On Expectations

My hearty and sincere congratulations to you the graduates, your parents, spouses, families, friends, and to the faculty and staff at the Ochsner Clinic, on the completion of this phase in your never-ending quest for postgraduate medical education. This is an important time to smell the roses, enjoy your accomplishments and look forward to even more fulfilling careers in medicine. You have immersed yourselves, indeed committed yourselves, to a profession that continues to improve partially because of the high expectations of those outside the medical community, and probably more importantly, because of self-imposed expectations that are not only lofty, but constantly increasing.

Expectations can be defined as standards of conduct or performance expected by or of somebody (1). Undoubtedly, your families provided a foundation of expectations, but your achievements at this level can only be attributed to your own motivations, personal values, and work ethic (I am not aware of many medical residents who have made it through a difficult night by relying on parental prompts). In fact, your behavior is much more likely to have been shaped by the collective, locally defined expectations of your new medical colleagues. As Ochsner House Staff, you have undoubtedly bonded together to communally define your conduct or performance, your expectations. This cycle will repeat itself and you will now have opportunities to shape the course of our profession for the next generation of physicians.

Early in the morning of March 24, 1989, the oil tanker Exxon Valdez struck Bligh Reef in Prince William Sound and leaked 11 million gallons of crude oil, polluting over 1,200 miles of Alaskan coastline. The immediate impact on wildlife was captured in the news as vigorous rescue efforts were promptly mobilized. Subsequently, we were to learn that the captain was under the influence of alcohol and that this disaster could have and should have been avoided. Initial cleanup took over three years at a cost of over $2 billion, yet efforts continue, as environmentalists strive to undo the damage caused 17 years ago (2,3).

The impact on the environment, fishing and tourism industries has been the subject of many quantitative analyses (4). In 1994, a lawsuit in federal court in Alaska found the captain and Exxon to be reckless in causing the spill. Recovery and punitive damages were awarded. Exxon has paid the state of Alaska, the federal government, and citizens over $900 million for the court imposed fines. There was an additional verdict of $5 billion against Exxon in punitive damages (5). This verdict upheld the expectations of corporate liability for their human and systems errors leading to disasters. For society, the courts in some way set minimum standards of what is expected. Of interest, on the day of this $5 billion ruling against Exxon, its stock price actually rose since Wall Street had “expected” an even larger fine (6).

On Thursday, August 25, 2005, carefully tracked hurricane Katrina made landfall in Florida. It subsequently gained speed over the Gulf of Mexico, then on August 29, again made landfall over a broad segment of the Gulf Coast of Mississippi and Louisiana. You lived and worked through this natural disaster and do not need a lecture from someone who was 1,000 miles away, safe, dry, with electricity and a full refrigerator, watching events unfold on CNN. After the disaster from Mother Nature passed, breaches of the Corps of Engineers-designed and constructed levees then tragically complicated and exacerbated the already perilous situation (7). Although there were countless acts of heroism and compassion to which you undoubtedly contributed, we, the television viewing international audience, witnessed death and disruption.

Our government's inept, ineffective, and woefully inadequate recovery effort was captured on camera by crews that could transverse where aid workers did not. The thousands left stranded without water or minimal supplies in the midst of one of our nation's major metropolitan areas was in striking juxtaposition to the myriad of disaster relief programs that have been executed in even the mostgeographically remote and challenging regions. What did, and importantly, did not happen immediately in Katrina's wake in New Orleans did not meet minimum societal expectations and remains a national embarrassment. If the Corps of Engineers were a corporate entity, the courts would be busy defining the responsibility for breaches in the de minimis of expectations with settlements and punitive damages.

In medicine, credentialing committees and the courts define the minimum, the unacceptable conduct or performance. Indeed, “de minimis” is an abbreviated version of the Latin phrase “de minimis non curat lex,” meaning “the law cares not for trivial matters,” which by inference sets a lower limit to matters that merit the attention of the law. Although the courts are active with litigations attempting to determine whether an unfortunate outcome for a patient could be attributed to healthcare below expectations, this level of substandard practice is a rarity. Much more interesting, and less well-known to the public, is our profession that is continually striving to raise standards and expectations. This is a truly remarkable aspect of our profession: we keep raising the bar, improving patient care and outcomes, and as a consequence, heightening expectations.

