Acute renal failure (ARF) has traditionally been defined as the abrupt loss of kidney function that results in the retention of urea and other nitrogenous waste products and in the dysregulation of extracellular volume and electrolytes. The loss of kidney function is most easily detected by measurement of the serum creatinine which is used to estimate the glomerular filtration rate (GFR).
Three problems are associated with the use of the serum creatinine to quantitatively define ARF:
* Serum creatinine does not accurately reflect the GFR in a patient who is not in steady state. In the early stages of severe acute renal failure, the serum creatinine may be low even though the actual (not estimated) GFR is markedly reduced since there may not have been sufficient time for the creatinine to accumulate. (See "Assessment of kidney function: Serum creatinine; BUN; and GFR".)
* Creatinine is removed by dialysis. As a result, it is usually not possible to assess kidney function by measuring the serum creatinine once dialysis is initiated. One exception is when the serum creatinine continues to fall on days when hemodialysis is not performed, indicating recovery of renal function.
* Numerous epidemiologic studies and clinical trials have used different cut-off values for serum creatinine to quantitatively define ARF [1].
The lack of consensus in the quantitative definition of ARF, in particular, has hindered clinical research since it confounds comparisons between studies. Some definitions employed in clinical studies have been extremely complex with graded increments in serum creatinine for different baseline serum creatinine values [1,2]. As an example, in a classic study of the epidemiology of hospital-acquired acute renal failure, ARF was defined as a 0.5 mg/dL increase in serum creatinine if the baseline serum creatinine was ≤1.9 mg/dL, an 1.0 mg/dL increase in serum creatinine if the baseline serum creatinine was 2.0 to 4.9 mg/dL, and a 1.5 mg/dL increase in serum creatinine if the baseline serum creatinine was ≥5.0 mg/dL [2].
The Acute Dialysis Quality Initiative (ADQI) was created by a group of expert intensivists and nephrologists to develop consensus and evidence based guidelines for the treatment and prevention of acute renal failure [3]. Recognizing the need for a uniform definition for ARF, the ADQI group proposed a consensus graded definition, called the RIFLE criteria [4]. A modification of the RIFLE criteria was subsequently proposed by the Acute Kidney Injury Network, which included the ADQI group as well as representatives from other nephrology and intensive care societies [5-7].
Because of these initiatives, the term acute kidney injury (AKI) was proposed to represent the entire spectrum of acute renal failure. This topic review will address the current definitions of acute renal failure, particularly the RIFLE criteria and the AKIN modifications.
RIFLE CRITERIA — The RIFLE criteria consists of three graded levels of injury (Risk, Injury, and Failure) based upon either the magnitude of elevation in serum creatinine or urine output, and two outcome measures (Loss and End-stage renal disease). The RIFLE strata are as follows [4]:
* Risk — 1.5-fold increase in the serum creatinine or GFR decrease by 25 percent or urine output <0.5 mL/kg per hour for six hours
* Injury — Twofold increase in the serum creatinine or GFR decrease by 50 percent or urine output <0.5 mL/kg per hour for 12 hours
* Failure — Threefold increase in the serum creatinine or GFR decrease by 75 percent or urine output of <0.5 mL/kg per hour for 24 hours, or anuria for 12 hours
* Loss — Complete loss of kidney function (eg, need for renal replacement therapy) for more than four weeks
* ESRD — Complete loss of kidney function (eg, need for renal replacement therapy) for more than three months (figure 1)
The RIFLE criteria correlated with prognosis in a number of studies [8-14]. As an example, a systematic review of 13 studies demonstrated a stepwise increase in the relative risk of death in patients who met the RIFLE criteria for various stages of AKI [14]. Compared to patients who did not have AKI, patients in the RIFLE stages of "risk," "injury," and "failure" had increased relative mortality risks of 2.4 (CI 1.94-2.97), 4.15 (CI 3.14-5.48), and 6.37 (CI 5.14-7.9). Despite significant heterogeneity among studies, results from most individual reports were qualitatively similar.
Limitations — There are several important shortcomings to the RIFLE criteria:
* The "risk," "injury," and "failure" strata are defined by either changes in serum creatinine or urine output. The assignment of the corresponding changes in serum creatinine and changes in urine output to the same strata are NOT based on evidence. In the one assessment of the RIFLE classification that compared the serum creatinine and urine output criteria, the serum creatinine criteria were strong predictors of ICU mortality, whereas the urine output criteria did not independently predict mortality [12]. Thus, if the RIFLE classification is used to stratify risk, it is important that the criteria that result in the least favorable RIFLE strata be used [4].
* As mentioned above, the change in serum creatinine during acute renal failure does not directly correlate with the actual change in glomerular filtration rate, which alters the assignment of that patient to a particular RIFLE level. As an example, in a patient with an abrupt decline in renal function in the setting of severe ARF, the serum creatinine might rise from 1.0 to 1.5 mg/dL (88.4 to 133 micromol/L) on day one, 2.5 mg/dL (221 micromol/L) on day two, and 3.5 mg/dL (309 micromol/L) on day three. According to the RIFLE criteria, the patient would progress from "risk" on day one to "injury" on day two and "failure" on day three, even though the actual GFR has been <10 mL/min over the entire period. This issue is intrinsic to any assessment of acute renal failure based upon the serum creatinine level.
* It is impossible to calculate the change in serum creatinine in patients who present with ARF but without a baseline measurement of serum creatinine. The authors of the RIFLE criteria suggest back-calculating an estimated baseline serum creatinine concentration using the four-variable MDRD equation, assuming a baseline GFR of 75 mL/min per 1.73 m2 [4]. However, this approach has not been prospectively validated.
AKIN CRITERIA — Given these limitations, a modification of the RIFLE criteria has been proposed by the Acute Kidney Injury Network. The AKIN proposed both diagnostic criteria for ARF and a staging system that was based on the RIFLE criteria [5-7]. In addition, the term acute kidney injury (AKI) was proposed to represent the entire spectrum of acute renal failure.
