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REMARKS BY:	DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES
PLACE:		Mayo Clinic Medical School Commencement Address, Rochester, MN
DATE:		May 16, 1998

One wrote, "The patient has no past history of suicides." An obviously unflappable physician noted, "The patient expired on the floor uneventfully." Another commented, "When she fainted, her eyes rolled around the room." I'm a little concerned about this physician's attitude when he wrote, "Discharge status: Alive but without permission."

I do like this one, "Coming from Detroit, the man has no children." Finally, one exasperated doctor noted, "The patient refused an autopsy."

Obviously, there's quite a gulf between what the physician meant and what he wrote. But then, in a doctor's life, there are many obstacles between intention and reality. It's what T.S. Eliot meant by the line, "Between the idea and the reality.falls the shadow." The very idea behind this medical school is that "the needs of the patient come first." It's the hallmark, and benchmark, of doctors and researchers who are both good and great.

Putting patients first is what you want.it's what we want.it's what patients want. The reality is not that simple. In fact, in many ways, it was a lot easier for Hippocrates to uphold his oath than it will be for you. Hippocrates didn't have the medicine that you have today. But Hippocrates also didn't have the health care system you have today, either. For that matter, neither did Vesalius, Harvey , Koch, Salk or the Doctors Mayo. They never encountered the competing choices, the rapid changes, the unlimited challenges you face today.

I believe there are four paramount challenges that will test your resolve, your commitment, and your ability to put the needs of your patients first..to dispel the shadow between intention and reality. They are the challenges of technology, interaction, quality, and the patients themselves. These challenges are not unfortunate developments in science and medicine-quite the contrary. But like all challenges, you can only meet them if you're fully prepared.

The first challenge is to master technology while mustering the human touch. Certainly, the defining feature of science and medicine today is the perpetual advance and quickening pace of technology change. Long gone are the days when Dr. Quinn's medical bag contained little more than quinine and compassion. Your bag of tricks contains a growing range of new devices, methods, and practices which are opening new doors to treatment, and new windows to prevention. Computers and cyberspace have uplinked the world of science and medicine, with doctors and researchers linked to and through PCs, data bases and research centers around the world. But quite often, the age of computers is also the age of confusion, where we suffer an affliction known as "T.M.I."-too much information. In the past 20 years, the number of articles you had to read to keep up with the world of medicine has exploded from 500 to 10,000 per year. For those of you who will practice medicine, this will help you discern new and better treatments. But it won't always be easy to decide which treatments are effective, what practices are healthy, and what methods are trustworthy.

And today's medical advances serve to further dehumanize our patients-As we regard our genes and our bodies as microchips and computers to be decoded and debugged. And as we regard our personalities and our emotions as chemical reactions to be stabilized and normalized. The more we learn about the elements of life, the harder it is to remember that you're treating a life. That it's not a disease that came in, but a patient.and that the patient isn't a case, but an individual with a heart and a soul. As Dr. Will Mayo said over 75 years ago, "There is a spiritual as well as material quality in the care of sick people," Compassion and concern may seem outmoded in this age of high-tech modern medicine and managed care. But, in fact, modern medicine has confirmed the power of the human touch. So modern medicine isn't just about curing-but about caring.

While you're trying to balance the spiritual and the material, you'll also have to meet the second challenge-the challenge of interaction. When Dr. Christian Barnard wanted to undertake that first heart transplant 30 years ago, he not only had to assemble the right team, he had to pioneer the way those team members would work together for the good of the patient. In much the same way, all of you must deal with the profound changes in the way that physicians and researchers do their jobs.

Traditionally, it was just doctor and patient-or a lone researcher. One English surgeon who trained at Mayo remarked, "[Medicine is] the most highly individualistic profession in the world." But in those days, you didn't have teams of specialists, researchers, technicians or hospital staff hovering around patients. Lawyers, health insurance executives, and federal research agency representatives weren't hovering either. In 1900, for example, a young laborer was admitted to Pennsylvania Hospital in Philadelphia with an injured leg. Fifty-one days later he was released from the hospital-his leg set to heal-without a single x- ray. And with a one-page medical record. In all that time, all he saw were the physician assigned his case and the nurses assigned his ward.

Times have certainly changed. Today, you'll be dealing with entire networks of doctors, researchers, technicians, health care professionals, nurse specialists, health insurance executives, and the ever present feds. Your interactions with them-how well you function as part of a team-will directly affect how well you serve your patients. Of course, Mayo graduates already know this. You've been trained in the importance of teamwork-the sharing of experience and expertise. William Worrall Mayo once remarked, "No one is big enough to be independent of others." Group practice has always been one of Mayo's defining features. And your "1914 Building," showed the world how to set up for group practice, to make patient care even more effective and efficient.

And that brings me to your third challenge to putting patients first. It's quality. Patients today are demanding the highest quality health care-and they deserve it. They know that our health care system has no equal. They know that we have some of the finest doctors, medical schools, researchers and science in the world. But they also know that it's not the best for everyone, all the time. When movie audiences burst into applause when a character complains about her HMO, it's a rising public voice saying this can't be "as good as it gets." Patients want to see a specialist if needed. They want to know all medical options. They want their medical records kept confidential. They want emergency room treatment when warranted. They want to hold research to the highest standards. That's what success does-it raises the bar.

Right now, this Administration is challenging the health care industry to guarantee a "Patients' Bill of Rights" that will ensure access, choice, privacy and recourse for shoddy care for everyone. With the stroke of his pen, the President has already guaranteed these rights for everyone in a federal insurance plan- including federal workers; military personnel; anyone in the Indian Health Service; Medicare and Medicaid recipients. That's one-third of all Americans. The ripple effect will be like dropping a stone into a still pond.

I predict this new demand for quality will fundamentally reshape American health care and the very crux of the doctor-patient relationship. And that leads to your fourth challenge: The change in the patients themselves. Years ago, an English doctor posted a sign in his waiting room that said: "To speed the process-please have all of your symptoms ready." Back then, patients came to doctors asking, "Please help me."

Today, patients are consumers of health care. Patients are not as automatically trusting, not as accepting, not as forgiving as they were back when Normal Rockwell painted his famous scene of the kindly town doctor holding his stethoscope to the little girl's doll. Patients are more demanding, more vocal, more informed. Patients are no longer willing to settle for less than the best-the best medicine, the best care, the best bedside manner. They want a physician with the skills of ER's Dr. Mark Green.the sensitivity of MASH's Dr. Hawkeye Pierce.and perhaps the looks of George Clooney or Jane Seymour thrown in for good measure. All of these are good things. We want patients to demand the best, to take an active role in their health care and their healing.

I won't deny that meeting the challenges of putting patients first will be difficult. But they're facts of life. You already have the keys to meet those challenges. It's not only your education.the best in the world. It's not only your dedication that got you this far.

It's yourselves. Your intellect and you imagination. Your compassion and your concern. Your ethics and your energy. Most of all, your humanity. Because no miracle or milestone in health care can change what has remained the same since Hippocrates' day: That patient care comes down to you. It comes down to each and every one of you to ensure that his timeless oath is never swept out of the halls of medicine.

Congratulations to all of you as you begin the most wondrous, miraculous, joyous trip of your life.your journeys as doctors and researchers.

Along the way you will experience obstacles and road blocks-but I can think of few other journeys that will allow you to experience so much of the magic, mystery and marvel of life.Enjoy.