 Final speaker is Richard Gunderman, the Chancellor Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, Philanthropy and Medical Humanities and Health Studies all at Indiana University. Richard received his A.B. from Wabash College and his M.D. and Ph.D. here at the University of Chicago and also an M.P.H. at Indiana. He was the Chancellor Scholar of the Federal Republic of Germany and received an honorary doctorate of humane letters from Garrett Theological Seminary at Northwestern. Richard has written many articles over four hundred and eight books. He's past president of the faculty at Indiana University School of Medicine, correspondent for The Atlantic. And today Richard will speak to us on the topic Excellence in Ethics. It's a delight to welcome Richard back to the University of Chicago. I keep learning about ethics. I don't know much about it, but I'm an avid learner. One thing I've learned is that my students have a lot to teach me, and I want to share with you a lesson today I learned from one of my students. And from my point of view, it has to do with the beauty of transcendence. I don't know about where you work, but where I work what's sometimes called physician engagement but might just as well be described as morale, is sometimes poor and perhaps on the decline. People worry that the relationship between physicians and patients is becoming weaker. Many of us in medicine don't comprehend the systems we rely on every day to care for our patients. Information technology seems to have displaced the best interest of patients sometimes in the way we practice. The physician's judgment seems to have been devalued. I'm assessed almost strictly in terms of productivity, by which I mean quantitative outputs even though I don't think that's the most important thing I contribute. And finally, I feel I have less and less authority in deciding how to practice medicine. Sometimes I feel pretty sorry for myself. This is a puzzling montage. Those of you with keen eyes will be able to tell what's going on here, but for the moment I'll leave this a mystery except to say that this is the story of Nathan. And Nathan is the man you see in these six photographs. You know that each day in the United States about 3,500 Americans are told that they had cancer. Nathan was 35 years old when he had cancer. His experience was a little different because he's a physician. I personally think this is the second best book ever written about cancer, a fascinating tale. I encourage you to use the emperor of all maladies, deep insights into how we came to understand cancer. I read that book, thinking I understood cancer, and then I re-encountered my student, Nathan, who taught me something that I didn't get from the book. Nathan had for about six weeks had a hard right supercalibular swelling and was noticing reddish nodules on his hands that he assumed were the product of some infection or perhaps an allergy he'd developed. A colleague whose mother had just died of gastric cancer told him he ought to get that checked out. So they laid an ultrasound transducer on his supercalibular fossa. It was immediately apparent that the nodes were highly abnormal. He went for a biopsy. The biopsy was strongly suggestive of lymphoma. Nathan has told his wife before he was going to have this biopsy the night before, but then he had to call her and tell her that he probably had lymphoma. Her response, what? What do you mean? How can that be? You know, a very traumatic event for this family. But I came to think that they coped with cancer, learned from cancer, and were in fact transformed by cancer in a way that I would describe as lyrical and even beautiful in terms of what I think might be ethics. So later that same day after he told his wife their kids came home, this is Henry Moore's family unit. They never asked about whether dad was going to die, but they were quite concerned that he might lose his hair. And he turns out to have either a poorly treatable B-cell lymphoma or Hodgkin's disease. They're in the Walmart checkout line the next evening when they get a single word text message Hodgkin and Nathan's wife yells out how unlikely that somebody would be delighted to learn that they had Hodgkin lymphoma. This of course is Thomas Hodgkin who first described the disease in 1832. What was the prognosis of Hodgkin lymphoma in 1915? Yeah, basically zero. It was uniformly fatal. Some of you know the story during World War II in Barry, Italy, the German Luftwaffe makes an unexpected bombing raid and sinks all 27 military ships in the harbor, one of which it turns out, although our government won't admit it, is jam-packed with nitrogen mustard gases of the sort that had been used during trench warfare in World War I. Happily the doctors who treated those soldiers and Italian civilians realized that many of their patients had become pancytopenic. Their blood counts had dropped to close to zero. Could that be useful in treating leukemias and lymphomas? And now as you know the prognosis for somebody diagnosed with Hodgkin's disease is perhaps 90% or