2021 Commencement address by Dr. Atul Gawande
Following is the prepared text of the address by Dr. Atul Gawande for delivery at Stanford’s Commencement ceremony for advanced degree candidates on June 12, 2021.
Congratulations graduates. Thank you all – President Tessier-Lavigne, faculty, students – for inviting me. I can think of no greater honor than being asked back to one’s alma mater to speak at graduation. Especially this graduation.
In May, I celebrated the graduation of my own child from college, from Berklee College of Music. It was such a beautiful milestone. But it was deflating to have to mark it from our family room, with Hunter sitting on the couch in cap and gown, watching a virtual ceremony, after a tough year of virtual music school without ensembles and performances. To think that a month later, we could be here together with you is thrilling.
This past pandemic year blew up everyone’s lives. So many suffered. The coronavirus has taken millions of lives from our planet and made tens of millions more so sick they needed hospitalization to keep breathing. Those with the least wealth and opportunity, the least ability to retreat behind screens, suffered most. But no one escaped loss of some kind.
The disease grounded our planes. It closed our borders. It shuttered workplaces and schools. It took away our ability to come together to hear music, to break bread, to hold weddings and funerals, to simply let children play. It did this for an entire year.
For much of the world, the worst is not past. We’re lucky to live in this country, which has supplied such remarkably effective vaccines and in such quantities that we’re now giving away hundreds of millions of doses globally. Vaccines reached so many people that, against all expectations, we can gather like this to cheer for your graduation.
I remember my graduation one sunlit day like this years ago. I remember the raucous joy of processing into this stadium with my friends. I remember scanning the crowd for the faces of my family. And I remember the annoying question everyone asks new graduates: “So what now for you?”
I had an answer. More education. Your answer might be the same. Or it might be a job, a trip, a move back home. But the truth was that none of us knew what was ahead for us.
How could we? Many of my classmates would have careers doing work that didn’t even exist in 1987, when we stood where you are. For example, I had classmates who’d make their mark helping the people of a post-communist Russia and Eastern Europe and a post-apartheid South Africa – none of which was more than a fever dream back then. My tech friends would later take jobs with names that would have been incomprehensible – such as app designer, driverless car engineer, data scientist, chief information security officer, blogger, or, for that matter, Peloton instructor. In medicine, friends later worked in unimagined fields like genomics, face transplantation, and mRNA vaccine production. No less fantastical, in public health, friends would work to implement the country’s first health reform program to seek universal coverage, signed into law by America’s first Black president.
My classmates would also have personal life experiences that were equally unpredictable, though more familiar. They’d fall in love. They’d fall out of love. They’d navigate sickness and injury. They’d grow families, and they’d lose family members. A few died too soon.
“What now?” is a question you will ask your whole life.
Entering medical school, I had a plan. I wanted to do public health research and practice medicine. So I planned to train in primary care. The specialty fit these interests and, as a bonus, had the shortest residency program. But then, my clinical rotation in surgery up-ended my tidy scheme. What I saw captivated me. The surrealness of opening the bodies of living people drew me in instead of pushing me away. And so did the surgeons – all of them ordinary, flawed human beings, with imperfect skills, incomplete knowledge, and yet the confidence to nonetheless act, and to take accountability for whatever outcome resulted.
People say, “Follow your passion.” But how many of you know what that is? I didn’t. I had my share of enthusiasms, but sitting where you are, I wouldn’t have called any my passion. I had no idea which would endure and which would fade.
Over time, however, I came to tell the difference between things that merely absorbed me – the way TikTok videos now do – and things that energized me. Seeing the difference took time. Coming to Stanford from rural Ohio was mind-altering. It exposed me to a wider range of things to do and be than I’d known. During freshman year, my roommates and I signed up at KZSU for a late night slot spinning records. A professor gave me a job in his laboratory working on a devastating retinal disease. I learned to play electric guitar. I volunteered to stuff envelopes for a presidential campaign.
Many interests came and went. But I came to recognize when something truly energized me. The radio show, for example, was not such a case. Our slot was Tuesdays from 2 to 5 a.m. After two or three shows, the fun of our on-air repartee and championing our latest new wave heroes waned dramatically. I began sleeping in and totally flaked out on my roommates.
On the other hand, I consistently lost track of time in the lab. Likewise for my late-night discussions with my political science friends. I ended up taking so many policy and political theory electives that I added a second major to my biology major. I wasn’t good at anything yet, but I found a few things I was willing to work at long enough to get better. I learned to pay attention when that happened.
More recently, I attended a talk by Dr. Bob Wachter, who now chairs the department of medicine at UCSF. Answering a question from a graduate student seeking advice, he said something that stuck with me. He said, “Say yes to everything before you’re forty; and say no to everything after you’re forty.” Looking back, I realized this was pretty much what I’d done.
In your formative years, you don’t know – you can’t know – what will ultimately matter to you; what will grab you by the shoulders and awaken you and stay with you. So you have to be open to trying stuff – to saying yes. As you do, pay attention to what fuels you and what doesn’t. You want to pull apart the experience and figure out specifically what lifted you and what sapped you. And then you want to do all you can to organize your life to do more of the first and less of the second.
