When I took down my blog last year, I went back and read through most of the posts. The posts I regret — the posts I deleted first — were attacks on specific people or bloggers, very SIWOTI kinds of arguments that don’t really matter to anybody. And I decided I would never do that kind of blogging again.

So this is not that kind of post, but I just can’t let Dr. Salwitz skate past without a few remarks. I mean, really: “At the hospital, we will …  Make new syringes into trash…. Dull scalpels.  Plan vacations….  Give out beds to homeless.” I hope to Hippocrates I don’t need to go to the hospital the day after the day they cured cancer. “We’re sorry, Mr. Cross: you can’t get any needle drugs because we threw away all our syringes, you can’t have surgery until we sharpen all the scalpels we decided to make dull, you can’t see a doctor until they all get back from vacation, and we don’t have a bed for you because we gave all of our Hill-Rom electronic adjustable memory-foam hospital beds that cost $5,000 (used) out to homeless people who are now pushing them around town unplugged and defunct. But you see, this all a good thing: we just cured cancer. You’re f—-ed, but cancer is cured.” Cancer is of course the only disease that matters to anyone, anywhere, ever. The day cancer is cured, the rest of us sick people had better be out there throwing confetti or lighting fireworks or whatever.

And if you currently have or have ever had cancer, guess who Dr. Salwitz considers the ‘soldiers’ in that fight? Not you, my friend. Instead, “the lab tester, blood drawer, x-ray taker, pharmacy mixer, front desker, researcher, bill sender, educator, social worker, floor cleaner, food cooker, CT scanner, doctors and every disease task doer”. So congrats — in the war on cancer, those of you with the disease are just the battlefield, not part of the army. The ‘bill sender’ that sends you the bill you can’t pay because you lost your insurance when you got fired because you were too sick to work: he’s a soldier, but you’re… a survivor? victim? refugee?

Don’t get me wrong: it will be a good day when we cure cancer. I don’t think cancer is a good thing. But I’m also aware that it’s not at all the only bad thing out there. So maybe Dr. Salwitz could just nod in that direction, instead of writing as if a cure for cancer will bring the end of history. And I know this is selfish of me, but the thing I am most looking forward to from the cure for cancer is an airtight excuse not to give money to the cancer walk-a-thonners. That will be a great day, though I have the sneaking suspicion that the very next year I’ll get a ton of emails asking me to contribute money to a walk-a-thon commemorating the victory against cancer, or some such malarkey. That Komen lady will never give up — of that, I am certain.

There, now. I have done my sniping, and it’s time to get serious and meaningful and important. You don’t have to take any of the above too seriously, but the rest is stone-cold reality.

Dr. Salwitz writes that, “I will see life on the day we cure cancer.” I get what he means, but here’s the thing: there will be life to see every second of every day between now and the day we cure cancer. Cancer — disease in general — does not make our lives invisible. Dr. Salwitz does not need to wait for a cure to open his eyes to those lives — the amazing, insistent, exhilarating, exhausting lives being lived by the people all around him, especially his patients. It is there, it is there right now, and it cannot wait for a cure.

The cancer people — the ‘soldiers’, not the patients — have this idea that all we really need to make things right is a cure. A cure will make cancer disappear forever. And it’s a fantasy. It’s not going to happen, and if it does, there would still be millions of people suffering the effects of having had cancer. If my illness were cured tomorrow, I would still be messed up and fragile and difficult. I would still be haunted by death. But even if my illness is never cured, I will still be every bit as alive as I was before I got sick. And I want physicians who see that, who are willing to help me fight to live that life now. I can’t wait for a cure. I won’t suspend my life waiting for a cure that might never come.

Ultimately, I don’t care whether I am cured or not, whether I live or die, so long as the life I have right now is meaningful. I don’t think Dr. Salwitz gets that, and I worry this is a widespread attitude among the medical community. Patients — whether or not they have cancer — do not need a cure to start living. What they do need is physicians with open eyes and hearts and minds, who are ready to help them fight to live as best they can today.

Hello Class of [insert year]. Congratulations on this very special day. If you think your parents are excited for you, wait till you hear from your lenders. I don’t envy you that.

Nor do I envy you the effort you have had to expend to get here. You must be tired. I will be brief.

Your education and training puts you in the elite of knowledge-based professions. In this increasingly knowledge-driven economy, you are drawing ever closer to the peak. Your skills are invaluable to society; your expertise essential to civilized life. Without you or people like you, our society would literally fall apart. You can expect – and you will command – tremendous respect for your achievements  and accomplishments thus far.

There are, however, different kinds of knowledge. You have been trained in the clinical, and nobody in their right mind will question your qualifications of clinical issues. Which isn’t to say you won’t be questioned; there’s always Jenny McCarthy, whose most valuable contribution to civilization was sucking the chrome off a trailer hitch in “BASEketball“.

But the people who come to see  you: they will come because your knowledge can help them. Many of them will depend on you – their lives will depend on you – to use your knowledge to solve a problem they face. Diseases. Injuries. Disabilities. And I trust you will excel in this task.

The vast majority of problems you will see have a simple, straightforward remedy. Antibiotics for strep. A cast for a broken bone. Stitches for a deep cut. A band-aid and reassurance for a worried parent.

And the people you see – the people you help – will be tremendously grateful to you. You will have their thanks, and their respect, and no small amount of their money. (Someone will get the money, anyway – even if your share seems too small.) And they will leave the clinic and go back to their homes, to their lives, to their worlds.

