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Harvard Medical School Commencement

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Each of these student speakers has already set the stage for the graduation of this extraordinary class. This class comes with, I'm sure, a range of emotions that we can only guess at-- exhilaration and exhaustion among them. But also, as we've already heard, a lot of gratitude for the opportunities that they have been given. They also deserve gratitude from us for undertaking the rigorous education which they have, for pushing themselves to the limits and now for going into the world ready to use their talents and their education on behalf of the rest of us.

They have made many sacrifices. More than 70 percent of this class had to take out loans to complete the degrees that they receive today. They will be paying back those loans for a number of years, and I hope that we as a nation will continue to look for ways to provide financial support to students such as these so that they do not have to go into the debt that these young graduates have. (Applause) Some of these graduates, these new doctors and dentists, are the first in their families to attend college. Some have completed their educations while they were caring for their own families. Some are recent immigrants to our country. More than 15 percent managed to earn additional degrees, and all of them have worked extremely hard. They deserve this celebration by family and friends, and by alumni of these institutions who are gathered here to pay you credit. I hope that each of you feels the competence and the confidence that you've already heard described, because I can imagine that as you think about your n ew futures you've got some questions in your mind. You're thinking about the next chapters of your lives.

Now, I don't think the food wherever you're going will be as good as the restaurants on Newbury Street. The sleeping accommodations are not going to be exactly five-star ones. You know where you're going, it's called internship or specialty training. As we've already heard that means a lot of hard work and not very much sleep. And some of you in the dark of night when those beepers go off or those phone calls come may ask yourselves, `My goodness, am I ready for all of this?' Based on what I have learned about your class and your preparation, I think the answer is very clear -- you certainly are. You are more than prepared to enter the world of medicine and dentistry and serve your patients.

I was very impressed by the oath that the class has written, which you'll find at the end of your program. That oath describes very well what this class of extraordinary young men and women are committing themselves to doing. No group of new doctors and dentists has ever been better prepared to care for their patients. No group has ever been better prepared to help us usher in the next century, the next millennium of medicine. From the clinic to the classroom to the community you have received a first-rate education from one of the finest schools in the world.

We've already heard about the extraordinary diversity in your class. If you think back for a minute, a hundred or so years ago, to classes that also stood on the brink of a new century and new discoveries, you can see starkly the differences. The doors of medical education were virtually glued shut to women and people of color. Tuition here at Harvard was a couple of hundred dollars and you didn't even need a bachelors degree to get into Harvard Medical School. Until the 1870's, there were no written exams. And in fact, when President Elliott first suggested them, there was an objection because many of the students couldn't write. Yet like you, the students at the end of the last century had much to look forward to. When Oliver Wendell Holmes spoke at the 100th Anniversary of the Harvard Medical School, he referred to some things that never change, such as students sleeping in class. He noted that bleeding had almost become an unknown procedure, and he celebrated the exciting advances in surgical anesthesi a, germ theory, and the microscope. He thought they would produce miracles that sounded as though they would come straight from some new Gulliver's Travels.

That day that he talked, future physicians such as yourselves were staring down challenges like cholera and typhoid. There were no antibiotics, no antiseptic surgery in America. The sanitation conditions were horrible. But those young doctors and dentists, like you, were armed with something very important called hope. The hope that they could write a new future for medicine in the 20th century, and they did. Today, all of you stand on the shoulders of those Harvard graduates and faculty who have come before you and pioneered many of the advances that we take for granted today. You stand on the shoulders of all the Nobel Laureates from Harvard who have unlocked the secrets behind some of the world's greatest medical mysteries. Even today, there are so many Harvard alumni here in the United States and around the world who are working to unlock the secrets of cancer and research into sickle cell disease, working to rid the world of AIDS and doing so much more. Now it is your turn to join them. It is your time to lead. You've been given the chance to use your education and training during the most exciting time ever in medicine.

