TEDGlobal 2011
Abraham Verghese: A doctor's touch
Abraham Verghese: En læges berøring
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Moderne medicin er i fare for at miste et magtfuldt, gammeldags værktøj: Menneskelig berøring. Læge og forfatter Abraham Verghese beskriver vores mærkelige nye verden, hvor patienter blot er datapunkter, og påberåber en tilbagevenden til den traditionelle en-til-en fysiske undersøgelse.
Abraham Verghese - Physician and author
In our era of the patient-as-data-point, Abraham Verghese believes in the old-fashioned physical exam, the bedside chat, the power of informed observation. Full bio
In our era of the patient-as-data-point, Abraham Verghese believes in the old-fashioned physical exam, the bedside chat, the power of informed observation. Full bio
Double-click the English transcript below to play the video.
00:15
A few months ago,
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For et par måneder siden
00:17
a 40 year-old woman came to an emergency room
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kom en nogen og 40 år gammel kvinde på skadestuen
00:20
in a hospital close to where I live,
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på et hospital tæt på, hvor jeg bor,
00:22
and she was brought in confused.
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og hun blev bragt forvirret ind.
00:24
Her blood pressure was an alarming
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Hendes blodtryk var en alarmerende
00:26
230 over 170.
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230 over 170.
00:29
Within a few minutes, she went into cardiac collapse.
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Inden for få minutter fik hun hjertestop.
00:32
She was resuscitated, stabilized,
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Hun blev genoplivet, stabiliseret,
00:35
whisked over to a CAT scan suite
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kom hurtigt til en CAT scanning
00:37
right next to the emergency room,
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lige ved siden af skadestuen,
00:39
because they were concerned about blood clots in the lung.
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fordi de frygtede blodpropper i lungen.
00:42
And the CAT scan revealed
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Og CAT scanningen viste
00:44
no blood clots in the lung,
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ingen blodpropper i lungen,
00:46
but it showed bilateral, visible, palpable breast masses,
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men den viste bilaterale, synlige, følbare
knuder i brystet,
knuder i brystet,
00:51
breast tumors,
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brysttumorer,
00:53
that had metastasized widely
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der havde metastaseret stort set
00:55
all over the body.
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til hele kroppen.
00:57
And the real tragedy was, if you look through her records,
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Og den virkelige tragedie var, hvis man gennemgår
hendes journaler,
hendes journaler,
01:00
she had been seen
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var hun blevet tilset
01:02
in four or five other health care institutions
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i fire eller fem andre sundhedsinstitutioner
01:04
in the preceding two years.
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i de forgangne to år.
01:06
Four or five opportunities
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Fire eller fem muligheder
01:08
to see the breast masses, touch the breast mass,
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for at se knuderne i brystet, mærke brystmassen,
01:10
intervene at a much earlier stage
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gribe ind på et tidligere stadie,
01:13
than when we saw her.
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end da vi så hende.
01:15
Ladies and gentlemen,
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Mine damer og herrer,
01:17
that is not an unusual story.
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det er ikke en usædvanlig historie.
01:19
Unfortunately, it happens all the time.
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Desværre sker det hele tiden.
01:22
I joke, but I only half joke,
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Jeg spøger med, men kun halvt,
01:24
that if you come to one of our hospitals missing a limb,
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at hvis man kommer til et af vores hospitaler
uden et lem,
uden et lem,
01:27
no one will believe you till they get a CAT scan, MRI
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vil ingen tro dig, før de får en CAT eller MRI scanning
01:30
or orthopedic consult.
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eller ortopædisk konsultation.
01:32
I am not a Luddite.
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Jeg er ikke maskinstormer.
01:34
I teach at Stanford.
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Jeg underviser på Stanford.
01:36
I'm a physician practicing with cutting-edge technology.
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Jeg er en læge, der praktiserer
med banebrydende teknologi.
med banebrydende teknologi.