Diagnostic criteria — The proposed diagnostic criteria for ARF are an abrupt (within 48 hours) absolute increase in the serum creatinine concentration of ≥0.3 mg/dL (26.4 micromol/L) from baseline, a percentage increase in the serum creatinine concentration of ≥50 percent, or oliguria of less than 0.5 mL/kg per hour for more than six hours (table 1).
The latter two of these criteria are identical to the RIFLE "risk" criteria. The addition of an absolute change in serum creatinine of ≥0.3 mg/dL is based on epidemiologic data that have demonstrated an 80 percent increase in mortality risk associated with changes in serum creatinine concentration of as little as 0.3 to 0.5 mg/dL [15]. Including a time constraint of 48 hours is based upon data that showed that poorer outcomes were associated with small changes in the creatinine when the rise in creatinine was observed within 24 to 48 hours [16,17].
Two additional caveats were proposed by the AKIN group:
* The diagnostic criteria should be applied only after volume status had been optimized
* Urinary tract obstruction needed to be excluded if oliguria was used as the sole diagnostic criterion.
A flaw with the last caveat is that, according to the current definition, AKI would still be used to describe the patient with acute urinary tract obstruction and an acute increase in serum creatinine. It is not clear whether the AKIN modifications to RIFLE have substantively changed the classification of patients with AKI or improved its ability to predict hospital mortality [18].
Staging system — The classification or staging system for ARF is comprised of three stages of increasing severity, which correspond to risk (stage 1), injury (stage 2), and failure (stage 3) of the RIFLE criteria. Loss and ESRD are removed from the staging system and defined as outcomes.
The clinical applicability of these staging systems is uncertain. However, they will likely have some utility in standardizing the definitions for epidemiologic studies and for establishing inclusion criteria and endpoints for clinical trials.
Ultimately these definitions are likely to be replaced by more sensitive and specific biomarkers of renal injury.
CLINICAL UTILITY — The RIFLE and AKIN criteria have helped to focus attention that decrements in renal function that result in small changes in serum creatinine concentration are associated with significant clinical consequences. However, the precise clinical utility of these criteria is uncertain. There is also an inherent confusion within these criteria as to whether prerenal and obstructive etiologies of ARF are subsumed in or are external to the definition of AKI.
We believe that these criteria have greatest utility in epidemiologic studies and in defining consistent inclusion criteria and/or endpoints for clinical studies. Their utility at the bedside is less clear and it seems likely that they will eventually be replaced at least in part by sensitive and specific biomarkers of renal tubular injury. The use of such biomarkers, analogous to troponin as a marker of myocardial injury, will permit development of a new paradigm for classifying acute kidney injury that is not solely dependent upon serum creatinine or other functional markers.
We do believe that adoption of the term acute kidney injury (AKI) to replace the older terminology of acute renal failure is highly appropriate. Just as acute lung injury is used to describe acute pulmonary injury that has not progressed to overt organ failure, we believe that AKI is more representative of the full spectrum of acute kidney dysfunction.
SUMMARY
* Acute renal failure (ARF) has traditionally been defined as the abrupt loss of kidney function resulting in the retention of urea and other nitrogenous waste products and in the dysregulation of extracellular volume and electrolytes. (See 'Introduction' above.)
* Although the loss of kidney function is most easily detected by measurement of the serum creatinine, several problems are associated with the use of this measure to quantitatively define ARF, particularly the lack of consensus in the quantitative definition. (See 'Introduction' above.)
* The Acute Dialysis Quality Initiative (ADQI) has proposed a graded definition of ARF called the RIFLE criteria. The Acute Kidney Injury Network (AKIN) modified the RIFLE criteria in order to include less severe ARF, to impose a time constraint of 48 hours, and to allow for correction of volume status and obstructive causes of ARF prior to classification. (See 'Rifle criteria' above and 'AKIN criteria' above.) These criteria have their greatest utility in epidemiologic studies.
* The AKIN proposed the term acute kidney injury (AKI) to represent the entire spectrum of acute renal failure. The proposed diagnostic criteria are an abrupt (within 48 hours) absolute increase in the serum creatinine concentration of ≥0.3 mg/dL (26.4 micromol/L) from baseline, a percentage increase in the serum creatinine concentration of ≥50 percent, or oliguria of less than 0.5 mL/kg per hour for more than six hours. These criteria will likely be revised, and possibly replaced, as biomarkers of tubular injury are developed. (See 'Diagnostic criteria' above.)
* We agree that adoption of the term acute kidney injury to replace the older terminology of acute renal failure is highly appropriate. AKI better represents the full spectrum of acute kidney dysfunction. (See 'Clinical utility' above
Wednesday, September 15, 2010
Sunday, September 12, 2010
FLexner Report
The Flexner Report[1] is a book-length study of medical education in the United States and Canada, written by the professional educator Abraham Flexner and published in 1910 under the aegis of the Carnegie Foundation. Many aspects of the present-day American medical profession stem from the Flexner Report and its aftermath.
The Report (also called Carnegie Foundation Bulletin Number Four), called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. Many American medical schools fell short of the standard advocated in the Report, and subsequent to its publication, nearly half of such schools merged or were closed outright. The Report also concluded that there were too many medical schools in the USA, and that too many doctors were being trained. A repercussion of the Flexner Report resulting from the closure or consolidation of university training, was reversion of American universities to male-only admittance programs to accommodate a smaller admission pool. Universities had begun opening and expanding female admissions as part of women's and co-educational facilities only in the mid-to-latter part of the 19th century with the founding of co-educational Oberlin College in 1833 and private colleges such as Vassar College and Pembroke College.
[edit] History
In 1904 the AMA created the Council on Medical Education (CME) whose objective was to restructure American medical education. At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. In 1908, the CME asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME's reformist agenda and hasten the elimination of medical schools that failed to meet the CME's standards. The president of the Carnegie Foundation, Henry Pritchett, a staunch advocate of medical school reform, chose Flexner to conduct the survey.
At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated." The Report became notorious for its harsh description of certain establishments, for example describing Chicago's 14 medical schools as "a disgrace to the State whose laws permit its existence... indescribably foul... the plague spot of the nation."
