A Magical and Lucky Place

Dartmouth College has always been a “magical and lucky place” for the Achebe family. In 1972 – twenty years before I had the privilege to walk down the ancient and august hallways of its medical school, the Ivy League college invited an African novelist to receive his first honorary doctorate degree. That former, war-time, roving cultural ambassador from a defeated republic called Biafra, packed up his things and set out on a transatlantic journey to America. Accompanying him would be his equally war-weary, exhausted wife and four young children. That man was my father, Chinua Achebe, and I, at five years of age, was one of the excited youngsters in tow.

Over the years, Chinua Achebe – the author of classic novels known as “the African trilogy – Things Fall Apart, Arrow of God, and No Longer At Ease” amongst 20 other poems, short stories, novels, and collections of essays – would often refer to the “Big Green” as “his lucky place” as it provided an auspicious beginning – permitting, as it were, eventually, over forty other Colleges and Universities from across the world to honor him with honorary doctorates.

In 1990, Chinua Achebe was again invited to return to the lush, green campus, this time as a Montgomery fellow. My younger sister and I joined dad during his Winter residence in a house provided to Montgomery fellows overlooking Occom Pond on the Dartmouth College campus – which was at once cozy, expansive, and adorned with serene, manicured gardens.

It was during that visit, that I fell in love with Dartmouth, and nurtured a desire to attend its medical school. A few years later, I got a chance and the privilege to apply to the incoming class of 1996. I remember weeping and jumping for joy and gratitude – almost touching the ceiling – when I received my acceptance letter in 1992. I still vividly recall the acceptance package with several documents encased in a deep green file embossed with the medical school insignia.

My medical school journey began two weeks earlier than our peers in what was termed a “Summer enrichment program.” I was one of about 12 of the class of 81 incoming students – mainly minorities of color, creed, sexual orientation, and gender – who were given the opportunity to get acquainted with the Dartmouth ethos, the Dartmouth Medical School environment, and culture and engage with its faculty over an intense fortnight of classes, seminars, and social gatherings.

The spirit of gratitude

Gratitude can feel like cliché; a number of people in this room today will look away, stare blankly at the ceiling, yawn, or roll their eyes at the mere mention of the word. For the young graduating physicians in the room today, let me strongly encourage you to maintain a disposition of selfless gratitude –to all those that teach, help, assist, or care for you along the way - anchored in the knowledge that several scientific studies demonstrate a link between gratitude and improved mental and physical health, stronger social bonds; and life-long resilience – all from embracing an optimistic, solution-oriented approach to the challenges that we encounter in life.

The role of teachers

Permit me to speak unabashedly about how grateful I am to God, my family, and my teachers. It is impossible to fully appreciate the role teachers play in one’s development. Dartmouth medical school and my teachers helped mold me into the person I am today and for that, I will be forever grateful.

Let me begin with Dr. Martha Regan Smith MD, EdD, who was at the time, Associate Dean for Education, Assistant Dean for Minority Affairs at Dartmouth Medical School. Dr Regan-Smith would play a pivotal and transformative role in my academic, intellectual, and emotional life – and would forever serve as my personal, indelible, exemplar of “the kind, generous, American – a truly beautiful soul” -thank you Dr Regan Smith.

Maneuvering through the often unfathomable maze of medical school required constant support and pointers from advisors, professors, fellow students, and residents alike. James R. Bell, MD, Professor Emeritus of Internal Medicine, Chief of Cardiology at the Veterans Affairs Hospital, White River Junction for 30 years, was my academic advisor. A kind and patient man, I remember spending hours in meetings with him as I received invaluable counsel on strategies to survive, and in some cases excel in medical school. Thank you, Dr. Bell.

One can never forget the irrepressible, Anatomy Professor, Michael Binder, MD, who invited a select group of us to his home in the woods for dinner after we (I, barely) passed the first Anatomy quiz. Later in the year, I was heading for a failing grade in Neuroanatomy, until the loved Dr. William Mosenthal, had me show up every Saturday at 6 am for tutoring classes, after which my grades soared like a rocket – well, ok…more like moving up the stairs from the basement to the ground floor! I learned later that Linda Martin, DMS Office of Student Affairs; and Sue Ann Hennessy, then the Assistant Dean, Student Affairs, played a quiet, behind-the-scenes role in making sure that those lessons took place. Thank you!

And there were superstar professors – who even then were icons of our profession: Harold Sox – former chair of the department of medicine at Geisel School of Medicine at Dartmouth College – with whom I took several electives and studied his critically important textbook Medical Decision Making; Elmer R. Phefferkorn, Ph.D., emeritus professor of microbiology and immunology, and chair of the department from 1980-1992 – who along with Ford von Reyn MD, a professor of medicine and an infectious disease specialist – encouraged my fascination with the field; Allan Munck, PhD, Dr. Arthur Naitove, Dr. David Nierenberg, and Joe O’Donnell, MD, emeritus professor of medicine and of psychiatry and academic dean – whose work on medical compassion and empathy was and continues to be deeply impactful in my life and work.

