Dean's Corner: Transitions

As you march forward, dean says, remember to look back

Dean Flier

HMS Class Day address by Jeffrey S. Flier, 21st Dean of the Faculty of Medicine, Harvard University, May 26, 2016 

I'm delighted to be your commencement speaker today, but I don't want you to think I'm totally new to this kind of thing.

Fourty-four years ago, almost to the day, in 1972, my parents and younger brother drove from the Pelham Parkway neighborhood of the Bronx to the new Mount Sinai Medical School across from Central Park to watch me graduate in Mt. Sinai's first graduating class.

They saw me deliver the student speech that day and knew I'd helped to select the commencement speaker.

Jeffrey S. Flier, Dean of the Faculty of Medicine, Harvard University
Jeffrey S. Flier, Dean of the Faculty of Medicine, Harvard University

Jeffrey S. Flier, Dean of the Faculty of Medicine, Harvard University

I admit: I made a few mistakes that day but it took me a few years to figure that out. The people who gathered there wanted to celebrate. I led off with a fiery, political speech. I blasted everything I saw wrong with health care—and politics. And believe me, there was plenty that was wrong. Hey. It was the 70's. What a platform I had.

But very few there wanted to hear my views.

Then came our commencement speaker—a prominent physician with a strong, and what I thought were appropriately provocative, views on various subjects. What were those views?

He felt using medicine then available to treat the mentally ill was generally a huge mistake. He believed the mentally ill, a term he really had a right to be left alone. He wrote a book saying he didn’t like it. He called for emptying psychiatric hospitals and wards as fast as possible and ending the involuntary commitment of patients. I had sympathy for those views at that time. 

As he spoke, the Department of Psychiatry professors looked like they were going into cardiac arrest. The longer he talked, the more they glared at me, knowing I had a role in selecting him.

But don't worry, Class of 2016. I will not repeat the error I made in 1972 by delivering a politically charged speech today. (Though I certainly did consider it until a few days ago.) This is a moment to celebrate—for you and for me to celebrate. Not only are all of you graduating. But this class of 2016 is truly impressive.

A Moment to Celebrate

I could single out each one of you for something exciting that you have done while you have been here. Let me give you just a few examples.

We have a student who, in addition to being a Rhodes scholar, used his passion and skills in health policy to create Be Jersey Strong, a program helping uninsured individuals in his home state to sign up for available insurance. And that student is Aakash Shah.

We have a student who worked with others at HMS and elsewhere to develop a prototype for something called Surgibox, a way to deliver safe, affordable, transportable and sterile surgical equipment. It won the grand prize in this year's Harvard Innovation Lab Presidents challenge. And that is Debbie Teodorescu.

We have a student who worked tirelessly with students, faculty and staff to create a welcoming environment for LGBT students, patients and staff throughout HMS. And that is Cary Crall.

We have a student who joined with others to found the first student-faculty collaborative pediatric clinic in the nation at Massachusetts General Hospital- Revere.  And that is Amy O’Brien.

There is obviously so much more I could say about each student in this remarkable class. So, let’s together applaud all 164 of our HMS graduates today.

And let's together recognize the people here whose work, sacrifice and love made these achievements possible. Let's have a standing ovation for your parents, family, friends, partners and significant others.

I also am proud to share with you that I am the father of a newly minted HMS graduate, Lydia Flier, so today is especially meaningful for me and for my wife, daughter and brother, who are all on the HMS faculty and here today.

And lets applaud all the faculty, staff and other mentors who have supported and encouraged all of your endeavors.

Today we celebrate this day, our great school and all of you.

Yes, there are distinguished students at medical schools all over this country celebrating, too. But we can be excused today for thinking that this school, this place, is unique.

In fact, there are times each day when I'm racing to a meeting, when I pass students and wish I could stop and talk. I’d like to know you all for the wonderful, complex people you are, with hopes and dreams—and occasional complaints—though having a daughter here ensures that I do hear about many of those. But there hasn’t been time. And I’ve rarely had the opportunity to speak with you, to get to know you or to tell you about myself.

