LLUAHSC SCOPE Summer 2001

"End of the Beginning"

[SCOPE, Summer 2001]

Editor's note: Francis S. Collins, PhD, MD, physician, geneticist, and director of the National Human Genome Research Institute, part of the U.S. Government's National Institutes of Health, gave the following address to School of Medicine graduates during the commencement ceremony on Sunday, May 27. Dr. Collins also received the Boucek Award during the same ceremony.

Thank you, Dean Bull, for a very kind introduction. Chancellor Hart, President Behrens, distinguished faculty of this great medical school, graduating students, and especially parents, families, spouses, and significant others who have sweated, slaved, and sacrificed to make this day possible--and I know you have--congratulations!

You know, as William Butler Yates wrote, "Education is not the filling of a pail, it is the lighting of a fire." We are here to celebrate the lighting of your collective fires this morning, and though the air may be damp, I sense your spirits cannot be dampened.

Hooray, and congratulations!

Well I'm deeply honored to be your speaker here this morning. This format is a real challenge to a physician/scientist--no slides, no handouts, no Powerpoint™. SM graduates

Yet, we do have something in common today, you and I. You have spent four intense years learning about the elegant intricacies of the human body in health and in disease. And now, stopping for the moment to celebrate this remarkable milestone, you look forward to applying the full power of what you have learned to the healing arts.

Those of us engaged in the human genome project have spent 11 years on our own remarkable milestone, the reading of the human DNA instruction book--our DNA code. And that is now 95 percent complete, sitting on the Internet for you

to go and help us figure out what it means, with enormous promise for the future of medicine.

So I think it's not a stretch to say we're both at the "end of the beginning" here this morning, contemplating and excited by what lies ahead.

Collins/award If you will, we're all in the "bullpen" waiting to go out and pitch the real game.

And we will do that together because the promise of studying the genome is a promise for medicine, and it will be one which you participate in if it is going to, in fact, yield all those benefits that we dream of.

Well, recognizing that the program allows only a modest amount of time for this presentation, and that the wisdom conveyed in commencement speeches tends to have a half life measured in milliseconds, what can I say to you here this morning at the end of your beginning?

For a fleeting moment I thought, "Well, perhaps I should read you the sequence of the human genome." Collins

After all, it's a pretty impressive book, and it's a historic milestone in the course of humankind that we now have it in front of us, so maybe I should just stand up here and read through the whole 3.1 billion base pairs. You would probably agree this is a pretty important moment, so maybe you'd be willing to stay on and listen for a bit.

But I went through a little calculation, and it wouldn't probably have turned out so well because you really would have had to bring quite a lot of refreshment with you. At the pace that I was contemplating, it would take us about 32 years to get through it.

So I'm going to spare you that. But I hope you will stop for a minute and marvel at the fact that you have 32 years' worth of genetic information inside each cell of your body.

Isn't God's creation amazing? [applause].

So as I tried to remember the dozen or more commencement addresses that I've sat through, seeking for some help here from some previous speaker that might guide me, I confess that only one of them leaves even the faintest memory of what was said.

I decided to pay attention to one which was actually delivered at my high school graduation by a Presbyterian minister, and, with apologies to him because I will probably distort the wisdom of his message a bit, I'm going to adopt his theme.

So what's the theme? My message really is an exhortation, supported by a focus on four questions.

The exhortation: "Seek a balanced life." Well, what does that mean?

Medicine is a "selfish mistress"--you've heard that said and it's true.

Do not allow the pressures of your profession--nobel though it is--to crowd out all the other aspects of a fulfilled life.

Collins Now, how do you achieve this? Well, I suggest that if you focus on four questions--the four "food groups" of a balanced life--you will be well-served.

So let's go through those. Question one: "How will you practice your profession?"

Despite the challenges of managed care--and there are many--and the erosion of the physician's ability to practice his or her art based solely on what is best for the patient, medicine remains a noble profession, and you are truly privileged to enter it.

Furthermore, a grand era is underway that you are going to have a chance to participate in.

