Challenges to the New Physician: Commencement Address, Louisiana State University Medical School, Shreveport, Louisiana
In this example of the many commencement addresses he delivered during his two terms as U.S. Surgeon General, Koop reminded
his audience of the ethical commitments of physicians, including forging a supportive relationship with patients and their
parents based on informed consent; ministering to patients in a health care system driven by scientific and technological
advances that created distance between physicians and patients; helping parents cope with the financial burden imposed on
families by costly operations and long-term care for children with birth defects; and ensuring quality of care in a time when
the role of government in regulating health care and medicine was diminishing.
Number of Image Pages:
18 (1,184,823 Bytes)
1982-05-29 (May 29, 1982)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
Health Services Needs and Demand
Practice Guidelines as Topic
"Concerns Facing the PHS [Public Health Service]: Presented before the Interagency Institute for Federal Health Care Executives,
Clayton, Missouri" [Reminiscence] (2003)
Deputy Assistant Secretary for Health and Surgeon General
U.S. Department of Health and Human Services
Louisiana State University Medical School
May 29, 1982
(Greetings to hosts, guests.)
I am truly delighted to be here this morning to share, for a few minutes, that wonderful sense of pride and accomplishment
that each of you must be feeling on this, the final day of your formal schooling in medicine.
It's been many years and several other degrees since I first earned my M.D. Still, I remember the unique glow I felt on
becoming a doctor of medicine. There's no other feeling like it. Congratulations to each of you for reaching this day
and also feeling that special glow of achievement.
I graduated from Cornell exactly 41 years ago this week. I am sure we had a marvelous commencement speaker and it was a very
moving ceremony. Except for that personal glow I spoke of the moment ago, I remember very little of that event. I do recall,
however, with the benefit of hindsight, that no one came to the microphone to tell me and my classmates several things we
ought to have been told, as we embarked on her medical career.
During the past four decades I've learned some things about the science of medicine. I've been something of a specialist's
specialist in pediatric surgery over the past 35 years. But I would guess that you've heard quite a bit about the science
of medicine during your studies here at LSU. So want to take my few minutes here at the podium to talk about the art of medicine.
Maybe I can pass on to you some of the things I wish I had been told on the day I sat as you do now, eager to join the company
of educated physicians.
First, let me briefly touch on five principles that have become part of my manner of medical practice. I kind of stumbled
onto them as the situations arose, but they served me well and I offer them in the hope that -- 40 years from now -- you may
remember something of real utility that you picked up at this very exciting ceremony.
A guiding principle for me is that I have always tried to make the parents of my patients my allies. I really want them to
stand with me against the disease that is affecting their child. I want them to know I am ready to share both their triumph
and their tragedy, they we're going into this thing not as adversaries but his partners.
Taking that approach, following that principle, has forced me to communicate with the parents, to listen to their anxieties,
their information about the patient, their child, and it makes them listen to me, to understand what is at stake, what the
odds might be, what to be ready for. If your patients are not children, as mine were, your allies, then, are the patients
Not too long ago it dawned on me that, after 40 years of active surgical practice I have never had a patient or family of
a patient pursue litigation against me. Never. I'm very proud of that fact and I firmly believe it stems from the special
effort I have made to build that relationship between me and the families of my patients.
Escaping a lawsuit was not the motivation. It became an unexpected dividend. There are many other dividends as well; not the
least of which is been the privilege of sharing with the family there deep joy when the procedure was successful. I would
hope that each of you will be able to experience that same joy -- and for the same reason, because you took the time and care
to communicate with the people you are trying to help. They need it. You may need it more.
A second principle is to be ready for surprise in your practice. Today, you may think you know what it is that gives you your
sense of excitement as a physician. Good. Hang onto that. But don't stop there. Don't close yourself off to what else
is happening to you.
