The Class of COVID-19 Commencement Address

– Had to hit record. That’s how you know it’s live ’cause I already screwed something up. I’m gonna presume we’re live, and it is a virtual 2020 health care class graduation ceremony we’re gonna do right now. Do I have a gown? No, can I get a gown? Probably, am I too cheap and lazy? Definitely, do you deserve better? Well, let’s think about you guys class of 2020, all right? As a physician I graduated in 1999.

I actually got to give my graduation speech, which is online for UCSF, at this beautiful facility. Everybody was there, it was such an emotional time. Our parents were there, our family were there. It was a culmination of all this work and effort on this path to our calling. What does the class of 2020 get? They get me live, actually, worst than that. I got an email from the AMA because for some reason they think I’m a member even though I have never been. And it said, “Hey, come to our virtual AMA, “American Medical Association graduation, “for the class of 2020 on Wednesday the 20th. “We are gonna have people who play doctors on TV, “but aren’t actually doctors “giving you inspirational words of wisdom.” And that’s about as authentic as the AMA’s public membership numbers, it’s all BS.

No one is gonna tell you the truth, guys, but the class of 2020, the truth is you guys have been screwed. You’ve been absolutely devastatingly screwed. All this work and you don’t get the ceremony, the pomp, the circumstance, and the payoff, but wait, because there is stuff that you do get that is unique in the history of everything we’ve done in health care. And you’re at this cusp so you might get some payoff. Now, one thing you’ll notice, and I’m gonna make this up as we go, and I’m gonna speak from the heart. I’m gonna tell you stuff that no one’s gonna tell you because people are scared, people are in denial, actually, about what our health care system is, and what it means to follow your calling, and to find out that the actual system that you’re working in is so bereft of a moral center that you feel that conflict every single day, and you are graduating into this system, right? And so you need to know how are you going to survive and thrive? You’re gonna have to know what’s actually true. And the first thing you need to realize, and you’ve probably figured it out from COVID-19 ’cause you guys are actually not the class of 2020, you’re the class of COVID-19.

You’re gonna figure out really fast that nobody knows what the hell they’re doing, all right? Your mentors don’t really know what they’re doing. You don’t know what you’re doing most of the time. And the system is a nonsystem, and it doesn’t know what it’s doing because it’s an abstract concept to begin with, which means we all have to acknowledge with humility that in medicine in particular we’re still figuring it out as we go. We have to be able to be honest with ourselves, with out patients, and say we don’t know sometimes. We just don’t know. A lot of what you have been trained to do doesn’t work. Doesn’t actually improve outcomes for patients that actually matter to them. Doesn’t save money for a system. Doesn’t make society better.

And we have to understand and explore what those are, and then focus on the things that do work, but that means we have to cut through this denial that more is better, that the more things we do to people the better medicine we’re practicing. It’s just simply not true. What COVID-19 has shown us my dear graduates is that we don’t know what we’re doing. Should we wear cloth masks? Should we not wear masks? Should we wash our hands? Should we lockdown? Should we not lockdown? Science evolves, and we have to be humble in the face of what we don’t know, but the thing that you guys have gotten from your training is the tools to actually critically think, and go, wait, you know what, no, this doesn’t make sense. Wait a minute, what if? Use your imagination, what are other explanations? What are possible complications? What are downsides of things that we’re doing? And when you go out in the world you have to think that way, right? And when you approach your career, and your calling with that humility what will happen is you’ll find you are vastly less likely to get sued.

Let’s talk about practicalities for a second. You’re entering this world where everyone’s telling you. You got to cover your butt. You got to do all this testing. You got to make sure to document everything. You have to do all of this because otherwise you might get sued. What gets you sued is not connecting with your patients, not communicating with them, not being an authentic human being, and most importantly not saying I don’t know, and I’m sorry when a mistake has been made, and I and my team will work unceasingly to make sure we never make that same mistake again that happened with your mother, or your father, or your child. And I’m so sorry. Can we be human beings with our patients instead of these stuffy robots, which, by the way, we will be replaced with if we don’t show the unique healing potential of being a human with another human. You are much less likely to be sued if you’re honest, authentic, and you apologize when necessary when you make a mistake because we are all human beings. And medicine is an imperfect science and art. So be humble in the face of what we don’t know. It’s easy when you’re a student because you’re terrified, and some people throw up walls of denial, and say I’m gonna pretend I’m smarter than I am, or I’m gonna fake it ’til I make it.

