University of Texas Health Science Center San Antonio School of Medicine
Distinguished Alumnus 2012
Manuscript of Acceptance Address
James L. Holly, MD
October 13, 2012
Thank you. You will not know in this life, what this evening and this award means to me.
Forty-eight years ago, on December 7, 1964, I had my first date with a young lady. On February 7, 1965, I asked her to marry me and on August 7, 1965 – the same year that Medicare Care became law – she said, “Yes,” when she maybe should have said, “I’ll think about it.” That young lady is my wife of almost 48 years, Carolyn Bellue Holly. We have traveled this medical professional journey together all of the way. It is a fact; it is not false humility, or self effacement to say, “Without her and her support, I would not be standing her tonight.” My son, his wife and their four children – the delight and joy of my heart – are here. My daughter and her family were unable to attend.
On November 22, 1968, 44 years ago, I received my letter of acceptance to the 1969 class at UTMSSA. It is signed by my professional mentor, Dr. F. C. Pannill. My wife framed it and I brought it with me tonight. On October 9, 2012, I wrote Dr. William Henrich, the President of the Health Science Center and said:
“As Carolyn and I prepare to go to San Antonio this weekend to receive the honor which I most desired in this life – to be a Distinguished Alumnus of my beloved School of Medicine – I wish to tell you and Mary that if I had a choice of knowing
you and being your friend, or receiving this award, I would choose to be your friend. You have afforded me opportunities which I never imaged would be possible and I am grateful. You have extended your warm embrace to me and to my family beyond anything I could have imagined and I am grateful.
“As Carolyn and I continue to hope and to believe for your full and complete recovery, we want you to know the esteem in which we hold you and the love which we have for both of you. God bless you. Larry”
In August, 2012, I attended Dr. Pannill’s Memorial Service; on October 10, 2012, I wrote his children and grandchildren and said:
“Today, I am preparing to leave tomorrow for San Antonio. On Saturday night, I shall receive the 2012 Distinguished Alumnus Award. I shall carry with me to this event, the framed copy of my letter of acceptance to the 1969 entering class, signed by ‘MY’ Dean, Dr. Carter Pannill. My greatest regret is that your father and grandfather will not be there. In my professional career, no person has influenced me more than Dr. Pannill – I could no more call him Carter, than I could stop breathing. He shall always be the epitome of professionalism, leadership, scholarship and the kind of physician I have always wanted to be.
“You know these things but as I stand before the convocation on Saturday evening, I want to know that I have laid this honor at his feet and expressed my gratitude that I knew and loved him and that he respected me. No honor could be more valued by me. I am pleased for you to know that in my judgment, Dr. Henrich and your father are men of the same caliber and cut from the same cloth. I think your father would like that.”
Tonight, I remember that I have always been proud of my school of medicine and that I have often wondered if my school of medicine could and would be proud of me.
Basic Science, Clinical Science Human Science
I have also always been proud of the basic science and research programs of my School of Medicine. I am proud that my School is steadily joining the first rank of programs in research dollars and in academic excellence in the sciences.
It is the foundation of my basic science education and the continuing research programs which inform the evidence-based medicine that SETMA practices every day. It is that research and the substance of the evidence-based medicine which allows us to make the proposition with our patients that, “If you make a change, it will make a difference.” It is that science foundation which allows us to calculate all twelve of the Framingham Cardiovascular Risk Scores for each patient each time we see them
It is the foundation of the Krebs Cycle, Adenosine Triphospate (ATP), exercise physiology and pulmonary physiology which allows us to:
- Prepare a personalized exercise prescription for each of our patients at each visit.
- Teach our patients about energy metabolism with a weight-management assessment including energy expenditure, BMI, BMR, Body Fat and protein requirement.
- Confront each patient with pulmonary and cardiovascular consequences of exposure to primary, secondary, or tertiary tobacco smoke.
This program is called the LESS Initiative (Lose weight, Exercise and Stop Smoking). SETMA’s LESS Initiative has been peer reviewed by the Agency for Healthcare Research and Quality and has been published on their Innovation Exchange as a recommendation to others.