Surgeons loved operate. And the more difficult the operation, the greater the challenge, the more they want to go ahead and
do it and do it successfully. Frequently, I have had to carry out an anastomosis on an esophageal atresia in a three-pound
baby. It's like sewing together the ends of two pieces of what spaghetti in the bottom of an ice cream cone. I've
done it many times -- successfully -- and it brings with it a great deal of personal and professional satisfaction. But then,
I always thought that kind of thing would be very satisfying to accomplish.
But over the years I've discovered that my real satisfaction comes from diagnosing in the parents the specific point of
their anxiety, finding out what really troubles them, finding out about the whole event, and then working to alleviate that.
I know that most of the problem will be resolved in the OR itself, but there are other reasons for anxiety and I want to deal
with them as well. It's an immensely satisfying part of my practice that I hadn't been taught -- but I have come to
value very deeply.
Next, I have discovered that money is very, very important in medicine. Not in the way you think. Money in the long run is
far more important to your patients than it will be to you. Please remember that, as you explain to your patients and their
families the things they will be responsible for -- especially things not covered by insurance. For example, they may not
know there will be an operating room charge and a surgeons bill and a fee for the service of anesthesiologist, too.
It has been my lifelong experience that the person receiving medical care is less concerned about costs per se than about
the fairness of those costs. And patients don't want to be surprised either. They cannot suddenly come up with several
additional hundreds or thousands of dollars. 10 years ago, for every $100 a person earned, he or she would probably spend
$8 on personal medical care. This year, the share has gone up to $11. People are taking that additional money from things
like education, food, clothing, transportation, and housing. It hurts. So, in your practice, don't surprise your patients.
Inform them as carefully as you can about the economics of the care they will receive . . . do it in the same manner as you
tell them about the medical side of their care.
A fourth principle is really a corollary of the first. Learn very early to communicate well not only with your patients but
with your medical and paramedical colleagues, also. Whether you are receiving or delivering consultation in the form of a
lab report or an opinion or whatever; give it some time. Make sure you understand -- and are understood. You and your patients
will benefit from following this principle.
And finally, inform your patients about what is going on. I don't believe you can tell a patient too much. I am always
disconcerted by my colleagues to find the legal imperative for informed consent to be restrictive and burdensome. Informed
consent ought not to have become a legal requirement; it should have been and should be automatically a part of every physician's
mode of practice. Make it part of yours.
A dozen years ago, when I taught a course in medical ethics I used to start one of my lectures with this dictum: "Informed
consent is the hallmark of the caring, intelligent physician." The concept at that time was still being debated in medicine.
But for me, the debate was over. And it should be over for each of you as well. Tell your patients what is happening. Ask
them for their help in understanding. Gain their consent not as a legal formality, but as an integral part of your practice.
Now that you have access to Koop's five principles, let me explore with you for a bit the environment in which you will
be exercising those principles.
You are entering medicine at an unusual time . . . but an opportune time. For many years your predecessors have argued that
the federal government should no longer intervene in the practice of medicine. They did not like being regulated. Today, that
battle is being won by medicine -- this is a period of deregulation in medicine, when the federal government is reducing its
level of intervention and transferring authorities and resources to the states and to the private sector -- to you and your
Today's graduates from medical schools may well consider themselves free of many regulatory obligations. But you will
not be free of any of your ethical obligations. For example, this administration proposes that we phase out over the next
two years all federal involvement in professional standards review and in health planning. That does not mean those activities
will disappear. Quite the contrary.
We believe that the medical profession will assume full responsibility for the quality of care its members deliver to their
patients. That's our ethical responsibility and you and I must grasp it as rightfully ours. Similarly, where health planning
is providing the community with a better vision of what health care ought to be, then physicians should be active in helping
to make planning work. The professional life is not one long free lunch. Your predecessors in medical practice know this and
have still worked hard to have the responsibility moved in their direction. Now you have the unique opportunity of coming
along at a time when your energy, your ideas, your fresh outlook will be invaluable to medicine as it takes back what government
had assumed to do. It's a personal challenge and a professional obligation for each of you. Don't pass it by.