For a few of your patients, your knowledge won’t be enough. You won’t know how to cure Huntington’s disease. You won’t know how to cure MS, or RA, or IBD, or any of dozens of illnesses still baffling medical science. For people with these diseases, your knowledge won’t be enough. You won’t have the knowledge necessary to send them back to their lives. Nobody does. That’s something you – and they – will have to learn to live with, for the time being. Their problems will be ongoing, and will cost these people tremendously – in money, in time, in tears, sweat, blood.

Many of them will die from their illnesses. And I am sorry you will have to be party to that. Don’t torture yourself if you didn’t know enough to save them. Just don’t stop learning.

In the meantime, the fact that their illnesses persist means they will face a myriad of additional problems. These problems are not clinical. They are beyond your training and expertise.

To take an example from my own life: shortly after I graduated from college, I was in the middle of a mild flare of my disease. I was functional, I could work, but I looked sick. And as I interviewed for jobs – I was well-qualified – it was obvious that I was sick. And nobody would hire me. Which meant I could not get health insurance. These problems affected my clinical situation – I volunteered for clinical trials, as a way to get health care – but they were not simply clinical problems.

Your patients will face stigma. They will struggle through routine, daily tasks. They will have difficulty working. They will have difficulty paying you to help them. They will face emotional stress and pain well beyond what their physical condition might suggest. Spouses and loved ones will reject and abandon them.

Many of them will face these struggles utterly alone. And they will bring their lives into your clinic. You will be sorely tempted to ignore these problems, or to minimize them, but you should not.

You are right to think that these are not “your problems”, because they are not clinical problems. They are not the problems you have been trained to address. We might call them instead “social problems” – to capture in a broad stroke what is economic, emotional, relational, and political about being ill. Disease may be a clinical problem at root, but illness in full bloom is very much a social problem.

Just as there is clinical knowledge – and you are its vanguard – so there is social knowledge. Many of you – thank God – have an aptitude for social knowledge, but you are not experts. In fact, precious few people are. Most of your patients – the ones who need your help the most – will not have access to anyone will the sort of social-knowledge expertise that might help them.

So they will face a host of problems for which there is no “doctor”. And some of these social problems will be more pernicious than disease itself. Some of these problems will be every bit as disabling as their diagnosis.

As experts in clinical knowledge, you are taught to narrow problems down to a single point. It’s not enough to treat every skin problem the same, nor every skin cancer the same. You instead narrow the problem down to a single point – basal cell carcinoma, perhaps – and that is the problem you solve. Yes, I am oversimplifying – but a great many of the problems you have been trained to solve are like this.

Social problems are not like this. They do not exist at a single point. They are often vast and nebulous, in defiance of any attempt to narrow or simplify them. They are often “wicked”, in the technical sense – you think you’re solving one problem, and create three others.

I am not saying you should shy away from these problems. I am warning you: they are much tougher than anything you are trained for. I want you to be engaged and interested in how your patients live outside the clinic, but if you think you have found a simple, single solution to their problems, you are wrong. You are applying clinical knowledge to social problems, and at best you will not help your patients. At worst, you will harm them, perhaps grievously.

(And by the way, you will never be sued or punished for this sort of mistake , as you might be for clinical mistakes. There are doctors who destroy their patients with clinical solutions to social problems, without ever realizing what they are doing. I have survived two of them myself.)

To offer a possibly controversial example on a large scale: we are in the midst of a debate over health care reform, with physicians tending towards either pole. On on side, there are physicians who vehemently insist that the market is the solution to our health care problems, as if “the market” were a pill dispensed by your local economist that we could all take. On the other side, there are physicians who vociferously push for a single-payer overhaul – as if we could simply anaesthetize our health-care system, wheel it into the OR, and emerge a few hours later with single-payer. This is clinical thinking, applied to social problems.

Neither one has much chance of working, at least not in the ways their physician supporters expect. It takes social knowledge to appreciate that fact.

But even if you don’t know much about social problems, you can always learn. There are ways to train people to be experts in social knowledge. You have likely received minimal, if any, training in the social problems surrounding disease, and for that I am sorry. I wish it were otherwise, but perhaps the clinical was already demanding enough.

In all likelihood, you will learn most of your social knowledge on your own. One of your best resources – apart from here and now – is, of course, your patients. Listen to them. Talk to them. Ask them about their lives. Ask them how you can help. As you learn, do not be too quick to arrive at your conclusions.

Whatever else you do, please do not assume that your expertise lends itself to social knowledge. When you step through the clinic doors into the realm of the social, you have just as much to learn as the rest of us. You are just as unqualified as anyone else.

Rest assured: you can spend your entire career in ignorance of the social problems your patients face, and still be a very fine doctor by the standards of your field. You may choose to ignore those problems and focus exclusively on clinical problems – and many of you probably will. But if you are among them, for Pete’s sake, don’t pretend you are doing anything more.

A few of you will attempt to balance social and clinical knowledge, and your reputation as a clinician will likely suffer. But the payoff is this: if you succeed, if you come to appreciate the social problems patients face even half as much as you understand their clinical problems, you will have the ability to help millions of people. It goes without saying that you will not see most of these people in your clinic, but your knowledge will have tremendous potential to transform their lives for the better – in fact, to transform society for the better.

In either case, you first must learn to recognize the difference between the clinical and social. If you cannot do that, you might well be a help to your patients, but you will never – never – be the help they need.

Again, congratulations – and good luck.

*Attention medical schools: it is in fact possible for you to live out this fantasy, and my definition of “fabulously well-paid” is really quite modest. Email me.