Nevertheless, several schools received praise for excellent performance, including Harvard, Western Reserve, Michigan, Wake Forest University School of Medicine, McGill, University of Toronto, and especially Johns Hopkins - the latter was described as 'model for medical education'. [2]
Wake Forest University School of Medicine was praised for: "The laboratories of this little school are, as far as they go, models in their way. Everything about them indicates intelligence and earnestness. The dissecting room is clean and odorless, the bodies undergoing dissection being cared for in the most approved modern manner. Separate laboratories, properly equipped, are provided for ordinary undergraduate work in bacteriology, pathology, and histology, and the instructor has a private laboratory besides. Chemistry is taught in the well equipped college laboratory; physiology is slight; there is no pharmacology. There is a small museum; animals, charts, and books are provided." [3]
It should be noted that Wake Forest University School of Medicine, formerly Bowman Gray School of Medicine, opened a in a new town as a four-year school in 1941.
[edit] Recommended changes
When Flexner researched his report, many American medical schools were "proprietary", namely small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. A degree was typically awarded after only two years of study. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be desired. The regulation of the medical profession by state government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word "quack" flourished. There is no evidence that the mass of Americans were dissatisfied with this situation.
Flexner looked this situation in the face. Using the Johns Hopkins University School of Medicine as the ideal[4], he boldly recommended that:
* Admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. When Flexner researched his report, only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education (p 28). According to Hiatt and Stockton, by 1920 92% of U.S. medical schools required this of applicants.
* The length of medical education be four years, and its content should be what the CME agreed to in 1905.
* Proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even.
Less known is Flexner's recommendation that medical schools appoint full-time clinical professors. Holders of these appointments would become "true university teachers, barred from all but charity practice, in the interest of teaching." Flexner pursued this objective for years, despite widespread opposition from existing medical faculty.
Flexner was the child of German immigrants, and had studied and traveled in Europe. He was well aware that one could not practice medicine in continental Europe without having undergone an extensive specialized university education. In effect, Flexner was demanding that American medical education conform to prevailing practice in continental Europe.
By and large, medical schools in Canada and the United States have followed Flexner's recommendations down to the present day. Recently, however, schools have increased their emphasis on public health matters.
[edit] Consequences of the report
To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:
* A physician receives at least six, and preferably eight, years of post-secondary formal instruction, nearly always in a university setting;
* Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry. Medical research adheres fully to the protocols of scientific research;[5]
* Average physician quality has increased significantly;[6]
* No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;
* Each state branch of the American Medical Association has oversight over the conventional medical schools located within the state;
* Medicine in the USA and Canada becomes a highly paid and well-respected profession;
* The annual number of medical school graduates sharply declined, and the resulting reduction in the supply of doctors makes the availability and affordability of medical care problematic. The Report led to the closure of the sort of medical schools that trained doctors willing to charge their patients less. Moreover, before the Report, high quality doctors varied their fees according to what they believed their patients could afford, a practice known as price discrimination. The extent of price discrimination in American medicine declined in the aftermath of the Report;
* Kessel (1958) argued that the Flexner Report in effect began the cartelization of the American medical profession, a cartelization enforced by the American Medical Association and backed by the police power of each American state. This de facto cartel restricted the supply of physicians, and raised the incomes of the remaining practitioners.
The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day. "An education in medicine," wrote Flexner, "involves both learning and learning how; the student cannot effectively know, unless he knows how." Although the report is more than 99 years old, many of its recommendations are still relevant—particularly those concerning the physician as a "social instrument... whose function is fast becoming social and preventive, rather than individual and curative."
[edit] Closure of many medical schools
According to Hiatt and Stockton (p. 8), Flexner sought to shrink the number of medical schools in the USA to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting M.D. or D.O. degrees as of the date of the Report (1910) closed within two to three decades. (No Canadian medical school was deemed inadequate, and none closed or merged subsequent to the Report.) In 1904, there were 160 M.D. granting institutions with more than 28,000 students. By 1920, there were only 85 M.D. granting institution, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the USA.
Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report's recommendation that all "proprietary" schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving M.D. granting institutions in 1935, 57 were part of a university. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report's recommendations.
[edit] American medicine becomes a less diverse profession
One of the consequences of Flexner's advocacy of university-based medical education was that medical education became much more expensive, putting such education out of reach of all but upper class white males. The small "proprietary" schools Flexner condemned, which were contended to be have been based in generations-old folk traditions rather than relatively recent western science, did admit African-Americans, women, and students of limited financial means. These students usually could not afford six to eight years of university education, and were often simply denied admission to medical schools affiliated with universities. At the same time, the Report tended to delegitimize existing women doctors and doctors of color. While many such doctors continued to practice, usually within underserviced clienteles, they did so under proscribed circumstances and for less pay. In general, the standardization of medical education advocated in the Report led to the domination of American medicine by well-off white males. It also made it more difficult for people of color, residents of rural areas, and for those of limited means generally to obtain medical care in any form. The Flexner report recommended the closure of several African American medical schools, including the Leonard Medical Center, the oldest four-year medical school in the country, of any persuasion, not just for African-Americans. Ironically one of the schools was located in his own hometown of Louisville, Kentucky, Louisville National Medical College.
[edit] Impact on alternative medicine
When Flexner researched his report, "modern" medicine faced vigorous competition from several quarters, including osteopathic medicine, eclectic medicine, physiomedicalism, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than biomedicine, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.[citation needed]
[edit] Impact on osteopathic medicine
Although almost all the alternative medical schools listed in Flexner's report were closed, the American Osteopathic Association (AOA) were able to bring a number of osteopathic medical schools into compliance with Flexner's recommendations. As a result, American osteopathic medical schools today teach from an evidence-based, medicalised, scientific knowledge base. The curricula of DO and MD awarding medical schools differ only minimally, the chief difference being the additional instruction in osteopathic schools of manipulative medicine. This dramatic convergence of osteopathic and biomedical training demonstrates the sweeping effect the Flexner report had, not only in the closure of inadequate schools, but also in the standardization of the curricula of surviving schools.