But there is another aspect to this time in human history. I think people -- especially young people -- are taking a second
look at values and are trying to build their lives around the values that hold meaning for them. Maybe there is a revulsion
against violence -- nation-to-nation, as well as person-to-person -- that is taking hold. In any case, I think we are really
beginning to care about each other, openly and freely and even joyfully.
The practicing physician is in a unique profession, since it requires not only the science of medicine but also this art of
reaching out to people and caring about them. In fact, it is the science itself that has made this attitude so vital. For
example, over the past 25 years this country has been able to bring about a dramatic 32 percent decline in the death rate
for heart disease, a 49 percent drop in the death rate for stroke, and a 23 percent decline in the death rate for all types
of accidents. And for cancer -- the second leading cause of death in this country -- the mortality rate for people under the
age of 45 has dropped by 33 percent.
How does this affect you? First of all, you have to be less sure of outcomes, which means you will have to employ "Koop's
First Principle" of communication with patients and families of patients. While much is left to be desired, the plain
fact is that Americans do generally eat better and take care of themselves and, therefore, have a better chance of surviving
serious -- even catastrophic -- illnesses, with the help of modern technology. And the statistics bear this out. I don't
recommend that you begin to play percentages. I just hope that you retain a healthy skepticism about your own expert diagnoses.
Your patients may fool you and recover.
But there is the other side, too. Once you commit yourself to caring about your patients, you are committed through good times
and bad. Sometimes you will treat your patients. At other times, quite frankly, you will "minister" to them, with
all the connotations embedded in that mysterious word. Some patients will recover, but not lead the kind of life they had
once known. You, as the "ministering" physician, will be the one the family will turn to for some hope and guidance,
for a word or a touch of compassion to signal your sharing of strength and love.
It is a curious paradox of contemporary life: the more expert and scientific and technological we become, the more we must
deal with profoundly human outcomes -- emotions and feelings and attitudes that are beyond the fashioning of scientific experts.
You have just completed an excellent course of instruction in the science of healing -- caring, repairing, treating, and preventing.
And the better you are, the more you will need to exercise your art of healing . . . your essential humanity.
Those qualities will be tested soon enough by the nature of some of the changes taking place within our society. I want to
focus on just two, in order to suggest the challenges ahead for each of you, both as physician and his human being. The two
are the growth of our aging population and the new concern for disabled persons.
During the last quarter of the century the median age of the American population will gradually creep upward. In 1975 the
median age of the American population was 28.8 years. In the year 2000 the median age of 35.5 years, according to the latest
median estimate by the Census Bureau.
During this decade of the 1980s, the age cohort of 35 to 44, the so-called "Baby Boom Generation," will expand by
about 40 percent. Shortly after the turn-of-the-century, about 1 in 5 Americans will be a senior citizen -- about 50 million
compared to today's 25 million. Equally important is the fact that nearly half those senior citizens will be age 75 or
These statistics tell me that now is the time for all of us medicine to rethink our attitudes about aging. As physicians,
we are trained to prevent the occurrence of premature death. We don't want to see people die before their time. But what
is their time? What is the quality of life supposed to be if you live until your time? What is the quality of medical care
for people who are close to the end of their time, compared to patients with a lot of time left?
Each of us has a reflexive answer of some kind to these questions. But it may not be a good enough answer. Your reflexes may
not be reliable, when dealing with issues of such profound importance to how we will live and practice -- and how your patients
will live as well.
A man who reaches the age of 65 now has a life expectancy of another 12 years. A woman of the same age, 15 years. Will we
provide them only with as much curative and reparative care as we can, or will we practice preventive medicine as well? What
about the 65-year-old person who has smoked two packs of cigarettes a day -- and then stops. That person will see his or her
pulmonary functions return toward normal. Of course, if there is already the beginning of a bronchogenic carcinoma, quitting
cigarettes will not reverse the situation. Will we be sensitive enough to advise that 65-year-old to stop smoking?
