Annie was my first patient at UCSF. Before John Danovich's motorcycle mayhem, depression and substance abuse, we all met Annie the CPR dummy in a simpler time. She had no past, no complications with a co-dependant girl-friend, no iatrogenic pain killer addiction spurred on by chronic back pain. She was found down in a classroom, where we, all new first year medical students, were learning the basics of life support. And we were asked to save her.

I surveyed the situation: things didn't look good. Annie had a trickle of drool around her mouth from the last student's attempts at rescue breathing, but I thought it only polite to ignore that given the gravity of the situation. Annie hadn't breathed spontaneously since I entered the room half an hour ago. Her skin felt plastic when I put my hand on her shoulder. And, most remarkably, she had lost both arms and both legs in some unknown previous mishap. The situation was grim.

Annie never really had a chance. Apart from her formidable health problems (quadruple-amputee, Glasgow Coma Score of three, plasti-dermia), her best available health care was from medical students with one week of experience. And we were far from doctors. We were former school teachers, consultants and Peace Corps volunteers. We had excelled in our fields, and we could field a champion volleyball team or a professional orchestra with equal finesse. We performed opera; we published articles. One of us worked on a nuclear submarine. We wore our starched white coats with empty pockets and hung our new stethoscopes around our necks with studied indifference, but we were not doctors.

While the real doctors saved lives, I was floundering to save Annie. I forgot to lock my elbows over her chest, and my compressions were too weak to pump her blood. Annie never complained. Nor did the next hundred real patients as we squinted our eyes and cocked our heads to try to hear murmurs. Or tried to take a sexual history while ignoring the warm red blush that spread up from our ties. Or tried our first procedure in too small, too clumsy latex gloves without showing that our hands were shaking. We were small and clumsy ourselves, lacking the presence of the white-haired attendings who are at ease with illness. Yet, we were always somehow in the way, seeming to stand awkwardly between our patients and real medicine.

Somehow, all those patients knew we were learning. They understood we would be uncertain and we would make mistakes but they let us try anyway. They took our stumbling with humor, with patience, and occasionally with pity, then they let us try again.

One of my most memorable stumbles was my second day of my rotation in the Neonatal Intensive Care Unit. I was nervous because this was my first sub-internship, a month when fourth year medical students assume more responsibility for their patients. My patients were especially intimidating because they were all less than one month old. They seemed more fragile because the unit was sterile and required a surgical scrub whenever entering it.

I noticed the butterflies in my stomach early that morning as I was gathering details on each of my patients. I hadn't felt butterflies since my first months in the hospital and I realized how much I wanted to do well. But, as the time approached for me to present the patients in front of the attending and team, the butterflies became beetles which became full fledged hummingbirds.

We began rounds with my patient, a one week old boy born with his bladder open on his abdomen. I recounted his activities overnight and gave detailed numbers about his breathing pattern, heart rate and acid-base status. The attending stopped me, noting that my patient's blood was acidic and asked me what would cause this.

Quizzing by an attending is colloquially termed "pimping." I'm uncertain of the etymology of the word, but I don't think it reflects well on the one being pimped. This would be a benign pimp, one where I should know the relatively easy answer. I recited all the facts I could remember about acid-base, about neonates, about the bladder-hoping to get the answer by the shotgun approach. This is called a "flail" and the word brings to mind all the desperation and useless energy of the moment. The attending pimped, and I flailed. I flailed and she pimped. And all the while, the hummingbirds increased in both velocity and number.

Medicine is taught through experience and the best lessons are learned from patients. We care for patients and soon reach the limits of our understanding, the border of our comfort. And that's where we start to learn. Learning medicine requires practice, and practice requires mistakes. We learn by doing, by trial and error, because you can't teach these skills from a book. We've spent these years making a long list of mistakes. We squint and stare at the chest xray, hoping to see what they see: that the stratus clouds of the lungs will be too wispy or too thick and that we will see the pneumonia. We push the needle towards where we thought we felt the tiny kick of the radial artery, hoping to get the jump of blood into the syringe. We make a thousand mistakes in order to earn that first success. And we make many more to refine our skills, our judgment, our practice of medicine.