Just think, who could have imagined even thirty years ago the revolutions in biology and technology, to see change in demographics, and the shifts in the way that we fund the health care system. All of these changes offer incredible opportunities and fundamental challenges. The real challenge for all of you, it seems to me, is how in the midst of these truly revolutionary changes, you can stay true to the oath you will take today to make, as you say, the health of my patients my first concern. I know that many of you worry about this. I imagine there have been many conversations about what is happening in the health care system and how you will handle these new challenges, how you will manage the business of medicine from compromising the profession of medicine, how you will keep sacred the bond between patient, and doctor and patient and dentist.

In that extraordinary oath you've written, I think that there is a pathway to the future, a pathway that is not only one for you to follow, but for all physicians and dentists and lay people as well. When you pledge today to promote health and prevent disease, you do so at a time when there are extraordinary breakthroughs. You know all about them. Treatments for strokes and AIDS, the potential to slow diseases like Alzheimers, computer technology allowing you to share lifesaving information in real time, the mapping of the human genome that is revealing evolutionary secrets as we discover genes that are linked to breast cancer, colon cancer, and Parkinson's Disease.

And yet, with all of these breakthroughs come some questions that each of us, and particularly each of you, will have to address. For example, these kinds of advances don't just happen by accident or overnight. They are the result of sustained investments in research, especially in basic science. That is why we all have a stake in supporting the President's proposal for a 21st century research fund to increase our federal budget at NIH to historic levels. We should be increasing our budget at NIH as much as we can, at least by 50 percent over the next five years. That would give us the kind of investment that would enable you and your colleagues in the sciences to make these breakthroughs real in the lives of your patients. I hope that all of us (applause) will make clear that the United States must continue to be a leader in basic research and biomedical research, and that the United States government must, at this point in our history, make the kind of significant commitment that will enable us to move fo rward on the fronts that many of you will work on either in the research labs or apply in your practices.

Now, these continuing advancements in research and treatment also challenge us to ensure that our ethics keep pace with our science. We've all heard stories about people who are avoiding critical tests that their doctors recommend, or refusing to use their insurance out of fear that they will be discriminated against or have their privacy violated. It will do us little good if we discover genes that cause breast cancer or colon cancer, but people are afraid to be tested to find out if they have it because they worry that the information will cause them to lose their job or lose their insurance. You should be able to look your patients in the eye and say `information about your genes will be used to heal you, not deny you a job or affordable health insurance.' The President has asked Congress to pass legislation prohibiting the use of genetic screening information to discriminate in health insurance and employment. The Congress should act to end genetic discrimination now (applause) and you should be able to guarantee your patients the privacy of their medical records.

At a time when personal health information is electronically criss-crossing the country, moving among health plans, insurance companies, and employers with fewer federal safeguards than the records of your video rentals, it is time to pass a law safeguarding the medical records and information of every American. (Applause) When you take your oath and you pledge to respect the dignity and autonomy of your patients in living and in dying, you make that promise in a world of rapidly changing demographics. The baby boomers like me are graying. Americans are living longer with less disability. Now that is good news. It is what my husband likes to call a high-class problem.

But, as with any nation whose population is aging, we face tough questions about how we will provide and finance healthcare for this expanding group of older citizens. Think back. Before Medicare was enacted, almost fifty percent of older Americans went without health insurance. They found themselves often mired in poverty and chronic illness. People used to work their entire lives only to enter their later years facing unthinkable choices between paying their heating bills and their medical bills. We hear a lot of talk about what's wrong with government, but we shouldn't forget about what we have done right. Medicare forever changed what it means to grow old in this country and we have to make sure that it is there for generations to come. But Medicare, like any program in the public or the private sector, must adapt to a new world. The President worked in a bi-partisan fashion to extend the life of the trust fund as part of the Balanced Budget Act of 1997. And the changes in Medicare included not only an extension of its life, but more health plan choices and treatment options, and new prevention benefits like yearly mammogram, and colo-rectal screening, and diabetes self-management.

