Bend the Curve

How to prepare for a life in medicine

The following is the text of the 2012 medical school commencement address delivered at Brown University by Joseph B. Martin, HMS dean emeritus and the Edward R. and Anne G. Lefler Professor of Neurobiology and author of "Alfalfa to Ivy: Memoir of a Harvard Medical School Dean."  Here, Martin describes his own experiences in medicine as a series of curves, offering advice to students on how to be prepared for all the changes they will encounter during their careers.

I know that commencement speeches should be inspiring, optimistic and most importantly, brief. I know that I represent one of the last obstacles between you and your diploma. Let’s begin with inspiring.

In polls asking about respect for professions and other jobs, doctors remain near the top of the list, along with nurses, among the most admired of professions.
Joseph B. Martin, HMS dean emeritus and the Edward R. and Anne G. Lefler professor of neurobiology.

I know of no other field of endeavor that offers so much variety and so many exceptional opportunities as the one you are embarking on today. I am, at my age, perhaps a bit nostalgic, but I remain convinced that medicine, serving those we are privileged to care for and care about, is the noblest of professions.

My own graduation was exactly 50 years ago and I cannot imagine having chosen a more satisfying direction.

Today, I don’t feel much different than I did then, until I greet the guy in the mirror each morning and hear my grandson, Cole, ask; “Grandpa, why do you have all those wrinkles around your eyes?" 

"That is a sign of wisdom," I reply, hoping that at age 9 he will believe it. My how time has flown by! 

But I refuse to think that we are separated by 50 years. Indeed, there is no gap separating you and me. We are part of a continuum, dating back over 2,500 years, of commitment to and willingness to adhere to the principles of the Hippocratic Oath. Medicine is a curve of progress, of achievements and of victories over disease and disability.

Events in life are commonly referred to as peaks and valleys, ups and downs, and so on, but rarely as curves. But I like this metaphor better. Life in your field of medicine is a series of curves, a change in direction more often gradual than abrupt but each sufficient to alter forever the trajectory of a lifetime. Being optimistic is critical to taking advantage of each bend in your curve. Let me briefly tell you about some of my experiences.

I was born in Alberta, Canada, raised on dairy farm, with childhood aspirations to be a missionary doctor in China, India or Africa. In medical school, my academic standing encouraged members of the school’s faculty to support me in seeking a career in academic medicine, with a specialty in neurology. There developed during that period of my life a great interest in research, which led me after five years of clinical training to re-enter student life at the University of Rochester to study neuroscience. It was a group of patients I saw that led to my research interests. Each of them had postural hypotension, fainting when they stood up quickly, a condition we call orthostatic hypotension, often idiopathic, and now sometimes called the Shy-Drager syndrome or MSA—multiple system atrophy—a brain degenerative disease. It was involvement with my patients that triggered the interest in research.

I wondered why, when they stood up and the blood pressure tanked that they failed to show a compensatory tachycardia. Their autonomic nervous system reflex from baroreceptors to medulla back to the heart was not working. I wanted to find out why. This curiosity led me to the study of hypothalamic regulation of the endocrine system.

From my experiences, each event was a curve—from boyhood on a farm to pre-med, to medical school, to neurology and to graduate work that finally, after 15 years, resulted in my first real job, something my mother began to doubt would ever occur, with an appointment at McGill University in Montreal.

Each bend in the curve came about through serendipity, guided by prescient mentors and the heroes I met who framed the context and reality of my ambitions. Life is a series of accidents, not plans, of unexpected moments never dreamed of.

I have entitled my talk, “Bend the Curve”.

But, just a minute, you might be saying; I thought "bend the curve" was an economic term applied recently to the unsustainable costs of health care. Right. If you Google the phrase, that is what comes up, and I want to describe how this is relevant to our consideration here today.

It is common to see a graph of health care costs over time showing a larger cost per individual and an increased percentage of the country’s gross domestic product (or total output) being spent on the health care system and our patients. Now the latter is not bad if it provides jobs and better health for our citizens. But when the money disappears into the health care system, the inefficient, fragmented, specialty driven, corporate-profit motivated medical-industrial complex, we should worry. Here the object should be to bend the cost curve downward, by improving health care access and containing costs that are not conducive to better health.

As I gaze out at your class, the graduates of the class of 2012, you are now embarking on a direction framed by that great event in mid-March—Match Day—that now has determined the bend in your curve and increased the likelihood of you getting to where you eventually want to go and, in every case, allowing you to pursue the directions you determine best.

I have analyzed the career choices framed by your selections for residency training and find them very representative of U.S graduates in general; the largest number going toward internal medicine, a smaller group in pediatrics and obstetrics/gynecology, and in neurology and psychiatry, with a vast sprinkling of surgical sub-specialties. And, I am pleased to note, several of you are entering family medicine and primary care.

So far, much of the trajectory of your curve has been more passive, perhaps, than active; more driven by the rules of the preparation demanded for the profession, but now preparing you for the differentiation your life will command.