How about you just are open and authentic, and try really, really hard, and find amazing mentors that will lead you on the path, right? Without those mentors, without those teachers beyond school you will never find the true expression of what this is, which is a calling. You need those people, you need to seek them out, and you never need to settle for less than what you feel is that mentor, which means you have to keep searching, right? So the other thing I think that people aren’t telling you you’re hearing a lot about how horrible health care is, right? And you’ll hear it from me, too. This is such a mess, and what are we gonna do because it’s like we’re just treating a computer screen, and we’re clicking boxes, and people aren’t covered, and people are struggling, but the truth is you guys are the generation that is gonna see the actualization of what we call health 3.0. You’re gonna be the ones who actually bring it to fruition, and let me explain what that is. Our original health care system, health 1.0, that sort of 20th century doctor/patient in this beautiful sacred relationship, right? Maybe you bartered a chicken for care, doctor came to the house. Sure, it was always a white dude, and sure they were dominant over every other member of the health care team, the nurses, and the respiratory therapists. And, sure, there weren’t any administrators to boss them around so they were unfettered by all that bureaucratic intrusion, but they were also unfettered by a lot of science.

They really couldn’t do a whole lot, so what they did was they spent time with their patients. It was this analog beautiful relationship where they got to know their patients. The patients didn’t know much ’cause there wasn’t this Internets that Al Gore invented, and so we’re left with this very paternalistic, yet very deep relationship, and that was health 1.0. Fee-for-service, so they did something, and they got paid, which means therein lies the downfall of health 1.0 because when you get paid to do things to people, and they don’t have any information to say, maybe you shouldn’t do this. What’s gonna happen? You’re gonna do things to people. The costs are gonna go up. There’s gonna be fraud, and all those things happened with health 1.0. And patients started to wake up and realize, wait, we can get information. And other people on the health care team said, wait, we’re valuable contributors. It’s not just doctors it’s a whole team everybody doing their piece, their part of the puzzle to create this emergent whole that’s bigger than the sum of the parts. So health 1.0 wasn’t the glory days. It wasn’t the good old days when you actually look back at it. It was limited and partial, right? So where are we now? We’re at health 2.0. And health 2.0 started with this promise that technology, automation, business processes, lean assembly line techniques, all the tools and processes that worked in business in manufacturing, could be brought to bear to medicine which means instead of not being able to read somebody’s handwriting you could have an electronic health record that would put all the data at your fingertips, and, also, incidentally, be able to do something, which is key to health 2.0, which is measuring how you’re doing. In other words, develop a series of criteria by which you are measured, whether it’s patient satisfaction on some scale, whether it’s did you click the Lisinopril box because the patient has congestive heart failure? Did you ask them to quit smoking?

Box, box, box, box, box, quality, quality quality, and up comes the measurement industrial complex that comes to measure you whether it’s the Joint Commission, whether it’s NCQI, whatever it is, this whole infrastructure arises, and the electronic health record is there so that you can document via clicks that you’re doing the right thing on the assembly line for your part of the assembly line because you are now a cog in the machinery of health 2.0. And it was beautiful in the sense that, oh, we actually thought about quality. We thought about quality improvement. We thought about optimizing processes, but what ended up actually happening? 60% of doctors won’t recommend the career to their kids. Burnout, which they’re calling it, which is victim shaming, by the way. Burnout is at record highs. Physician suicide, nurse suicide, some of the highest rates of any professions, why? Well, it’s partially because we turned a beautiful analog human relationship, which is the healing art of medicine into a click box commodity that is to be measured, quantified, and optimized. And the electronic health record that was supposed to free us enslaved us. Now you graduating right now do not understand the magnitude of what has happened because you have never existed in a world that predated this. I was there for paper notes, health 1.0. My father is health 1.0, primary care physician in rural California doing his thing.

