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Wednesday, 19 August 2009

White Coat Ceremony ...

... At Penn Medical School

By Ernest F. Rosato --14 August 2009

Thank you, Deans Morrison and Goldfarb.

Thank you, Dr. Morris for that introduction. Thank you for the privilege of this assignment.

When I hear myself introduced in this fashion, my initial reaction is that I can hardly wait to hear what I have to say; and hope that I measure up. In that regard I have asked my current medical students whether they remember their White Coat Ceremony. All do and with great enthusiasm. But, when asked what the Keynote Speaker had to say, I generally draw a blank. So listen-up! I shall see you again. There may be a quiz in a few years.

Welcome to this newest class of this oldest medical school in America. Welcome to your parents and other loved ones who are here to celebrate with you. Welcome to your first year at the school of medicine. Welcome from someone who has just completed his first year of his second half century. My love for this school, and its traditions remains undiminished. Tradition is the theme of the day. Tradition – The handing down of information, beliefs, and customs, by word of mouth or by example from one generation to another without a written instruction. This is not the formal history; this represents the stories that we tell one another when we gather at a later day and recount our common experience. It is what bonds us together in a shared remembrance, generally of good times of life. This day also recognizes the humanistic themes of a medical life. The White Coat Ceremony culminates in the recitation of the Oath of Hippocrates. You will state that you will practice in an honorable manner considering only the benefit to fellow humans. Also to be just and generous to each other. Do not forget this. You are to be good and faithful to your patients but you are also to be good to one another. Nothing is sadder to see than a physician seeking his/her advancement by denigrating his colleagues.

My favorite story illustrating medical rightness is the parable of the Good Samaritan. It is from the Gospel of Luke, Luke the Physician. An expert in law asked Jesus how to attain eternal life, the rabbi replied with a question. What is written in the law? The man answered, "Love the Lord your God and love your neighbor as yourself". And Jesus replied, "You have answered correctly. Do this and you will live." But the man followed up. "Who is my neighbor, teacher?" And then the parable. A man set upon by robbers was left half dead without possessions or even clothes. He was passed over by several of his countrymen. But a Samaritan took pity, bound his wounds, took him to an Inn and cared for him. On leaving he left money with the innkeeper to look after him. Jesus asked, "Who was the good neighbor?" Remember this parable when you repeat after Hippocrates. "I will practice my art in uprighteousness and honor. That unto whatever home I shall enter, it shall be for the good of the sick to the utmost of my power." The Samaritan was not kinsman, no monetary reward was possible, his travels and own life were interrupted, and no thanks were asked for. A human is broken. The tradition of medicine is to provide care. Care indeed for the very least of your neighbors. You will confront these issues many times and it will not always be easy. Do your best.

The white coat of course is not tradition but a symbol of tradition. Physicians did not always dress this way. In the old days when physicians attended homes they wore ordinary clothes. When they attended homes, they saw their patient in a different setting from an office or hospital, saw them in the midst of a family often dependant upon the patient, certainly loving the patient, and certainly all affected by the illness that the physician was there to attend. Only later did the white coat become emblematic of medicine and this occurred in the last century when science and technology provided rapid advances in medical care, and when medical care shifted from care in the home to care in an office or a hospital. It was in this setting that donning the white coat became a means to identify with laboratory science which was elevating medical care to new and higher levels. "The scientific physician." But as in all things in life, something gained is something lost. Many felt that the shift to science provided the best care but that it came with the loss of the human touch. But so, so what. I don't need a nice doctor, I need a good doctor, and of course this is at least half true. No one wants to shoot the rapids with an amateur at the helm. We must be good physicians and this school will provide you with that skill if you work at it. But in truth the journey often ends badly, sometimes quickly, sometimes agonizingly slowly. Some of the most thankful letters I have received came from those times where science failed but we did not forget that these were human passengers. It was in this spirit that the white coat ceremony was born, spearheaded by Dr. Arnold Gold at Columbia (Neurologist and Pediatrician). I have no doubt that, if asked, each of you would say that the prospective joy of a medical life is to care for people. This ceremony is not to confirm that intention in you, but to say that we in the School of Medicine share your dedication and affirm its beauty.

Just as an aside, you probably know that your new white coat is now under some attack. Some claim that it harbors bacteria that threatens patients, some that it frightens people so that they avoid the doctor because of a "white coat" syndrome. It reminds me of a time when you were coming up to get your driver's license. As your time approached rumors would surface that in fact the driving age was just about to be raised. Worry! Worry! But no matter, the white coat is a symbol, it is not the tradition. Whether it is outlawed or retained will not change the spirit in which you don it today.

You ask, "Where did it all begin, this Pennsylvania tradition"? Today's presentations will provide some of that history. The founding by John Morgan and William Shippen, Jr., sons of Philadelphia who went abroad to study in Edinburgh, Scotland, hence the thistle in the School of Medicine emblem. How they returned to their city to found the first medical school in the American Colonies. That school has prospered under generations of leaders. You will see some of the list of these illustrious names and their great accomplishments. Thomas Eakins' portrait of D. Hayes Agnew in the Agnew Clinic immortalizes the development of the Department of Surgery and heralds in the age of scientific advancement in medicine.