The Report (also called Carnegie Foundation Bulletin Number Four), called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. Many American medical schools fell short of the standard advocated in the Report, and subsequent to its publication, nearly half of such schools merged or were closed outright. The Report also concluded that there were too many medical schools in the USA, and that too many doctors were being trained. A repercussion of the Flexner Report resulting from the closure or consolidation of university training, was reversion of American universities to male-only admittance programs to accommodate a smaller admission pool. Universities had begun opening and expanding female admissions as part of women's and co-educational facilities only in the mid-to-latter part of the 19th century with the founding of co-educational Oberlin College in 1833 and private colleges such as Vassar College and Pembroke College.
[edit] History
In 1904 the AMA created the Council on Medical Education (CME) whose objective was to restructure American medical education. At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. In 1908, the CME asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME's reformist agenda and hasten the elimination of medical schools that failed to meet the CME's standards. The president of the Carnegie Foundation, Henry Pritchett, a staunch advocate of medical school reform, chose Flexner to conduct the survey.
At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated." The Report became notorious for its harsh description of certain establishments, for example describing Chicago's 14 medical schools as "a disgrace to the State whose laws permit its existence... indescribably foul... the plague spot of the nation."
Nevertheless, several schools received praise for excellent performance, including Harvard, Western Reserve, Michigan, Wake Forest University School of Medicine, McGill, University of Toronto, and especially Johns Hopkins - the latter was described as 'model for medical education'. [2]
Wake Forest University School of Medicine was praised for: "The laboratories of this little school are, as far as they go, models in their way. Everything about them indicates intelligence and earnestness. The dissecting room is clean and odorless, the bodies undergoing dissection being cared for in the most approved modern manner. Separate laboratories, properly equipped, are provided for ordinary undergraduate work in bacteriology, pathology, and histology, and the instructor has a private laboratory besides. Chemistry is taught in the well equipped college laboratory; physiology is slight; there is no pharmacology. There is a small museum; animals, charts, and books are provided." [3]
It should be noted that Wake Forest University School of Medicine, formerly Bowman Gray School of Medicine, opened a in a new town as a four-year school in 1941.
[edit] Recommended changes
When Flexner researched his report, many American medical schools were "proprietary", namely small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. A degree was typically awarded after only two years of study. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be desired. The regulation of the medical profession by state government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word "quack" flourished. There is no evidence that the mass of Americans were dissatisfied with this situation.
Flexner looked this situation in the face. Using the Johns Hopkins University School of Medicine as the ideal[4], he boldly recommended that:
* Admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. When Flexner researched his report, only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education (p 28). According to Hiatt and Stockton, by 1920 92% of U.S. medical schools required this of applicants.
* The length of medical education be four years, and its content should be what the CME agreed to in 1905.
* Proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even.
Less known is Flexner's recommendation that medical schools appoint full-time clinical professors. Holders of these appointments would become "true university teachers, barred from all but charity practice, in the interest of teaching." Flexner pursued this objective for years, despite widespread opposition from existing medical faculty.
Flexner was the child of German immigrants, and had studied and traveled in Europe. He was well aware that one could not practice medicine in continental Europe without having undergone an extensive specialized university education. In effect, Flexner was demanding that American medical education conform to prevailing practice in continental Europe.
By and large, medical schools in Canada and the United States have followed Flexner's recommendations down to the present day. Recently, however, schools have increased their emphasis on public health matters.
[edit] Consequences of the report
To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:
* A physician receives at least six, and preferably eight, years of post-secondary formal instruction, nearly always in a university setting;
* Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry. Medical research adheres fully to the protocols of scientific research;[5]
* Average physician quality has increased significantly;[6]
* No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;
* Each state branch of the American Medical Association has oversight over the conventional medical schools located within the state;
* Medicine in the USA and Canada becomes a highly paid and well-respected profession;
* The annual number of medical school graduates sharply declined, and the resulting reduction in the supply of doctors makes the availability and affordability of medical care problematic. The Report led to the closure of the sort of medical schools that trained doctors willing to charge their patients less. Moreover, before the Report, high quality doctors varied their fees according to what they believed their patients could afford, a practice known as price discrimination. The extent of price discrimination in American medicine declined in the aftermath of the Report;
* Kessel (1958) argued that the Flexner Report in effect began the cartelization of the American medical profession, a cartelization enforced by the American Medical Association and backed by the police power of each American state. This de facto cartel restricted the supply of physicians, and raised the incomes of the remaining practitioners.
The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day. "An education in medicine," wrote Flexner, "involves both learning and learning how; the student cannot effectively know, unless he knows how." Although the report is more than 99 years old, many of its recommendations are still relevant—particularly those concerning the physician as a "social instrument... whose function is fast becoming social and preventive, rather than individual and curative."
[edit] Closure of many medical schools
According to Hiatt and Stockton (p. 8), Flexner sought to shrink the number of medical schools in the USA to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting M.D. or D.O. degrees as of the date of the Report (1910) closed within two to three decades. (No Canadian medical school was deemed inadequate, and none closed or merged subsequent to the Report.) In 1904, there were 160 M.D. granting institutions with more than 28,000 students. By 1920, there were only 85 M.D. granting institution, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the USA.
Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report's recommendation that all "proprietary" schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving M.D. granting institutions in 1935, 57 were part of a university. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report's recommendations.
[edit] American medicine becomes a less diverse profession
One of the consequences of Flexner's advocacy of university-based medical education was that medical education became much more expensive, putting such education out of reach of all but upper class white males. The small "proprietary" schools Flexner condemned, which were contended to be have been based in generations-old folk traditions rather than relatively recent western science, did admit African-Americans, women, and students of limited financial means. These students usually could not afford six to eight years of university education, and were often simply denied admission to medical schools affiliated with universities. At the same time, the Report tended to delegitimize existing women doctors and doctors of color. While many such doctors continued to practice, usually within underserviced clienteles, they did so under proscribed circumstances and for less pay. In general, the standardization of medical education advocated in the Report led to the domination of American medicine by well-off white males. It also made it more difficult for people of color, residents of rural areas, and for those of limited means generally to obtain medical care in any form. The Flexner report recommended the closure of several African American medical schools, including the Leonard Medical Center, the oldest four-year medical school in the country, of any persuasion, not just for African-Americans. Ironically one of the schools was located in his own hometown of Louisville, Kentucky, Louisville National Medical College.
