What Matters?

HMS alumnus and TV producer Neal Baer talks to grads about the quality of empathy

Neal Baer speech

 

What matters to you? What keeps you up at night? What situations distress you? What brings you deep joy? And what fills you with sorrow? What scares you? And what inspires you? What gave you the dream of becoming a doctor?

And how will you make that dream matter?

Read more about HMS/HSDM Commencement and Class Day here

You freshly minted physicians are the valiant. Over these past four years you’ve been given profound gifts: the art of compassion and the science of healing. Who better to use these gifts to lead the charge for social justice?

As you begin your practice of medicine, you must never forget that health care is a fundamental right that reflects the very essence of our humanity. When we strip away that right, we wound our ability to care for one another. We lose our greatest and uniquely human quality: empathy. And the world turns bitterly cold. Health care is not merely a service; health care is not a commodity reserved only for those lucky enough to be able to pay top dollar for the best that medicine has to offer. People will place their lives and trust, their present pain and future joy, in your hands.

What could matter more?

Now it’s time for you to go out and gather experience. You’ve been fortified with an armamentarium of studies, data and a tour of the human body and all the pathology and disease that can assault it. You’ve memorized pharmaceuticals and the Krebs cycle, though I doubt you all relied on mnemonics as much as we did 20 years ago.

Some days I wake up repeating ‘want my hot dog,’ the mnemonic for substances crossing the placenta, or “a wet bed,” to illustrate kidney function: A – maintaining ACID-base balance; W – maintaining WATER balance; E –ELECTROLYTE balance; T – TOXIN removal.

One has to admit that in some odd way these provocative memory boosters told stories we’d not soon forget. Perhaps that’s why they worked. My white-coat pockets were crammed with index cards and small spiral notebooks; now you have an app that can instantaneously give you any fact you need, along with illustrations. Harrison’s Principles of Internal Medicine on your iPhone! I don’t know if I should weep or cheer.

And yet with all your tools, all your knowledge, all your personalized medicine, immunotherapy, cutting-edge stem cell treatments, and CRISPR, 40 percent of adult Americans—40 percent—are obese.

When I graduated a little more than 20 years ago that number was just over 15 percent—so we’ve seen a staggering increase. And the type 2 diabetes rate, well, that’s skyrocketed since I was sitting where you are. And opioid abuse and addiction, that’s something that was certainly seen, but not in the deplorable numbers of today.

I’m not painting a rosy picture, because with 70 percent of our adult population obese or overweight, you, my new MDs, have your work cut out for you. And it’s not just here—obesity, arguably the biggest health crisis we face, is spinning out of control around the globe.

How did this happen, with all the bioinformatics, translational science, and genetic breakthroughs that have occurred, many of them right here at our medical school?

I stepped into a tutorial last year and heard third-year students struggling to help their patients with metabolic syndrome—an insidious combination of hypertension, obesity and type 2 diabetes. These students were frustrated over their patients’ poor compliance with taking their medications. Why is helping our patients live healthier lives often so difficult?

I believe one of the reasons obesity is on the rise is because of the powerful narratives that are constantly bombarding us—in advertisements, on billboards, in restaurants and in stores.

Coca-Cola tells consumers to ‘open happiness,’ and the CEO of Pepsi talks of designing Doritos for women with a lighter crunch that leave no flavored residue on the fingers because, she notes, women don’t like to crunch loudly or lick their fingers in public the way that men do. Next on her corporate research agenda she says is this driving question: ‘How can you put [Doritos] in a purse? Because women love to carry a snack in their purse.’

Forty-six percent of the sugar consumed in the U.S. is in sugar-sweetened beverages.  Twenty-five percent of our daily calories come from snacks. And 61 percent of the foods we buy are highly processed. Is it any wonder that our country is facing an obesity pandemic? And yet, these disturbing figures seem to have had little impact on the food and beverage choices we make.

You may be asking yourselves why we pay so little attention to these data that warn us of an impending health catastrophe. Is it just that we’re overwhelmed by all these numbers? Nevertheless, a big part of your job will be to treat the diseases that afflict so many people who are obese or overweight, often because they over consume these foods that are inexpensive and constantly promoted. What is your role in promoting your patients’ health? Should you speak up? And if so, how? And will it matter?

I think these things matter deeply. When a person is not healthy, he or she isn’t able to live life to the fullest. And millions of people are not healthy. In fact, I think that the inflammation so many individuals must cope with on a daily basis may be contributing to some of our political woes and the rancor people express across the country. When you feel crappy, you often act crappy or at least cranky.