David Y. Cooper, writing in his book, "The Innovation and Tradition at the University of Pennsylvania School of Medicine" recognizes this history thus no one walks alone through the halls of the University of Pennsylvania; all are accompanied by the many portraits on the wall, the busts on the pedestals, and the memorabilia in the display cases. They tell in passing the history of an institution that extends back more than 240 years. The first medical school in this country. But you ask, "Where did it all begin for you?" Remember that I think of tradition as an unwritten passage passed through the generations. I of course, and like you, arrived here with my own traditions. I had good parents, a physician father, so that I knew something of a medical life, 8 years with the Catholic nuns – You are always seen and a record is kept, 8 years with the Jesuits – whose motto was for the greater glory of God and whose goal was a sound mind and a sound body. I was directed here, actually sent, by my Professor and Chair of Biology Dr. Mark Bauer, a Jesuit priest with a Ph.D. from Princeton. He assured me that the tradition of learning here was best and I never found cause to disagree. This school provided me with the education that made me a good physician in 1962. It provided me with the tradition of learning that I think has allowed me to remain a good physician in 2009.

Where did it all begin for me? It began with Professors who were not yet pictures on the wall, nor names on buildings. They walked the halls in buildings which were named for their own predecessors. Let me tell you of a few. Isidor Ravdin, whose picture hangs in the lobby of the main entrance to the hospital, the Ravdin Institute, was born in Indiana, came to Medical School at the University of Pennsylvania in 1916 and stayed for a long and productive life. He was Chairman of Surgery from 1945 to 1960. He was a giant of his time with exceptional achievements in medicine, in the military in World War II, and in civic affairs. Rav, as his friends and admirers called him, had a vibrant personality and a love for all people great and small. He could be a demanding man, sometimes harsh, sometimes paternalistic, as was characteristic of surgery in the day. He was demanding but forgiving. For example if you somehow failed to measure up, he would fire you. "You're fired" he would say, and there was no appeal. You simply left for a few hours, and then you returned. The matter would not be mentioned again. Point made, and received. For all of that paternalism and bruskness, everyone loved Rav because he loved his students and believed in them. The best illustration of this was his own surgery. Dr. Rhoads relates the story in his memoires. Dr. Ravdin had developed cholecystitis and needed gallbladder surgery. Dr. Alan O. Whipple came down from New York and Dr. Eldridge Eliason the Chairman of Surgery here was also in attendance. Dr. Jonathan Rhoads went to pick up Betty Ravdin, thinking his rose to be social support but was told on arrival that Rav had said he was to do the surgery and Whipple would assist. Dr. Rhoads was two years out of his training. He believed in his students. Dr. Ravdin was devoted to research and education. His famous address to the American College of Surgeons was entitled, "A Physician and Something More." He spurred the surgical community to embrace the scholarly life. This was heady stuff for us youngsters who previously thought that physicians came from the debating societies and surgeons from the rugby field. But if you were to run with Rav; your sights had to be set high. You had to be something more. Dr. Rhoads again, "Dr. Ravdin was at his best as a developer of young people. His vision of what they could accomplish was generally more optimistic than their own; and with his encouragement they often rose to his expectations rather than be limited by their own narrow horizons." A physician and something more. Julian Johnson was the first Professor of Cardiothoracic Surgery here. His portrait is in the anteroom outside Medical Alumni Hall in the Maloney Building. He is in surgical garb and his steely resolve is obvious. He had an intensity in patient care that was surely fueled by the frequent failures encountered during these pioneer days of heart surgery. No expenditure of energy no amount of time spent was considered too much. He drove himself and he drove his protégés very hard. Many found him too hard but he also had many admirerers and I was one of them. He told me once that he never was hard on someone who had made a mistake. They would be hard enough on themselves and needed support rather than further criticism. It was failure of effort and dedication that drew his ire. When someone recognized you for an accomplishment he would say, "I taught him everything he knows" if he concurred with the compliment. Once shortly before his death he shared a hospital room with my patient scheduled for surgery the following day. After we exchanged pleasantries, Dr. Johnson told my patient that he need have no concerns because, "I taught him everything he knows". Dr. Johnson was dying and he knew it and yet he could reach out to comfort his roommate and to provide for me his final assessment that he was satisfied with how I had turned out. That was the last time that I saw him. I recall he told me that we don't always recognize our best teachers in the event but only with the passage of time. The best are not always the easiest and they always push you to excel.

I have singled-out these two because of my relationship with them in my earliest years; years most similar to your present style of life. I have not tried to encompass Dr. Jonathan Rhoads who hangs on the wall of the Rhoads Pavilion because he guided my surgical life for forty years as mentor and colleague. I can only urge you to read about him. He was a most extraordinary man, and exerted a most extraordinary influence.

Tradition -– The oral telling from one generation to the next. When we older surgeons gather, we still speak of these men, tell stories about them, and they live in us because they have changed our hearts and souls. When we are gone, they will retreat back on to the walls, brought out only on great occasions such as this. Their stories will be replaced by stories about others. The Department under Dr. Barker, Dr. Kaiser, and now Dr. Drebin yes and hopefully stories about me and that will be pleasing because stories about me reflect what I have learned from these men and the countless others who have been here for the past fifty years. Rosato stories do abound. They reflect the stories that I received that I then took into my soul and bent them a certain way and out they came as Rosato lore. But it is not Rosato lore, it is the lore of this University. This is the essence of tradition. We take the story, we bring it into ourselves, and then we pass it along in one continuing spirit, the tradition of medicine at the University of Pennsylvania. So you ask where does it all begin? For you, it begins today. You will hear the story, you will bend it, you will pass it on. I envy you, your youth and the pleasure of this school that await you. You are gathered here in your clean white coats. Soon, too quickly, you will finish. Your coat will have some frays, some smudges, but it will fit you better. You will be more comfortable in it. Then if you look inside you may imagine a faint hue of red and blue. You will indeed be a physician, and something more.