[edit] Impact on alternative medicine
When Flexner researched his report, "modern" medicine faced vigorous competition from several quarters, including osteopathic medicine, eclectic medicine, physiomedicalism, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than biomedicine, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.[citation needed]
[edit] Impact on osteopathic medicine
Although almost all the alternative medical schools listed in Flexner's report were closed, the American Osteopathic Association (AOA) were able to bring a number of osteopathic medical schools into compliance with Flexner's recommendations. As a result, American osteopathic medical schools today teach from an evidence-based, medicalised, scientific knowledge base. The curricula of DO and MD awarding medical schools differ only minimally, the chief difference being the additional instruction in osteopathic schools of manipulative medicine. This dramatic convergence of osteopathic and biomedical training demonstrates the sweeping effect the Flexner report had, not only in the closure of inadequate schools, but also in the standardization of the curricula of surviving schools.
Thursday, September 2, 2010
yale address
Yale Medical School Graduation Address
Donald M. Berwick, MD, MPP
New Haven, Connecticut: May 24, 2010
Dean Alpern, Faculty, Families, Friends, and Honored Graduates...
I don‟t have words enough to express my gratitude for the chance to speak with you on your special day. It would be a pleasure and honor at any graduation ceremony. But, I have to tell you, to be up here in this role in the presence of my own daughter on the day that she becomes a doctor is a joy I wouldn‟t dare have dreamed up. I hope that each of you will someday have the chance to feel as much gratitude and pride and love as I feel right now, joining you, and, especially, joining Jessica. Thank you very much. I am so proud of you, Jessica.
Now, I have to tell you the truth about Jessica. Jessica was supposed to be a boy. At least that‟s what the ultrasonographer said when we took a look at “him” in utero. “Never been wrong,” said the ultrasound tech as she pointed out the anatomy – there was the “thing.” My wife and I were delighted. We saw the thing, too. Clearly. We had two sons already, and they were fantastic. A third boy – terrific!
But, you know, to be honest, and with no offense intended to Ben and Dan, who are here today, too, we were sort of hoping for a change. I had only brothers, and Ann, my wife, I knew, wanted a chance to raise a daughter. To our friends we said, “Boy… Girl…We don‟t care; just as long as he is healthy.” But… we were lying, just a little.
And then: the surprise. I was right there, in the c-section room – Ann delivered all four of our children by c-section – and, instead of Jonas, whom we were waiting for, out popped, not Jonas, but Jessica. “Oh, my goodness,” the obstetrician exclaimed, “it‟s a girl!” Imagine the joy – Ann and I literally squealed. We screamed. “A daughter,” Ann screamed, “a daughter. We have a daughter!”
The obstetrician said, “Hmmmm…. That never happened before. That „thing‟ on the ultrasound must have been the umbilical cord.” Whatever. No question at all – that was one of the peak moments of my entire life. I will never, ever forget it. I had a daughter.
How do I know that moment of miracle – that surprise and celebration? Well, it‟s obvious. I told you. I was there – I was right there in the c-section room, holding my wife‟s hand. Greeting my new, unexpected daughter. Watching the miracle.
Maybe you know this; maybe you don‟t. But, if that had happened 20 years before Jessica was born, or even 10, I would have missed it. I wouldn‟t have been there. I couldn’t have been there, because fathers weren‟t allowed in c-section rooms. We weren‟t supposed to be there. That was the rule. Then, somebody changed the rule; somebody courageous, I suspect. And, so, I got to see a miracle.
Let me read to you an email I received on Thursday, December 19, 2009. It came from Mrs. Jocelyn Anne Gruzenski – she goes by “Jackie.” I did not know Jackie Gruzenski at the time; she wrote to me out of the blue. But I have since connected with her. And, she gave me permission to read her email to me to you. Here‟s what she wrote:
“Dr. Berwick, …
“My husband was Dr. William Paul Gruzenski, a psychiatrist for 39 years. He was admitted to (a hospital she names in Pennsylvania) after developing a cerebral bleed with a hypertensive crisis. My issue is that I was denied access to my husband except for very strict visiting, four times a day for 30 minutes, and that my husband was hospitalized behind a locked door. My husband and I were rarely separated except for work,” she wrote. “He wanted me present in the ICU, and he challenged the ICU nurse and MD saying, „She is not a visitor, she is my wife.‟ But, it made no difference. My husband was in the ICU for eight days out of his last 16 days alive, and there were a lot of missed opportunities for us.”
Mrs. Gruzenski continued: “I am advocating to the hospital administration that visiting hours have to be open especially for spouses… I do not feel that his care was individualized to meet his needs; he wanted me there more than I was allowed. I feel it was a very cruel thing that was done to us…”
Listen, again, to the words of Dr. Gruzenski: “She is not a visitor; she is my wife.” Hear, again, Mrs. Gruzenski: “I feel that it was a very cruel thing that was done to us.”
“Cruel” is a powerful word for Mrs. Gruzenski to use, isn‟t it? Her email and the emails that followed that first one are without exception dignified, respectful, tempered. Why does she say, “cruel”?
We will have to imagine ourselves there. “My husband and I loved each other very deeply,” she writes to me, “and we wanted to share our last days and moments together. We both knew the gravity of his illness, and my husband wanted quality of life, not quantity.”
What might a husband and wife of 19 years, aware of the short time left together, wish to talk about – wish to do – in the last days? I don‟t know for Dr. and Mrs. Gruzenski. But, I do know for me. I would talk about our children. I would talk about the best trip we ever took together, and even argue, smiling, about whose idea it was. I would remember the black bear we met in a clearing in the Wrangell-St. Elias Range; the cabin at Assiniboine; the Jøtenheim mountains of Norway. I would remember being lost in Kyoto and lost in Prague and lost on Mount Washington, and always found again. Mushroom soup at Café Budapest. And seeing Jessica born, and Ben, and Dan, and Becca. We would have so much to talk about. So much. The nurses would pad in and out of the hospital room, checking i.v.s and measuring pulses and planning their dinners and their weekends. And none of what the nurses and doctors did would matter to us at all; we wouldn‟t even notice them. We would know exactly who the visitors were – they, the doctors and the nurses. They, they would be the visitors in this tiny corner of our whole lives together – they, not us. In the John Denver song it goes this way, “… and all the time that you‟re with me, we will be at home.”
