COMMENTARY

A COVID Commencement Speech: What New Docs Have Lost, Gained

Jillian Horton, MD, FRCPC

Disclosures

May 27, 2020

To the graduating class of 2020,

Let's start with one word: Congratulations! That word is far too simple and overused to capture what this moment actually means. I can only hope that it somehow feels bigger coming from those of us who know what you have been through, what you are going through, and what you are about to go through.

Jillian Horton, MD, FRCPC

People always say that the biggest days in life are never exactly as you imagine them. That said, this year's commencements are over-the-top by anyone's standards. Somewhere, a dean is attending a virtual graduation in pajama bottoms and flip-flops...

None of you should feel obligated to pretend that muted celebrations, virtual ceremonies, and socially distant commencement speeches like this one are sufficient to acknowledge all you've achieved. It is just the best we can do right now. I know that isn't very satisfying. If you don't already know, you'll soon find that "doing the best we can do right now" is often all we have to offer our patients, especially during a crisis like this.

When I thought about what to say to you, the COVID class, young doctors starting your careers during a great pandemic, I found myself thinking of a story from my own life. A few years ago, I met a colleague in our hospital coffee shop. I was there to deliver a card on behalf of a patient. My colleague had operated on that patient a few months earlier. She saved his life.

That patient was my dad.

My colleague's eyes filled with tears as she read me what my father wrote: "I had always hoped to see one of my grandchildren graduate from high school. Thanks to you, that is still a possibility." As moved as I was by his words, I was also surprised. My dad said that? Really?

My father is a stoic and deeply practical man. I had no idea that attending my eldest son's graduation—an event that is still several years in the future—meant that much to him. My dad has had a difficult life. Not only did he grow up during the Great Depression, but he and my mother have had to mourn the death of two children—one of whom died during this pandemic. To me, my father has always been a no-nonsense, big-picture kind of man. I didn't think he'd care that much about a ceremony I always thought of as unnecessary and artifice.

But he did care. A lot. So much so that, when facing death, it was partly his motivation for survival.

There's a good chance that people you love have been just as invested in watching you cross a stage for your med school graduation. People you love have likely been dreaming of seeing you receive your degree, of hearing the word "doctor" in front of your name for the first time. Maybe that thought kept them going through their own hard times. Maybe you've pictured yourself walking across that stage, thinking "Mom and Dad, this is for you."

Instead, thanks to the pandemic, it is entirely possible that many of you haven't even seen your family in months, that you can't be with them at all right now. Instead of your graduation being a beacon of hope, a unifying moment of celebration, a victorious day, it's another Zoom meeting. It's just more time spent at a computer. It's just another thing you'll have to cope with.

I know that some of you feel too ashamed to tell anybody how disappointed you are. I know that some of you have felt trained to keep your emotions to yourself in certain circumstances. I know that some of you are afraid that someone will tell you to just be grateful for what you have, because misery is all over the world right now, because some people have lost everything. If you haven't learned this yet, know it now: Grief and gratitude are not mutually exclusive.

You aren't selfish for wanting a meaningful recognition of years and years of hard work and sacrifice. What you are mourning right now is not sitting in a crowded auditorium and listening to a speech like this. You are mourning everything that celebration symbolized. That is what you've lost, and no one should underestimate or undervalue that. As my dad would tell you, as he did tell his surgeon, we literally live for moments like this.

In some ways, I find it interesting how surprised we are by the disruption of this global medical emergency. After all, our medical training is a masterclass in how quickly life can change.

It changes with one "shadow" on an x-ray.

It changes with one complication during childbirth.

It changes with one lump where a lump doesn't belong.

Suddenly, there's no wedding. There's no christening. There's no chance to watch your grandson graduate. Honestly, it should make you wonder why becoming a doctor doesn't decimate all our expectations that anything can ever turn out well.

To survive something as demanding as medical education, we protect ourselves by putting our faith in structure and expectations. We work on preset schedules and timelines. We look forward to specific moments of transformation. When those things go away, it feels like the universe broke a pact with us. For some of you, this may be the first time the illusion of that pact has been shattered. It is painful, and you don't need to pretend that it isn't.

But here's what I promise you: This will make you a better doctor. Why? Because it is going to rid you of the things you only thought protected you, the barriers between you and your patients. I'm not talking about personal protective equipment. We need more, not less of that, and we need it urgently.

I'm talking about another barrier: the imaginary wall you've built between you and your patients. It is the one that some teachers mistakenly tell you is a prerequisite for survival in medicine. It is just like how some attendings are fond of quipping that you should never forget "the patient is the one with the disease."

Forget that advice. This pandemic should have already taught you how wrong it is.

What has happened for all of us in the past few months is a complete collapse of that separation, of that imagined wall. Now, you see your own futures as fragile, as dependent on external forces as any patient under your care.

This is a hard realization to process that comes on top of everything else you have had to manage, process, and learn to become physician. But it is an important lesson. It is a valuable lesson. It will make you into the best version of the doctor you were always going to become.

You will be tempted to rebuild that wall. You will be tempted to separate yourself again, to protect yourself, to divide the world back into "us," the medical community, and "them," the patients.

I am asking you not to.

If you do not rebuild that wall, you will remember that our patients are often people who have lost their structure and expectations, things they waited for, things that they worked toward. If you think medical school is expensive, well, you're right. It is. But our real learning in life, the most profound and lasting insights, usually come at an even greater cost. The price of our insight at this moment is almost incomprehensible, but the truth is also that it has given us a gift. That gift is clarity.

I once attended a wedding in an ICU. The groom died a few days later. We don't ask why someone would get married knowing they only had days left to live. We immediately understand the power of that moment, the symbolism, how clear it must have been to that couple in those final terrible moment of their joined lives what truly mattered. Another one of my patients died last year, just days before a long-awaited grandbaby could be born. The baby wouldn't have magically grown to remember him if they briefly met. My patient mourned the symbol, the expectation, the forehead touch between generations.

You've been handed something, placed into a situation, and asked to incorporate it into the story of your life. A crisis has a way of forcing us to grow up sooner than we planned, of teaching us lessons we couldn't have otherwise learned, of allowing us to hear and see people we used to think were on the other side of an imaginary wall.

I hope my father will see my son's graduation. I know that if he doesn't, if an ongoing pandemic or other circumstances prevent that moment, I will try to follow my own advice to you today.

Do the best you can right now.

Grief and gratitude are not mutually exclusive.

Let your imaginary walls fall down.

Class of 2020, I promise, you will never be forgotten. Not because of what this crisis has taken from you, but because you will be transformed by it in ways that will reveal themselves in due course. The world has changed, and so have you. You are better because of this. Patients will heal because of this. Medicine will grow because of this. And so will you.

Thank you.

Jillian Horton, MD, FRCPC, is associate head of the Department of Internal Medicine, director of the Alan Klass Program in Health and Humanities, and a former associate dean of undergraduate student affairs at the University of Manitoba in Winnipeg, Canada. She was recently named as the recipient of the 2020 Gold Humanism Award from the Gold Foundation Canada and the Association of Faculties of Medicine Canada. Her memoir about medicine and medical education will be released by Harper Collins Canada in February 2021.

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