I am proud of my School of Medicine’s clinical science program and of the new clinical-skills center, although the thought of that facility spreads fear in my heart. I am proud that SETMA’s use of medical informatics and statistical analytics is founded on the clinic science excellence of my School of Medicine. I am please to know that if I practice for eight more years, that half of my 48 years of practice will have been done with the use of electronic health records (EHR) and with electronic patient management.
This expertise has allowed SETMA to:
- Design, deploy and employ population management tools for all of our patients.
- Publicly report by provider name on over 300 quality metrics on our website at www.setma.com.
- Engage in the transformation of healthcare by internalizing the passion and vision for excellence in clinical practice which all of our professors exampled before us and taught to us.
My School of Medicine’s clinical science has enabled SETMA to eliminate ethnic disparities in diabetes and hypertension care of the patients we treat.
In May of 2010, I wrote an article entitled, Technology and Humanity: The Critical Balance in 21st Century Healthcare. In part that article stated: “Technology must never blind us to the human…In our quest for excellence, we must not be seduced by technology with its numbers and tables. This is particularly the case in healthcare. In the future of medicine, the tension - not a conflict but a dynamic balance - must be properly maintained between humanity and technology.
“Technology can contribute to the solving of many of our disease problems but ultimately cannot solve the ‘health problems’ we face. It is my judgment that the major issue facing healthcare delivery today is that men and women, boys and girls have replaced the trust they once had in their physician with a trust in technology.
“The entire focus and energy of ‘health home’ is to rediscover that trusting bond between patient and provider. In the ‘health home,’ technology becomes a tool to be used and not an end to be pursued. The outcomes of pure technology alone are not as satisfying as those where trust and technology are properly balanced in healthcare delivery.
“The challenge for our new generation of healthcare providers and for those of us who are finishing our careers is that we must be technologically competent while at the same time being personally compassionate and engaged with our patients. This is not easy because of the efficiency (excellence divided by time) of applied technology. A referral or a procedure is often faster and more quantifiable than is a conversation or counseling.
“As we move deeper into the 21st Century, we do so knowing that the technological advances we face are astounding. Our grandchildren's generation will experience healthcare methods and possibilities which seem like science fiction to us today. Yet, that technology risks decreasing the value of our lives, if we do not in the midst of technology retain our humanity. As we celebrate science, we must not fail to embrace the minister, the ethicist, the humanist, the theologian, indeed the ones who remind us that being the bionic man or women will not make us more human but it seriously risks causing us to being dehumanized. And in doing so, we may just find the right balance between technology and trust and thereby find the solution to true healthcare.”
Winston Churchill’s response to the sinking of the Titanic juxtapositioned technology and humanity. Upon hearing of the tragedy of the Titanic’s sinking, Winston Churchill wrote to his wife and said, "The Titanic disaster is the prevailing theme here. The story is a good one. The strict observance of the great traditions of the sea towards women and children reflects nothing but honor upon our civilization...I cannot help feeling proud of our race and its traditions as proved by this event. Boat loads of women and children tossing on the sea – safe and sound – and the rest – Silence. Honor to their memory."
“Forty-eight hours later, Churchill added the following comment: "The whole episode fascinates me. It shows that in spite of all the inequalities and artificialities of our modern life, at the bottom, tested to its foundations, our civilization is humane, Christian and absolutely democratic. How differently Imperial Rome or Ancient Greece would have settled the problem. The swells, the potentates would have gone off with their concubines and pet slaves and soldier guards, and then the sailors would have had their chance headed by the captain; as for the rest – whoever could bribe the crew the most would have had the preference and the rest could go to hell. But such ethics can neither build Titanics with science nor lose them with honor."
The Center for Medical Humanity and Ethics
To the excellence of basic science and clinical science, my School of Medicine has added the laboratory for “human science.” It is here that students learn that without hope and trust science is helpless. When your greatest hope is that today you will not be shot in a drive by shooting, decisions about your healthcare are not a high priority.
