Wednesday, August 11, 2010

Dr. Berwick, in his own words, to his own daughter

Today, I came across an outstanding commencement address given by Dr. Don Berwick to his daughter's graduating medical school class. Read what he had to say to these newly-minted physicians, and tell me, do his words fit the description of the "rationer-in-chief" ascribed to him by his critics?

(Although I encourage you to read the address in its entirety, major excerpts are presented below.)

"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 ...

... 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 ... 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 ... Someone who did not understand who was at home and who was the guest - who was the intruder ...

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. 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 ...'

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 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.


Today's questions: What is your reaction to Dr. Berwick's address to his daughter and her newly-minted physician colleagues? What do you think it says about the philosophy he brings to public service?


Bracken said...

Wow. That's an incredibly powerful speech, and definitely gives you something to think about every day.

ryanjo said...

A poignant example, the older doctor and his wife, their last days abused by technology and medical protocol. I think a good reminder of a physician's responsibility to his patients to defend them from an increasingly bureaucratic medical system.

How ironic that this is the same Dr. Berwick who professes "love" for Britain's NHS. A survey of English newspapers comments on Dr. Berwick's praise for the NHS related sad stories of the same type he told the medical graduates. As Jane Daley of the Daily Telegraph said, "Dr Berwick thinks that our own dear National Institute for Clinical Excellence (Nice) – which is scarcely ever out of the headlines for denying some poor suffering victim a remedy that is available in other countries – is simply wonderful."

Arvind said...

The sentiments are very noble indeed. But the pretensions of grandeur and power are simply a lie. He knows in his heart that there is no such thing as physician power or independence, since he will be heading the mother of all agencies that will set the rules by which these young doctors will be forced to play by - a set of rules they had no opportunity to study or debate. He conveniently forgot to tell these docs that by the time they are in practice, they will be practicing based on federally-dictated set of do's and don'ts, and that Dr. Berwick and his small group will be deciding what is "medically necessary" and what is not. Of course, I would not expect you, Bob, to notice all this, since you have already judged him to be great.

PCP said...

Dr. Berwick speaks to the art of medicine, that has long been trampled upon by a variety of powerful interests including the CMS.
Every form, every mandate, every health IT mandate, every pay cut that causes doctors to cram another patient into their daily schedule, every DTC advertisement, every trial lawyer's trust demolishing advert, etc leads to something lost.
One can speak in platitudes and insist that young professionals rise above it all. However it all seems a little disingenuous when those representing the corrosive changes over the past decade start preaching to those of us in the trenches.

Jay Larson MD said...

Because the health care system is focused on the bottom line (finances, number of hospital acquired complications, A1C level, etc.)people become somewhat secondary and are treated as such. Medicine should put people first and let the bottom line fall where it may. Administrators have a hard time grasping this concept.

Arvind and PCP make good points about the "power and independence" of physicians in today's highly regulated system.

Just out of curiosity, I wonder how many of the graduating Yale medical students plan a career in general medicine, infectious disease medicine or endocrinology?

Dr. Don Berwick's commencement may have fallen on deaf ears if the class will follow the current trend towards ROAD specialties.
It is hard to develop a caring relationship with someone under the effects propafol or midazolam.

The Unseen Patient said...

A very poignant address that goes to the core of being a physician. Dr Berwick beautifully describes a the side of caring that we as physicians may not see but what our patients are constantly watching for. What we too often consider an after thought but what our patients hope would be a forethought.

However, Dr Berwick neglected to mention in the many disguises of who the person is in the bed, that the separation that was imposed on "Jackie" while her husband was critically ill, is the separation that gays and lesbians experience every time they accompany their wife, husband or partner to a hospital.

It is unfortunate that a person whose position will set national health policy did not use his clinical example to bring to the attention of these newly formed MD's perhaps the most discriminatory aspects of health care in America.


Andy Hedberg said...

