Dartmouth Medical School Class Day Address
June 7, 2008
By Andrew C. Saunders, ‘08 

Muhimbili Hospital, Dar es Salaam, Tanzania. The day starts with grand rounds. A presentation on congenital infections – if I close my eyes, ignore the accents and 115 degree heat, I could convince myself I am back at Dartmouth. Medical students taking notes, young doctors called upon to answer questions and interpret laboratory results. The lecture draws to a close and I am engaged in pleasant small talk with the physician I will be accompanying on rounds that day. Save being soaked in sweat from head to toe at 9 AM, I know this routine. We make our way to the wards, and suddenly I am a million miles away from Dartmouth-Hitchcock.

First stop is the general pediatrics ward. The rooms are packed with children, some are lying on the floor. We stop at the bed of a 9-year old boy. His entire body is swollen, and he is able to only briefly open his eyes. His kidneys are not working properly, and the build up of waste products is depressing his level of consciousness. His text book prognosis is good – the attending physician explains to me that a short term course of dialysis is indicated until his kidney function recovers. However, she continues on to say that it is simply not possible for him to receive this treatment given the limited financial resources of the hospital and his family. He is expected to die within the week.

At the next patient's bed, the story is similarly distressing. A thin boy looking much younger than his 13 years was recently diagnosed with type I diabetes. His initial blood glucose from the laboratory supported the diagnosis, but any additional monitoring tests are too expensive. Finger stick glucose meters are available, but the hospital does not have any test strips. The glucose readings are of limited utility anyway, according to the attending, as the pharmacy has been out of insulin for the past two days.

We then make our way to a clinic. A new diagnosis of HIV, a twelve-year old boy. He's been sick all of his life, his grandfather says. Both of his parents died of AIDS years ago, but the child was not tested until recently. He falls asleep as soon as he sits down, and falls asleep several more times during the exam. He has an extensive fungal infection in his throat and is having difficulty swallowing. He is started on anti-retroviral therapy immediately, but his disease is very advanced. I later learn that he died the following week. At one point when the attending walks away, I'm left standing with a Tanzanian medical student. She turns to me and says, “This must be very different than where you come from”.

We come from Dartmouth, a well-known university with myriad resources. A university in a wealthy country that offers an excellent quality of life. We come from privilege. We have received an education far beyond the reach of most of the world's citizens, those domestic and abroad. Society is trusting us with the lives of our fellow human beings. Life has been good to us.

But we do not exist in isolation. We are members of a global community, and we have incurred a debt to the world that has granted our good fortune. Why did we want to go to medical school in the first place? Take a moment and think back to your medical school application personal statement. I am sure that almost all of us waxed poetic on a novel construction of the “I want to help people” theme. Four years ago, we were all set; everyone's intentions were in the right place.

The challenge will be keeping track of this debt over the coming years. Educational debt – don't worry, there are people that will make sure you remember you owe approximately the yearly operating budget of the state of Vermont. But your obligation to the community, however you choose to define it, is on your head. No email reminders, no collection agents, nothing to keep you from letting it slip to the bottom of the pile. Medical school has been hard, and we're about to start working even harder. We will be overworked, sleep deprived, and uncertain. There will be social obligations we are unable to fulfill. We will consume a truly ridiculous amount of hospital food. As a survival tactic, our focus will be short-sighted – finishing rounds, getting through the next case, making it until morning. Getting through our intern year, finishing residency, completing a fellowship, landing a job where we work fewer hours. We will be busy and stretched thin; there will be no “good time” to start chipping away at our obligation. Yet no one wrote an essay pining for the eventual comfortable job. 

Today, more than ever before, we're in a position to begin planning how we may repay our societal debt. We came to Dartmouth with only vague ideas of what it might mean to practice medicine. Over the years we have had opportunities to learn from and care for people in many different environments. We've assisted during novel life-saving surgical procedures in academic medical centers. Or maybe we held something, at least. We have worked alongside the community physician who knows and cares for multiple generations of the same family. We've felt the pain of the physician struggling to provide the best care possible in resource-limited settings. We have witnessed what great medicine can be, and have formed opinions as to what great medicine should be. We can take what we have learned and apply it toward a humanitarian end.

And so we gather here today a changed group of individuals. We're doctors now, so I'm told. Privilege now engenders responsibility. Never forget what it was that brought you to medicine. Try to dig up a copy of the essay you wrote when you applied to Dartmouth. Read it, or at least try to recall the particulars you wrote about. Then realize you've done it – you got in, you passed your exams, you survived the wards; there's an M.D. after your name now. And finally, harking to the words the Tanzanian medical student shared with me, remember that for most of the world, things are very different than where we come from.

In an effort to ring true to the past four years, I will close with an exam question for us all to answer. This is the last question you will ever be asked as a medical student.

How will you repay your obligation to a world that has granted you so much? You may enlist the help of anyone you wish; you are allotted exactly one lifetime to compose your answer. Doctors, you may now open your examination booklets and begin. Congratulations.