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The Dean's Column: 194th Commencement



Class of 2018, on this milestone day—your day—my message to you is “Embrace the unfamiliar.”

You’re graduating into an age in which physicians will be called upon to reinvent themselves, routinely, every decade or two; for some specialties, an even shorter cycle. Surviving, let alone thriving, in this kind of hyperdynamic environment will call on you to cultivate certain traits within yourselves. An ability to reach beyond the familiar is one of these traits, and I’d like to examine it from three different perspectives.

Apropos to the hyperdynamic landscape you now face, let’s start with how we anticipate disruptive change. Doing so effectively means keeping our antennae up for the unfamiliar—detecting that transformational device, that disruptive process or service poised to unsettle our here and now.

Interestingly, the transformational element often coexists for a time, side by side, with the existing element that it is poised to displace—admixed if you will, in a sort of transformed-plus-
existing mosaic.

Early on, still surrounded by mostly familiar, it’s all too easy to psychologically wall off that which is unfamiliar, to ignore those transformed pieces that portend radical change. Slowly emergent, not particularly threatening to our routines of the now, the transformed creeps up on us, imperceptibly insinuating itself into the mosaic. With the looming disruption so masked, we don’t bother to prepare for a radically new reality. But soon enough, the mosaic becomes increasingly dominated by the transformed, until one day—poof!—there’s a tipping point, and the existing is gone, fully transformed. And then—well, it’s too late.


Not a revolution. One minute things are so; the next minute they are not so. And not an evolution, where one sees intermediate hybrid forms emerging in stages. Think mosaics. If you ignore the unfamiliar creeping into the mosaic, the game is soon over. You’ve reached the “Kodak moment”—the moment the world’s largest maker of camera film realized that consumers had gone digital, and they were too far away to chase. It was too late.

Most revolutions slowly evolve under our very noses—subtly enough so as not to jar our steady-state, day-to-day rhythms. In the words of George Orwell, “To see what is in front of one’s nose needs a constant struggle.”

Best that we not make Kodak’s mistake. One glaring unfamiliar in the healthcare mosaic now before us is what amounts to a converging holy alliance among artificial intelligence, robotics, telepresence, handheld medical diagnostic devices, and nonphysician providers. If you went into medicine seeing yourself as an Oslerian, all-knowing master diagnostician—a real-life Dr. House—you’re likely to be disappointed. Before too long, the subset of filtered patients making it through the gauntlet will appear before you already diagnosed—maybe at home, maybe in the front office—by AI-empowered nonphysician providers and an armamentarium of next-gen diagnostic tools. This AI-driven upheaval in healthcare delivery will be every bit as profound as Amazon’s decimation of Main Street stores.

AI will radically recast professions like ours. All this unfamiliar seems so obvious, right? Yet we still get out of our cars each morning, engage in our familiar, daily routines, plod on as usual—without AI, without deep learning, without robotics.


You were here at Jefferson during a truly historic phase of this 200-year-old institution. You’ve witnessed firsthand the tripling of our clinical footprint through death-defying mergers; our rolling out the nation’s most ambitious academic telehealth program; the out-of-the-box union of a health sciences university with one known for textiles, fashion, design, and architecture; the literal blowing up and replacement of our lecture-based curriculum with a radically new JeffMD; the innovations reflected in our pioneering Medicine+ co-curriculum, with a view toward training a new kind of 21st-century physician who can think across fields. This was our very purposeful journey to embrace the unfamiliar.

Look at it from a second angle: The unfamiliar can be right there in front of our eyes, but readily ignored when not viewed at proper scale. Scale is critical. We are too often insulated from looming disruption because things that are familiar on a small scale tend to be unfamiliar and ignorable at large scale.

I’ve become obsessed of late with this mental trickery of scale—our utter lack of appreciation for proportion.

Last month, at a conference organized by the Jefferson-affiliated Transcending Trauma Project, I was on a panel with a survivor of the Rwandan butchery—an estimated 500,000 to 1 million Rwandans killed during the 100-day period from April to July 1994, close to 70 percent of the Tutsi population.