Lecture One: Betrayal of Trust: Critical Issues In Global Healthcare
As a part of the 2012 Alumni Weekend, we were invited to attend the Center for Medical Humanities & Ethics’ Tenth Anniversary Celebration: A Voice for Compassion in Medicine for Ten Years: 2002-2012. The first lecture which I attended was the 10th Annual Frank Bryant, Jr. MD, Memorial Lecture in Medical Ethics, Betrayal of Trust: Critical issues in Global Healthcare, by Laurie Garrett, Senior Fellow for Global Health, Council on Foreign Relations.
As I listened to the needs of the world for nutrition, clean water, environmental protection and healthcare, particularly in regard to HIV Aids, I realized that I can’t deal with global health personally. But I can lead my practice, as I have, to screen all patients for HIV. I can set the example, as I have, of being tested myself and of having my grandchildren tested. And I can act compassionately in my community toward all.
I had my blood drawn for an HIV test on live television and announced that the following week I would announce the results. During that week, I realized how wrong that was. If my test happened to be negative and if I announced that, and if everyone whose test is negative announced that, then those who feared that they may be positive and who desperately need to be tested would be reluctant to do so. Therefore, the next week, I announced that I was not going to disclose whether my test was positive or negative and I encouraged everyone to maintain the confidentiality of their result except with their family and healthcare provider.
Twenty years ago, a Beaumont physician was indicted for sexually molestation of a minor. He was my friend and I called him. I told him that I objected to his behavior but I wanted to help if I could. His response was sobering. He said, “Larry, I knew that if you rejected me, I had no hope.” I befriended him even after he was convicted and after he discovered that he was HIV positive and even after he developed an HIV related infection. My wife and I visited with him as his health failed and on the night that he was dying, we stood by his side, she holding his left hand and me holding his right. We shared this last experience of life; the experience of death.
As he breathed his last, I looked down at the hand which I was holding and his finger-nail bed was bleeding. The blood was dropping on my bare hand. I washed my hand carefully, confident that it was not possible to contract HIV in that manner but having no doubt that I was glad that my friend had not died alone. I cannot deal with global healthcare individually, but in the universe of my friend’s life, Carolyn and I met his global needs.
Lecture 2: The Pen and the Stethoscope
The second lecture was The 2012 Ewing Halsell Distinguished Lecture, The Pen and The Stethoscope by Abraham Vergehese, MD, Professor of Medicine at Stanford and Founding Director of the Center for Medical Humanities and Ethics. The relationship between Medicine and Literature is deep. Particularly, when we remember that the “literature” of most lives is not published but is oral history and often is the dialogue of cinematography. People love to talk and if you listen, they are telling “their story.” Often the story is a short story about an event in their life, but sometimes it is grand tome of their entire life.
Charles Dickens illustrated this for us as he put into the mouth of David Copperfield in the first paragraph of his novel, the words, “Whether I shall turn out to be the hero of my own life or whether that station will be held by anybody else, these pages must show.” The reality is that not only is the course of healthcare determined by a person’s story; healthcare is often delivered by the sensitive, compassionate, attentive listening to another’s story.
Three years ago, I was making rounds one morning. The nurses rushed to me on one ward and said, “You must not go into this room. The patient has said that he will kill the next doctor who comes into the room.” I asked, “Does he have a gun?” They agreed that they thought he did not and I said, “Then let’s go see him.” Two burly hospital employees had been summoned without my knowledge and they quickly followed me into the room.
As I stood at the foot of the patient’s bed, I greeted him and said, “May I listen to your lungs?” He looked at me quizzically and said, “Yes.” I examined him and then ask several questions. I listened to “his story” for thirty minutes. You must realize that I have a short attention span and this is very unusual for me, but I was prepared to spend the day if he talked that long. While he did not use the words, he relayed his feelings of worthlessness and of isolation. He had lost all personal autonomy. He had no income, no family, no friends, no relationships, which supported or loved him. And, the one place where he could regain significance was in the control over his body. But, no one had ever asked him for permission to enter his personal space; so he lashed out in anger.
