Speaker’s Address   Commencement Address Ross University School of Medicine June 6, 2008               New York City   Alvin R. Tarlov, M.D. Professor of Medicine at the University of Chicago   President Shepherd, Dean Coleman, Chairman Keller, Chairman Hamburger, Members of the Board of Directors, Faculty, Friends of the Graduates, Parents and other Family Members, and Graduates of the Class of 2008.   I am pleased with the honor you have bestowed upon me by your invitation to be the Commencement Speaker today. Thank you.   This year marks the 30th Anniversary of the founding of Ross University and its School of Medicine. That founding has made a substantial contribution to the number of highly qualified physicians serving the health care needs of the American people. With innovation, originality, and courage the leadership, faculty, and students of the University and School have steadily built high quality into its medical education program, and that has been well documented. You have established a tradition that will sustain and enrich the School’s contribution into the future.   Graduates, this occasion signals your transition from “becoming a physician” to “being a physician.” I congratulate each of you members of the Ross University School of Medicine Class of 2008 and warmly welcome you as colleagues into the ancient, venerable, noble, and global family of physicians.   Most of you were born in the early 1980s when there were about 3,700,000 births per year. Only a fraction of those babies were born to mothers, fathers, and families in which early childhood education and development could flourish, into homes that were secure, loving, and supportive, where spoken language and reading were emphasized, where play and learning were the same activity, and where your social, emotional, moral, physical and cognitive development could thrive. After five years of learning and development overseen by your mother and father who, after all, are every child’s first teachers, you entered kindergarten superbly prepared to learn. We owe your mothers and fathers a huge and appreciative lifetime of gratitude for providing you with the foundation required for a life of success and contribution.   At age five you entered a school system from which after thirteen years you emerged well prepared for advanced education. You were chosen from an exceptionally large number of applicants for admission to a college from which future doctors, other professionals, and skilled workers prepare for success in work, family building, and life. From your cohort of college graduated four or five years ago a small fraction applied to medical school, a small fraction of that fraction were selected for admission, and an even smaller fraction will graduate this month to begin the next phase of development as independently practicing physicians. Do the math yourselves, 3,700,000 births, twenty years of successive selections through schools and other enriching experiences…born many, selected few…the Ross University School of Medicine Class of 2008. You are, in brief, among the most successful and privilegedyoung men and women in our society. Perhaps only one from a thousand at the starting gate in the early 1980s. Does privilege command responsibility?   But home and school were not the whole story. Your twenty-five years of development and learning occurred in a thick matrix of culture, ethnicity and religious distinctiveness, startling technological advancements, economic imperatives and requirements, politics, war and other challenges related to global strife. Viscous social environments do undergo slow change as human beings endowed with extraordinary resilience and adaptability bring about adjustments in the enveloping social order. Those slow but definitive adjustments confer distinctiveness on the direction of social change in cycles of twenty to twenty-five years. The total sum population of twenty successive birth cohorts is referred to as a generation. The GI Generation born from 1925 to 1945, The Baby Boomer Generation born from 1946 t0 1965, the X Generation followed the Boomers, and so forth. Your generation includes all individuals born in the twenty-year period from 1983 to 2002. All of your generation has already been born. You, the Class of 2008, were the first born in your generation, while the last born are now in second grade, first grade and kindergarten. Your generation is named the “Millennium Makeover Generation.”   You, the Makeover Generation, number 78 million people, about 25 percent of the entire U.S. population. Currently, in 2008, 34 million of you have reached voting age. By 2020, all 78 million of you will be voters. A salient feature of Makeovers is that you are the first generation of Americans to be one hundred percent connected to the internet, and dependent on it for interpersonal relations and networking, employment, personal and family management, information, news, political participation, shopping, self-identity and more.   Already, your generation is distinctive in many dimensions. Merely Google “Millennium Makeover” to find out. I will summarize. As a group you are indifferent to racial and gender specificity. Makeovers seem to have no issues with gay and lesbian couples. In politics, Makeovers have stunned the political sector by the record-setting extent of your participation in all aspects of the political process including advocacy, blogging, text messaging, use of YouTube and MySpace, personal financial contributions to political campaigns, community organizing, get-out-the-vote projects, voting yourselves, and so on even far from home and work. Makeovers are unusually well informed and show tolerance for disagreement, and prefer compromise to deadlock. Inequalities in health, medical care and income, and disadvantages such as poverty, racism, and differential opportunity are unacceptable to you. You envision a better life for everyone, and believe that it can be accomplished, and you are ready to work and sacrifice to achieve it. From that comes the moniker, Makeover.   