There were others such as Donald Bartlett Jr, MD, Emeritus Professor of Physiology and Neurobiology; Professor Stanley Carpenter – who invited me to his office just for a handshake, after I did well in Connective Tissue section of Anatomy; Allen J. Dietrich, MD, Emeritus Professor of Community and Family Medicine – who saved me from making a catastrophic choice during residency match period; and Constance E. Brinckerhoff, Ph.D., Emeritus Professor of Medicine – who was our professor of Biochemistry and challenged me constantly to get through her rigorous curriculum. Other standouts include John G. Brooks, MD, Emeritus Professor of Pediatrics, Dr Nordgren, Emeritus Professor of Pediatrics and Neurology – a kind mentor, to whom I have returned over the years for wisdom.

In recent years, I have turned to Dartmouth Medical School again for further sustenance and inspiration: asking the distinguished Lisa V. Adams, MD, Professor of Medicine, Community and Family Medicine and Epidemiology and Shawn O'Leary, Director, Office of Diversity, Inclusion, and Community Engagement to serve on the board of advisors of my company AIDE PBC – that focuses on developing the African continent. To all these wonderful people, I am deeply grateful, if I forgot to mention anyone here – forgive me and pass it off as a function of aging rather than ingratitude.

The physician as servant leader

Like it or not, the prestigious Ivy League, Dartmouth medical degree will help propel many of you graduating today into positions of leadership. There now exists substantial literature to suggest that leaders who express gratitude are more influential, respected, and happier. In a watershed Glassdoor survey, 81% of employees said they would work harder for a grateful boss. Best of all, positive recognition is contagious.

So, what is Servant leadership? Robert Greenleaf is widely considered the modern “father of servant leadership intellectual thought.” His work describes

“Servant leadership [as] a leadership philosophy built on the belief that the most effective leaders strive to serve others, rather than accrue power or take control. The aforementioned others can include customers, partners, patients, fellow employees, and the community at large.”

Medicine, perhaps, provides one of the best opportunities for servant leadership. In clinical practice, the physician leader relies on the expertise of members of the clinical team – nurses, medical assistants, pharmacists, physical therapists, etc. – to care for patients. Such a leader appreciates and validates the contributions of all members of this team, acknowledging the fact that without their individual inputs – their own jobs, indeed the entire healthcare company – could collapse.

Servant leaders have many crucial characteristics that they share: they tend to exude humility, charity, gratitude, temperance, patience, diligence, empathy, and kindness, practice active listening and direct engagement; and serve as vehicles for the facilitation of the growth of their employees.

In return, servant leaders engender confidence in others, foster employee satisfaction, lower turnover, improve productivity and therefore profits of corporations, encourage, bolster, and build better corporate cultural practices and employee trust, and help create a conducive environment for innovation and excellence.

Challenges and Solutions Ahead

Medical graduates are entering the healthcare workforce – albeit as residents – that is at a crossroads. At no other time in the history of Medicine are Servant leaders needed more than they are today. I will end by highlighting four areas of the healthcare system that we all need to pay close attention to and charge the graduates to help provide solutions.

1) The Problem: A healthcare system in crisis

Robert Pearl MD reminds us that “Healthcare inflation has exceeded GDP growth for half a century. As a result, employers, elected officials, and American families are finding the cost of care progressively out of reach. These three statistics prove how precarious our healthcare system has become. And they indicate that something will have to give—soon.”

* Currently, about 158 million Americans (or nearly half of the nation’s 330 million population) are covered by a combination of Medicare, Medicaid, and subsidized enrollment in the state and federal exchanges. Experts predict that percentage will climb.

* According to the Centers for Medicare & Medicaid Services (CMS), enrollment in Medicaid surpassed 90 million in 2022. This program, which serves 38 million children enrolled in Medicaid or CHIP, Pregnant women, Low-income adults, Elderly adults, and people with disabilities will serve more than 100 million people in fiscal year 2023 (or 1 in 3 insured Americans). Since 2020, Medicaid enrollment has jumped 30% thanks to expansion programs in several more states under the Affordable Care Act and Covid-19 public health emergency funding.

* We are approaching a tipping point – a twilight zone, paradoxical state - where physicians, hospitals, clinics, health systems, or provider groups can no longer afford to enroll or turn away Medicaid patients. The Centers for Medicare & Medicaid Services (CMS) needs to look at reimbursement rates urgently and critically for 50% of the nation’s population; conversely, health systems and providers need to embrace the new era of Capitation and Value-based Care.