So this, of course, is where you come in. How can you make a difference? What can you do? And in making a difference how can you care for yourselves and keep the inflammation at bay? How can you enjoy your own lives during this time of political, economic, and social upheaval

For me, and I think for you, the answer lies in storytelling. I’ve been fortunate as a producer and writer on television shows like ER and Law & Order: Special Victims Unit to tell stories about the complex public health issues facing us today, from gun violence to teen access to abortion, from vaccination to fetal alcohol syndrome.

Medical topics and health policy issues such as these must be explored on television dramas because dramas are a reflection of the day-to-day struggles in our lives. Here we can dramatize the messiness and conflicts inherent in the practice of medicine and through characters’ beliefs and actions.

How do I know that stories make a difference? When we conducted a study with the Kaiser Family Foundation on the impact of an episode of ER that dealt with HPV as the primary cause of cervical cancer, we were stunned. Before the show aired, 19 percent of the viewers knew that HPV is associated with cervical cancer; after the show aired that number rose to 60 percent. Our story made a difference.

Changing behavior, particularly when it comes to improving public health, is challenging, and in light of the figures I’ve cited, daunting. I’ve learned personally and professionally that I can’t change anyone’s behavior, except my own—and that’s really tough. Yes, court decisions and laws that embrace social justice, like Brown v. Board of Education and the Affordable Care Act—can change behavior outwardly, but we must also find ways to promote ethical self-efficacy.

But how?

Facts and figures compiled in policy reports or medical journals organize the world in ways that make it possible for us to grapple with complex social issues. But, as the renowned social scientist Paul Slovic has shown us, data do not drive our hearts.

Consider, as his research so astutely demonstrates in his 2007 paper “Psychic Numbing and Genocide,” that we as human beings are moved not by the mass devastation in Syria or Myanmar but by the single child desperately in need. Our brains are wired to respond to the individual, not to the faceless crowd. Data do not drive our hearts.

I think stories on TV—and all other forms of storytelling—captivate us because we see our own lives in the characters’ struggles. We root for some; loathe or love others. Stories are stand-ins for our own lives. Stories about individuals are what engage us, transport us and can move us to take action. They shake us up; help us to see other points of view through characters we can identify with. Perhaps we begin to think about things a little differently from the way we had thought about them before. Perhaps we begin to find common ground.

Each of you has many stories to tell of patients you will never forget. You’ll always remember their valor, their dignity, their humor, their determination, as well as their anger and their defeats. You must tell their stories.

Your patients will suffer greatly from the consequences of their own poor choices, habits and actions, and it will be your job to help them respond to those consequences in healthier ways. Obesity, gun violence in schools and lack of access to good health care are too often hypocritically explained away as unfortunate facts of life.  We now live in this bizarre fugue state of constantly trying to cope with these unfortunate events rather than changing the social structures, laws and policies that allow them to linger and metastasize.

These are public health problems. And there is a solution.

And that is through storytelling.

I call the stories that moved you, the stories that will stay with you always, your private stories. And I believe that our duty as physicians does not lie only in the clinic, on the wards or in the OR, but in making our private stories public. Public storytelling requires us to draw on our personal experiences as physicians and to bring them to public attention in order to improve people’s health and lives.

How does telling your own stories matter, you may be wondering. First, it’s empowering to testify, to convey your experience and knowledge, not only for the listener, but also for yourself. Telling your stories means that you matter and your patients matter. And as Slovic points out, telling a compelling story about an individual or a family can create a relatable hook to spark our empathy. Think of a time when your own heart changed after you heard a story or saw a movie or play or read a novel. You carry that story with you. It changes you, just as it has changed others, moving us along, even if it’s slowly, toward healthy social change.

"You don’t have to be a television writer to have an impact."

And what about your patients’ stories? Here the role of empathy is paramount. We can never truly get inside someone else’s head. As a gay white man, I don’t know what it feels like to be straight, lesbian or transgender. I don’t know how it feels to walk through the world as an African American, Asian American, Native American or Latino man, woman or child. But through empathy, ignited by the stories people tell, I can imagine what it’s like to be someone different from myself. And that is the beginning of compassion and social justice. This means that you must listen carefully to your patients’ stories, and with their permission give them voice. But you must also help your patients voice their own stories because nothing is more empowering than telling one’s own story.

You have so much power in your own stories to do good. Shine an antiseptic light on injustice with your stories.

I think medicine attracts the naturally curious. Most physicians I’ve met have a hunger for knowing about the wonders of medical science and what it can accomplish. Physicians just dig knowing how our bodies work, and that curiosity spills over into all sorts of other areas, including music, literature, poetry and art, which not only enrich your own lives, but also propel you to learn deeply about your patients’ lives. Curiosity is the gateway to empathy. Curiosity presses you to look at and listen to, touch and even smell the patient. In a beautiful piece written in the Annals of Internal Medicine in 1999, Dr. Faith Fitzgerald wrote, “it is curiosity that converts strangers … into people we can empathize with. To participate in the feelings and ideas of one’s patients—to empathize—one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past and social surrounds.” 