As a medical student during your early didactic years, you were expected to perform in classroom activities and behavior as a simple continuation of your seemingly never-ending life as students. The transition to the bedside and direct involvement in patient care was probably unlike any of your other prior learning experiences. I am sure you vividly recall this and the many other firsts in your unique medical training. The person-to-person, issue-by-issue contacts you faced with patient contact did not come with a well-used lesson plan. But, our experiences, our teachers, and our peers were shaped by high expectations of what was to occur during these patient encounters.

As residents and fellows, you participated in shaping the expectations of more junior trainees. When a new medical student was assigned to your team, you passively and actively transmitted expectations. You set standards! Think of all the different rotations you have had during your internship, residency, and for some, fellowship. Every first day was orientation not just to the new-to-you patients but also to the standards and expectations of that clinical service. Just think of all the interactions you have had with your peers and the faculty at the Ochsner Clinic that have contributed to shaping your expectations. We collectively set these high standards and you will now have an even greater role in influencing others.

When I started graduate school, classroom work was structured and had commonplace expectations. On the other hand, the laboratory was a totally new environment with unclear expectations – there were no classes, no notes, no exams on certain chapters from the professor's favorite (often their own) expensive textbook. But, I was not alone, adrift in the search for new knowledge: students were provided with a thesis advisor, and if you were really fortunate, a true mentor. At this point, my life intersected with Edward D. Frohlich and, in one person, I had a role model, an academic parent, and friend for life. In looking back, it is now apparent to me that Ed not only guided me, but he set standards for the manner in which research is conducted, as well as a full appreciation for the privileges and responsibilities of practicing medicine. The most important learning was not the transmission of an accepted knowledge-base, as this is constantly changing, but rather the vital, timeless lesson was how to maintain an openness, to continually learn and seek the best currently available information to understand and practice medicine. Dr. Frohlich's enthusiasm towards better understanding processes leading to diseases – his term “Pathophysiology” – was, and for me remains, infectious. Although I physically left his side in 1976, I continue to draw on his wisdom and reach for his high expectations as I pursue my own career.

This is the priceless gift he has given to me and, if I may be so bold, that I attempt to impart to others. Today's factual knowledge will be tomorrow's old tales. In the years since I have been practicing Cardiology we have had a complete turnaround in how we approach and treat patients. Management of acute myocardial infarction and heart failure provide vivid examples. Twenty-five years ago, the Cardiology Fellow was the most expert person in the hospital at stamping out every premature ventricular contraction. Today, we know that this can be counterproductive. Therapy for an MI was bed rest, sedation, and electrical cardioversion of sustained VT or VF. There was no such thing as infarct size limitation, thrombolytics, primary angioplasty, door to reperfusion, salvaging myocytes; lifesaving uses of antiplatelet therapy were unknown, statins had not been invented and certainly had not been employed to manage patients. The concept of ventricular unloading work was in its infancy, left ventricular remodeling had not been conceptualized as a target of therapy in patients with acute myocardial infarction or heart failure, and these patients did not have the benefit of ACE inhibitors.

Even more interesting, beta-blockers, which were available, were specifically contraindicated in patients with impaired cardiac function. These are just some examples from one particular aspect of one field of medicine. They underscore the idea that if you practice medicine based on the information available when you were in training, you will soon be depriving your patients of benefits of more optimal therapies - the importance of continuing medical education (CME). As you are completing this aspect of your training, you are expected to have a firm understanding of the importance of continuing to pursue an evidence based approach to couple with compassionate patient care - these are our standards, these are our continually expanding expectations.

In addition to being lifelong students, you have chosen a career that has the highest expectations for how we interact with our patients, with the patients of others, and with each other. As you continue the next exciting phase in your gratifying careers, I urge you to continue to reject behavior and attitudes in yourselves and others that are unbecoming of a physician. In his out-of-print but never out-of-date book on medical ethics, Doing Right, by Dr Solomon Papper (8), Ed Frohlich's role model said, “Judge a society by how it treats its weakest members.”

As physicians, you will have many opportunities to contribute to raising our collective expectations. We have been given a gift of high expectations you must treasure, use, nourish, and pass on to physicians more junior than yourselves. As you celebrate this punctuation of your medical education, realize its part in a lifelong journey that is best enjoyed by sharing with others. Congratulations, keep setting higher expectations, and enjoy the next phase of your respective journeys.

• Ochsner Clinic and Alton Ochsner Medical Foundation