Someone stole all of that from Dr. and Mrs. Gruzenski. A nameless someone. I suspect an unknowing someone. Someone who did not understand who was at home and who was the guest – who was the intruder. Someone who forgot about the black bear and the best mushroom soup we ever had – the jewels of shared experience that glimmer with meaning in our lives. Someone who put the i.v. first, and the soul second.
Of course, it isn‟t really “someone” at all. We don‟t even know who, or what it is. Its voice sounds rational. Its words are these: “It is our policy,” “It‟s against the rule,” “It would be a problem,” and even, incredibly, “It is in your own best interest.” What is irrational is not those phrases; they seem to make sense. What is irrational is what follows those phrases, in ellipsis, unsaid: “It is our policy … that you cannot hold your husband‟s hand.” “It is against the rules … to let you see this or to let you know this.” “It would be a problem … if we treated you on your own terms not ours.” “It is in your own best interest … to miss your daughter‟s moment of birth.” This is the voice of power; and power does not always think the whole thing through.
Berwick Yale Medical School Graduation Address, May 2010 5
Even when it has no name and no locus, power can be, to borrow Mrs. Gruzenski‟s word, “cruel.”
I want you to celebrate this day. I want you to experience all of the pride, all of the joy that it brings you to have reached this milestone. I am not telling you Dr. and Mrs. Gruzenski‟s story to sadden you. I am telling it to inspire you. I want you to remember it, if you can possibly remember anything I am saying to you at this chock-full moment of your lives, because that story gives you a choice.
You see, today you take a big step into power. With your white coat and your Latin, with your anatomy lessons and your stethoscope, you enter today a life of new and vast privilege. You may not notice your power at first. You will not always feel powerful or privileged – not when you are filling out endless billing forms and swallowing requirements and struggling through hard days of too many tasks. But this will be true: In return for your years of learning and your dedication to a life of service and your willingness to take an oath to that duty, society will give you access and rights that it gives to no one else. Society will allow you to hear secrets from frightened human beings that they are too scared to tell anyone else. Society will permit you to use drugs and instruments that can do great harm as well as great good, and that in the hands of others would be weapons. Society will give you special titles and spaces of privilege, as if you were priests. Society will let you build walls and write rules.
And in that role, with that power, you will meet Dr. and Mrs. Gruzenski over, and over, and over again. You will meet them every day – every hour. They will be in disguise. They will be disguised as a new mother afraid to touch her preemie on the ventilator in the incubator. Disguised as the construction worker too embarrassed to admit that he didn‟t hear a word you just said after, “It might be cancer.” Disguised as the busy lawyer who cannot afford for you to keep her waiting, but too polite to say so. Disguised at the alcoholic bottoming out who was the handsome champion of his soccer team and dreamed of being an architect someday. Disguised as the child over whom you tower. Disguised as the 90-year-old grandmother, over whom you tower. Disguised as the professor in the MRI machine who has been told to lie still, but who desperately needs to urinate and is ashamed. Disguised as the man who would prefer to know; and as the man who would prefer not to know. Disguised as the woman who would prefer to sit; and as the woman who would prefer to stand. And as the man who wants you to call him, “Bill,” and as the man who prefers to be called, “Dr. Gruzenski.”
Mrs. Gruzenski wrote, “My husband was a very caring physician and administrator for many years, but during his hospitalization, he was not even afforded the respect of being called, „Doctor.‟” Dr. Gruzenski wanted to be called, “Dr. Gruzenski.” But, they did not do so.
You can. That choice is not in the hands of nameless power, not fated to control by deaf habit. Not “our policy,” “the rule.” Just you. Your choice. Your rule. Your power.
What is at stake here may seem a small thing in the face of the enormous health care world you have joined. It is as a nickel to the $2.6 trillion industry. But that small thing is what matters. I will tell you: it is all that matters. All that matters is the person. The person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wondering mind. The learned mind. The Husband. The Wife. The Son. The Daughter. In the moment.
In the moment, it is all about choice. You have a magical opportunity. You have the opportunity to decide. Yes, you can read the rule book; and someday you can even write the rule book. Decide. Yes, you can hide behind the protocols and the policies. Decide. Yes, you can
say “we,” when you mean, “I.” Yes, you can lock the door. “Sorry, Mrs. Gruzenski, your 30 minutes are up.” You can say that.
But, you can also unlock the door. You can ask, “Shall I call you “Dr. Gruzenski”? “Would you like to be alone?” “Is this a convenient time?” “Is there something else I can do for you?” You can say, “You‟re the boss.” You can say, “Tell me about the best trip you ever took. Tell me about the time you saw your daughter born.”
In my first week of medical school, I was assigned a tutor: Dr. Edward Frank. He was a vascular surgeon, and he was to supervise me in my physical diagnosis course. I read what Harvard Medical School called, “The Red Book.” It was all about the history and physical exam. Hundreds of questions to ask – history, physical, chief complaint, review of systems, and on and on. I stayed up very late, studying all those questions; memorizing the ritual. I knew all the right questions, I thought. I met Dr. Frank the next afternoon, and he took me to see Mrs. Goldberg, who was in the hospital to have her gall bladder taken out. Dr. Frank brought me into Mrs. Goldberg‟s room, into her presence, introduced me, and invited me to begin. My very first history and physical.
“Tell me, Mrs. Goldberg,” I said, “when did your pain begin?” Dr. Frank, the surgeon, interrupted me. He gently put his hand on my shoulder, and he gave me a gift I will never, ever forget. And I will pass his gift to you. His gift was a question that The Red Book left out.
“Oh, Don,” he said. “Before you ask that, let me tell you something very special. Did you know that Mrs. Goldberg has a brand new grandson?”