And he’s seen this change, and he warned me about it, and I said, no, man, technology is gonna help us. It’s gonna save us, it’s gonna bring us together. Then the EHR went live. I was on call that night at Stanford when everything changed. I could read the notes, I could understand the handwriting, I could see the labs, inbound data was fantastic except for those stupid popups, and the alert fatigue, and all of that. The problem was because we could document, because we could look at all this data we did. We were able to log in from home. Suddenly we have to document more and more and more so we can paid by the DRGs, and all the ICD codes we have to diagnose, and make sure we’re covering our butts so we don’t get sued, so we copy/paste all this boilerplate that doesn’t mean anything so we can get paid, and not get sued. And the next thing you know we are our own court reporter. We’re the lawyers who are also our own court reporter. And we spend more time looking at that screen, the pajama time we’re supposed to be spending with our children, and our loved ones is spent clicking these boxes from home.

I used to have two monitors open going back and forth, clicking boxes, answering inbox, doing all of this, and I had finished my shift as a hospitalist because you know what? We’re type A, neurotic, high intelligence people who go into health care, and we care about stuff, and we’re deeply afraid of failing when it comes down to it. We are always afraid, right? Do you guys feel that? How scared are you in school? Do you come into class sometimes with sweaty armpits, heart palpitations, feeling nervous? Do you lay awake at night afraid that someone’s gonna figure out you’re a fraud, or that you’re an imposter? Do you worry that you’re gonna hurt or kill someone through a mistake because you’re not a God even though you’re trying to pretend to be one? That’s who we are that go into health care, right? We know what we don’t know, and it terrifies us. Now weaponize that with an electronic health record where now all the data is there. I can know a bunch of stuff, so I got to try. And what does that do? It destroys any human being who tries to do that. And you can optimize it, and you can do all this, but the way it’s designed it was not designed by doctors, or nurses for us, no. It was designed by software engineers, and billing coders for hospital systems. It is an electronic cash register. We should call it an ECR, it’s enslaved us.

You don’t know this graduating class of 2020 because you never knew a world without this oppressor, but you will know, and you will help build a world without this oppressor because we’ll transcend it, all right? So health 2.0 which had all this promise has weaponized everything that makes us who we are against us. We’re now terrified of failing our quality measures. We’re now stressed about performance, and what happens? Tension, anxiety, stress. How do we deal with it? Well, we’re suffering something that is called moral injury. It’s where we’re forced to do things everyday that violate our deeply held moral beliefs. So whether it’s having to do procedures because that’s how we’re paid when we know it’s actually not helping this patient, or whether it’s clicking boxes instead of looking in the eye of the young mother whose terrified. And then what happens we feel that conflict. We deny that it’s a conflict. We build walls around ourselves, and that, that is the path to the end-stage of moral injury. Repeated insult over time like a chronic disease leads to dialysis. What’s the dialysis of moral injury? It’s burnout. Emotional exhaustion, depersonalization, feelings of low accomplishment. Health 2.0 is the perfect incubator for chronic moral injury, and end-stage burnout. And the electronic cash register is a big part of that. And I don’t care if you’re a nurse, or a respiratory therapist, or a physician, and you’re a student in those disciplines, and you’re graduating into this world, but you will feel that at some point unless you’ve built so much wall that now you’re so depersonalized, and so emotionally numb that you don’t feel anything, in which case you are not gonna feel the connection to the sacred calling that you didn’t choose it chose you. So, it’s getting dark isn’t it?