I hate mistakes. I've spent the majority of my life trying to avoid making mistakes. We have earned our entrance into medical school, in part, by our ability to make fewer mistakes than the next person. And now, medicine is telling us that we will make mistakes, that we must make mistakes in order to learn. That there is no other way to learn. Medicine is built on a history of stumbles. If it has climbed to any exalted height, it is only because of the innumerable errors, mistakes and corrected hypotheses that are its foundation. I came to medical school hoping to learn to avoid mistakes. Instead, I've found that we must be willing to make mistakes over and over again in order to learn. Each has a lesson to teach. Still, it can be difficult to extract some lessons.

So, that day on the neonatal unit, the mistakes were thick and the learning was rich. The attending was pimping and I was flailing. And to add one last word to your new med school vocabulary: that's when I "crumped." To crump is to actively fall apart. Usually, it's done by patients. That day, I was doing it. One of the other team members said, "Pete you don't look good" and another said, "you're white as a sheet."

That's when I felt it coming. There is a horrible, inevitable moment when you know that you will vomit in only a few small seconds, but it hasn't happened yet. It is enough time to run towards the scrub sink in the front of the unit, but not enough time to make it there safely. But you run anyway, because you may as well try. And you cover your mouth with your hands, even though you know from physics that your cupped palms cannot possible contain or stop the upwelling tide. In fact, those same hands which cannot stop the inevitable instead spray it laterally. And vomit now completely obscures your glasses, and you are blind, and running, and vomiting in the neonatal intensive care unit.

I am still trying to discern the lesson from this dramatic embarrassment. Some sort of lesson might make it all worthwhile. But I don't know what I learned that day. Often, these mistakes don't have a reason or a fault. They just become experience: Experience that shows us as more entirely human than we want.

In preparing this speech, I found that most of us have some mistake, some embarrassment in which the moral is not entirely clear. My favorite is the student who found himself first to arrive at a code, when a patient needs acute life support. He climbed over the chest, locked his elbows and began chest compressions just as Annie had taught him. As the flurry of activity began to build around him, a blood pressure cuff was passed over the patient. The Velcro on the cuff snagged the drawstring on his scrub bottoms and released the knot holding up his pants. With each chest compression, his pants fell a centimeter lower, revealing more of his fish-print boxers.

What is the lesson to be learned in these stories? Except perhaps to give us an extra dose of humility, a lesson in humanity. We yearn for a perfection in medicine, but we know we will never attain it. Mistakes are inevitable and necessary. The mistakes we make don't just show our fallibility but also our willingness to be wrong and to have tried. We connect with our patients most when we press the limits of our knowledge. Trying to answer what is happening and why, and what we can and cannot do. The terrain is pock-marked with error: the patient with a clearing rash and improved mental status who dies suddenly the next day; the drug we hope will work although we're not sure how; the infant who heals despite us and our foreboding. Of course, we have to try. Because success is worth the hundred embarrassments that came before it. Because good medicine requires making mistakes and learning from them. Because, in the end, this is why patients came to us: just try.

I saw Annie again recently. I was glad to see her. She was doing well, despite three new generations of medical students flailing on her chest. This time, she was the dummy for advanced cardiac life support class taught in our last class in medical school. She gave me one last chance to practice, to build confidence, to learn to be a doctor.

It had been almost four years since I had seen her, days after 9/11. Learning life support had seemed immediate and necessary in those uncertain days, too, as we held our breaths waiting for another disaster. Instead, New York City set up tents in Central Park to care for a deluge of injured survivors that never came. Tragedy happens, even without mistakes. And doctors were left with little ability to heal.

We gave blood, we called friends and family and gave comfort and support where we could. It seemed pitifully small. But, I think it was the time we were most like doctors. We were just trying, unsure whether we could help but willing to try.

We have finished four years and innumerable mistakes. Now, we are a walk and a handshake from becoming the doctors we've been impersonating for four years. The doctors who know how to turn the sick well again. Now, after four years, I see the lines of concern and uncertainty on the faces of my favorite doctors-- concern for the next mistake. What distinguishes these attendings from their students, from us, is not just the books they have read but the mistakes they've seen and the mistakes they've made. The knowledge of the fundamental uncertainty of medicine that makes it such a human endeavor. And the courage to rise from mistakes willing to learn from them and to make more.

Next year, we move on to internship: to new mistakes and new lessons. To wish that next year is perfect would be hopeless and stagnant. So, instead, I'll wish us the best of mistakes. The happy endings, the funny stories. The ones that train a surgeon's hand, a radiologist's eye and an internist's judgment. The ones that train intuition and demonstrate humanity. And most of all, the willingness to rise from mistakes willing to make more.