No need to go that far back. Overlapping your four years at our medical college, close to a half-million people were killed in Syria, not to mention the millions maimed and displaced. Connected to my own family history, the 1.5 million children extinguished in the Holocaust genocide—and disturbingly, we learn that 40 percent of millennials don’t have a clue what the Holocaust is, with others saying that they are tiring of its mention.

And yet, what is the news covering? A deluge of the nonsensical, no matter the channel or political persuasion. Nonsensical. Notwithstanding the whirlwind of telecommunication advances, we are as disconnected as ever from past, present, and future—and a big part of that disconnect is the utter lack of a sense of proportion.

No doubt, the death of one is a tragedy. But why is the death of a million less so? Because we can relate to the one. The one is familiar, while the million is unfamiliar. Familiar will trump the unfamiliar every time. My plea: Consciously counter this mental trap. Think small, but force yourselves to also think big. Look outward. See the familiar one, but also see the unfamiliar many.

Clinging to the familiar has a third related impact: It confines our imaginations, it impedes us from looking beyond our narrow screens.

During World War II, American behaviorist B.F. Skinner attempted to develop a pigeon-controlled, guided bomb. Train pigeons, housed in the nose of the bomb, to act as “pilots.” Three lenses mounted in the nose projected an image of the target on a screen. The pigeons, stationed in front of the screen, were trained to recognize the target—and by pecking on it, correct any deviations in the bomb’s course and keep it on its glide path. Perhaps, fortunately for pigeons, electronic guidance systems spelled doom for their newly minted job.


But it’s not just pigeons—it’s us. Too often, we find ourselves pecking away at the screen, driven by algorithms, proceeding mechanically. I’ve always viewed Project Pigeon as a powerful metaphor for the narrow perspective, for being confined to familiar paths, pecking away at the limiting screens in front of us, tracking our own personal glide bomb, whatever it might be.

So what’s the antidote? Random walks. Wander; stray beyond the familiar. Take leaps of imagination, let intelligence flow freely.

Abraham Flexner, who revolutionized 20th-century medical education, authored a small volume titled Usefulness of Useless Knowledge, in which he makes a strong case for nonapplied research, freewheeling, untethered discovery, or what he calls “exploratory blue-sky research.” He argues eloquently for scientists having the freedom to wander into unfamiliar territories, even when there is no clear path to practical application. From such wandering have come revolutionary technologies. Usefulness of Useless Knowledge is an ode to the embrace of the unfamiliar.

This notion of random walking ties directly to another one: the “adjacent possible.” Last month, at the launch of the Jefferson Humanities Forum series, the topic was “Fusion”—creativity that emerges at the boundaries of unrelated disciplines. Steven Johnson, a luminary in our understanding of drivers of innovation, spoke about the concept of “the adjacent possible—a kind of shadow future, hovering on the edges of the present state of things, a map of all the ways in which the present can reinvent itself … its boundaries grow as you explore them. Each new combination opens up the possibility of other new combinations.” The adjacent possible, by definition, hovers in that weird and murky territory cohabited by familiar and unfamiliar.


So leverage the “adjacent possible.” Let it catapult your imagination. From circus creator P.T. Barnum, “One’s station is only limited by his imagination.”

Class of 2018, time to sum up: I urge you to pay heed to the unfamiliar—use it to better intuit the future and anticipate disruptive change, to appreciate scale and put yourselves in perspective within a much larger world around you, to imagine creative solutions by randomly walking through adjacent possibilities. Break loose from your pigeon screens. As too many of our leaders skirt the pain of being awakened from their narrow visions, you be the ones to see what is right there in front of your noses.

From the lyrics of Queen in “The Show Must Go On”: “My soul is painted like the wings of butterflies, fairy tales of yesterday will grow but never die. I can fly, my friends.”

Graduates, head out of Jefferson and fly!