It is the obigation of all of physicians to heed the call to work against the inhumane situation described in this vignette. Compassion in all our activities is paramount. It is also important to change the broken parts of our health care system, which Dr. Berwick is well qualified to attempt. Universal access (which England has), evidence based testing and treatments, and appropriate reductions in health care costs are areas needing analysis and attention if America is to have uniform excellence and sustainabllty in the future. The evidence suggests that under the new health reform bill, and Dr. Berwick's leadership of CMS, major prgress can be made.

Unknown said...

To begin, I am a fourth year medical student going into primary care and this directly applies to me...
We have two options when reading this address. We can take, in my opinion, the weak road or the strong road. Our new generation, as well as the one that raised us, is one of apathy and selfishness. We are only concerned about how changes affect us. We have lost the sacrifice and the consideration of our patients and fellow staff. This address, no matter how hard your heart may be, springs up a humanism in you that is undeniable. You can choose to brush it off and make excuses about policies and money, or you can stand up and be the physician that is described. I agree that there are a lot of issues in medicine today (billing, paperwork, bureaucracy to name only a few). However, if those issues render you cold and uncaring, my friend, I strongly suggest you find another profession. This profession is one of nobility. It is one of selfLESSness. This is a high calling. A good book states, "to whom much has been given; much will be expected." Well, if you are a physician, much has been given to you. What are you going to do with it?

Gramps said...

I serve the patient. I serve humanity. I am one soldier in the endless war on human suffering and disease. I respect Dr. Berwick as one soldier respects another, and hope that his leadership will permit me to serve more effectively. All physicians of today have tools made possible by countless soldiers who have gone before. Our work is sacred unless we allow it to become something less.

Gary R. Gibson, MD, FACP

Unknown said...

I'm confused about Dr. Berwick's call to compassion about treating patients as individual human beings with lives, emotions, and families. I thought he was in love with Britain's NHS. In that system, there is no consideration of the person or family. There, your health needs are decided through rationing panels that see the patient as a calculated value, or worse, cost to society. The bureaucratic control over a system that should be centered around a relationship between a doctor and a patient and the patient's history, forces clear cut regulations, approved/disapproved treatments, and long waiting lines. If Dr. Gruzenski were a patient under Dr. Berwick's plan, situations like he described would become more commonplace as medical decisions are defined by formulas for saving the government money, not a Physician's training, intuition, and "compassion". And that's if Dr. Gruzenski doesn't have to wait days to weeks to get a spot in the overcrowded hospitals and clinics, like in Britain.
Reason this one out: universal government healthcare adds an overwhelming demand of now-free-healthcare patients (not really free) to a system with a fixed number of physicians and healthcare facilities. Then, you have the growing number of current Dr's wanting to retire early in the face of this, college students with an increased fear and uncertainty about going into medicine, pay cuts in medicare, increased regulations and bureaucracies on an already bogged down system, and a higher quota of primary care doctors required to see all these patients. These are just some of the immediate effects. Ronald Reagan once predicted that universal healthcare could ultimately go as far as to tell doctors where they can and can't live. If there are too many docs in one town, "I'm sorry you can't move there, our quota for that city is full, we need you over here." Not to mention standard pay rates for doctors, as we could all be on the government payroll. Is medical school tuition gonna go down to reflect these changes? Don't count on it. The idea of universal healthcare is very old. It has been presented many times in America's history, but fortunately for doctors AND patients, the American people said no and our representatives listened. Only this time, 70% of Americans said no again, but our representatives decided not to represent us and instead deceive the public and force it onto us because "they know what's best". Like what was best for Dr. Gruzenski and his wife. Thanks Dr. Berwick for showing us another example what will come with universal healthcare...more people not listened to.
Bottomline: Healthcare can be improved much easier by addressing and removing the foreign bodies and pathogens in the system to restore homeostasis, not amputating the whole thing and replacing it with a defective artificial prosthesis.
Quote to leave you with:
"We have to pass the bill to find out what's in it."
Comforting isn't it?
Hope you enjoyed that!