Remarks to the graduating residency class, Eisenhower Army Medical Center, Augusta Georgia, June 9, 2017. Some of the material will be familiar to regular readers but struck me as the most important thing I could share with these accomplished clinicians, officers and leaders.
Thirty years ago this June I graduated from my pediatric residency at Walter Reed Army Medical Center in Washington. That was a while ago. For reference, it was the last years of Reagan’s second term, the year the first Simpson’s episode was aired, the year Tim Tebow and Zack Efron were born. It’s practically ancient history. Many of the residents graduating this June weren’t born yet.
The ceremony was held on the great lawn in front of the main entrance of a building that has since been closed and abandoned. I was one of several hundred graduates and the highlight of my memories from the day are the few minutes in the crowd of graduates standing around at the veranda after the ceremony drinking punch and eating cake when we were briefly separated from our three year old son. We found him as quickly as we realized he was gone as we saw one after another of the men standing nearby startle and look down as someone tugged at their green polyester, black striped pant-legs and a little blond haired boy looked up and asked: “Daddy?” “Daddy?” “Daddy?”
I am certain that there was a speaker at my graduation ceremony. And I suspect that he probably gave a speech. But for the life of me I can’t remember who it was or what he said. So I know what I’m up against. I also know the competition. I watched Will Farrell on YouTube as he give the graduation speech at USC this year. Three years ago when my daughter graduated from nursing school at the University of Miami Jimmy Buffett gave a great graduation speech. I wish I could remember what either of them said.
I do remember they made three or four points and I planned to do the same. But I thought about the risk of the audience remembering any of them let alone me remembering as I tried to speak without notes. Instead I decided to leave you with one. One point I’d like you to consider; something I don’t remember anyone mentioning to me when I was in medical school or residency but something that proved pivotal when I was practicing primary care, specialty care, as a hospital leader and also as father of seven, grandfather of four (almost five) and husband of 37 years this summer.
One early morning while I was working at the Ft. Belvoir hospital my daughter called me from Miami where she was attending nursing school. She was riding her bike (without a helmet I am sure) in the predawn darkness on her way to the train station. Her pediatrician father wasn’t happy about the circumstances. But she was heading to her first day of clinical rotations and had a question for me: “Dad, what advice do you have for me on my first day with patients?”
It caught me off guard, in part because I was a little worried about her on her bike in the dark on the phone. But it didn’t take me long to come up with an answer:
“Remember to look into their eyes.”
As a general pediatrician at Ft. Hood Texas in the late eighties (before the days of computers and electronic medical records) we were scheduled for acute patients every five minutes. A typical morning or afternoon seeing patients with acute problems included 36 encounters in three hours. The clinic was open every day of the year. Weekends and holidays one pediatrician worked for six hours and saw 72 patients and the other saw 36. There wasn’t much time to establish rapport.
Somehow – I think because of Grace as prayer was a part of my patient care – I realized that if I sat down in every visit, leaned forward, made eye contact and then mirrored the parent’s face with my own the patient’s perception of the visit was more positive and they were more satisfied that they had been heard. I also found it was a discipline to help me to really listen. I have since become aware of the research confirming all of these but especially the relationship of eye contact during a physician encounter.
Direct eye contact or intentional gaze is positively related to the patient’s assessment of the clinician’s empathy. Eye contact is significantly related to patient perceptions of clinician attributes, such as connectedness and liking. The shorter the visit, the more the percentage of eye contact time is an important indicator for the patient’s perception of empathy (Montague E, et al. Nonverbal interpersonal interactions in clinical encounters and patient perceptions of empathy. J Participat Med. 2013 Aug 14; 5:e33). Lots more could be said about the importance of eye contact with patients and families in the intensive care unit as well as the impact of the electronic record on our ability to make and maintain eye contact. And even when I was in West Africa caring for patients with Ebola where there was little language in common there was eye contact and touch – through three layers of gloves – to communicate empathy and compassion in the face of tragedy and loss.
As a pediatric department chief I also found eye contact to be critically helpful. I think the most important thing about morning report or morning huddle for a leader is that it gives you regular, repeated time to look into the eyes of your peers and subordinates and to become sensitive to subtle changes in affect or mood. One morning report one of the residents teased another of her peers in the audience during a presentation. After the laughter subsided, I glanced back and looking into the affected resident’s eyes I saw she was fighting back tears. I quietly picked up the phone on the wall next to me and paged her out of the meeting, then met her out in the hallway to allow her time to compose herself (which she did quickly). It meant a lot to me and must have meant a lot to her. I heard about the event from a friend of hers a decade and a half later.
As hospital CEO I found that looking into the eyes of patients, families and subordinates was an important part of the culture we were trying to create. We had a rotating “Focus Five” that our leadership team worked on and for a long time we concentrated on getting staff to only use their iPhones or Blackberries when they were “off stage” and not with patients. Specifically staff was encouraged not to look at their phones when they were moving through the organization or working at reception areas but to greet patients and peers and make eye contact instead.
Rushing to a meeting with a few deputies one morning we passed a young mother pushing her baby in a stroller. She was an acquaintance of my wife’s whom I had met once or twice before. Eye contact told me that something wasn’t right. “How’s it going?” I asked her. She said “Fine” but I could tell it wasn’t. I asked the “second question” (the one we don’t always take time to ask): “You don’t seem fine…?” Tears followed. Her husband was hospitalized and she was worried about him. We spent time together and I was late for the meeting I had been rushing to. It was time well spent.
We could spend hours talking about the importance of this principle to our families, especially in the age of iPhones. One of the most profound lessons I have learned in my life was taught to me by my three year old daughter when she was trying to talk to me while I was distracted doing something; reading the paper or some computer screen. She took my face in her little hands, turned it towards her, made eye contact and said, “Daddy, wisten to me!” She knew if she had my eyes, she had my ears and my attention.
There is a phrase from the Northern Natal region of South Africa that I first read in a book by business guru Peter Senge.
“Sawubono” – “Sikhona”
“I see you” is the greeting. “I am here” is the reply.
I see you. I am here.
I have to tell you that being present with our patients and peers has never been more important. But I wouldn’t have stayed in military medicine, wouldn’t still be a patient in the system and wouldn’t support it if I didn’t believe that there was something unique about it. There is something our patients need that can be found in military medicine that may not be a part of the way our civilian colleagues think. It’s not what they normally see.
On any given day there is a woman on the labor and delivery unit of your military hospital having her second or third child, trying to raise her children while her husband recovers from his third or fourth deployment. He did not come back the man she knew and she wonders if he ever will.
If you pause for a moment and look into her eyes you will see something that our civilian colleagues might miss because you have seen it before. You have been there yourself. She needs something more than her baby delivered: “I see you. I am here.”
There is a soldier in our military orthopedics clinic with a painful knee that has seen far too much for his 28 years. He has lost his brothers in battle and he has lost a part of himself. If you look up from his knee for a moment and you look into his eyes you will see something that our civilian colleagues might miss because you have seen it before. You have been there yourself. He needs something more than his knee taken care of: I see you I am here.
Perhaps the most important thing we can take away from this day, from this graduation celebration at the end of one life-phase and the beginning of another is this commitment that will make us better physicians, better friends, better bosses, parents, spouses – for our patients, our peers, our family members and to those we will have the privilege to lead:
I see you. I am here.
Best to you always. To my military colleagues: Take care of our Army, our military.
Take care of our Warriors and their families.
Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.wordpress.com/