As I listened to him and his lament of powerlessness and hopelessness, I wondered how I could give him both power and hope. I realized that one way would be to give him power over me and to give him the hope that he could contact someone about his needs. At the end of my visit, I gave him my cell phone number and told him to call me anytime he had a problem or any time he needed an appointment and couldn’t get it.
The result has been remarkable. Today, he is one of my dearest friends. He has never abused he privilege of calling me but calls me about many “non-traditional” health issues. He was arrested and he called me. Turns out, he was falsely accused as stated by an experienced police officer but a young officer pressed charges. His attorney was incompetent and he was convicted. If he could afford the probation fees he could avoid prison, but he had no money. It would normal not occur to us that probation fees could be a healthcare expense, but in his case it was. SETMA’s Foundation has paid and continues to pay his probation fees and he is healthier than he has been in his life. This all started by listening to his story. Everyone has a story and they are eager to tell it and it is an essential part of their healthcare. It is not necessary to record it in the medical record but it is necessary to record it in your heart.
Lecture 3: Music and Medicine: Beethoven
The third lecture was delivered by Richard Kogan, MD, Psychiatrist and concert Pianist, Artistic Director of Weill Cornell Music and Medicine Program. What a treat and delight. The Boston Globe wrote, “Kogan has somehow managed to excel at the world’s two most demanding professions – music and medicine.” On Friday evening, in the University’s Holly Auditorium, excel he did.
At the end of the presentation, I asked the question; “Do you think that the intersection of medicine and music includes the continuity between the physics of harmonics in music and the science of equilibrium and balance in medicine?” How are these related?
If you place a thousand tuning forks in a room and then you “sound” one by striking it, all of the tuning forks which are of the same frequency or a multiple of that frequency will begin to vibrate. They will “sound together” This is the same principle of the orchestra, where many instruments, each of which create a different sound by a different method, together make a harmonious sound. The Greek word symphonia is transliterated into English which addresses this concept and from which we get our word “symphony.” In a composition, there may be dissonance or cacophony, or what is called a “fugue.” Yet, out of this sound, which may seem chaotic, the composer will weave a resolution into a melodic and lovely crescendo. The language of music is made up, like the language of discourse, of thesis, antitheses and ultimately a synthesis.
In medicine, we find patients whose bodily systems have become disharmonious and/or chaotic. Our goal is to restore the balance, the equilibrium, indeed, the harmony of the body. Because music is a metaphor for medicine and medicine is a metaphor for music, treatment can often create a temporary “physical cacophony” in the life and body of the patient, which is resolved in the end by the healthful restoring of equilibrium and harmony. In oncology, we give patients whose bodies are out of balance, a “fugue” of chemotherapy, with the hope and expectation that in the end balance will be restored. In ancient religious literature, we find examples of music alone restoring mental balance and health.
Sound is produced by vibrations and music is a special sound. Most musical instruments utilize a “sounding board,” such as in the piano, to sustain, clarify, and shape the sound of the strings struck by a “hammer.” If you take a Swiss music box and hold it in your hand, it produces a pleasant sound, but if you place it on a wooden surface, the wood becomes a “sounding board,” which will project the rich sound throughout the house. “Sounding forth” is the meaning of the Greek word execheo, in which you can see and hear the word “echo.” In one document, execheo is translated “sounding board.” Without the “sounding board,’ the piano forte sounds like a harpsichord but with the sounding board, the music is melodious and beautiful.
Each of the alumni are the “sounding board,” the “sounding forth,” the execheo of our professors and of our School of Medicine. We “re-sound” the lives and message of our teachers through our lives, adding the harmony of our own lives to theirs. Without us as the “sounding board,” the knowledge and skills of our professors are limited in scope and outreach.