01:38
But I'd like to make the case to you
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Men jeg vil gerne argumentere for
01:40
in the next 17 minutes
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i de næste 17 minutter,
01:42
that when we shortcut the physical exam,
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at når vi skærer den fysiske undersøgelse væk,
01:46
when we lean towards ordering tests
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når vi læner mod at bestille prøver
01:48
instead of talking to and examining the patient,
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i stedet for at tale til og undersøge patienten,
01:51
we not only overlook simple diagnoses
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vil vi ikke kun overse simple diagnoser,
01:54
that can be diagnosed at a treatable, early stage,
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der kan diagnosticeres på et tidligt stadie, hvor det kan behandles,
01:57
but we're losing much more than that.
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vi mister meget mere end det.
01:59
We're losing a ritual.
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Vi mister et ritual.
02:01
We're losing a ritual that I believe is transformative, transcendent,
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Vi mister et ritual, som jeg mener er omdannende, transcendent
02:04
and is at the heart
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og i hjertet
02:06
of the patient-physician relationship.
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af patient-læge-forholdet.
02:08
This may actually be heresy to say this at TED,
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Det kan muligvis være kætteri at sige dette på TED,
02:11
but I'd like to introduce you
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men jeg vil gerne introducere jer
02:13
to the most important innovation,
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for den vigtigste opfindelse,
02:15
I think, in medicine
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synes jeg, i medicin
02:17
to come in the next 10 years,
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i de næste 10 år,
02:19
and that is the power of the human hand --
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og det er den menneskelige hånds magt --
02:21
to touch, to comfort, to diagnose
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at berøre, trøste, diagnosticere
02:24
and to bring about treatment.
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og sørge for behandling.
02:26
I'd like to introduce you first to this person
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Jeg vil gerne introducere jer for denne person,
02:29
whose image you may or may not recognize.
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hvis billede I måske genkender.
02:31
This is Sir Arthur Conan Doyle.
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Dette er Sir Arthur Conan Doyle.
02:33
Since we're in Edinburgh, I'm a big fan of Conan Doyle.
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Da vi er i Edinburg, er jeg en stor fan af Conan Doyle.
02:36
You might not know that Conan Doyle went to medical school
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I ved måske ikke, at Conan Doyle studerede medicin
02:38
here in Edinburgh,
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her i Edinburgh,
02:40
and his character, Sherlock Holmes,
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og hans karakter, Sherlock Holmes,
02:42
was inspired by Sir Joseph Bell.
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var inspireret af Sir Joseph Bell.
02:45
Joseph Bell was an extraordinary teacher by all accounts.
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Joseph Bell var en usædvanlig lærer på alle måder.
02:48
And Conan Doyle, writing about Bell,
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Og Conan Doyle, skrivende om Bell,
02:51
described the following exchange
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beskrev den følgende udveksling
02:53
between Bell and his students.
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mellem Bell og hans studerende.
02:55
So picture Bell sitting in the outpatient department,
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Forestil jer Bell siddende i ambulatoriet,
02:58
students all around him,
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studerende rundt om ham,
03:00
patients signing up in the emergency room
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patienter, der skriver sig ind på skadestuen
03:02
and being registered and being brought in.
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og bliver registrerede og bragt ind.
03:05
And a woman comes in with a child,
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En kvinde kommer ind med et barn,
03:07
and Conan Doyle describes the following exchange.
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og Conan Doyle beskriver den følgende
udveksling.
udveksling.
03:10
The woman says, "Good Morning."
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Kvinden siger, "Godmorgen."
03:14
Bell says, "What sort of crossing did you have
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Bell siger, "Hvordan var turen
03:17
on the ferry from Burntisland?"
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med færgen fra Burntisland?"
03:20
She says, "It was good."
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Hun siger, "Den var god."
03:22
And he says, "What did you do with the other child?"
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Og han siger, "Hvad gjorde du med det andet
barn?"
barn?"
03:25
She says, "I left him with my sister at Leith."
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Hun siger, "Jeg gav ham til min søster på Leith."