So allow me to suggest some ways to bend your curve going forward, to be prepared for the startling and unanticipated directions your careers will take.

First, enter the next stages of your experience with a deep commitment to lifelong learning. I was speaking with a colleague at Harvard Medical School about what to encourage young physicians to do; he suggested to keep your eyes open for the unusual, the unexpected. Every patient you see has a new story to tell; each will inspire observation and each should be a teaching lesson. Look for the surprise in the story, for it is in this way that new discoveries are made. The best research remains that which is patient-focused.

Second, you are entering a transformational moment in the delivery of health care in the U.S. Let me remind you of a few facts:

The United States spends 17 percent of its Gross Domestic Product on health care.

This amounts to approximately $8,000 per person per year, nearly twice that of Canada, the U.K. and Japan.

There are presently 45-50 million people without insurance, another 30 to 40 million who are uninsured for part of each year through lapses in coverage between jobs or during periods of growing unemployment, and many more whose insurance is inadequate to meet the expenses of a major illness.

Estimates indicate that up to 50 percent of personal bankruptcies are triggered by excessive health care costs or catastrophic illnesses.

Many leading institutions, including major university hospitals, have grown enormously in size in clinical care and research but have become unable to provide equal growing capacity for primary care services.

An aging population with anticipated needs in managing chronic disease often have no “medical home” to coordinate care, which results in fragmented, episodic care given mostly by specialists who communicate little or not at all with each other.

A new model for minor medical care is developing in pharmacies and in stores like Wal-Mart, with ineffective linkage to physicians for follow-up treatment. This business model is generally challenged by the deliverers of status quo medicine without adequate exploration of the possibilities this model represents. Not surprisingly, perhaps, fewer and fewer medical school graduates are going into primary care.

So, to summarize my second point, spiraling costs, the general failure of a primary health care delivery system, over-specialization, lack of access to the best care for the uninsured and those living in underserved, often rural, communities demand new approaches. You will be in the mainstream of this radical change. Many among us awaited with trepidation the outcome of the Supreme Court ruling regarding the constitutional validity of the Health Care Reform Act. Although the Court let stand the current law, you will be in the midst of a new turmoil not seen in this country since the Civil Rights Movement and the introduction of Medicare in the 1960s.

Observe these events closely, but more importantly, I want you to participate in them. Grab hold and be part of a revolution that is now inevitable. Choose your position and fight for it.

Third, inherent in this evolving world will be new requirements for teamwork and sharing of professional opportunities with others in the health care workforce. Those of you in primary care and in specialties will need partnerships with nurse practitioners and physician assistants, as well as pharmacists and social workers. You will observe the expansion of primary care into settings once deemed inappropriate. How can we team with nurses in schools to provide preventive care, immunizations and minor health care?

Fourth, be a part of your communities beyond your own workplace. Join friends and neighbors in the activities of schools, churches, synagogues and mosques. Let your children see that you care about the community you reside in and help them learn to exercise their gifts and skills as you do to the betterment of the world.

Fifth, you will experience a transformation in the imprint that science will bring to your practices and, in the case of those of you headed for academic careers, in your approach to science. You know of the power of genomics, still largely theoretical, but inevitably going to impact the personalized medicine and pharmacogenomics that will increasingly invade all aspects of good care. What drug will be most beneficial and safest for Mrs. Jones but dangerous for Mr. Smith? How will the inexpensive availability of your patient’s fully characterized genome sequence lead to new informed consent rules, new biomedical ethical issues of who should know what?

Sixth, you are entering a world of globalized medicine. Great advances are being made in research and treatments in countries off the beaten path only a short time ago—India, China, Poland, Brazil, and South Africa. The patients you will see may well have traveled recently to these and other countries, as tourists or indeed as patients. We no longer hold the only source of sophisticated care. And travel has brought us closer together, amplifying the possibility of widespread contagious events, such as occurred with the SARS outbreak a few years ago, which spread quickly from Hong Kong to Vancouver and Toronto, and which remains a possibility with avian flu. I have no doubt you will witness the first truly effective vaccine for malaria, and will hopefully note improved access to treatments available for HIV/AIDS in every country. Be sure to ask your patients where they have traveled in the last six months.

Lastly, your generation will see the average lifespan approach 85-90 years. This accompanies the great success we have seen in treatment of hypertension, heart disease, arthritis and the replacement of worn-out hips, hearts and kidneys, and now even repair of brain damage. You have likely also heard of the remarkable work linking thinking to moving in paralyzed patients, where electrodes placed on the motor cortex, with impulses recorded there, are transmitted to computer-directed movements of a paralyzed limb. One can only imagine the direction this kind of work will take. I hope, even in my own lifetime, to see effective disease-delaying treatments for Alzheimer’s disease and Parkinson’s disease.

I have mixed emotions looking out upon you today. I have been witness to so much progress in the past 50 years. But the best is yet to come, and you will be there to see it. Go ahead and bend the curve.