Hopes and Dreams

Today, I do get a few minutes to share something of my hopes and dreams with you. Yes, people your parent’s age have them too. Oh, and while you’re listening, it's OK to let your thoughts drift a bit. You might think about what's happened in your lives since the day you set foot in Boston, and at HMS. You might be thinking about what's ahead. What will change in your career and in this profession?

This is not just a day to celebrate. It's also a day of transition. We are all facing them.

Many of you will leave here hopeful—and perhaps a bit worried. Have I chosen the right specialty? Have I chosen the right residency? Should we put off the wedding till next year?

You aren't the only ones in transition. Your parents may go home feeling a little lost. For perhaps the first time in twenty-six years, their child is no longer a student.  

And yes, our profession is in a time of transition. Over the course of history HMS has made mistakes, and the transitions that sought to correct them were profoundly important. Just reflect on the arguments being made well into the 20th century about how wrong it would be to allow women to study here—or Jews, or Blacks. And then, celebrate the diversity of our school today.

But our profession has much more work to do on that subject and many others.

Last month I read two articles with disturbing headlines and you may have seen them as well.

First: “Medical Errors a Lead Cause of Death”

Trained doctors still sometimes operate on the wrong leg or other body parts. Though much progress has been made, we have failed to sufficiently reduce medical errors within our hospitals and practices. We know this needs to be fixed. Some of the brightest minds at HMS and elsewhere are dedicating their careers to addressing this problem. But we haven't yet fixed it.

Here's the second headline: “Study: 1 in 3 Antibiotic Prescriptions Unneeded”

It's hard to overstate the value of antibiotics — everyone knows about that. That's why it's so frustrating to read that physicians gave out millions of inappropriate antibiotic prescriptions last year; some estimate one-third of all prescriptions. That's not just a waste of money. These prescriptions promote antibiotic resistance, an increasingly critical therapeutic challenge.

And the way physicians prescribe opiates, most often with the appropriate intent to reduce pain, what we all seek to do, contributes today to the epidemic of opiate overdose deaths.

Always Transitioning

We are always transitioning between the imperfections of today, as illustrated by these examples and many others I can give, and the better care we seek in our future. I know those of you under this tent will play a key role in making that happen.

But, while you can see some transitions ahead, you cannot imagine them all. When my parents watched me walk across the stage in 1972, they thought they knew what lay ahead for me. I would be a doctor, of course. After further training, I'd open an office to deliver care in the Bronx, or, if I was really successful ... maybe in Manhattan.

But I didn't do what they, or I, imagined at that time. Many of you won't do what your parents, or you, today imagine either. For this is a time of change for everyone.

My life was forever altered when, as a young trainee in endocrinology, I made a discovery that taught me that generating change through discovery was not a fantasy. It also taught me I had far more skill in that domain than I had previously known. 

Excited by my one discovery in 1975, I chose research as a core of my career. It took me in directions that I never imagined on the day I graduated from medical school.

Now, one reason you too can go in so many different directions is the career you have chosen.

The simple act of taking your graduation oath today offers you many exciting paths to explore.

Now, I realize some of you already had a path in mind before you set foot on this campus. You'll follow that path, doggedly, brilliantly and the day you retire you'll look back with pride on an amazing career. 

Some of you want to change the lives of millions like our extraordinary colleague and teacher, Paul Farmer.

But changing the world doesn't require becoming Paul Farmer, as Paul himself will tell you if you ask him. 

To diagnose or treat one patient changes the world—for that person.

Those of you sitting here today will change the world as caregivers. As researchers. As policy wonks. As leaders.

Some of you will change careers three, four or five times in the decades ahead. Some of you will excel and become the leaders in areas that simply don’t exist today.

Some of you may provide the answer to the age-old question: What does the spleen do? 