03:28
And he says,
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Og han siger,
03:30
"And did you take the shortcut down Inverleith Row
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"Og tog du genvejen ned af Inverleith Row
03:32
to get here to the infirmary?"
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for at komme til sygehuset?"
03:34
She says, "I did."
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Hun siger, "Det gjorde jeg."
03:36
And he says, "Would you still be working at the linoleum factory?"
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Og han siger, "Arbejder du stadig på linoleumsfabrikken?"
03:40
And she says, "I am."
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Og hun siger, "Det gør jeg."
03:42
And Bell then goes on to explain to the students.
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Og Bell starter med at forklare for sine studerende.
03:44
He says, "You see, when she said, 'Good morning,'
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Han siger, "Ser I, da hun sagde, 'Godmorgen,'
03:47
I picked up her Fife accent.
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anede jeg hendes Fife-accent.
03:49
And the nearest ferry crossing from Fife is from Burntisland.
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Og den nærmeste færge fra Fife afgår fra Burnisland.
03:52
And so she must have taken the ferry over.
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Og derfor måtte hun have taget færgen over.
03:55
You notice that the coat she's carrying
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Læg mærke til, at jakken, hun bærer,
03:57
is too small for the child who is with her,
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er for lille til barnet, der er med hende,
04:00
and therefore, she started out the journey with two children,
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og derfor begyndte hun turen med to børn,
04:03
but dropped one off along the way.
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men afleverede det ene på vejen.
04:06
You notice the clay on the soles of her feet.
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Læg mærke til leret på hendes skosåler.
04:08
Such red clay is not found within a hundred miles of Edinburgh,
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Den slags rødt ler findes ikke inden for hundrede mil fra Edinburgh,
04:12
except in the botanical gardens.
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bortset fra i botanisk have.
04:14
And therefore, she took a short cut down Inverleith Row
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Og derfor skød hun genvej ned ad Inverleith Row
04:17
to arrive here.
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for at komme her.
04:19
And finally, she has a dermatitis
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Og endelig har hun hudbetændelse
04:21
on the fingers of her right hand,
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på hendes højre hånds fingre,
04:23
a dermatitis that is unique
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en betændelse, der er unik
04:25
to the linoleum factory workers in Burntisland."
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for linoleumfabriksarbejderne i Burnisland."
04:28
And when Bell actually strips the patient,
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Og da Bell får afklædt patienten,
04:30
begins to examine the patient,
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begynder at undersøge patienten,
04:32
you can only imagine how much more he would discern.
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kan man kun forestille sig, hvor meget mere han ville udlede.
04:35
And as a teacher of medicine, as a student myself,
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Og som lærer i medicin og studerende selv
04:38
I was so inspired by that story.
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blev jeg inspireret af den historie.
04:40
But you might not realize
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Men I ved måske ikke,
04:42
that our ability to look into the body
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at vores evne til at se ind i kroppen
04:44
in this simple way, using our senses,
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på denne simple måde med vores sanser
04:46
is quite recent.
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er ret ny.
04:48
The picture I'm showing you is of Leopold Auenbrugger
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Billedet, jeg viser jer, er af Leopold Auenbrugger,
04:51
who, in the late 1700s,
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der sidst i 1800-tallet
04:53
discovered percussion.
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opdagede percussion.
04:55
And the story is that Leopold Auenbrugger
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Historien går, at Leopold Auenbrugger
04:58
was the son of an innkeeper.
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var søn af en krofatter.
05:01
And his father used to go down into the basement
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Hans far plejede at gå ned i kælderen
05:04
to tap on the sides of casks of wine
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for at banke på vintøndernes sider
05:06
to determine how much wine was left
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og bestemme, hvor meget vin, der var tilbage,
05:08
and whether to reorder.
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og om der skulle bestilles mere.
05:10
And so when Auenbrugger became a physician,
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Så da Auenbrugger blev læge,
05:12
he began to do the same thing.
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begyndte han at gøre det samme.
05:14
He began to tap on the chests of his patients,
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Han begyndte at banke på sine patienters bryst,
05:17
on their abdomens.