There is now a consensus between Republicans and Democrats that we have to address the long-term future of Medicare together. This should not be a partisan issue. Therefore, the President and Congress have appointed a National Bi-partisan Commission on the Future of Medicare that is scheduled to report in 1999. I hope that during the process of its deliberations and certainly in reaction to its report that all of you, and all of your colleagues will make sure your voices are heard, because we have to ensure that whatever changes are made are made in the best interest of patients.

You will dedicate yourselves to the profession of medicine and dentistry at a time when revolutions in our own health care delivery system are blurring the lines between payers, and providers, and insurers. There are more than 160 million people enrolled in managed care plans, an increase of 75 percent just since 1990. More physicians are forming their own health plans and working to find new ways to share risks and control costs. There is, however, another responsibility, that these new forms of care do not mean sub-standard care, that the bottom line of profits never eclipses the bottom line of good medicine. And you have to be on the front lines of ensuring that that occurs. Think about a recent statistic that came from a survey I read: "Sixty percent of Americans say they are worried, that if they were sick their health plans would be more concerned about saving money than giving them the best treatment." Physicians have been on the front lines arguing against these, standing up for patients who have be en denied treatments that were recommended by their doctors. Physicians have spent countless hours on telephones arguing with insurers to try to make sure that a patient got the care that the physician thought necessary. We have to work to make it absolutely clear that it should be the medical professional who determines treatment options, not a checklist administered from some office thousands of miles away. (Applause)

Whatever kind of insurance plan any American has, that American should feel they will get quality care. What better place to make that pledge than here at this graduation. Dr. Mitchell Rabkin introduced the first Patients Bill of Rights here at Harvard hospital. Patients should never have to beg and plead to see a specialist they need. When an emergency arises they should get the care whenever and wherever they need it. They should have a right to a fast and fair appeal when they or their physician disagree with decisions about their care. Congress should pass a Patients Bill of Rights to protect every American and pass it this year. (applause)

One of the most serious and unintended consequences of the changes in the financing and delivery of healthcare in America is its effect on academic health centers like this one. You have seen first-hand in your training what happens when new market forces squeeze academic health centers. Now you have also been part of putting some good models in place here in Boston, when managed care plans have joined forces with teaching hospitals. But the problem is one that is not just the concern of Harvard or Harvard's graduates, but should be the concern of every American. Because, just stop and think for a minute what our academic health centers have meant to each and every one of us.

Academic health centers have many missions. But three of them, in particular, have helped to make American health care the best in the world. The research mission of the academic health center has not been replicated anywhere else and could not be. We are all grateful for the extraordinary breakthroughs in research that have happened in the labs and clinics of academic health centers. The mission of training young doctors, and dentists, and nurses, and other health care professionals is also the province of the academic health center. And thirdly, the care for the most vulnerable, whether they are vulnerable because they are poor and disadvantaged, or they are vulnerable because they are sick and without hope, the academic health center has been there as a place of last refuge.

Now those three missions: research, education and training, and uncompensated care for the vulnerable, are not profitable missions. You rarely can make any money at all in the short-run, and even the medium-run, in research. You certainly cannot make money off training young physicians or dentists and you lose money when you open your doors to the most vulnerable. Yet, in this brave new world of HMOs and health care agencies that look to the bottom line, many academic health centers are being told, "I'm sorry, we're not reimbursing you for these functions which are not directly related to the patient care activities that we have listed in our brochure. So you will not receive compensation for research, education, training. And you're just going to have to send those poor patients somewhere else."

That attitude fails to recognize that the reason American health care is so good is because we've had the best research, education and training opportunities available of any country in the world. If we squeeze out those functions, if we force places like Harvard to have to cut back on what they do best, it is not only Harvard that will suffer, it is hospitals and patients throughout the world. It is time for us to recognize that paying for those academic health centers and their vital missions is in the best interest of us all. Historically, Medicare has borne a great deal of the cost, paying directly and indirectly for graduate medical education. We should do everything possible to continue Medicare and the federal government's commitment to academic health centers. But, I believe it is also fair and appropriate for every health plan and every insurance policy to pay something toward the maintenance of our academic health centers since we all benefit from the work which they do on our behalf. (Applause) This is not one of those abstract debates that should only take place in Washington behind closed doors. It should be brought out in the light of day. Those of you on the front lines of delivering high quality medicine, doing cutting-edge research, and caring for the poorest and the sickest among us should make sure your voices are heard.

