A Starfish Approach to a Crisis of Dignity
Erik A. Ranheim, MD, PhD
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The medical students of the class of 2019 provided me the honor of delivering the keynote address at their commencement ceremony. In my remarks, I sought to acknowledge the difficult times in which we live and the epidemic of health care burnout, while providing what I hope is a useful touchstone to help physicians keep doing our important work. The final section of my address is included below.
You are entering medicine in a very strange age—one that is more toxic to our patients and ourselves than we care to admit. Somehow, science and logic have become a political position as opposed to simply being truths that one could use to debate competing approaches to problem solving.
Meanwhile, the infant mortality rate for African American babies in Wisconsin is the same as that of Syria. The weekly reports from the Centers for Disease Control and Prevention on infectious diseases look more and more like it is 1919. Indeed, you are graduating following the third straight year of declining life expectancy in the United States, something that hasn’t happened since your predecessors received bachelor’s degrees in medicine exactly 100 years ago in the midst of a war and an epidemic. The spike in suicides, drug overdoses, and liver disease reflects a new sort of epidemic – one, I would argue, that is driven by a loss of personal dignity. As physicians, you will struggle to help your patients navigate a world in which the meaning and purpose found in a lifelong job, a lifelong hometown, and a lifelong community will be quite rare.
As you enter residency and act as full-fledged physicians, you too will have moments that chip away at your dignity. Attendings too small to treat you both as a learner and a colleague. Patients that doubt your ability to care for them because of your gender, your skin color, or the pronounceability of your name. You are entering a field in which over 50% of practitioners are burned out, with all sorts of negative consequences for both patients and physicians, one of whom commits suicide every day in America. Think about that state of affairs— the entire graduating classes of Wisconsin’s 2 medical schools are needed just to replace that group of lost doctors. And you paid hundreds of thousands of dollars for this?
This all sounds quite grim, but I have good news for you. The degree that you receive today, along with the oath you are professing to get that professional degree, comes with enormous power and opportunity to replenish the dignity of your patients and yourselves many times per day—a luxury that you are obliged to take advantage of. An opportunity far more critical to “wellness” and professional fulfillment than 100 lunch-time yoga classes, onsite child care, or being reminded to breathe by your damn watch.
Typically, these sorts of speeches are filled with calls to great achievements, curing cancer, saving the world sorts of things. And by all means please, win that Nobel prize and that Lasker medal. Find the intervention that prevents breast cancer from metastasizing, help an accident victim walk again, or if not that, at least, as a personal favor to the Dean and me, reverse male pattern baldness. But that is not my focus today. The vast majority of you— of us—are not going to be in contention for a Nobel prize; so rather than sitting back and thinking this speaker is talking to some of my classmates but not to me, please understand that I am not letting any of you off the hook. I expect you to help restore dignity wherever you can. And you can – unlike most of the world, you will interact with many people every day for whom your words, your touch, and your empathy mean a great deal. They can mean the difference between dignity and despair. So don’t get consumed by cynicism and the reality TV show of our current state. Pay attention to those in front of you and help to restore that dignity with each interaction.
Some of you may have heard my wife and me relate this story from Loren Eiseley, that we kept reminding each other of as we worked to provide a street medicine program serving people who struggle with homelessness in Madison. The scope of the problem was overwhelming to both of us at times. I hope that when you doubt your impact as a physician, you may recall this short parable:
An old man is taking his daily walk along a beach following a large storm. The beach is littered with starfish in both directions as far as the eye can see. He spots a young girl coming towards him, stopping every once in a while to pick one up and fling it back into the sea. When they meet, he asks the girl what she is doing. “I am throwing starfish back into the water – they cannot crawl there on their own and when the sun gets higher, they will die on the beach.” “Yes,” said the old man, “But there are tens of thousands of them; I am afraid you won’t be able to make much of a difference.” The girl picks up another and throws it into the waves, looks up at him and says, “I made a difference to that one.”¹
Naomi Shihab Nye captured the essence of what I’m trying to say in her poem entitled “Famous”² from which I share the final two stanzas:
I want to be famous to shuffling men
who smile while crossing streets,
sticky children in grocery lines,
famous as the one who smiled back.
I want to be famous in the way a pulley is famous,
or a buttonhole, not because it did anything spectacular,
but because it never forgot what it could do.
Do not forget what you can do – what you will do, is sacred. As functional as a pulley and buttonhole, yes, but sacred. Be famous to the man stripped of dignity in his hospital gown or in his sockless, blistered feet in the shelter. Be famous to the terrified parents of a sick child awaiting the results of biopsies and scans. Be famous to the teenager thinking her life is too painful to continue, or the villager in a distant, poorer place, shaking with malarial fever. You have been entrusted the power, and the obligation to do this every day. This is not setting the bar of professional fulfillment low to trick you into happiness; this is the key to the whole thing – you are very special pulleys and very special buttonholes. Do not forget what you can do, one starfish at a time. As the newest members of this noble profession, on this 50th anniversary of the publication of Slaughter House Five, a book very much concerned with dignity, I leave you with the life advice of Kurt Vonnegut:
Hello, babies. Welcome to Earth. It’s hot in the summer and cold in the winter. It’s round and wet and crowded. At the outside, babies, you’ve got about a hundred years here. There’s only one rule that I know of, babies — ‘God damn it, you’ve got to be kind.”³
Author Affiliation: University of Wisconsin School of Medicine and Public Health, Madison, Wis (Ranheim).
Corresponding Author: Erik A. Ranheim, MD, PhD, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, K4/432 CSC, Madison, WI 53792-8550; phone 608.263.0057; email firstname.lastname@example.org.
Funding/Support: None declared.
Financial Disclosures: None declared.
2. Nye, Naomi Shihab. “Famous” in: Words Under the Words: Selected Poems. Portland, OR: Far Corner Books; 1995.
3. Vonnegut Jr., Kurt (1965). God Bless You, Mr. Rosewater. New York, NY: Holt, Rinehart, and Winston; 1965.