Decide. You can read the rules. Or, you can say, “Pardon me.” “Pardon this unwelcome interruption in your lives. Thank you for inviting me to help. Thank you for letting me visit. I
Berwick Yale Medical School Graduation Address, May 2010 8
am your guest, and I know it. Now, please, Mrs. Gruzenski, Dr. Gruzenski, what may I do for you?”
Congratulations on your achievement today. Feel proud. You ought to. When you put on your white coat, my dear friends, you become a doctor.
But, now I will tell you a secret – a mystery. Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care – in the sacred presence of people just like you – when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, an “aching” world, as your Chaplain put it this morning, that has never needed healing more.
Congratulations.
Donald M. Berwick, MD, MPP
New Haven, Connecticut: May 24, 2010
Dean Alpern, Faculty, Families, Friends, and Honored Graduates...
I don‟t have words enough to express my gratitude for the chance to speak with you on your special day. It would be a pleasure and honor at any graduation ceremony. But, I have to tell you, to be up here in this role in the presence of my own daughter on the day that she becomes a doctor is a joy I wouldn‟t dare have dreamed up. I hope that each of you will someday have the chance to feel as much gratitude and pride and love as I feel right now, joining you, and, especially, joining Jessica. Thank you very much. I am so proud of you, Jessica.
Now, I have to tell you the truth about Jessica. Jessica was supposed to be a boy. At least that‟s what the ultrasonographer said when we took a look at “him” in utero. “Never been wrong,” said the ultrasound tech as she pointed out the anatomy – there was the “thing.” My wife and I were delighted. We saw the thing, too. Clearly. We had two sons already, and they were fantastic. A third boy – terrific!
But, you know, to be honest, and with no offense intended to Ben and Dan, who are here today, too, we were sort of hoping for a change. I had only brothers, and Ann, my wife, I knew, wanted a chance to raise a daughter. To our friends we said, “Boy… Girl…We don‟t care; just as long as he is healthy.” But… we were lying, just a little.
And then: the surprise. I was right there, in the c-section room – Ann delivered all four of our children by c-section – and, instead of Jonas, whom we were waiting for, out popped, not Jonas, but Jessica. “Oh, my goodness,” the obstetrician exclaimed, “it‟s a girl!” Imagine the joy – Ann and I literally squealed. We screamed. “A daughter,” Ann screamed, “a daughter. We have a daughter!”
The obstetrician said, “Hmmmm…. That never happened before. That „thing‟ on the ultrasound must have been the umbilical cord.” Whatever. No question at all – that was one of the peak moments of my entire life. I will never, ever forget it. I had a daughter.
How do I know that moment of miracle – that surprise and celebration? Well, it‟s obvious. I told you. I was there – I was right there in the c-section room, holding my wife‟s hand. Greeting my new, unexpected daughter. Watching the miracle.
Maybe you know this; maybe you don‟t. But, if that had happened 20 years before Jessica was born, or even 10, I would have missed it. I wouldn‟t have been there. I couldn’t have been there, because fathers weren‟t allowed in c-section rooms. We weren‟t supposed to be there. That was the rule. Then, somebody changed the rule; somebody courageous, I suspect. And, so, I got to see a miracle.
Let me read to you an email I received on Thursday, December 19, 2009. It came from Mrs. Jocelyn Anne Gruzenski – she goes by “Jackie.” I did not know Jackie Gruzenski at the time; she wrote to me out of the blue. But I have since connected with her. And, she gave me permission to read her email to me to you. Here‟s what she wrote:
“Dr. Berwick, …
“My husband was Dr. William Paul Gruzenski, a psychiatrist for 39 years. He was admitted to (a hospital she names in Pennsylvania) after developing a cerebral bleed with a hypertensive crisis. My issue is that I was denied access to my husband except for very strict visiting, four times a day for 30 minutes, and that my husband was hospitalized behind a locked door. My husband and I were rarely separated except for work,” she wrote. “He wanted me present in the ICU, and he challenged the ICU nurse and MD saying, „She is not a visitor, she is my wife.‟ But, it made no difference. My husband was in the ICU for eight days out of his last 16 days alive, and there were a lot of missed opportunities for us.”
Mrs. Gruzenski continued: “I am advocating to the hospital administration that visiting hours have to be open especially for spouses… I do not feel that his care was individualized to meet his needs; he wanted me there more than I was allowed. I feel it was a very cruel thing that was done to us…”
Listen, again, to the words of Dr. Gruzenski: “She is not a visitor; she is my wife.” Hear, again, Mrs. Gruzenski: “I feel that it was a very cruel thing that was done to us.”
“Cruel” is a powerful word for Mrs. Gruzenski to use, isn‟t it? Her email and the emails that followed that first one are without exception dignified, respectful, tempered. Why does she say, “cruel”?
We will have to imagine ourselves there. “My husband and I loved each other very deeply,” she writes to me, “and we wanted to share our last days and moments together. We both knew the gravity of his illness, and my husband wanted quality of life, not quantity.”
What might a husband and wife of 19 years, aware of the short time left together, wish to talk about – wish to do – in the last days? I don‟t know for Dr. and Mrs. Gruzenski. But, I do know for me. I would talk about our children. I would talk about the best trip we ever took together, and even argue, smiling, about whose idea it was. I would remember the black bear we met in a clearing in the Wrangell-St. Elias Range; the cabin at Assiniboine; the Jøtenheim mountains of Norway. I would remember being lost in Kyoto and lost in Prague and lost on Mount Washington, and always found again. Mushroom soup at Café Budapest. And seeing Jessica born, and Ben, and Dan, and Becca. We would have so much to talk about. So much. The nurses would pad in and out of the hospital room, checking i.v.s and measuring pulses and planning their dinners and their weekends. And none of what the nurses and doctors did would matter to us at all; we wouldn‟t even notice them. We would know exactly who the visitors were – they, the doctors and the nurses. They, they would be the visitors in this tiny corner of our whole lives together – they, not us. In the John Denver song it goes this way, “… and all the time that you‟re with me, we will be at home.”
Someone stole all of that from Dr. and Mrs. Gruzenski. A nameless someone. I suspect an unknowing someone. Someone who did not understand who was at home and who was the guest – who was the intruder. Someone who forgot about the black bear and the best mushroom soup we ever had – the jewels of shared experience that glimmer with meaning in our lives. Someone who put the i.v. first, and the soul second.