The full flowering of evidence-based medicine lies near at hand--new technologies giving us unprecedented abilities to diagnose and treat illness; new therapies, many of them based upon the revolution in genomics, allowing us to practice our therapeutic art in a fashion that will be much more successful than what we have had in the past.

I would guess that in some 10 years, preventive medicine will be transformed into an individualized effort, based upon some analysis of individual future risks of illness, studying DNA as the clue to provide that information.

And perhaps in another 10 or 15 years, we will see therapeutics utterly different than they are now, with most of the drugs that we use based upon an understanding of the genome.

This portends an era where our therapies do not treat the secondary problems--the downstream effects--but actually go right to the primary problem that underlies the illness.

And how much we have waited--and how long we have waited--for that time.

But in this enthusiasm about technology, I think there is also risk. Albert Schweitzer wrote, "Our technology must never exceed our humanity."

The genome project from the outset--recognizing the risks here of the ethical, legal, and social implications of this advance in research--has been devoting a significant amount of our effort to studying those ethical, legal, and social issues.

Out of this has come a wealth of scholarship to inform the path ahead.

But that will not be properly negotiated without involvement by a broad spectrum of society, and particularly so by you as physicians, and by the Church.

Clearly, we must become engaged as we begin to contemplate what the limits are that we would like to set around genetic technologies, which can clearly be of enormous benefit in healing disease--and where I believe it would be unethical not to pursue them, but which could also, if misused, injure people or perhaps go in directions that God would not approve.

Now in this exhortation to you about practicing your profession, two caveats: first, don't expect your pathway to be linear. Mine certainly wasn't.

Sitting in your seat 24 years ago, I never would have dreamed of being involved in a project to read out the sequence of the human genome--nobody had thought of that project at that point.

So, stay loose; be prepared for changes.

Second caveat--and this is the very point that I suspect many of you have learned, but it's easy to forget: remember that the way we touch lives is done one person at a time.

I do tend to forget that, and when it happens to me, I get all carried away with the excitement of what's going on. I think back to a day 10 years ago when I spent three weeks as a volunteer missionary physician in Nigeria.

I went to Nigeria full of enthusiasm for what I might be able to accomplish there, imagining that in my three weeks I would turn around this country and its 93 million folks from a difficult health system to something much better.

And after a few days there, I realized the enormity of the problem, because while I could treat individuals who came into this small cramped hospital--and I could even help some of them--they would go back out to the same circumstances that had caused them to become ill in the first place.

I was feeling pretty discouraged and wondering, "Why am I here?"

We had admitted a young farmer the night before who came in with a pericardial effusion--or fluid around his heart--caused by tuberculosis. He was quite near death at his arrival in the hospital.

With my heart in my mouth, I undertook to remove the fluid from around his heart without the benefit of the usual technologies that you would find in the United States.

Miraculously enough, that was successful. During rounds the next morning, he looked vastly better.

But yet, it still seemed to me, "What's the point here? He's going back out to the same circumstances."

He stopped me on rounds and said, "You know, you're different. I get the feeling you haven't been around here very long." I didn't realize it was that obvious.

And then he said, "You know, I also have the feeling that you're wondering why you're here."

That really took me aback, because I didn't think that was so obvious.

He said, "I have a word for you. You came here for one reason. You came here for me."

I'll never forget those words. How off the mark I was with these grand ideas about what I could accomplish, when in fact all medicine is ever about is one person at a time--"you came here for me"--that ought to be enough.

So have your grand plans--have the most wonderful dreams you can come up with, and God bless you for your attempts to change the world.

But don't forget that in medicine, as in life, good things happen one person at a time. The Good Samaritan, whose sculpture is behind you, reminds us of that.

Second question: "How will you nurture your faith?"

This medical school is unique in the United States in its open embrace of the Christian faith. You are fortunate indeed to have trained in such a welcoming environment, where your faculty and fellow students acknowledge Christ as the greatest physician. In other schools where I speak, that would not be the case.

But your faith will likely be severely challenged along the way. Many of you will find yourselves in perhaps less supportive environments in the future, facing pressures from your colleagues. Personal crises, family tragedies, professional disappointments probably loom in the future for most of us.

