Ravin Davidoff White Coat Ceremony 2015 Remarks

Dean Antman, respective Associate and Assistant Deans, incoming MD class of 2019, very proud parents and family and distinguished guests

For me this is truly an honor to be asked to speak at the White Coat ceremony for Boston University Chobanian & Avedisian School of Medicine. I spent a little time researching the history of this event, and it appears that the first White Coat Ceremony was at Columbia University’s College of Physicians and Surgeons in 1993. The Gold Foundation has described the WCC, (you will soon learn the many, many abbreviations we use in Medicine, it is our special code) anyhow the foundation described the WCC as an experience by which, and I quote, “participating schools alert beginning students to the need to balance experience in science with compassionate care” and that it “helps to identify characteristics of a complete doctor”. Interestingly there have been numerous articles that relate to the ethics of this moment. Criticisms have been levelled at whether swearing an oath prior to starting is appropriate, that it fosters improper student faculty relationships and interprets the meaning of the white coat selectively and that this moment imparts a sense of entitlement rather than compassion and humility.

Well, I must say, I view this moment in quite a different way. There is nothing about today that represents the culmination of a journey. Wearing a white coat today and for the rest of your life confers a sense of responsibility and privilege that, to me, and to most of us who are physicians, actually imparts a sense of anxiety most days at the enormity of our task and the constant search to get it right.

I thought I would take a moment to tell you a little about myself and how I got here. I suspect among you there will be similarities about our journeys.

My grandparents and parents came from Eastern Europe and had fled the pogroms and persecution of Jews that was rife in the late 1800’s and early 1900’s. They heard about the discovery of gold in Johannesburg, South Africa in 1886 and decided to seek a better life there. My Dad arrived as an 8 year old in 1920 with his Mother and a small little suitcase with all his possessions. My Dad left school at age 14 to earn a living for his family, married my Mom and their lives were focused on ensuring that my 2 brothers and I received a strong education and that we would have the tools to become professionals. I was never quite sure why they thought Medicine and Dentistry were suitable careers but as we talked about it, I realized they knew that these professions were exportable and that might prove useful at some time. I grew up as a privileged white during the height of Apartheid in South Africa. I entered Medical School in 1971 straight from High School (yes, I’m that old!) and to be frank, I really didn’t know what I was getting into. Well we didn’t have a White Coat ceremony and I remember little about my first day at Medical School other than 200 mostly white, mostly male 17 and 18 year olds sitting in a sterile conference room and the Dean looking out at us saying

“Look to your right, look to your left. One of the 3 of you will not be in the class next year…good luck to you all.” And then the journey began, with great anxiety about whether I would make it…and I really didn’t know what it was.  And that turned out to be true that over the first 2 years of medical school, 1/3 of the class failed and never became physicians. The first few years of Medical School in South Africa were in many ways the weeding out process that you all have already so successfully navigated.

Medical School in South Africa was an amazing educational experience and although this is difficult to say, in part, it was because of Apartheid that it was such a strong clinical training. In the hospitals for the Black patients, the pathology was astonishing – scurvy, Beri-Beri, pellagra, porphyria, leprosy, acute rheumatic fever and on and on. I delivered 50 babies in a short 4th year rotation, I placed chest tubes routinely, cared for patients with multiple stab wounds as a result of seemingly random violence after a soccer game. Many of these illnesses and traumatic injuries were associated with the poverty, the neglect of rural patients in Africa coupled with mistrust of the Western healthcare system resulting in very late presentation of diseases, so many of them preventable or treatable. Couple that with reasonably current technology, amazing clinician educators schooled in the British system and it was easy to be a well-rounded clinician with tremendous clinical exposure in the South African environment. These experiences during my formative days of training amplified my painful awareness of the socio-political ramifications of apartheid. I visited and spent many days at the 3200 bed Baragwanath Hospital during my training and drove past Soweto on each of these occasions yet I never entered Soweto until 2010 when I returned to participate in a course. Soweto was a place that White people would not enter during the Apartheid era.

So I arrived at Boston City Hospital in 1981 which is one of the 2 legacy hospitals which merged in 1996 to create Boston Medical Center, the principal teaching hospital of Boston University. I didn’t really know what Boston University Chobanian & Avedisian School of Medicine represented when I began but it has been a perfect environment for me to counterbalance the reasons I left South Africa. I am so proud to be part of institutions on this medical campus that promote inquiry, science, collegiality, a constant search for the truth, a commitment to train the next generation of physicians while fully embracing that healthcare is a right, not a privilege.

And here I am 44 years later as an incredibly proud member of the Medical Profession. Over my desk is a framed copy of Maimonides Prayer for the Physician and each day, I look at it. Many days I glance at it without paying attention but other days I pause and carefully read the words. I have chosen to link a few components so these are not continuous but I will read them as if they are

“Deem me worthy of seeing in the sufferer who seeks my advice – a person – neither rich nor poor….show me only the man…for the knowledge of healing is boundless…any lapse in my knowledge can bring illness and death.”