My charge to the graduates and Medical Schools

For far too long we have allowed non-medical people – non-physicians and nurses – to run the medical system. More young physicians – Physician Servant leaders - with MBAs or their equivalent are needed in Medical Administration and/or leadership positions. I challenge more young doctors to obtain business degrees (and medical schools to encourage this movement through combined programs with Tuck and other Business schools across this country) so that they can join the army of healthcare leaders that are sorely needed to pull the greatest healthcare system back from the precipice.

2) The Problem: The Need for Primary Care Physicians

The Brookings Institute provides that “all signals point in the same direction – we need to increase the proportion of physicians… [who] practice primary care with reduced pressures of income/financing. Medicare has contributed to the current imbalance by paying specialists too much and PCPs too little. This phenomenon, combined with its emulation by other payers, has increased the income gap between PCPs and specialists. While CMS’ new Primary Cares initiative may ameliorate the problem somewhat, an overhaul of the Physician fee schedule (PFS) to match payment rates more appropriately to the value produced by particular services would help enormously. That improvement in the Medicare fee schedule, combined with a loan forgiveness program for PCPs, would reduce the gap enough to encourage substantially more physicians in training to choose to practice in primary care…The evidence shows that raising the PCP proportion would yield such substantial benefits in both health and savings that failure to do so would be a lost opportunity with major consequences.”

My Charge to the Graduates and Medical Schools: Dartmouth has been at the forefront of National Research Medical Schools that have placed a correct emphasis on producing first-rate primary care physicians. Please continue that gallant effort. Note to graduates: If you are interested in Specialties – we love you too – but join the fight to provide the best possible overall health to our patients by taking a few minutes to review their health maintenance goals and encouraging them to get screenings where appropriate.

3) The Problem: Burnout and Mental health illnesses amongst physicians.

There is a hidden, seldomly spoken about, mental health epidemic amongst physicians and nurses, indeed all healthcare workers.

It’s okay not to be okay.

Many of our colleagues have struggled with mental illnesses, culminating in a spike in suicides among physicians during the Covid-19 pandemic. As Covid-19 begins to subside in its intensity, the fissures that it left behind like a drought-stricken riverbed, are still very apparent – albeit without remedy. It should not come as a surprise that physicians have the highest rates of suicide among all professionals. Physicians and nurses are 2-3 times more likely to complete suicide than the general population, with female physicians especially at risk.[xiv]If you are struggling with mental illness, please reach out to your loved ones, and colleagues and get the time and professional help you need. Please.

Given the aforementioned, it is little wonder that a recent study performed by the American Pharmaceutical giant 3Mfound that “clinicians battle widespread burnout and dissatisfaction in a complex health care environment with competing priorities, administrative burden, and lack of time. On top of that, documentation and compliance requirements never stop.”

58% of physicians often have feelings of burnout the study found.

68% of clinicians say burnout has negatively affected their relationships.

54% of burned-out physicians say it severely impacts their lives.

Clinical documentation burden is also causing burnout:

60% of physicians say bureaucratic tasks contribute to burnout. Physicians report spending nearly 50% of their workday on HER (Electronic Health Records) and desk work while spending only 27% of their total time on direct clinical face time with patients.

More than one-third of physicians reported moderately high or excessive time spent on the EHR at home.

Results from a recent Doximity poll show that 46% of physicians believe decreasing administrative burden would be the most effective intervention in reducing burnout, followed by improving work-life balance (27%), and reducing clinical caseload (21%).

The utilization of voice recognition technology, and innovative AI solutions have also been postulated as potential answers to burnout. Understanding these prevailing challenges bedeviling the healthcare system will better prepare our new graduates with the tools to cope and the skills to provide solutions to this professional scourge.

4) The Problem: The Cost of Racism to All of Us

According to a new study by the big bank Citigroup, the United States of America suffered $16 trillion loss over 20 years due to racism. Consider that the USA’s total GDP is $26.47 trillion. Without that loss, the GDP today would be $42.47 trillion. That’s an enormous cost to everyone. The study offers policies to add $5 trillion in extra economic activity over the next five years.

My Charge to the graduates and Medical Schools: Perhaps no study gives more credence to MLK’s words: “Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly.” To Dartmouth, please continue to recruit and train the best and brightest minority students that you can find. To the graduates: be Crusaders of Social Justice, fight all kinds of discrimination, and be beacons of light for equity and fairness.

I leave you with this: According to the great philosopher Denzel Washington: “Don’t just aspire to make a living, aspire to make a difference.” As physicians servant leaders march boldly into the world and leave an indelible, positive imprint on it! Good luck and God’s speed!

•Being a Keynote Address by Dr. Chidi Chike Achebe, MD, MPH, MBA, to the 2023 Graduating Class of Geisel School of Medicine, Dartmouth College, United States, on May 27, 2023.

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