This is where my mind goes when I’m in these states because I remember my own path. And I remember in medical school, again, staying up with anxiety, terrified to do that presentation on the wards that people would figure out what a dummy I was, right? That imposter syndrome that afflicts so many of us. In fact, if you don’t have it at some point I question whether you know what you don’t know because that’s a dangerous situation if you’re blind to it. So make sure you figure out what you don’t know, or you’re the victim of the Dunning-Kruger effect, and you’re dangerous, all right? So this sort of fear and anxiety is such a big driver not just in health 2.0, but in life for driven people. So, here comes one piece of advice. If I could go back in time, and tell my medical school self that was graduating one piece of advice that I wish I’d known at that time, and it would have been this. And it’s gonna sound dumb, and you guys are gonna be like you’re full of crap, but it is absolutely true. Take a fraction of that diligence that you used to learn the Krebs cycle, or pyruvate dehydrogenase, or I-cell disease, or study first aid for the boards, or take the NCLEX, or any of that junk. Take a fraction of the diligence that it took you to do that, which is a huge accomplishment, and learn to fricking watch your own mind non-judgmentally, thoughts and feelings and sensations as they arrive, and as they arise, and recognize that you didn’t author those thoughts, and feelings, and sensations, they just happened. And you can either get lost in that sauce, and fall down a loop of anxiety, and worry, and more anxiety, and more worry and stress, or you can watch it and go, wow, look at that. Something’s causing fear, what is it? It’s this thought. And non-judgmentally I can watch it and let it go.

It takes practice, it takes diligence, but it’s not that hard, you’ve been through worse. That tool set, these guys call it mindfulness. Some people call it meditation. I just call it paying attention to being aware, being alive, watching yourself. You want to be a smarty pants doctor or nurse, or respiratory therapist, or CNA, whatever it is you’re doing and graduating into, you don’t even know how your mind works. You are blind to the thing that’s staring you in the face every single day. I was blind, lost in my own ego, lost in my own fear, lost in my own thoughts, and perceptions, and emotions, and what ends up happening? You project that fear out onto others, and others suffer almost as much as you suffer. Mindfulness, meditation, whatever you want to call it, the practice that you need to start now, if you haven’t already, is not just about you, it’s about all those people around you that are gonna be affected by a worse version of you than you could have been if you’d paid attention, right? So, that’s one piece of advice that I think is crucial. Now related to that, and we’re still in health 2.0, right? This is the other piece of advice that I’d wish I’d known then which is everybody in their fricken graduating speeches is gonna use the term empathy. You need to be empathetic, it’s all about empathy. Crap, I did it in my ’99 UCSF graduation speech at the end.

I said something to the effect of a little bit of empathy, and a little bit of humor go such a long way in our profession, right? Yeah, I was wrong. Empathy is garbage, it’s terrible, don’t do it. And you guys have heard me talk about… Fans of the show have heard me talk about this before because people who haven’t heard me talk about this before are thinking he’s an insane monster. Well, this is what I mean. What is empathy? Empathy, and I’m being very specific here. It’s about semantics a little bit. Affective empathy, emotional empathy, feeling another’s pain as your own. Taking on their suffering and pain as your own, empathizing with them is horrible in health care. And I will tell you why. Because empathy in that way will burn you out. You will feel that pain. You will suffer as they do. And you will make decisions that are influenced by that suffering, but may not be the wisest decisions. You will want the suffering to end. And the other issue with empathy is it’s a narrow spotlight. You can only empathize with one person maybe at a time, and often the empathy is more powerful if they feel like you, if they’re your race, or your gender, or they remind you of someone you know. That is a dangerous kind of empathy. It’s beautiful when it’s your family, when it’s your loved ones, when you empathize with your child, and they’ve stubbed their toe, or your partner and you can feel their pain, and be there with them that’s different, but when you’re talking about those you’re trying to care for in a rational way, in a way that’s effective, and in a way that you don’t bring this pain home, and destroy yourself.

