus on specific metrics and their possible manipulation. We’ve let down our constituents, not only our vets but also our board of trustees as well, the American taxpayers. These are turbulent waters for sure, but you would be naive to think that you’re immune from such events in the future. Data integrity and accurate reporting to journals, grant applications, financial institutions, boards of directors and others guide practice in all disciplines, from medicine to financial markets to education. Ask today’s teachers, for example, if they feel any pressure to teach to standardized test scores.
While at its core the measures certainly have utility in analyzing quality, access, finances, and the like, as we have studied, it’s the data points themselves, not the population information per se, that has become a driver for action and change. I am confident VA will come out of this a better organization, but we all should take heed of Ken Kizer, former VA Under Secretary for Health, who lamented in a recent Washington Post interview that “the measures have become the end, as opposed to a means to an end.”
Which brings me to takeaway number three: While we’ve focused here on translational medicine and delivery science, we have to expand this conversation to the communication processes, policies and ethics of properly using data and its information to shape our health-care systems.
Ok, time to wrap this up—as I learned in the Army: “be good, be brief, and be gone!” So there you have it—three lessons: get ready and go outside your comfort zone; public health has a face and a name; and accurate data should shape ethical decisions, not be the sole driver of decisions.
In closing, we really owe thanks to our professors, TAs, and fellow students for a great learning experience. We also need to recognize the TDI staff that behind the scenes makes it happen. It’s been quite a ride and for some of us, an incredibly long one.
For part-timers, we also owe our work colleagues a great deal of gratitude; for me personally without the support of Shane, Andy, and others, I could never have maintained my sanity at my day job.
And finally, I can’t thank enough my family for the love and support they’ve shown through yet another training program, and one more graduation ceremony. We all owe our families so much for their care and support over the years—give them a hug, or at least send them a text.
So that’s it, I’m done, and we’re done! Thanks for sharing the ride and Godspeed.
Anne de Papp, Class Day Speaker
Chip Souba, Dean of the Geisel School of Medicine
Aris Damianos, Alumni Council President
Paul Charlton, MD Class Speaker
Marie Onakomaiya, PhD Class Speaker
Good morning and welcome Dr. de Papp, Dean Souba, Dean Kull, members of the faculty, distinguished guests, family and friends. Thank you all for being here this morning to celebrate with us: the Geisel Classes of 2014. It is an honor and my pleasure to address you all today on behalf of the graduate students at Geisel.
"Chance favors the prepared mind." My favorite quote by Dr. Louis Pasteur, because these simple words remind us that if we are not ready when opportunities find us, we often miss them. In my mind that is what luck is, being ready. Fellow graduates are the lucky ones. And you and I know that if we had not done the work and stayed focused, we would not be sitting here today. For that, to each and every one of you, congratulations!
As I thought about what to talk about today, I decided to start at the beginning.
When I came to Dartmouth almost five years ago, I did not know what to expect. I was far away from home, in the coldest place I'd ever been and it was a chance for a new life. I was very excited. I was here to learn and to do research—and coming from undergrad, what I thought “doing research” was about was going to a lab every day and performing experiments. I quickly realized that this was only one part of the graduate experience. For one, there were many more mice than I could have ever imagined. There was also so much more reading and thinking and writing and speaking involved.
I was also unprepared for the failure. You see, when you first start graduate school, everyone tells you to expect that at least 70 percent (a modest estimate) of your experiments will fail. I’m sure many of us can relate to this now from firsthand experience. But as a first-year student you really don’t believe it. It’s usually in your second and third years after the qualifying exam that this reality becomes your life. Now we understand that just meant you were doing it right. That was the first thing I learned from my time in graduate school: work hard and never give up because perseverance pays off and will always leave you with a sense of accomplishment, no matter the final outcome.
