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Office of Student Affairs 
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Commencement 2004Finding the right balance Remarks by Interim Dean Dennis D. Spencer, M.D. I want to welcome the Yale School of Medicine’s newest doctors, the Class of 2004, and extend a very special welcome to those members of your families, friends and loved ones who have encouraged and helped you be here today. We are both enjoying a rite of passage today: me from my interim role as your dean and you from this extraordinary medical school. I have known this was a special place for the last 33 years, first as a house officer, then as a faculty member and finally as chairman of neurosurgery. But it was not until this year, while serving as dean, that I finally understood the additional dimension of the Yale educational system—why it works so well in this place and why, because of the Yale System, you are so well prepared to be the next generation of leaders in American medicine. You will lead because you understand the power of critical thinking and the value of extraordinary basic research. And because you understand that the prefix “Dr.” that you receive with this diploma is not a merely symbolic one; it is there to remind you that you have joined with me in a profession that holds devotion to our patients as our single most important common linkage. Although what we have done here today is something Joseph Campbell would remind us is full of the wonderful mythology of ritual, you are a different person with this diploma, ready now to find your place in the cycle of medicine. What is the cycle of medicine? One of our most beloved deans of the Yale School of Medicine, Lewis Thomas, explains the cycle in his essay “On Becoming a Doctor.” Prior to the mid-19th century, physicians were compelled to always “do” something to their patients, and there was a feeling that all diseases were terminal unless there was an intervention of some kind. And of course the more dramatic the intervention, the more solidly it held sway. In the late 19th century traditional, aggressive interventions were revealed as often more harmful than benign neglect, and thus began an era of more contemplative examinations and longer discussions with patients that replaced invasive therapeutics such as blood letting, purging and skull trephining. The extra time devoted simply to listening to patients had a far greater effect on health, in some instances, than did time-honored treatments. However, as it generally does, the pendulum swung again during the 20th century with the rapid technological advancements that occurred—particularly in surgery, which had suffered during the hands-off era of the late 1800s. The importance of this swing was reflected in a Commencement address 100 years ago this spring at Yale on “The Training of the Surgeon,” delivered by the father of American surgery, William Stewart Halsted, a Yale alumnus and chief of surgery at Johns Hopkins. In that address, he emphasized the remarkable progress that surgery was making by bringing the rigorous German teaching paradigm to the United States and the concomitant discoveries in anesthesia and antisepsis. He moved a generation of physicians away from contemplation and into the war-like metaphors of conquering disease with battle plans tuned to rigorous discipline. His student Harvey Cushing, another Yale alumnus and the acknowledged father of neurosurgery, was a product of that discipline. But Cushing pushed the paradigm further and used much of his time as a house officer and young faculty member at Hopkins to establish the Hunterian Laboratory of research. He remarked in a commencement address 22 years after Halsted: “We have gained much for science but have lost much for practice by the course we are following, and I look forward to a time when the pendulum will swing back, not to a day when the spirit of research will be any less active, but to a day when suitable representatives of the clinical departments will be delegated to correlate the teaching in the science courses so that their bearing on what is to come may be constantly kept in mind.” (Does this sound familiar?) By the 1960s we were entering another cycle of science expanding, asking all sorts of important but seemingly impractical questions only lightly disguised as relevant to disease, with a wink between scientists. This truly reductionist period ended with the deciphering of the human genetic code and the sudden real clamor of the public and legislature that science had for too long made unfulfilled promises and that cancer, vascular disease and chronic conditions associated with aging must succumb to modernity. So this is now where you will start your career, in another cycle of intervention and with the pressure of rapidly applied biological scientific discoveries. I urge you to meet this challenge as René Dubos suggests in his little monograph “Quest: Reflections on Medicine, Science and Humanity,” by forming new institutions for the study and treatment of disease. By this he meant institutions that would bypass the silos of rigid focused research. Those of you graduating today are uniquely poised to follow Dubos’ maxim in a way that will short circuit the cycles of intervention and reductionism, because, as products of this medical school, you have participated in and understand the rigors of research, but you also have sat at the bedside of a dying patient. This is my vision—that you will create within the old institutions new continuums of research and patient care. On one end of this continuum, basic research will be allowed to ask those impractical questions seemingly irrelevant to disease but driven by the need to understand basic structure and function. On the other end will be the patients, where empirical care and technology provide volumes of data, questions and intuitive solutions. In between, some of you will make discoveries about disease pathogenesis and, through translational models, move those discoveries into human investigation and ultimately treatment. You may be primarily a clinician or primarily a scientist, but you will learn the language of the problem, you will work together on multidisciplinary, interdepartmental teams focused on both research and patient care and you will adopt metaphors other than war—metaphors of growth (the gardener) and exploration (the voyager) and evolution (the survival of the fittest.) For example, you may decide to grow a laboratory. You may regard it as a kind of greenhouse whose rich soils are computer hardware and gels. And you may build diverse scientific teams and encourage the kind of cross pollination that produces new species—some by design and some by serendipity. Now you must remember one more thing. Evidence-based practice and hypothesis-driven science are satisfying and necessary components of our careers in medicine. But your diploma and the oath you took today demand that you be a physician, which is more than understanding scientific principles or being able to conduct a detailed physical examination. Those are tools that take you part of the way to the maxim embraced by Dr. Edward Trudeau, “To cure sometimes, to relieve often, to comfort always.” But you can’t get all the way there until you know who your patient is and know as much about his or her environment as you do about the EKG. I can best explain this by asking you to visualize with me a portrait of a physician making a house call that I once saw in a museum. You see the physician in the entryway as he pauses before ascending the stairs to the sick room. He is looking around at the pictures, the clothing, the forms and functionality of the patient’s life. When you can answer the question of why that is as important as the gene chip we all may some day wear describing our vulnerability to one of death’s processes, then you will have truly earned this diploma. Again I want to congratulate your family, friends and loved ones for encouraging and supporting your studies. I am very proud of you and am truly grateful to be sharing this unforgettable moment with you.
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