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på deres maver.
05:19
And basically everything we know about percussion,
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Stort set alt vi kender til percussion,
05:21
which you can think of as an ultrasound of its day --
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som man kan kalde den tids ultralyd --
05:25
organ enlargement, fluid around the heart, fluid in the lungs,
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organforstørrelse, væske om hjertet, væske i lungerne,
05:28
abdominal changes --
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forandringer i maven --
05:30
all of this he described in this wonderful manuscript
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alt dette beskriver han i dette manuskript
05:32
"Inventum Novum," "New Invention,"
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"Inventum Novum," "Ny Opfindelse,"
05:35
which would have disappeared into obscurity,
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som ville være gået i glemmebogen,
05:37
except for the fact that this physician, Corvisart,
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hvis ikke for denne læge, Corvisart,
05:40
a famous French physician --
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en kendt fransk læge --
05:42
famous only because he was physician to this gentleman --
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kun kendt, fordi han var læge for denne herre --
05:45
Corvisart repopularized and reintroduced the work.
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Corvisart genpopulariserede og genintroducerede værket.
05:49
And it was followed a year or two later
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Det blev fulgt op et år eller to senere
05:51
by Laennec discovering the stethoscope.
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af Laennecs opdagelse af stetoskopet.
05:54
Laennec, it is said, was walking in the streets of Paris
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Laennec, siges det, spadserede i Paris' gader
05:57
and saw two children playing with a stick.
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og så to børn lege med en pind.
05:59
One was scratching at the end of the stick,
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Det ene kradsede på pindens ende,
06:02
another child listened at the other end.
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et andet barn lyttede i den anden ende.
06:04
And Laennec thought this would be a wonderful way
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Og Laennec tænkte, dette ville være en skøn måde
06:06
to listen to the chest or listen to the abdomen
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at lytte til brystet eller bugen
06:08
using what he called "the cylinder."
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ved at bruge, hvad han kaldte "cylinderen."
06:10
Later he renamed it the stethoscope.
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Senere omdøbte han det stetoskopet.
06:12
And that is how stethoscope and auscultation was born.
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Sådan blev stetoskopet og auskultation født.
06:16
So within a few years,
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Så i løbet af få år
06:18
in the late 1800s, early 1900s,
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i slutningen af 1800-, starten af 1900-tallet,
06:20
all of a sudden,
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lige pludselig,
06:22
the barber surgeon had given way
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var barberkirurgen blevet skubbet til side
06:25
to the physician who was trying to make a diagnosis.
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af lægen, der forsøgte at stille en diagnose.
06:28
If you'll recall, prior to that time,
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Husk på, at før den tid,
06:30
no matter what ailed you, you went to see the barber surgeon
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uanset hvad man fejlede, gik man til barberkirurgen,
06:33
who wound up cupping you,
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der endte med at tappe en,
06:35
bleeding you, purging you.
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bløde en, rense en.
06:37
And, oh yes, if you wanted,
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Og, åh ja, hvis man ønskede det,
06:39
he would give you a haircut -- short on the sides, long in the back --
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ville han klippe en -- kort i siderne,
lang i nakken --
lang i nakken --
06:42
and pull your tooth while he was at it.
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og trække en tand ud, nu han var i gang.
06:44
He made no attempt at diagnosis.
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Han forsøgte ikke at diagnosticere.
06:46
In fact, some of you might well know
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Nogle af jer ved måske endda,
06:48
that the barber pole, the red and white stripes,
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at barberpælen, de røde og hvide striber,
06:51
represents the blood bandages of the barber surgeon,
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repræsenterer barberkirurgens blodige bandager,
06:54
and the receptacles on either end
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og beholderne i hver ende
06:56
represent the pots in which the blood was collected.
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repræsenterer potterne, hvori blodet blev opsamlet.
06:59
But the arrival of auscultation and percussion
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Men auskultations og percussions ankomst
07:02
represented a sea change,
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repræsenterede et skift,
07:04
a moment when physicians were beginning to look inside the body.