so. Nathan's wife is mayor. Nathan's been baking on the fact that chemo is going to be this great white-loss program. That made her giggle. Doctors said you'll probably lose your hair around week three or four. That's been hard for Nathan to come to grips with. The doctor said it's going to be painful. Nathan dropped his head and looked at me with puppy-dog eyes, thinking the doctor was saying emotionally painful. But reading Nathan's body language, the doctor said it again, it's going to be painful. At which time my head I was like, he really means physical pain, and Nathan wasn't getting it, so I said, Babe, the doctor is telling you it's actually going to hurt when your hair comes out. And Nathan was like, what? But I lost it. It was so funny to me. We just laughed and the doctor said, man, you guys are really handling this news well. And immediately Nathan said, the Lord is good and this has been a great six days. You'd have to know Nathan and Mayor, but he is a physician who knows what he's talking about and he really means that. This is a stellar example in my own limited experience of some young people who suffered beautifully, not only bouncing back from a serious blow, but actually undergoing a kind of transformation. This is Nathan. Early Monday in the morning I experienced one of those rare raw moments when the Lord that up until now I've only read or heard stories of never before have I been faced down on the ground sobbing and pulling up my hair in anguish. There was much groaning going on. In that moment I was wrestling with God my emotions over what would happen to my family if this trial did not have a good ending. When I say beautiful, I don't mean they were oblivious to what they were going to and not scared to death, but there was a certain beauty in it. So that's Nathan, round one of chemotherapy. He'll have a total of 12 rounds over six months and suffer many of the side effects you'd expect like nausea and fatigue and so forth. Mary again, his wife, Nathan got his first chemo last Tuesday evening, felt pretty good through Thursday morning and went to work that day. The only side effect he felt were nausea. While being at work he just hit a wall and came home around two. And since it has been like Nathan was in the corner of the ring with his gloves down and chemo just took punch after punch with its side effects. Then the onslaught of abdominal cramping began day and night nonstop. Seeing your buddy curled up on the bathroom floor in the early hours of the morning is heartbreaking and the feeling of helplessness is overwhelming. As for me, I didn't foresee the loneliness. My buddy is either sleeping or not himself mentally or hurting and it's just kind of a feeling of missing my friend. So Nathan resented most the chemo brain as he put it that he developed. This of course is Nathan with mayor. He went from sleeping eight hours a night to sleeping 14 hours a night and he had his biggest exam of his life, his board exam to take in a period of about a month. And he felt like he was some kind of apathetic robot. I totally regret I didn't have my phone on video when I went to see Nathan. He was so hysterical. I was laughing so hard which I felt bad about because when I giggle I have a hard time stopping. He was so concerned about his hair and commented how glad he was that he wore underwear today that didn't have holes in it which he refuses to throw out. But that was short lived because it seemed within minutes of going back, he just didn't handle the coming down from anesthesia well at all. And even the middle of his body retching and dry heaving he said, I don't know if I'm ready for chemo. The only thing he said he was scared of is not being able to proof read my email before I send it. One of the things that marked this family is that they were connected to a lot of other families, some medical, some not. And they were sending out basically daily updates on what was happening. So here's Nathan at the beginning of round nine, the kind of physical transformation you'd expect but that's not the transformation I want to stress today. Wednesday afternoon after Nathan's chemo he medicated up and went to bed. A neighbor and I went for a walk then I got a phone call that panicked me because it was from Nathan. He was supposed to be sleeping. Me, babe, are you okay? Nathan said with urgency, where are you? Me, I'm right here down the street. I'll run home and be there in a minute. Are you okay? Nathan, I'm coming to get you. Babe, I'm right here. What's wrong and you shouldn't be driving with meds on board. I need Vienna sausages right now. What? I'm pulling the car out now. I'm going to click and there's Nathan scarfing down the Vienna sausages. That could mean nothing but on the other hand it could mean something. Mayor had never had Vienna sausages nor seen Nathan eat them in the 14 years of their marriage and presumably this came from some point very deep in his childhood. There's Nathan and Mayor with their two children. I wasn't so much worried about myself but about my family. What would happen