As individually, we are the ‘echo” of our teachers, we collectively are the symphony of them. It is as the student who felt worthless stated at the end of Glenn Holland’s career in the movie, Mr. Holand’s Opus. Now the governor of the state. and a self-confident and accomplished woman, this once timid child said:
“Mr. Holland had a profound influence on my life and on a lot of lives I know. But I have a feeling that he considers a great part of his own life misspent. Rumor had it he was always working on this symphony of his. And this was going to make him famous, rich, probably both. But Mr. Holland isn't rich and he isn't famous, at least not outside of our little town. So it might be easy for him to think himself a failure.
But he would be wrong, because I think that he's achieved a success far beyond riches and fame. Look around you. There is not a life in this room that you have not touched, and each of us is a better person because of you. We are your symphony Mr. Holland. We are the melodies and the notes of your opus. We are the music of your life.”
Harmony and equilibrium, whether in music or medicine, are the physicians’ or the musicians’ goals which are the same and often their methods overlap as well. The following story tells you how the harmony and equilibrium – the health – was restored to a patient’s life without curing his disease.
In February, 2009, I saw a patient in the hospital for the first time. He was angry, hostile, bitter and depressed. It was impossible to coax him out of his mood. Nurses did not want to go into his room, he was so unpleasant.. I was seeing him for one of my partners and he was new to our practice. He had no insurance and no job. When he was ready to leave the hospital, I gave him an appointment to see me, even though he was not my patient.
In his follow-up visit, his affect had not changed. In that visit, I discovered the patient was only taking four of nine medications because of expense. He could not afford gas to get the education he needed about his condition. He was genuinely disabled and could not work. He was losing his eyesight and could not afford to see an ophthalmologist. He did not know how to apply for disability. His diabetes had never been treated to goal.
When he left that visit, he had:
- An appointment to SETMA’s American Diabetes Association-approved diabetes self management education program. The fees for the education program were waived.
- A gas card paid for my SETMA’s Foundation with which to pay for the fuel to get the education which is critical to his care.
- All of his medication as SETMA’s staff negotiated a reduced cost with the patient’s pharmacy and made it possible for the pharmacy to bill The SETMA Foundation.
- Assistance from SETMA’s Care Coordination Department in his application for Social Security disability.
- A visit that day with SETMA’s ophthalmologist who arranged a referral to an experimental eye-preservation program in Houston, which was free.
Six weeks later, the patient returned for a follow-up visit. He had something which I could not prescribe for him; he had hope. He was smiling and happy. Without anti-depressants, or sedatives, he was no longer depressed as he now believed there was life after being diagnosed with diabetes for ten years. And, for the first time, his diabetes was treated to goal.
I continued to see him. Eighteen months later, he was in for a scheduled visit; he was sad. I asked him what the problem was and he said that he was afraid that we would get tired of helping him. He had applied for and had received disability but he would not be eligible for Medicare for two years. In two years. without care, he would be blind, in kidney failure, or dead. He asked if we would stop helping him. I said, “Yes, we will. Absolutely, the day after we go bankrupt.” Melodramatic, yes, but true. He smiled and relaxed. He now has Medicare; his diabetes is still controlled, and he is doing well.
Healthcare providers have always been warned about “transference,” which essentially is an emotional bond which a patient develops with a provider and which a provider can also develop with a patient. While there is a caution to be heeded here, in patient-centered medical home, there is an appropriate bond which develops between patients and providers. This bond is a caring compassion which has appropriate boundaries but is essential for trust and hope to power a medical home partially funded by a Foundation.
I realize that my “instrument” which contributes to the symphony created by the alumni of our School of Medicine will someday be silenced. And, as I often try to hear each of the instruments in the orchestra and cannot, sometimes the melody of our lives is absorbed by the whole so that we become anonymous contributors to the opus. But whether recognized or not, until that time, the honor which you have bestowed upon me is received with the humility of knowing that many worthy recipients will never be so honored publicly And that humility will engendered in me the diligence and discipline which is the result of knowing that I have received more than I deserve and that the cost of it to me was less than it is worth and that though I should work diligently for the rest of my life, I shall never satisfy the “debt of love and gratitude” which I owe to you all.
I am deeply grateful for this weekend. I thank you and I wish God’s blessings upon you all.
James L. Holly, MD