I'm 68. I also see myself in transition. I've been a researcher. A physician. A dean. Now, in addition to research and education, I want to deepen my focus on public policy. I’d like to reconnect this to the passion of my 1972 graduation speech. But this time I think I know a lot more than I did then. 

I face this transition both exhilarated and anxious about the future, not much different than many of you.

Improving the Profession

There is so much to be done to improve our profession and thereby human health. Through much of human history what physicians did was ineffective or harmful. For centuries, doctors believed leeches could balance the humors. Battlefield surgeons wiped knives on their boots, before the next amputation.

When I was a resident we thought patients with heart attacks needed weeks of bed rest. We were certainly wrong. Now we know they get better faster if they’re out of bed and walking the next day.

But the arc of medical progress will move forward and quite clearly at an accelerating pace, and the opportunities you will have in your careers will be thrilling.

You are entering a world where technology and new knowledge will make it possible to know more about a patient—or population—than ever before. As we learn more about the precise causes of disease, your ability to diagnose, prevent, and treat them with precision will increase dramatically.

New imaging modalities, remote sensing data on your patients, and population-level bioinformatics data will tell you more than we could have imagined in decades past.

And I'm not just talking about the future.

There are hundreds of stories of change from discovery and innovation at HMS during your years—and sometimes by you.

I'll just talk about two that I’ve been especially impressed by and which make me especially proud.

One involves the very first faculty member we hired in our basic science departments after I became dean.

The Genetics Department, a world famous department of genetics, wanted to hire an assistant professor. I agreed but said, "Here's the deal. It has to be someone interested in human genetics, rather than genetics of model organisms like the fly or the worm,"  which give us profound insight.  But at that juncture the thought was human genetics would be a good idea. 

Not everyone agreed. "We should pick the best possible scientist," people said, "regardless of what they work on."

We compromised. A brilliant compromise. We hired the best possible scientist and he happened to be working on human genetic disorders.

That person is Steve McCarroll. Some of you may be familiar with his groundbreaking work.

It is deeply innovative. It is already sparking change.

Still, that's not what excites me most about Steve's contribution. For that, you'll have to wait a couple of minutes.


Meanwhile, here's another story, about something we had rarely associated with innovation, and that's primary care.  I don't need to tell students about the primary care crisis in this country. I may need to fill in some of parents.

Primary care docs are like what my parents thought I would be. They are the first doctors to see someone with a new problem, and they provide comprehensive and longitudinal care.

But I'll tell you the truth. When I became dean, having been a physician-scientist, primary care wasn't on my radar. Soon after, a group of wonderful, activist students with a passionate interest in primary care persuaded me I was wrong. So, I did my homework.

I found this. First, good primary care improves health while lowering health care costs.  That's a good combination. 

Second, in the U.S., we provide less funding for primary care physician time than we do for more specialized disciplines. That's really a historical accident more than anything else. 

Third, because we didn't stress primary care, lots of students here believed we didn’t respect the choice of primary care careers.

What could I do? Any money I put towards starting a great primary care center meant, at that point, taking money from other worthy efforts.  That was difficult. 

Well, sometimes things happen and you say, "Yes, there is a God."

As we were wrestling with this problem, I received a phone call from a person I had previously met. He'd heard about our dilemma. Here's a short version of the conversation.

"I'd like to fund your center," he said.

I said something about how this would be rather expensive.

He said, "Send me a proposal. If it's really good I'll fund it. Up to 30 million dollars over the next 5 years.”

When I climbed back onto my chair, he said, "There is another stipulation. I’d like my gift to be anonymous."

So as much as I'd like to, I can't tell you today the name of this generous, compassionate and idealistic person.

But the measure of what he did is that since 2011, we have a center that

  • trains excited students how to give better care one patient at a time,
  • trains them how to create primary care partnerships with other health professionals and organizations, and
  • influences other schools to create centers because Harvard Medical School has done it.