The great privilege gifted to you by your parents and teachers, and capitalized on by your ability and hard work, in combination with the truly distinctive characteristics of you generation, confer upon you special responsibility as well as opportunity. Privilege joined to extraordinary collective capabilities, and responsibility enabled by opportunity, call you to action.   Medicine as a profession and as a practice has in the last half century undergone radical change in organization, funding, technologic foundation, and assessment strategies. These transformative changes have removed from the profession its opportunity for collective leadership, has substituted legal requirements for moral and ethical values, and threatens to render medicine an occupation without social purpose as opposed to a profession dedicated to improved health and well-being. Three unmistakable signs illustrative of the depth and seriousness of the problem include: first, expenditures for medical services, having risen two to five times the rate of inflation in each year of the past three decades, now comprises sixteen percent of the gross domestic product, yielding annual per capita expenditures for health on average twice that of the other economically developed nations of the world; second, despite those wide expenditure advantages, the state of health of the American people as measured by rates of disease, functional ability, disability, death, and life expectancy rank in the bottom quartile among the 30 economically developed nations of the world; third, 47 million Americans are without medical insurance, and another 25 million Americans are under-insured. One major cause of this public policy failure is that the rules of employment have become less supportive of employer sponsored health insurance, and accessing medical services often presents to families a difficult choice between medical attention for illness, and money for food, shelter and other necessities.   I urge you makeover physicians to consummate your privilege with the opportunities having emerged from the uniqueness of your generation to bring about reform and improvement in the medical care system. Begin by networking with fellow Makeovers in a long term endeavor to transform the medical care system to better serve the health and health care needs of the U.S. population. Strengthen the noble in medicine’s ethos. The following 7 broad and general objectives might serve as guidelines to get you started:   1. Join your Medical Associations: Join and become active in your medical associations, and use your membership in them as platforms for advocacy and coalition building for the reforms you seek.   2. Reduce National Health Care Expenditures: Work for reduction in national health care expenditures from current levels of 16% of the gross domestic product to lower levels of 12%. This will require setting explicit caps on national expenditures for health care. This might take 2 or several decades. But begin the logic adoption process now.   3. Provide Pro-Bono Public Service: Devote 10 percent of your practice time to care for the uninsured and the underprivileged until national health insurance for all has been adopted.   4. Advocate for National Health Insurance for All: Health Insurance for All, uninterruptedly from birth to death, must become a core principle of health care reform. Everyone covered, from birth to finish, no exceptions.   5. Reduce Inequalities: Gross and unfair inequalities in health and in access to health care have crept into our social and health care systems and undermined their moral bases. The inequalities must be reduced, and ultimately eliminated.   6. Reduce Medical Errors and Safety Violations: These two threats to good patient outcomes from diagnostic and therapeutic interventions, known for the past nineteen years, must be reduced and ultimately eliminated.   7. Adopt and Obey Higher Ethical and Moral Standards: Ethical and moral standards of practice have been advanced since Aristotle and Hippocrates 2,300 years ago. The standards have been relaxed or ignored over the past 50 years, and subverted by other motivations and competing conflicts of interest. Processes must be put in place to adopt and institutionalize a set of standards more in harmony with the realities of contemporary medicine and patients need for protection.   I do not imply that these seven suggestions will comprise a complete agenda for the majority of you. But, I do urge that each of you new physicians adopt a personal agenda based on your preferences and values to restore the strength, integrity, and social purpose of medicine in its makeover.   Achieving the reforms will not be readily accomplished. The challenges are multifaceted and complex. Maybe a lifetime will be required. But you can give yourself to a higher purpose while you practice medicine to strengthen its noble purposes, and to help make your community and nation a better place. There are 78 million others in the Makeover Generation who will help. You have the electronic tools and the generational strength and unity to bring it all together. You are maximally capable of the task.   Finally, to the graduates I wish you the best of good fortune in building your family and professional lives. To the mothers and fathers of the graduates, I admire and honor you who have raised them to the exemplary levels they have attained. And to the faculty and leadership of Ross University and its School of Medicine, you have earned the nation’s commendations for your accomplishments. Congratulations to all of you.   Thank you.