And need I add that, as this country begins to show more gray on the heads of its citizens, more gray will be appearing on
your head as well, and on the heads of your colleagues.
And now I would turn your attention to the disabled, a group of Americans that is also growing in numbers and -- for the physician
-- a group that presents its own special challenges.
Today about 1 of every 7 Americans is disabled or limited in some way from living a life that is normal for his or her age
group. That something like 35 million Americans . . . about a one-third increase over the number of Americans who are disabled
or had limitations on their activities in 1969. It is an increase far larger than our overall population increase during those
same 12 years. The numbers include . . .
- The nearly 5 million persons who suffer from impairments of the back, the spine, the shoulders, and the upper and lower
extremities. Many of these impairments are from injuries sustained in preventable highway accidents.
- There are also the 3 to 4 million people who live with disabling and chronic bronchitis, asthma, emphysema, and other respiratory
conditions that may be traced to smoking or to preventable high-risk conditions in the workplace.
- The total also includes about 6 million people who suffer from arthritis, rheumatism, and other musculoskeletal disorders
about which we need to learn much more in order to control and prevent them.
- And there are the 5 million or so people who have not died of heart disease, who were saved but are nevertheless limited
in what they can do for the rest of their lives. In a sense, many of them survive as casualties of poor nutrition, smoking,
lack of exercise, or an inability to handle the stresses of modern life. Those are also preventable causes.
In the single year 1980, the Department of Labor reported a total of 5.6 million occupation-related illnesses and traumatic
injuries. These produced a total of nearly 42 million lost work days. And the total earnings lost came to $2 billion.
Some person . . . some agency . . . someone has to make up that loss. It may be replaced by Worker's Compensation or insurance,
by a relative or friend, a charitable organization, or social service agency. The earnings may be replaced, but never replaced
will be the lost days and lost years of a full, active living.
At this point, I am asking you to break through those cultural barriers you may have acquired so far. If we have trouble coping
with the aged person -- and I think we do -- then how much more difficult will it be for physicians to cope with the aged
person who is also disabled. Thanks to modern medicine, both have a better chance of surviving -- and please remember that,
as of today, you are part of "modern medicine."
There are many Americans living satisfying and productive lives who are also disabled. They live that way, in many cases,
in spite of the attitudes of society that are barriers to acceptance. Physicians have a special responsibility to be aware
of these barriers -- in their own attitudes and in the attitudes of others, friends, colleagues, or family -- and to change
This is a challenge to you personally and professionally. We are inclined to focus on a primary disability, for example, the
condition that is presented to us, and we deal with that exclusively. We tend to neglect secondary disabilities; other possible
outcomes that will compound the life problems of our patient. Scoliosis, as an illustration, can lead to a second disability:
pulmonary dysfunction. And pulmonary dysfunction can, in turn, lead to cardiovascular disorders later in life. We dare not
pigeonhole our thinking or compartmentalize our practice for our own sakes and for the sake of our patients.
This is a "commencement" address to you. This is your beginning in an exciting, satisfying career. Your education
is not over at a ceremony like this. It's just getting started. And it will continue. I sincerely hope that each graduate
today grasps the depth of the challenges in the years ahead, challenges that may occupy most of your practice. There is no
age at which a patient becomes uninteresting to a physician. The oath we take, the professional and collegial promises we
make deny that. Every patient needs are best care, our best thinking, our highest human instincts. And if the patient is old
and disabled, possibly having multiple disabilities, are basic decency and humanity must overcome our deficiencies in training
and education and acculturation.
Looking ahead . . . facing these extraordinary and exciting challenges . . . moving with and not against human history . .
. that has always been the ultimate reward of medical practice for me, as I hope it will be for each of you.