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et øjeblik, hvor læger begyndte at se ind i kroppen.
07:07
And this particular painting, I think,
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Og lige præcis dette maleri, synes jer,
07:10
represents the pinnacle, the peak, of that clinical era.
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repræsenterer toppen af den kliniske æra.
07:13
This is a very famous painting:
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Dette er et meget kendt maleri:
07:15
"The Doctor" by Luke Fildes.
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"Doktoren" af Luke Fildes.
07:18
Luke Fildes was commissioned to paint this by Tate,
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Luke Fildes blev bestilt til at male dette af Tate,
07:21
who then established the Tate Gallery.
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som etablerede Tate Gallery.
07:23
And Tate asked Fildes to paint a painting
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Tate bad Fildes male et maleri
07:25
of social importance.
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med social vigtighed.
07:27
And it's interesting that Fildes picked this topic.
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Og det er interessant, at Fildes valgte dette emne.
07:30
Fildes' oldest son, Philip,
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Fildes' ældste søn, Philip,
07:33
died at the age of nine on Christmas Eve
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døde i en alder af ni juleaften
07:36
after a brief illness.
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efter en kort sygdom.
07:38
And Fildes was so taken by the physician
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Og Fildes blev så rørt over lægen,
07:41
who held vigil at the bedside for two, three nights,
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der holdt vagt ved sengen i to, tre nætter,
07:45
that he decided that he would try and depict
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at han besluttede, at han ville forsøge at afbilde
07:47
the physician in our time --
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vor tids læge --
07:49
almost a tribute to this physician.
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næsten en hyldest til denne læge.
07:51
And hence the painting "The Doctor," a very famous painting.
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Og derfor maleriet "Doktoren," et meget kendt maleri.
07:54
It's been on calendars, postage stamps in many different countries.
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Det har været på kalendere, frimærker i mange lande.
07:57
I've often wondered, what would Fildes have done
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Jeg har ofte tænkt, hvad ville Fildes havde gjort,
08:00
had he been asked to paint this painting
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var han blevet bedt male dette maleri
08:02
in the modern era,
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i den moderne æra,
08:04
in the year 2011?
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i år 2011?
08:07
Would he have substituted a computer screen
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Ville han have indsat en computerskærm,
08:11
for where he had the patient?
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hvor patienten havde været?
08:13
I've gotten into some trouble in Silicon Valley
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Jeg er kommet i problemer i Silicon Valley
08:15
for saying that the patient in the bed
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for at sige, at patienten i sengen
08:17
has almost become an icon
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næsten er blevet et ikon
08:20
for the real patient who's in the computer.
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for den virkelige patient, der er i computeren.
08:23
I've actually coined a term for that entity in the computer.
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Jeg har faktisk fundet på et ord for det væsen i computeren.
08:26
I call it the iPatient.
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Jeg kalder det iPatienten.
08:28
The iPatient is getting wonderful care all across America.
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iPatienten bliver sørget godt for over hele Amerika.
08:31
The real patient often wonders,
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Den virkelige patient tænker tit,
08:33
where is everyone?
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hvor er alle?
08:35
When are they going to come by and explain things to me?
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Hvornår kommer de og forklarer mig tingenes tilstand?
08:38
Who's in charge?
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Hvem fører an?
08:40
There's a real disjunction between the patient's perception
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Der er stor forskel på patientens opfattelse
08:43
and our own perceptions as physicians of the best medical care.
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og vores egen opfattelse som læger af den bedste
medicinske behandling.
medicinske behandling.
08:46
I want to show you a picture
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Jeg vil gerne vise jer et billede af,
08:48
of what rounds looked like
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hvordan stuegang så ud,
08:50
when I was in training.
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da jeg var under uddannelse.
08:52
The focus was around the patient.
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Fokus var på patienten.
08:54
We went from bed to bed. The attending physician was in charge.
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Vi gik fra seng til seng. Den ledende overlæge førte an.
