TELLING THEM THE MOST IMPORTANT THING

K. Patrick Ober, MD

It appeared to be one of the highest honors imaginable when it came, several years ago. I was invited to speak at the hooding ceremony for the medical school’s graduating class. I had participated in the ceremony for many years, and I knew that prior speakers included the Director of the National Institutes of Health, the Surgeon General, and people of that ilk.

I was led to believe that the class lobbied to have me instead of taking the chance that they might actually get somebody who was capable. I always find it a good feeling when I discover that other people have sacrificed their well-being as a gift to me. [Later, I usually feel guilty about their sacrifice.]

After basking in the initial glow of the honor, though, reality struck me. What had I done in agreeing to do this? 

In the first place, I had committed myself to going to Wait Chapel on a Sunday afternoon in May, and standing in front of the medical school class of 2012, their families, their friends, and their teachers.

That part, I could do.

But in the second place, I would also have to say something – and something of substance, presumably.

That was when I started to worry.

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MY CHALLENGE

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At the end of four years with this particular class, and after so many individual and collective conversations throughout those years, what else could I possibly say to them? Then I remembered what Reynolds Price described as “the old teacher’s frustration” in The Tongues of Angels:

Just as you cut a little path in their wilderness, you look up – they're gone and you haven't even told them the most important thing.”

Of course!

That’s exactly where things seemed to sit.

I had tried to help cut a little path for them…now they were soon to be gone…and no one I knew had mentioned the most important thing.

So, I knew what I needed to say.

It was time for me to tell them the most important thing.

 

 There was only one potential flaw in my plan, though, and Reynolds Price’s commentary was quick to call it to my attention:

“Which assumes, of course, that you know it."

 

Oh, yeah…there is that

 

It was going to be my final chance to address the class, though. The graduates would be heading into the world as newly minted physicians. There was no way around my responsibility.

The time had arrived for me to tell them the most important thing.

[If only I knew what it was.]

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HAPPY OR MISERABLE?

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I thought about the class for a while, not as the students they were, but as the doctors they were soon to be. I thought about all of the doctors I have ever known and how they seem to fall into two categories. Some are happy physicians. The others are miserable.

What separates doctors who are happy from those who are not?

Maybe that should be my message…sorting through the difference between a career of happiness and a lifetime of misery. That would be the most important thing.

Happiness, as I pondered the matter, was a challenge. It seemed to be loaded with Zen characteristics. We usually find happiness when we aren’t looking for it. To find happiness, we must avoid seeking happiness. The harder we try to find it, the harder it is to find.

[This talk was getting hard by the minute, I realized.]

Here are some of the solutions I discovered…

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DON’T TRY TO BE HAPPY…TRY TO BE USEFUL

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The happiest doctors, I observed, were not the ones who actively sought happiness. The happiest ones were usually the ones who devoted themselves to others, and let happiness find them.

 There seems to be a trick in this challenge of finding happiness without seeking happiness. Ralph Waldo Emerson suggested that we should devise surrogates for happiness, and then we should pursue the surrogates:

The purpose of life is not to be happy. It is to be useful, to be honorable, to be compassionate, to have it make some difference that you have lived and lived well.

 The great physician, Sir William Osler, agreed with Emerson:

We are here to add what we can to life, not to get what we can from life.

 The trick to acquiring happiness, then, may be in caring about others more than we care about ourselves.

 That is a hard thing to do.

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LEARN SOMETHING NEW EVERY DAY FROM SOMEONE YOU DON’T WANT AS A TEACHER

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Stagnation is detrimental to happiness. Learning creates energy. There can be an odd pleasure in learning something from someone who you think is not qualified to teach you. The most important education of our life can come from our least likely teachers. Embrace those opportunities to learn from people you want to run away from. [Your life will be filled with those people, and some of the joy of life comes from taking a  perverse pleasure in getting something good out of bad circumstances, just to prove that you can do it.] The poet Kahlil Gibran gave some wonderful examples of such learning opportunities:

“I have learned silence from the talkative, toleration from the intolerant, and kindness from the unkind...”

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READ A BOOK AND BUILD YOUR EMPATHY

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A doctor’s happiness comes from the ability to connect with patients. Empathy is the make-or-break skill in this. Empathy can be a fragile thing. It can evaporate with heat or break with pressure, but it also can also be nurtured. It can be grown and stored for future use. Reading fiction is one of the better ways to develop empathetic abilities.