if I wasn't here? What would happen to my wife and kids? Mayor again sleeps the best thing for him and when he's awake he's not feeling good. He feels like he's failing at life as a follower, husband, dad and employee. When he shared this with me, my heart broke. This is just as much a mental challenge as physical for him and I am so thankful knowing I'm unable to go to these dark places in Nathan's mind. I can pray. He said today that even though he doesn't want to or feel like he can during the dark days, he has started to discipline himself in thanking the Lord for things. He's also quite emotional during his dark days, which he's very frustrated by but I find quite endearing. He put my hand on his bald head the other morning and he started to tear up and he apologized for being so emotional. So Nathan had very lonely hours. I had several conversations with him during this period of time and I asked him, how do you manage? How do you cope with this? And Nathan reached over into his briefcase and pulled out a very large well-worn Bible and he recited three verses that were written on the inside back cover of this very big old Bible. This of course is Vincent Van Gogh's still life of the Van Gogh family Bible. Not at all joy when you fall into various trials knowing that the testing of your faith produces patience but let patience have its perfect work that you may be perfect and complete lacking in nothing. Second of three, therefore we don't lose heart even though our outward man is perishing yet the inward man is being renewed day by day for we do not look at things which are seen but at the things which are not seen. For the things which are seen are temporary but the things which are not seen are eternal. In this you greatly rejoice for now a little while if need be you've been grieved by various trials that the genuineness of your faith being much more precious than gold that perishes though it is tested by fire may be found to praise, honor, and glory. For some people those scriptural passages are very familiar and a source of comfort and inspiration for others they may seem utterly irrelevant but for Nathan they were the real account of what he was going for and what it was all pointed toward. The greatest novelist who ever lived by the way who's that? Leo Tolstoy, truth like gold is to be obtained not by growth but by washing away all that is not gold. Remember those factors that cause physicians to be burned out? My encounters with Nathan were an opportunity to have that washed away and to get reacquainted with the real gold that lies at the heart of the medical practice what it means to be a doctor and at least in my case I encountered that in the person of one of the people I once taught for many years. So these kind of things definitely get me down. This is Van Gogh's Dr. Gache who in fact cared for Vincent Van Gogh during the last months of his life. Not exactly a picture of optimism or hopefulness in fact a kind of vacant despair. How did Nathan and his family avoid vacant despair? How were their lives not only touched but transformed in a way that's made them a better family and Nathan a better doctor? Well here I think is the key. For Nathan at least and by the way this is Nathan thinking of new uses for his chemotherapy port that's the little implement he's holding there. From his point of view suffering makes sense only in the context of some transcendent order. From his point of view he literally couldn't understand what he was going through day to day except in the sense that it was transcendent means to climb above or something that he was being pulled from above to become more than he was. For Nathan it didn't make sense unless he could understand the sacrifice of his suffering as having some transcendent purpose a reminder to him that this isn't all about him but maybe teaching him things that he could use to serve others. And finally from his point of view you and I and our patients are instruments of the transcendent serving purposes not only beyond our control but even beyond our can and for Nathan his experience of cancer was an opportunity to learn that lesson like he never had before. These are this picture means a great deal to me that's Nathan in the center and you see him flanked on either side by two of his colleagues who elected to shave their heads in solidarity with their sick sick colleague. So we think when we think about burnout I think we often think about resilience. How can we possibly bounce back? How can I get back to T zero right where I was before I fell ill? That's what I expect my doctor the health care team to do for me but from Nathan's point of view his affliction was not a call to resilience it was really a call to transcendence that he was being called to become something more than he was a better physician a better husband a better father and a better human being through suffering and that's I think the sense in which Nathan can say with a straight face that he thinks there's a beauty in suffering which he experienced first hand I'll stop there thank you.