I see so many nurses and doctors bringing this home, and messaging me I don’t know how to stop this. This is how you stop it. The same way you’re paying attention to your emotions you can pay attention to a better form of empathy, which is cognitive empathy. I like to think of it as compassion. What is compassion? Compassion is love and concern in the face of human suffering, or any suffering if you want to be woke. Compassion is saying that patient in front of you I understand that they are suffering. I don’t have to feel it. I don’t have to experience it, but I understand that they’re suffering, and I can imagine what that must be like, and I want to help them. I want to show love and concern in the face of the suffering, and I want to do it in a way that reduces suffering as much as possible in the world, which means for the drug addicted individual in front of you someone’s suffering from addiction empathy would say, oh, I see them in withdrawal. Let’s just give them a little Dilaudid, or I don’t want to bring up this difficult conversation because it’s gonna cause them short-term pain. Compassion, love in the face of suffering says short-term pain in the service of long-term well-being, and flourishing is absolutely a trade-off you want, and you can rationally then make decisions that show love and concern while protecting yourself from that rush of emotion, and weight that you would take home with you. And you come away having done as much good for as many people as you can while sustaining your own ability to give because compassion can be practiced. Compassion can grow. It’s inexhaustible. We’re inexhaustible wells of love and concern when we do it correctly. And there are meditations to practice this, actually. There are monks who’ve done this. You can do fMRI studies on them, and look at their brain. You cannot exhaust their compassion because they do it rationally from a place of love instead of in an exhaustible, empathic way.

It’s very, very different. So that’s something I would have told myself then. Practice compassion, practice love, practice rational understanding, and grow your sense of compassion. Empathy is not. Feeling as someone else does is not a good way to go about your career, and you will make mistakes when you do that, okay? So that’s a piece that I think people really, really, really need to understand. So health 2.0 is where we are now, and you can see its failures. We have systems that actually aren’t functioning well. They’re not integrated properly. It’s dehumanized instead of re-humanized. And now we have COVID-19 which is the great stress test, which will wash away this old system that you’re about to enter my dear graduates if you let it. If you demand it. So what everyone else will tell is, hey, learn the rules, play by the rules, sure, try to innovate, sure, try to do this. I will say this. Learn the rules, work really hard, and the reason you’re learning the rules is so that you will know which ones to break, which ones to overthrow, which ones are nonsense, which ones are garbage, which ones promote harm in the world, but we just don’t it yet, and that will be your mission is to go out and figure that out, and apply what you’ve learned, and what you’re gonna continue to learn to that very process because what we’re finding now is this health care system doesn’t work, right? At this time our biggest institutions are in danger of going out of business. And people will tell you, oh, my gosh, are you gonna have a job? This is a terrible time. What’s going on? COVID-19, oh, my God. It’s the best time in the history of medicine to graduate into the world because you have a chance to actually enter a disrupted entity, and disrupt it further. How many messages have I gotten from medical students, and nursing students what I can do the system’s intractable? Oh, is it? It’s falling apart. It’s about as fragile a thing as could ever exist, and you are the ones that are antifragile.

You’re the ones dear graduates of class of 2020, you are the ones who get stronger from adversity, unlike our health care system which crumbles. Unlike our leaders which across the board, and across the political aisles don’t have any clue what they’re doing. You are the ones who’ve been through this. You’re the leaders that are gonna take us into health 3.0. And what is that? Health 3.0 is the world you will inhabit. It is the system that is more than a system. It’s an organism constantly evolving getting stronger from stresses to it. A pandemic comes it takes that information and grows, and the next time a pandemic comes it’s even stronger, and responds quicker, and the science and the humanity grow exponentially because everybody is re-humanized in a system that is team-based where people practice at the top of their training in service of the patients, but also in service of each other where they are technologically enabled, but never technologically enslaved, where we’re evidence supported, evidence empowered, but we’re never evidence enslaved. We don’t click a box based on some trial of a bunch of white people, and apply it to our 72-year-old Hispanic woman who has different hopes, dreams, fears, genetics than the Norwegian population we studied that’s all men. Health 3.0 takes the best aspects of 1.0 that deep human relationship, the clinician leadership, which by the way, we’ve given up in health 2.0. Guess who runs the show now? Administrators with MBAs who’ve never touched patients in most cases. Now there are beautiful clinical leaders, and there are beautiful MBAs who work with those clinical leaders, but far too often we’ve given up to administration. Why is that? Because we need them to click the boxes to go through the complex billing games that get us paid because we have a byzantine system where a patient can’t even figure out what it costs to get an appendectomy, and we expect them to be customers, and our hospitals to be hotels.