Stay curious. Keep asking questions, particularly when it comes to the social determinants of health that affect our wellness and well-being. Don’t only ask why these social determinants like poverty, exposure to toxins and violence, immigration status and access to health care exist. We know why. We have a president and Republican senators who would blithely kick 20 million people off their health insurance. You must also ask how we can change things to make sure everyone has access to the best care we can offer. And the best way I know how to do that is to vote and to tell powerful stories that stir the heart.

Each of you has your own story to tell, a story that has gripped you, changed the way you thought about the world, or moved you to tears. Take your private stories about domestic violence, drug abuse, HIV, access to health care and family planning clinics, needle exchange, alcohol abuse, victims of torture, food deserts, and make them public. You don’t have to be a television writer to have an impact.

Write op-ed pieces. Work in grassroots organizations. Testify before the legislature. run for elected office. Debate your enemies. March for justice. Stand for truth. Teach. Blog. Tweet. Start your own YouTube channel. Use cellular phones in new ways to improve people’s lives as students at the University of California at Berkeley did when they devised a way to attach a small microscope to a cell phone so that a blood smear could be sent to a lab far away. Consider how that can improve the treatment of malaria. Or did you know that students at Rice University have invented numerous devices, like a portable detector that can improve maternal outcomes of pregnant women with anemia? Take your private stories and invent new ways to treat patients. Devise ways to use new media to inform the public about breakthroughs that can improve people’s lives.

Astonishing treatments and inventions are being made in response to stories that moved their inventors. You can do that, too.

Thank you for the honor of letting me share my stories with you today and for giving me the opportunity to thank the dean, the administration and most of all, our vibrant, unmatched and dedicated faculty for sharing their stories as they’ve shepherded us to become healers.

So here is my challenge to you today, as you celebrate your entry into this glorious profession. As your head hits the pillow tonight and you close your eyes, think about a story that moved you in medical school. Then ask yourself: does it matter?

Allow me to share a few stories that have recently moved me.

Forty-nine percent of the 1.1 million people living in the US with HIV are now undetectable, which means they are receiving medication that will prevent them from transmitting the virus and will keep them healthy. That leaves 51 percent who aren’t receiving proper treatment.

Instead of asking does it matter, I’d like to change the question into a statement:  Make it matter. Let’s tell the story of HIV, which has not been addressed adequately in this country.

Did you know that in a recent New York Times Magazine article, Linda Villarosa wrote that “Last year, the Centers for Disease Control and Prevention, using the first comprehensive national estimates of lifetime risk of H.I.V. for several key populations, predicted that if current rates continue, one in two African-American gay and bisexual men will be infected with the virus. That compares with a lifetime risk of one in 99 for all Americans and one in 11 for white gay and bisexual men.”

Villarosa tells the story of Cedric Sturdevant, from Jackson, Mississippi, who’s traveled 300,000 miles “in a 13-year-old Ford Expedition with cracked seats and chipped paint.” He’s a visiting nurse who as a young man contracted HIV. Now he takes care of young gay and transgender women with HIV and AIDS, often driving hundreds of miles to deliver medication to those who live in isolation and shame. Fighting anti-LGBT stigma and the lack of access to treatment, Sturdevant has saved dozens and dozens of lives. He made it matter.

And now I tell everyone I can about the story of HIV and AIDS today in the United States. We discuss how we can work to get medications to everyone who needs them.

Fifty-five percent of the adults in my state, California, have diabetes or prediabetes, also known as impaired glucose tolerance. And one-third of those aged 18 to 39 are prediabetic. Recently, a new friend of mine was diagnosed with type 2 diabetes. An inveterate Coke and cookie lover, he decided that the risk of blindness, neuropathy, kidney and heart disease were not worth the brief enjoyment he found in the junk food he ate. Working with his physician, he learned about insulin resistance and the impact of sugar on his weight. He then decided to change his diet and cut out sugar completely. After exercising and losing nearly 50 pounds by not eating junk and processed food, he is no longer diabetic. My friend made it matter.

And I stopped eating sugar, too.

Take your stories and your passions and turn them into potent barbs to fight dogmatism and bigotry. Use your private stories that stir and move you and tell them any way you can. Invent new ways. Speak out. That is your mission: to improve people’s lives. You’ve got stories to tell and many new ones will come along that will rankle you and move you and become unforgettable and fill your hearts.  I’m standing here facing you, the next generation of physicians, who give me hope. Now go out there and tell your stories. Make it matter!

Adapted from a speech given by Neal Baer on Class Day, May 24, 2018.