To the 2018 Graduates: At the crux of it all is our patients

"Ahead of every one of you lies a career destined for opportunity, for years of intellectual curiosity, for years of financial security. But at the crux of it all is our patients, often hopeful yet vulnerable for the care you will provide them, paving the way for a legacy rooted in hard work, self-sacrifice and altruism."

Keynote Address, June 21, 2018 Postgraduate Graduation Ceremony
Dr. Martina Trinkaus

I would like to welcome our graduating residents, faculty and family and friends to this momentous occasion. I would like to thank Arno Kumagai for inviting me to speak before you today, many of whom I have worked with, many of whom I have heard about, and all of you that I know our entire faculty are honoured to call our colleagues.

The day that I was asked to give this speech, I did wonder what inspirational or aspirational messages I could impart to a group of physicians who have trained so diligently, and yet have over 30 to 40 years of a medical career before them. Within hours after my phone call with Dr. Kumagai, a knock came to my office door. I opened it so see a woman with short brown curly hair, mildly cushingoid, and someone I did not recognize. Right away she had a smile on her face and with tears forming in her eyes she hugged me, and excitedly indicated she was so glad to have caught me before I headed home for the day. After our hug, surprised and embarrassed, I stepped back and asked her who she was. Perhaps she confused me with my identical twin sister, who is an oncologist at another cancer center.

Our history predates to two years ago. I was visited by a family physician unexpectedly on a Tuesday morning. She was one of the inner city GPs who I had never met in person, but we shared a good number of patients that she referred to my hematology practice. She asked if I could review a CBC of one of her patients that she received the day before that she was concerned about. Looking at it, I noted there was pancytopenia, a high MCV and a small percentage of blasts were noted on the differential. After one minute of questioning, I indicated this patient of hers needed an urgent bone marrow biopsy as this looked like a high risk myelodysplasia or acute leukemia; both very serious blood cancers that would require intensive chemotherapy. I can recall her silence with this news as her eyes fixed down do her lap, her long brown hair falling forward. I can recall her gasp as she put her hands to her mouth. She indicated the blood work was hers. That she had two young boys at home. She started to cry. I too welled with tears in my eyes; a tumult of emotion overcame me. I knew the battle that lay before her. It is a moment I do not think I will ever forget.

Within minutes I completed her first of many bone marrow biopsies. Later that day I called her to tell her that she had high risk MDS and that because she was in her 40s my recommendation was for urgent inpatient chemotherapy at our referring leukemia center with a tentative plan for a subsequent bone marrow transplant. Despite her transfer of care, she kept in touch with me via email. For weeks I would receive her emails; responding to the enormity of her fear, her stress, and her disbelief which were palpable. She had many ups and downs during chemotherapy and eventual referral to Buffalo for a bone marrow transplant as there were no beds available in Toronto or Hamilton to accommodate her.

As she sat down in my office in February, it was clear she wanted to share so much of her journey with me. She was in remission, but still did not feel mentally or physically fit enough to return to work. She spoke of the challenges of her past two years, the endless blood tests, transfusions, antibiotics and overwhelming fatigue. She spoke of spending hours in waiting rooms, the challenges with ER visits, the anxiety behind waiting for life changing test results and the vulnerability of not knowing what would happen to her or her family on a daily basis. Sickness takes on a different ‘spin’ when one is on the other side of the ‘blue curtain,’ a perspective that many times even when I was a resident took for granted. The many hours of call, scholarly responsibilities and training often left me exhausted, burnt out and limited the degree of empathy or sympathy that I could share with my patients. The pace of our demanding jobs often distracts from the humility of sickness and dying. A sentiment that even this patient indicated she was guilty of with her own practice.

She left my office after 30 minutes thanking me for the original care provided and our email communication. It was I however that was thankful. She reminded me of the awesome responsibilities and professional privilege we have for our patients. There are not may jobs wherein a stranger will tell you some of their most intimate of details, or their greatest of fears. Our discussion reminded me of the need to be meticulous with our facts; a challenge that is becoming increasingly difficult with the rapid pace of research and the endless google searches of our patients that may challenge our recommendations.

Much of our 30-minute discussion that night focused on the art of communication. She spoke of the value behind ‘truly listening to your patients, to be prepared to offer second opinions, to drop your ego when discussing treatment plans amongst patients and colleagues’ as she put it. She spoke of mistakes being made in her treatments, but she was surprised how accepting she was of them when her medical team clearly learned from them. She stressed the need to speak simply with your patients; to clearly communicate. She would often get frustrated with terminology used in her case: as she learned that “treatable does not mean curable”. She spoke of not being afraid to touch your patients and give that eye contact. Those ‘artful’ basics of what we learn in medical school were often lost in her medical shuffle from ER rooms, to clinics, to hospital wards. She spoke of how she felt like a burden to some of her physicians, who were clearly busy with their volumes of patients and how she would be ‘afraid to upset [her] doctor who [she] relied on for lifesaving therapy.’ She spoke of how her kids would grade each physician they would meet based on how nice they were, rather than how many papers they published. Her words that day echoed the many times I have heard of Sir William Osler’s messages, many of which take me back to my medical school training:

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.”

“The person who takes medicine must recover twice, once from the disease and once from the medicine.”

“Care more for the individual patient than for the special features of the disease...Put yourself in his place...The kindly word, the cheerful greeting, the sympathetic look - these the patient understands.”

I have read many books on self reflection, leadership, and mortality since graduating from your stage. None compare to that 30-minute conversation I had with this one family physician and the many messages that were reinforced for me that day. I share her story with you tonight, as a reminder of the many lives you will touch in your next 30 to 40 years of your practice. Ahead of every one of you lies a career destined for opportunity, for years of intellectual curiosity, for years of financial security. But at the crux of it all is our patients, often hopeful yet vulnerable for the care you will provide them, paving the way for a legacy rooted in hard work, self-sacrifice and altruism.

Finally, I will conclude with some final thoughts. It needs some discussion as well that although we have this incredible vocation, it does not come without great sacrifice. In addition to this "art of medicine" with communicating to our patients and treating them with the best evidence-based practices, it is important that each of you work continuously to stay balanced, and to stay positive in your relationships. It is important to acknowledge that you will make mistakes, and this does not diminish the ability you have to treat and care (this is often the hardest lesson). It is important to acknowledge that you too are susceptible to mental and physical diseases. So, do take care of yourselves, take care of your families, and when you lose that balance it is important to talk about it openly. Share your experiences and reflect on them as I have reflected on this one. We are pulled and pushed in many directions to help and serve our patients, and these experiences help to reinforce that we can make a difference but again they can come at a cost. Another quotation from a colleague, "we didn't become doctors for a convenient life", yet, we still need to work daily at this work/life balance. Honour your patients and accept their gratitude that makes it all “worth while" and, be sure to ask for help when you need it both for yourself and for your patients in the same sense.

Best of luck and the sincerest of congratulations on the journey you've completed.