We can’t even give them a price because there’s money games between insurance companies, and hospitals, and doctors, and the rest of us, and they’re all trying to screw each other. Each of their profit margins is actually rather tiny, and all their money goes into hiring tons of billers, and coders, and administrators, and everybody, and Epic, and all of this to basically codify a system that’s fundamentally broken that’s totally wasteful. That is our system that we have now. So health 3.0 says, no, we get paid for outcomes that matter to our patients. We get paid more if our staff and physicians, and clinicians are happier and more satisfied, and have lower rates of moral injury, and lower rates of turnover. We’re paid to actually do the right thing. We do well financially if we do good for patients, and each other that’s health 3.0. And there are signs of it emerging all over. Take the best of 1.0, that human relationship, the clinician leadership. Reject what doesn’t work. Fee-for-service, paternalism, hierarchical care. What about 2.0? 2.0 says, hey, yes, quality, science matters. We cause so much harm because we don’t actually optimize our systems. We don’t think about what we’re doing. We don’t think critically. We don’t study it, we don’t analyze it. We just do it because some old dude on a stage said, yeah, this is how we’ve always done it. Take that, take technology that works, that serves that goal of quality improvement, of connecting with patients whether it’s email, text, Skype.

Abolish and overthrow HIPPA as a mandatory albatross around our neck that prevents innovation, prevents communication. Patients control their privacy. They can opt-in or out to the degree they want to. Make an electronic health record that’s truly a health record that actually has a user interface that doesn’t feel like it goes to a DOS prompt from the ’80s, that’s actually about caring not about billing. We can do that. There are models all around the country where this is happening. Some of the most innovative ones in Medicare Advantage where you’ve actually just given a little money and say do the right thing for patients don’t screw it up, and if you do well you save some of that money for yourself. Wow, how about that? Wouldn’t that be something? Instead of getting paid for every widget, every transaction, every co-pay. What’s a co-pay? It’s a way of keeping patients away from you. Did you go into this graduating class of 2020 not to see patients, to keep them away from you? No, you went into this to connect, to find the purpose within life. Forget about the meaning of life that’s BS. The meaning of life is the meaning within life. It’s between us, it’s our relationship with others. Our purpose in this life, in this world, that’s what we’re here to do.

Health 3.0 says take the best of 2.0. Reject the automation, the mechanization, the commodification, the administration, and shrink all of that. Change how we’re paid. Change how we work together in teams. How many of you guys in your classwork did any interdisciplinary stuff? If you were a medical student did you ever round with the nursing students? If you’re a pharmacist did you ever have interdisciplinary teams where you go to a class with nursing students? If you did that’s great. If you didn’t why the heck not? What’s wrong with our education, our medical education that we’re not training people to enter health 3.0, you know? This was supposed to be a commencement address. It’s becoming a rant about what you need to do, right? To fix this mess because you’re gonna do it because we screwed it up. Everybody tells you this it’s all on you, and you look at us and go you gave us recession, you gave us pandemic, thanks a lot old man. Okay, Gen-X’er, but it’s true you guys. It’s absolutely true. And health 3.0 is going to be the emergent that actually changes everything, and it’s gonna save you and your calling. You’re worried about moral injury. You’re worried about burnout. You’re worried about when you hear about the mental health statistics. All of that gets better when we transform the system, but the last thing I want to tell you about that if we’re talking about what I wish I had known. You can’t come out of medical school with an entitlement attitude, or any school that you’re graduating from with an entitlement attitude saying you know what? I’m already burned out. I already have moral injury. I just can’t, I just can’t with this.