With me, for example, I found that I was endlessly interested in getting under the surface to understand how the systems we depend on fail – the flaws of the complex systems inside our bodies and also inside our society that cause suffering. I had experiences that also revealed a love of getting my hands in there – to tinker with the systems and figure out what was possible to fix. Knowledge was one thing but execution was another, and I found I cared about both. In further experiences, I learned that I loved assembling the story of what happens when people try to fix system failures – how they succeed and how they don’t.
For a long time, this meant that I was pulled in three directions – to surgery, public health, and journalism. Over and over, people told me to choose. These things don’t fit together, they’d say. And for a very, very long time, they didn’t. All I saw was that each separately added something that fed me. And eventually each fed the other.
Surgery showed me the day-to-day reality of illness and our inadequate health systems. Writing let me investigate the flaws and ways to address them. And public health training showed me how to design systemic solutions and deliver them at population scale – for example, to deliver a team checklist for safer surgery that has now been adopted worldwide and saved more people from death and disability than car accidents inflict; or to design a structured conversation between clinicians and people with serious illnesses to ensure that treatment plans incorporate patient’s priorities besides just surviving; or to build mass vaccination centers and COVID testing programs to help us escape from this pandemic.
Every few years, I’ve faced a pivotal choice that scared me. One was deciding to train in surgery instead of internal medicine. The training was eight years instead of three. My wife Kathleen – we’d met here at Okada House – was pregnant with our first child. Surgery was not a natural cultural fit for me. My mentors in public health thought the direction was baffling. But still, there’d been that pull during my three months on service. So I told myself that I could transfer out if it didn’t work, and I said yes to surgery.
Three years later, I also said yes to writing a blog on the side, and then, during a two-year research period with only light clinical duties, I said yes to a chance to write longer pieces for The New Yorker magazine. A few months after I returned to full hospital duties, a publisher offered me the chance to expand those pieces into a book. I remember the day at the hospital that I said yes into the phone and accepted the contract. It was late when I got home that night. I had three children by then, and they were asleep upstairs. Suddenly, I was flat on my back in a panic on the living room floor. What did I just commit to doing? How in the world was I going to deliver during residency?
Kathleen had thought it was crazy, too. But she reminded me that I had already demonstrated the energy to stay up an extra hour or two every night, or to steal time between operations, to write. So I stilled my pounding heart. I kept making time for what energized and motivated me, and kept trying to remove time from what beat me down. This meant doing things that didn’t fit with my plan or the image others had of me. But I never regretted it.
I’ve had great luck and privilege just to have the opportunities I’ve had, like even to try to do surgery or to write. Simply by being in this community, you too have had choices and exposures that few others have. Most people face far tighter constraints on their life. But I have seen that even patients facing the end of life, the tightest constraint of all, have had room to assert priorities in their lives besides just living longer, to maximize time for what lifts them up and to try to limit what brings them down.
The other half of Bob Wachter’s advice, however, was, “Say no to everything after forty.” By that he meant that by that age, you should know enough about yourself – about what really matters to you – to focus on that. In fact, you have to say no to focus on it.
As you get older, this becomes your advantage. You begin to know yourself – your capabilities, your gaps, what motivates you – well enough to commit to efforts that can take a long time to realize. Years. Decades, if necessary. You even become willing to work for goals that will not be achieved in your lifetime.
* * *
I want to return to COVID for a moment. This plague forced us all to see our lives anew. Under crisis, we had to pare our lives down, decide what could be jettisoned and what truly mattered. We had to try living in new ways. We had to figure out how to endure.
For me, dealing with the uncertainty was the hardest part. How long would this plague last? How bad would it get? What troubled me most, though, was the fact that so much of the uncertainty was human-made, instead of virus-made.
The pandemic was, and still is, a spreading fire. Experts actually figured out rather quickly how to stop it – with wide testing, masks, avoidance of indoor crowding, use of good ventilation, and ultimately with vaccination. But knowledge is one thing and execution is another. Those communities that came together across political lines to acknowledge the threat and fight the fire were able to stop the fire. Our nation did not come together. The fact that we could not collectively summon the commitment required – that we’ve had key leaders who saw political opportunity in undermining that commitment – has been distressing beyond words.
Leaders have a choice. They can move ahead by driving division and stoking fear. Or they can move ahead by binding us together and confronting our fears. The divisive path generates attention more easily and more immediate gratification. That means we will always have those who take the divisive path. The fact that it is ultimately dispiriting for people, however, while the other path raises our spirits up, gave me confidence about which eventually will prevail. That confidence was shaken, to be sure. But we stand together here today because enough of us have come together across political lines, and increasingly across countries, to take up the vaccines and fight the fire.
The difference between the two paths is worth remembering as we each encounter that “What now?” question in our lives, that question about what we individually will commit to next. All of us are seeking how to express our worth. And everyone does have worth, equally, with everyone else as a human being. We do just by being here in the world. To discover how to express that worth, you just have to keep saying yes until you’ve found it. And if you do that, you will find it.
But the better choices are not often the easiest or most enjoyable ones. The most meaningful goals are usually slow to achieve. They are also usually the ones that bind people together rather than push them apart, that feed their purposes. For it turns out that the beautiful secret of how our species is made is that we are often most energized when we help others express their worth.
That truth is easy to miss behind our screens and watching the news. But it is the reason why all of us gathered here hold such confidence in you. And it is why we believe you and your entire generation are the reason our better angels will prevail.