Of course, it isn‟t really “someone” at all. We don‟t even know who, or what it is. Its voice sounds rational. Its words are these: “It is our policy,” “It‟s against the rule,” “It would be a problem,” and even, incredibly, “It is in your own best interest.” What is irrational is not those phrases; they seem to make sense. What is irrational is what follows those phrases, in ellipsis, unsaid: “It is our policy … that you cannot hold your husband‟s hand.” “It is against the rules … to let you see this or to let you know this.” “It would be a problem … if we treated you on your own terms not ours.” “It is in your own best interest … to miss your daughter‟s moment of birth.” This is the voice of power; and power does not always think the whole thing through.
Berwick Yale Medical School Graduation Address, May 2010 5
Even when it has no name and no locus, power can be, to borrow Mrs. Gruzenski‟s word, “cruel.”
I want you to celebrate this day. I want you to experience all of the pride, all of the joy that it brings you to have reached this milestone. I am not telling you Dr. and Mrs. Gruzenski‟s story to sadden you. I am telling it to inspire you. I want you to remember it, if you can possibly remember anything I am saying to you at this chock-full moment of your lives, because that story gives you a choice.
You see, today you take a big step into power. With your white coat and your Latin, with your anatomy lessons and your stethoscope, you enter today a life of new and vast privilege. You may not notice your power at first. You will not always feel powerful or privileged – not when you are filling out endless billing forms and swallowing requirements and struggling through hard days of too many tasks. But this will be true: In return for your years of learning and your dedication to a life of service and your willingness to take an oath to that duty, society will give you access and rights that it gives to no one else. Society will allow you to hear secrets from frightened human beings that they are too scared to tell anyone else. Society will permit you to use drugs and instruments that can do great harm as well as great good, and that in the hands of others would be weapons. Society will give you special titles and spaces of privilege, as if you were priests. Society will let you build walls and write rules.
And in that role, with that power, you will meet Dr. and Mrs. Gruzenski over, and over, and over again. You will meet them every day – every hour. They will be in disguise. They will be disguised as a new mother afraid to touch her preemie on the ventilator in the incubator. Disguised as the construction worker too embarrassed to admit that he didn‟t hear a word you just said after, “It might be cancer.” Disguised as the busy lawyer who cannot afford for you to keep her waiting, but too polite to say so. Disguised at the alcoholic bottoming out who was the handsome champion of his soccer team and dreamed of being an architect someday. Disguised as the child over whom you tower. Disguised as the 90-year-old grandmother, over whom you tower. Disguised as the professor in the MRI machine who has been told to lie still, but who desperately needs to urinate and is ashamed. Disguised as the man who would prefer to know; and as the man who would prefer not to know. Disguised as the woman who would prefer to sit; and as the woman who would prefer to stand. And as the man who wants you to call him, “Bill,” and as the man who prefers to be called, “Dr. Gruzenski.”
Mrs. Gruzenski wrote, “My husband was a very caring physician and administrator for many years, but during his hospitalization, he was not even afforded the respect of being called, „Doctor.‟” Dr. Gruzenski wanted to be called, “Dr. Gruzenski.” But, they did not do so.
You can. That choice is not in the hands of nameless power, not fated to control by deaf habit. Not “our policy,” “the rule.” Just you. Your choice. Your rule. Your power.
What is at stake here may seem a small thing in the face of the enormous health care world you have joined. It is as a nickel to the $2.6 trillion industry. But that small thing is what matters. I will tell you: it is all that matters. All that matters is the person. The person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wondering mind. The learned mind. The Husband. The Wife. The Son. The Daughter. In the moment.
In the moment, it is all about choice. You have a magical opportunity. You have the opportunity to decide. Yes, you can read the rule book; and someday you can even write the rule book. Decide. Yes, you can hide behind the protocols and the policies. Decide. Yes, you can
say “we,” when you mean, “I.” Yes, you can lock the door. “Sorry, Mrs. Gruzenski, your 30 minutes are up.” You can say that.
But, you can also unlock the door. You can ask, “Shall I call you “Dr. Gruzenski”? “Would you like to be alone?” “Is this a convenient time?” “Is there something else I can do for you?” You can say, “You‟re the boss.” You can say, “Tell me about the best trip you ever took. Tell me about the time you saw your daughter born.”
In my first week of medical school, I was assigned a tutor: Dr. Edward Frank. He was a vascular surgeon, and he was to supervise me in my physical diagnosis course. I read what Harvard Medical School called, “The Red Book.” It was all about the history and physical exam. Hundreds of questions to ask – history, physical, chief complaint, review of systems, and on and on. I stayed up very late, studying all those questions; memorizing the ritual. I knew all the right questions, I thought. I met Dr. Frank the next afternoon, and he took me to see Mrs. Goldberg, who was in the hospital to have her gall bladder taken out. Dr. Frank brought me into Mrs. Goldberg‟s room, into her presence, introduced me, and invited me to begin. My very first history and physical.
“Tell me, Mrs. Goldberg,” I said, “when did your pain begin?” Dr. Frank, the surgeon, interrupted me. He gently put his hand on my shoulder, and he gave me a gift I will never, ever forget. And I will pass his gift to you. His gift was a question that The Red Book left out.
“Oh, Don,” he said. “Before you ask that, let me tell you something very special. Did you know that Mrs. Goldberg has a brand new grandson?”
Decide. You can read the rules. Or, you can say, “Pardon me.” “Pardon this unwelcome interruption in your lives. Thank you for inviting me to help. Thank you for letting me visit. I
Berwick Yale Medical School Graduation Address, May 2010 8
am your guest, and I know it. Now, please, Mrs. Gruzenski, Dr. Gruzenski, what may I do for you?”
Congratulations on your achievement today. Feel proud. You ought to. When you put on your white coat, my dear friends, you become a doctor.
But, now I will tell you a secret – a mystery. Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care – in the sacred presence of people just like you – when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, an “aching” world, as your Chaplain put it this morning, that has never needed healing more.
Congratulations.
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