This is not an oath; this is a prayer and it is a universal prayer for us to perform our work at the highest level each day we are blessed to do this work.

A couple of weekends ago, I spent time with the parents of Josh Kriegel, my nephew, who is here under the tent as a member of this incoming class. As we talked, the word privilege kept coming up as a central theme. Every day I am so privileged to be a physician. Whether I am seeing patients in the office, reading echocardiograms of the heart, working to educate the next generation of residents and students or thinking how we maintain our mission as a hospital. I feel so privileged that I and we have the opportunity to care for people and deliver care with our credo being Exceptional Care. Without Exception. That is truly a privilege. And although there are many days when I go home wondering what I did all day and whether we will ever solve our problems, I know that our True North of delivering care to all is the ultimate privilege for me

But what Josh’s Mom and I also talked about is a different interpretation of Privilege. And that gets back somewhat to the criticism of the White Coat ceremony that I began with.

Let me tell you a little anecdote about a case I remember vividly from my early days as a doctor in South Africa. I was on call on a Sunday as an intern. A patient came in and was very sick with overwhelming infection, we use the term sepsis. It was my job to work out why he was septic. We couldn’t identify the source so we started him on antibiotics, and when I tried to get a urine sample from him, we could not get any. Eventually I realized that his bladder outlet was obstructed. I had to work out how to drain his very full bladder when the outlet was obstructed by a previous infection. I called around, people rallied around me, told me how I could enter the bladder through the lower abdomen, somebody went to get the instrument from another building across the street, I used this instrument I had never seen before let alone used, to enter the distended bladder through the abdomen and the severely infected urine was able to drain out. That, in conjunction with the antibiotics, helped the patient to make a full recovery.  I’m sure many of you are wondering where was the resident, the fellow, the attending physician, the specialist urologist but this was 1977 in South Africa and well….. times were different.

The next day, my truly beloved mentor, Professor Harry Seftel, came on rounds in this large open ward with patients lying side by side separated only by flimsy curtains. He yelled to the Nurse Manager, who in that environment was called Sister and bellowed, and I mean bellowed “Sister, tell this patient he was dead. Young Ravin saved him”. We all trembled just by the nature of his voice but I trembled because of the enormity of that statement. I quickly though realized, I could not have done anything for that patient without all the other pieces around me. If I, for one moment, would have thought it could wait until tomorrow or I could do it alone, the outcome would have been very different. Medicine is a team sport. There is far too much for any of us to know to ever feel complacent. Each of you as you move along the life-long journey of learning and caring for patients will face the complex dilemma of clinical decision-making. It is truly a glorious journey but it is challenging and daunting. From my perspective, the key to succeeding in this space is to always appreciate the privilege you have been granted to treat patients. You may only have a 20 minute encounter every 6 months, but patients will confide in you, expose their anxieties and ailments, reflect on their many challenges especially in our safety- net clinical environment where having cancer is not their biggest problem and keeping the lights and heat on and feeding their family is a more pressing problem. Yes, that is an unbelievably rewarding experience and privilege. But to have that privilege we need to “check our privilege”. This term has all sorts of connotations and although I have been talking about race, in the context I am using it here, the term relates to elitism and hierarchy. Life is too precious for that thinking and attitude to get in the way. Medicine is the ultimate team sport. There is so much to know and changes occur so rapidly that one can never keep up with everything. If we look back on the history of the science of medicine, we quickly realize that what is true one day will frequently be proven wrong the next. That is sad but real and exciting as Medicine discovers new ways to strive for the truth. But the humility associated with that reality is what will drive us all to ask the question with each patient and each clinical interaction: “What would I do if this were my mother, my father, brother or sister?” I would ask for help and guidance, I would research the science, I would consider the cultural issues and the complex interplay of clinical care, risks and side effects of treatment so that when we make a decision, we deliver the “Right Care – no more and no less.” That is the beauty of medicine – the perfect intersection of a commitment to knowledge, learning from others, and listening, truly listening to your patient

The white coat you will put on today marks the beginning of this journey. Wherever your medical training takes you, wear your white coat and MD title with pride and privilege but of much greater importance, with humility. Remember this important moment when the anxiety of starting is coupled with the enormity of the challenge, the thrill of the adventure ahead is balanced by the burden of responsibility. Under this big white coat, are the people who have helped you to get here and the kind of people, influences and support you will want by your side as you embark on the incredible journey. As a proud member of the medical profession, I welcome you to the start of a beautiful, and hopefully fulfilling, life-long journey. Welcome Class of 2019. Thank you