When a photographer goes to an assignment, the first thing on the mind is wondering how the defining moment will reveal itself.

At the University of Pittsburgh School of Medicine's "White Coat Ceremony" for the incoming medical students on Sunday, one such moment was provided by student Katherine Hoyson and her father, Dr. Greg Hoyson, a pediatrician. As he helped her into the white coat, her expression beamed the feelings of embarking upon the journey to become a doctor, too. (The photo appeared in Monday's Post-Gazette.)

But there was another defining moment: the keynote speech by Dr. Susan Dunmire, a Pitt Med graduate who also teaches there. As we follow the increasingly pitched debate over health care in this country, we should take note of Dr. Dunmire's heartfelt and plain-spoken charge to physicians. An adapted version of her speech appears below.

-- BOB DONALDSON,
Post-Gazette staff photographer
(bdonaldson@post-gazette.com)

For most of you, it has been a long and winding path to get here. The first real fork in the road came after high school. Waving goodbye to close friends, you packed up sheets, towels, fans, microwaves and arrived at college. The academics were tougher, the independence was exhilarating, and you realized that you were no longer on a predictable journey.

Today, you are all, once again, starting on a new fork in your road. The paths have become a bit narrower and more specialized. Everyone on this road has a common goal, to become a physician.

This trail is a bit unique -- because it requires that you set aside competitiveness with each other. Your goal is for everyone seated here to complete the journey successfully.

For the first time in your life, some of you may stumble. It is the responsibility of everyone here to assist those who falter. There are tough hills to climb, days when you will want to quit and nights filled with doubts.

Today, you begin your journey, donning your first white coat. This week, you will greet patients along your path with words that will become very familiar over the next several years: "Hello, I am a student doctor here to evaluate you. ..."

When I was preparing for this lecture, I looked in the back of my closet at home and found my first white coat. It is worn and covered with stains, but somehow I never could throw it away.

• On the lapel was a purple stain -- not blood, but a grape Popsicle. I still remember the thrill of relocating 2-year-old Joey's elbow. I felt like I was on top of the world. I proudly went back in the room to discharge him -- and he hurled his Popsicle at me in anger.

Lesson: Not all patients are grateful, even if you successfully treat them.

Almost daily, I decline to give patient antibiotics for their viral illness, even though they adamantly want them. Despite educating them on the overuse of antibiotics when they are not needed, they are occasionally dissatisfied. Sometimes, as physicians, the satisfaction must come from within yourself, just knowing that you did the right thing.

• The right sleeve has a dark brown faded stain. ... This one is blood.

I was a third-year student, rotating on trauma surgery, when a patient with a stab wound to the chest arrived. I watched in fascinated horror as the trauma surgeons opened his chest and asked me to put pressure on the aorta while they repaired the hole in his heart. The only aorta I had ever seen was in the anatomy lab and in textbooks.

The surgeon guided my gloved hand into the patient's chest and instructed me to push. The hole in the heart was repaired; I watched the heart fill with blood and slowly begin to contract. I felt the pulsations in the aorta, and the trauma surgeon asked me to let up the pressure.

The patient survived and I was astounded by what I had seen.

Lesson: This is why we are here. The joy we get from helping a patient is beyond description. Do not, however, let this success inflate your ego and make you feel infallible. You will make mistakes. We all do.

• There are five red pen marks across the back of the coat. Sara, a 23-year-old, arrived in the medicine clinic intoxicated and high on a variety of drugs. I listened to the secretary and nurse discuss "the drunk dirtbag" that had wandered into the clinic and asked the physician if they should have security throw her out.

I was sent into interview her and, with trepidation, I entered the room. An hour later, I emerged with the five red marks on my jacket.

Sara had told me that her husband had raped and beaten her last week and had stabbed her five times in the back -- she demonstrated this with a marker pen on my back. She was here seeking refuge and help with her addiction.

Lesson: Do not judge your patients until you have walked a mile in their shoes. Most of us have had a very sheltered life. It is our responsibility as physicians to try to understand our patient's challenges in life and to factor them into our decision-making. Do not hand a prescription to a patient if they have no money to fill it.

I treated a gentleman last week with a blood sugar of 550 who was diagnosed with diabetes two weeks earlier. [Normal blood sugar is 80 to 100.] He told me that for lunch, he had had a large plate of spaghetti and a piece of cake.

When I inquired about diet education, he told me that they had given him a book on diabetes in the clinic. When I asked if he had read it, he looked at the floor and quietly mumbled, "Ma'am, I can't read."

Clearly we had failed this gentleman as care providers.

I quietly put my white coat back into the cupboard and pondered what I could tell you today.

I have one piece of advice for all of you as students, physicians and individuals.

As a student: I advise you to take time for yourselves. Go for a bike ride, take a walk, enjoy a movie with friends

As a physician: Understand that there are times that it is necessary to accept the inevitable -- and comfort alone is what you will be able to offer your patient and family. You will be privileged to witness birth and be present at death. When you are faced with a 98-year-old with multiple system failure or a 36-year-old with end-stage metastatic cancer, do not run from the room ordering more medication and calling for resuscitation.

Sit down, hold the patient's hand, comfort with medication if necessary -- and accept that this, too, is one of your responsibilities.

As a person: I advise you to set your priorities and place family and friends at the top. The people sitting in this room have been with you throughout your journey. They will remain your support system through this trek as well. This is perhaps your greatest challenge.

Tomorrow, you take your first steps along this new path. May your journey be filled with laughter and good memories.