And intellectual challenges may come in front of you that cause you, in some instances, to question your faith because they're all around us, and I'm afraid some of them come from my own field--the field of genetics.

Let me pause for just a minute on this one. There are some who take advances in science, and particularly in genetics, as evidence that we humans are simply biological machines. Some would even replace the cross with the double helix.

Others would seek to polarize by asserting that one cannot be both a rigorous scientist and a person of faith.

I am here to tell you that's not true. There is nothing--nothing--that I have learned about the human genome that conflicts with my faith in a personal God [applause].

In fact, I came to my faith, not in childhood, but as an adult, as a medical resident after already starting a path toward genetics.

DNA is a chemical not to be worshipped. It is marvelous indeed, but it is not divine. It will not tell us what love is. It will not make our free will obsolete. It will not explain the moral law that C.S. Lewis writes so compellingly about, and which was a great part of my own conversion.

How then should you nurture your faith in face of all these challenges? Well, make it a priority. Do not neglect your church, your fellowship, despite those pressures on your time.

Find a prayer partner and help each other be accountable. Stretch yourself. Keep involved in medical missions. Put yourself in positions where your own capabilities, extensive though they may be, are inadequate--that's when you really find out the power of God.

The third question: "What role will love play in your life?" Well, of course there are four loves, but time is short, so I can only talk about two.

First, agape, love for each other. Prejudice still abounds. Though genetics is teaching us that there is no scientific basis for drawing precise boundaries around ethnic or racial groups, we still focus on physical differences of facial features or skin color or hair textures as if they meant something profound.

They do not. We are 99.9 percent the same [applause]. Saul Bellow, writing cynically about our society, says, "In expressing love, we belong among the undeveloped countries."

We have a chance to change that--again, one person at a time.

The second love, of course, romantic love, that enduring glowing fire. I don't agree with the wag who wrote, "The trouble with loving is that pets don't last long enough and people last too long."

But medicine traditionally places romantic love at risk. Whether you have found life's partner or are still looking, you will need to make this a priority if it's going to have that enduring fire that we all hope and dream of.

Fourth question--so far we've done work, we've talked faith, we've talked about love--the fourth question maybe doesn't belong on the same plane, but just the same, I think it's an important one: "How will you keep fun in your life?"

Yeah, fun. Medicine is full of sobering, tragic moments...so is the rest of life.

So don't forget to exercise your sense of humor--you're going to need it.

Collins Winston Churchill, who also taught us about the end of the beginning--my theme this morning--said the following: "You cannot deal with the most serious things in the world unless you also understand the most amusing."

Well I agree that fun is a bit of a difficult subject to lecture on, so instead an example--a song of the medical school experience is about to break forth.

I don't know exactly what your medical school experience has been, but I could guess because I remember mine.

This is a song to indicate some of that experience. Faculty don't take this too seriously, and don't worry, the last verse is really from the faculty perspective so, as usual, the faculty get the last word.

[Dr. Collins sang the following:]

Sung to the tune of "I did it my way" with accompaniment on an acoustical guitar.
I came, I bought the books, I clerked on wards, followed directions;
I worked, I studied hard, made lots of friends that had connections;
I crammed, they gave me grades, and may I say, not in a fair way;
But more, much more than this, I did it their way...
I learned so many things, although I know I'll never use them;
The courses that I took were all required, I didn't choose them;
You'll find that to survive, it's best to play the doctrinaire way;
And so, I knuckled down, and did it their way...
[Chorus] Well, yes there were times I wondered why, I had to cringe when I could fly, I had my doubts, but after all, I clipped my wings and learned to crawl;
I learned to bend, and in the end, I did it their way.
And now, my fine young friends, now that I am a full professor;
Where once I was oppressed, I have become the cruel oppressor;
With me, I hope you'll see the double helix is a highway;
And yes, you'll learn it's best to do it my way...
[Chorus] Well I'm just a man, what can I do, open your books, read chapter two; and if it seems a bit routine, don't talk to me, go see the dean;
Just start today, learn DNA, and do it my way.

[SCOPE, Summer 2001]