Now, all of these issues I've just mentioned were part of the overall plan that was presented a few years ago to reform our nation's health care system. Now clearly, that particular proposal was not successful, but it is critical that we do not give up on what must still be done. Many people ask me, "Well, were you discouraged after the defeat of health care reform?" Well yes, I was discouraged we didn't have the kind of debate that we should have had in Congress, so that people in the country could have seen clearly what our true choices were. But, I also believe that the debate and the effort was very important for America. We did educate ourselves about many of the issues that you here at Harvard know so well. And we also learned that when the political environment makes it impossible to take large steps in a direction you believe you must go, then you have either the choice of taking smaller steps or sitting on the sidelines and doing nothing. I come from the school of smaller steps. It is far better to try to make changes that will help at least some people than to do nothing and help no one.

So, we've seen some progress since 1994. Thanks, for example, to the leadership of Senator Kennedy here in Massachusetts, the Congress passed a bill prohibiting the loss of health insurance just because of the loss of a job or a pre-existing condition. Now there are problems with the implementation of that provision, but it is still an important step, and it is a value that makes clear that we are moving toward ensuring that people are not wrongfully deprived of their access to health insurance. We've also seen major legislation, the most significant since 1965, in making it possible for uninsured children to have access to health insurance.

But, our job is far from done. We have 41 million people living without health insurance. You've treated many of them in the hospitals where you've done your rotation and waited to be on call. Who will take care of these people in the future? Who will ensure that they will be taken care of? How will we pay for their care? And how will we pay for the extra costs that come when someone is not treated for a chronic disease or turned away from the emergency room? The job of health care reform in America cannot be done when any of our citizens? access to care depends on the color of their skin, or the neighborhood they live in, or the amount of money in their wallet.

Let?s be clear. As a nation, we have to continue to work toward universal, affordable, quality health care for every single American. (Applause) While all of us must continue to work toward that day and we will do our part, it is going to be up to each of you who graduates today to assume your place as one of the architects of this changing health care world. I'm afraid you can't just be bystanders or kibitzers because you have the information and the experience that all of us need. About 100 years ago, one of your predecessors said, "We are very glad to be in the class of 1900 and not 1800, because we confidently believe we shall all witness greater triumphs in the century now dawning." I hope each of you feels the same and I trust that in 100 years when your successors look back at the class of 1998, they will say that, given the opportunity, you went far beyond the instructions to do no harm at the patients' bedside. Instead, you worked in the service of your patients and humanity. And you worked to improve the system in which you care for your patients.

I hope also that we'll be able to look back and see that just as medicine conquered bacteria in the 20th century that the 21st will see the defeat of viruses; that chronic illness will be cured or tamed; that so many of the problems we have seen in disease around the world will finally be put at bay; that our grandchildren will have to look in history books to learn about the devastation of cancer or AIDS. During a time of great change, there is always uncertainty about which direction each of us individually will go and which direction collectively we will choose. We are at such a point in your lives as you enter this system.

I am extraordinarily hopeful as I look out at these graduates, that the decisions will be made with their guidance and expertise, and that the oath that they take today will be fulfilled in full measure. Because after all, it is they who must ensure that above all, `the health of my patients will be my first concern.' We need your competence and your confidence, as we've already heard. Even more, we may need your compassion--harnessed to that competence and confidence--and we will need your voices to ensure that what you know, what you see, what you experience cannot be ignored as our nation debates what direction we take. And I'm confident that if we follow your oath we will make the right decisions. Congratulations, good luck, and God speed.

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