There is still much more work to do before we fix the problems with primary care in this country, including finding better ways for HMS to involve the field of family medicine which I know many students would like us to do.  But now HMS is fully engaged in this area. 

What's the broader significance of that story?

Well, first, to paraphrase John Lennon: Life is what happens while you are making other plans.

I didn't have any idea when I started as dean that I would play any role in primary care. I'm as proud of that as I am anything that happened during my nine years as dean.

Success and Partnerships

But there's a second lesson. It's that Harvard hasn't educated you by itself. Your education does require partnerships.

A partnership between you and your family sitting in the back, the faculty sitting in front, the agencies which fund so much of our research, and yes, the benefactors who support our greatest goals—like the anonymous individual who didn't even want his name to be known.

Now, whatever path you take, you will succeed, at least in part, through partnerships.

And speaking of partnerships, let me return to Steve McCarroll.

So, in one of his lines of work, Steve was trying to solve a mystery: the genetic basis for schizophrenia, a disease that affects about 24 million people around the world with devastating effect.  We know too little about the biology of schizophrenia to map out fully effective treatments.

Dr. McCarroll led a large, worldwide team to identify the responsible genes. They found an area of the genome that seemed especially important.

But what was the identity and function of the schizophrenia-associated genes residing in that small area of the genome? They couldn’t figure that out, at least for awhile. 

On New Year's Eve back in 2013, Steve was heading to a party. His cell phone rang. It was an email from an HMS student who was working in his lab.

Steve opened it. The student, working alone even on New Year's Eve, had attached a graph so simple that you might not have thought it was important. But as soon as Steve looked at it, as he was quoted as saying in a recent New Yorker article, "It was immediately clear he had solved the genetic mystery."

That MD/PhD student became the first author on a truly groundbreaking paper, involving collaborations with additional faculty at HMS, describing a new theory for the origins of schizophrenia. I think this will be a durable theory. 

I'm so proud to tell you that student is graduating today. Aswin Sekar. Aswin, we recognize, of course, your exceptional achievement, but also what you symbolize: the intellect, insight, and drive of the entire class of 2016.

A Rare Privilege

To the class of 2016, let me say this. You approach the future with a truly rare privilege. As physicians, you will enrich the lives of others. Sometimes you will give them the gift of life. You will do that in many different ways.

You will demonstrate the gift of empathy and warmth that give patients hope when they have none.

You will show your talent by caring for patients in a clinical discipline.

You will make discoveries in basic, translational and population science.

You will leave the comfort of home to serve families halfway across the world, where health also means access to clean water, and mosquito netting.

You will shine within organizations whose critical work we know by their initials: NIH, CDC, FDA.

You will lead hospitals and medical schools.  Maybe one of you will lead this medical school. 

And some of you, quite remarkably, will do all of those things.

As I contemplate with you these varied future roles, I am reminded of the passion for justice that motivated my graduation speech in 1972. And so, as you leave to pursue your chosen paths, I do implore you to remain true to the deepest values that drove your decision to enter this profession. So much remains to be done. We will need your brilliance and your passion to endure, through careers during which your perseverance and your dedication will repeatedly be challenged.   

Forty-four years ago, when I delivered an excessively political graduation speech, I didn’t really know what lay ahead.

But I knew, if still incompletely, that I had earned one of the world's great gifts: a degree in medicine.

Class of 2016, as you make your transitions and journeys, armed with that degree, you will have been shaped by the path that four or more years ago led you to this wonderful campus.

As you march forward, I hope there will be moments when you remember to look back. Life, after all, should involve the memory of your triumphs.

This is one of those. 

Remember this day.

Remember sitting under this tent…

  • when the future stretched out before you;
  • when your teachers applauded because they knew your great work and your truly unlimited potential;
  • when your classmates hugged goodbye, vowing you would be together again; and
  • when your families, filled with pride and love celebrated what you had done ... and what you will do. Congratulations!