 Author Ann Patchett explained it this way in a 2012 article in the New York Times:

Let me underscore the obvious here: reading fiction is important. It is a vital means of imagining a life other than our own, which in turn makes us more empathetic beings. Following complex story lines stretches our brains beyond the 140 characters of sound-bite thinking, and staying within the world of a novel gives us the ability to be quiet and alone, two skills that are disappearing faster than the polar icecaps.

  [Read!]

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DON’T KEEP SCORE

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We have been taught to keep score in almost everything we do. Doctors grow up in a world of grades and class ranks, and then graduate into a world of spreadsheets and “relative value units.” We are incessantly held to measures of “physician productivity” [often developed by people who do not understand what it is that physicians actually do]. And what is the result of that? We now get trained to monetize every moment we spend with a patient, creating a style of interaction guaranteed to destroy any hope for professional satisfaction.

 Happiness finds us when we care about the well-being of other people more than we care about the money we can get from them. The most meaningful things we do for our patients are the intangibles that do not show up on an accountant’s spreadsheet. There is not a billing code for empathy. The financial spreadsheet and the emotional spreadsheet have nothing to do with each other.

 The best physicians I know have emotional spreadsheets that never balance. The best doctors give away more than they receive.

They give more hope.

They give more love.

They give more compassion.

In spite of all of the giving away of themselves, they also turn out to be the most fulfilled doctors I know. What they get in return is intangible, but it is essential to their professional satisfaction.

 Warning: Be alarmed if your emotional spreadsheet balances out at the end of every day. That means you have only been bartering, not caring. Exchanging a dollar bill for four quarters is a banking transaction. It is not an act of virtue.

 The famous basketball coach John Wooden explained it like this:

You can't live a perfect day without doing something for someone who will never be able to repay you.

 I have become convinced that our methods of keeping score are responsible for a lot of physician burnout and frustration, particularly when only financial measures are given weight and the most important human values are taken out of the equation.

 If I were asked to name one underlying principle that maximizes the likelihood of finding happiness, it would be this: DON’T KEEP SCORE WITH DOLLAR BILLS. It is the pathway to physician frustration and emotional emptiness.

 Our purpose in life, I am reasonably certain, is not to amass scraps of paper.

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TRUST YOUR OWN VALUES

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Our purpose in life, if we are fortunate enough to be able to practice medicine, is to use the gifts we were given to improve the lives of other human beings.

 Don’t expect the system you work within to help you with any of this. It is nice when it happens, but don’t count on it. The people who run today’s medical organizations are intensely involved in the business of medicine. They keep score with dollar bills. You may have to protect your own standards; there will be times when doing the right thing conflicts with maximizing income. William Osler warned us to have some healthy skepticism when we find ourselves in the presence of those whose values do not align with our values, if we hope to preserve our emotional health:

One of the first essentials in securing a good-natured equanimity is not to expect too much of the people amongst whom you dwell.

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PRACTICE THE ART OF MEDICINE ALONG WITH THE SCIENCE OF MEDICINE

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We need to excel in the science of medicine, but we can bring a special kind of good into the world through the art of medicine. The 13th century poet and mystic, Jalaluddin Rumi, has listed some of the options available to us: 

Be a lamp, or a lifeboat, or a ladder. Help someone's soul heal. Walk out of your house like a shepherd.

 Wake Forest’s own Maya Angelou added what may be the most important nuance:

People will forget what you did. People will forget what you said. But people will not forget how you made them feel.

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THE MOST IMPORTANT THING

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I told the graduates all of those things, and then I told them the most important thing.

 Wherever you are, I told them, you will be where you are supposed to be. No snowflake ever falls in the wrong place, according to a Zen saying. No matter where you are, there will always be someone in that place who needs you. There will always be something to learn.

 You have picked a profession where you almost have to be useful, just by getting up in the morning and showing up and doing what needs to be done…and doing it well.

 And when you manage to do that, happiness takes care of itself.

 That’s the most important thing

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Time slipped along, and in due course a change came over their spirits. They had completed the human being's first duty – which is to think about himself until he has exhausted the subject, then he is in a condition to take up minor interests and think of other people. This changes the complexion of his spirits – generally wholesomely.

 Mark Twain, “Was It Heaven? Or Hell”

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January 22, 2015

 

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