All of education is to teach us how to learn, how to experience the world critically. The second thing I learned during graduate school is that you cannot control life, but you can control how you react to it. It’s all about perspective. As graduate students (and people) I think we can all acknowledge that things are most difficult when we are in the middle of them. Sitting here now, with it all behind us, our diplomas already printed and waiting to be framed, our past agonizing over data, papers, and presentations probably don’t seem so bad. During my third year, I had that fall out moment. Right after I successfully survived the nightmare that is the qualifying exam, we had a fateful lab meeting —the project I had been working on for over a year was a bust because of an Excel stats error in the data from my first experiment, the one all the subsequent studies and a second project I had just started was based on. I was devastated. I felt like I had failed. Thankfully, it was a weekend, so I did something I’m sure many of us have done at one time or another: I cried on the phone to my mom. She, ever the optimist, told me to have hope and to not discard the data, since you never know.
A few weeks later, my mentor, Dr. Leslie Henderson, had the ingenious idea to compare males and females and see if there were any differences. We revisited the data and discovered there might be a sex difference after all. Two weeks ago, we submitted the paper for publication (fingers crossed!) and just last month the NIH officially recognized the importance of understanding and studying sex differences in biomedical research.
What a difference two years can make. The data are still the same. The only thing that changed was our perspective of the data. The lesson here is to know that life may not always happen the way you imagine but if you step up and are open, you will find a way, because the possibilities are endless.
Each of us has so much to offer, to our colleagues, our communities, and the world. The final thing I learned is this: step out of your comfort zone and embrace your community, because this is often how we encounter the most incredible things and people. It will also keep you grounded. I said in the beginning that I was happy to be getting a new start when I came to Dartmouth. But that first quarter, as the air froze and the darkness grew, that excitement turned to melancholy (there’s a lesson in there about how the sun gives perspective, but that’s a discussion for another time). I was alone, I was too far away from anything familiar, and I hadn’t found a sense of community.
It was during this trying time that I stumbled on the Graduate Relief Team, and it changed my life. It was a newly created group for graduate students to volunteer at events around the Upper Valley. From the first Habitat for Humanity build to my first time at the Upper Valley Haven, I began to have hope. This led to so many opportunities for service over the next few years than I could have ever imagined, at Dartmouth, in the Upper Valley and even beyond. All of which enriched my life here and made me feel connected to the community.
Some of the connections I will hold dear for years to come are with people I met and bonded with while attempting to give my time serving others. In the end, whatever impact my service had on the community will never live up to the impact the community had on me. Dr. Maya Angelou once said, “I have found that among its other benefits, giving liberates the soul of the giver.” That has been my experience. And now, when I think of home, Hanover comes to mind.
Looking back at first year in core classes, who knew how quickly time would fly? I see many of us here today who started together in PEMM AKA Party Every Monday Morning; we have come a long way! On this day, we are celebrating making it through the long days and nights: injecting mice, feeding cells, incubating western blots, and analyzing data. Wherever you end up, remember the dedication and time you spent on those things, whether they failed or gave you your greatest successes to date, and know that with perseverance and perspective you can change the world.
For many of us, this is the beginning of our non-student lives—what an exciting time! The ambiguity of change is often scary. My hope for all of us today is that we meet this with enthusiasm and the confidence that this is merely the beginning. Recognize that change is the only certainty, embrace it, get comfortable with the unknown and you will have new experiences. Remember our very own Dr. Seuss’s Oh the Places You'll Go. We are on the cusp of an incredible journey through life. And we have a solid foundation. We could not have made it here without the privilege of the experience and guidance of our exemplary and long-suffering mentors here at Dartmouth. Today we also celebrate their achievements.
I shall leave you now with some words from “Desiderata” by Max Ehrmann
“Enjoy your achievements as well as your plans.
Keep interested in your career, however humble;
it is a real possession in the changing fortunes of time…
You are a child of the universe,
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.
Therefore be at peace with God,
whatever you conceive [God] to be,
and whatever your labors and aspirations,
in the noisy confusion of life keep peace with your soul.
With all its sham, drudgery and broken dreams,
it is still a beautiful world.
Be cheerful.
Strive to be happy.
Thank you all and congratulations Geisel Class of 2014!
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Anne de Papp, Class Day Speaker
Chip Souba, Dean of the Geisel School of Medicine
Aris Damianos, Alumni Council President
Paul Charlton, MD Class Speaker
James Geiling, TDI Class Speaker