Okay, you’ve already lost. You’ve lost any chance to change this system. You still have to bust your ass. You have to do it every single day. You have to work like this is your calling, which it is. You have to show your mentors that you care enough, right? So then when you go and you say this is what we need to do to transform they are listening to you instead of writing you off as an entitled piece of crap. And I say this from personal experience because I’ve worked with graduates where I’m like are you kidding me? If I behaved like this I would have been fired from my residency, right? You need to be as passionate as you were when you went into this because that’s what’s gonna push you through, but in order to change the system you better have those tools that make you antifragile that allow you to. Forget about resiliency, resiliency, people, that’s the other lie they’re gonna tell you. You need to be resilient. Resiliency is a lie.

Resiliency is when you take something, you try to perturb it and it doesn’t budge. It’s resilient. You throw stress at it and it’s like I’m a wall. That’s horse crap, that’s not what you want to be unless you want to be so resilient that one day you just break. You want to be antifragile. Antifragile means throw stress at me. I’m stronger from the stress, right? How do you do that? You better learn that mindfulness and that meditation, and those tools. You better look at how you could be less reactive, have a space between your emotion and your stimulus, and what you actually do to respond, and that includes with your patients when you’re practicing compassion. The patient says something terrible to you. You’re a terrible doctor you’re too young. I can’t believe a woman’s taking care of me. I don’t get treated by black people. You’re gonna hear all of this. If you’re in one of those groups you’re gonna hear this, and how you respond determines whether you’re fragile, and you break, you’re resilient and you just put up a hand, or you’re antifragile and you realize that that comment from that patient is coming from a place of pain, suffering, fear. You don’t allow it, you don’t condone it, but you take a step and you realize this is not about me, and you respond in a way then that’s more compassionate, more rational, and more productive then you could of. That’s on you. You can’t blame a system for your inability to do that, all right? That’s on you. If you start to develop those personal tools, which you need to do now then changing the system is gonna be like that because you’re gonna come from a place of rational wisdom instead of reactivity. And that’s been our problem so far. We are a reactive bunch, especially, doctors.

Doctors are the worst. We don’t coordinate, we don’t work together. We take a crap on each other, right? How many medical students out there have experienced this as students? I did, by the end I was like I am done with this class. I am out of here, and I was part of the problem. I was as big of an a-hole as anybody else. It’s a conditioned process. We learn from the best, the previous generation. We have to break that cycle. The very last thing I want to say is if you think we’re gonna transform health care as doctors, or as nurses in a union, as doctors and we’re gonna have single-payer, and we’re gonna this, and we’re gonna do this, you’re smoking crack. It is only gonna happen when the 13 million health care professionals across the board come together as they have in this very tribe here the Z-pack. It’s everybody you guys. It’s not just doctors and nurses and med students. It’s everybody in health care comes together with a common goal. The goal is over here. We have different ways of getting to it. All health care is local, but you have to be a part of a bigger picture. You are a whole in yourself, and also part of a larger whole, and you have to recognize that and act that way. And that means if we come together there’s nothing that will stop us, absolutely nothing. Just like this BS COVID-19 pandemic is a joke compared to how antifragile you are, how powerful you are graduating class of 2020, and all the amazing things you’re gonna do that are partially facilitated by the fact that everything’s been disrupted by this mess, all right? So go out in the world woke. I don’t care what you’re advocating for.

Do it with passion. Do it connected to others. Individuals get knocked down, but if all of us stand up they cannot knock us down. And you’ll see our institutions in the face of enough people they will crumble and change. In the face of one person they’ll hammer you down, all right? Congratulations class of 2020. This is a huge occasion. I’m so sorry that it had to happen like this, okay? I hope you check out the AMA’s bogus ceremony tomorrow. We’re gonna have Zack Braff from “Scrubs” telling you, hey, guys, congratulations. I don’t know, I don’t know. At least they’re doing something I guess. I love you guys. Do me a favor, share this with someone whose graduating. Thank you to everyone who donates stars, and all our supporters, and everyone who left comments. I’m gonna peep through them. 41 minute graduation speech way too long, but I just went off the rails and did what I do. So I apologize for that, but it’s not about me it’s about you, and everything that you are gonna do. Congratulations, really from the bottom of my heart. It’s such a beautiful path that you’re going on. I love you, and we out.