08:57
Too often these days,
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Alt for ofte nu om dage
08:59
rounds look very much like this,
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ser stuegang meget ud som dette,
09:01
where the discussion is taking place
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hvor diskussionen finder sted
09:03
in a room far away from the patient.
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i et rum langt fra patienten.
09:06
The discussion is all about images on the computer, data.
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Diskussionen handler om billeder
på en computer, data.
på en computer, data.
09:09
And the one critical piece missing
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Og det ene vigtige element, der mangler,
09:11
is that of the patient.
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er patienten.
09:13
Now I've been influenced in this thinking
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Jeg er blevet påvirket til denne tankegang
09:16
by two anecdotes that I want to share with you.
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af to anekdoter, som jeg gerne vil dele med jer.
09:19
One had to do with a friend of mine who had a breast cancer,
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En handler om en ven, der havde brystkræft,
09:22
had a small breast cancer detected --
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fik opdaget en lille brystkræft --
09:25
had her lumpectomy in the town in which I lived.
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fik lumpektomi i byen, hvor jeg boede.
09:27
This is when I was in Texas.
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Dette er, da jeg var i Texas.
09:29
And she then spent a lot of time researching
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Hun brugte så en masse tid på at undersøge,
09:32
to find the best cancer center in the world
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hvilket der var det bedste kræftcenter i verden
09:35
to get her subsequent care.
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at få hendes efterbehandling.
09:37
And she found the place and decided to go there, went there.
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Hun fandt stedet og valgte at tage derhen.
09:40
Which is why I was surprised a few months later
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Hvilket er derfor, jeg blev overrasket få måneder efter
09:43
to see her back in our own town,
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over at se hende tilbage i byen
09:46
getting her subsequent care with her private oncologist.
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og modtage hendes efterbehandling hos hendes
private onkolog.
private onkolog.
09:49
And I pressed her, and I asked her,
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Jeg pressede og spurgte hende,
09:51
"Why did you come back and get your care here?"
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"Hvorfor kom du tilbage og får din behandling her?"
09:54
And she was reluctant to tell me.
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Hun ville helst ikke fortælle mig det.
09:56
She said, "The cancer center was wonderful.
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Hun sagde, "Kræftcenteret var skønt.
09:59
It had a beautiful facility,
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Det havde et smukt anlæg,
10:01
giant atrium, valet parking,
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kæmpe atrium, parkeringsservice,
10:03
a piano that played itself,
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et piano, der selv spillede,
10:05
a concierge that took you around from here to there.
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en concierge, der tog dig rundt fra her til der.
10:08
But," she said,
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Men," sagde hun,
10:10
"but they did not touch my breasts."
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"men de rørte ikke mine bryster."
10:14
Now you and I could argue
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Nu kan vi argumentere for,
10:16
that they probably did not need to touch her breasts.
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at de nok ikke behøvede at røre hendes bryster.
10:18
They had her scanned inside out.
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De fik hende scannet på alle ledder.
10:20
They understood her breast cancer at the molecular level;
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De forstod hendes brystkræft på det
molekylære niveau;
molekylære niveau;
10:23
they had no need to touch her breasts.
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de havde intet behov for at røre hendes bryster.
10:25
But to her, it mattered deeply.
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Men for hende betød det meget.
10:28
It was enough for her to make the decision
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Det var nok for hende til at foretage beslutningen
10:32
to get her subsequent care with her private oncologist
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at få sin efterbehandling hos hendes egen onkolog,
10:35
who, every time she went,
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der, hver gang hun kom,
10:37
examined both breasts including the axillary tail,
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undersøgte begge bryster og armhuler,
10:40
examined her axilla carefully,
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undersøgte hendes lymfeknuder grundigt,
10:42
examined her cervical region, her inguinal region,
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undersøgte hendes livmoderhals- og lyskeregioner,
10:44
did a thorough exam.
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foretog en grundig undersøgelse.
10:46
And to her, that spoke of a kind of attentiveness that she needed.
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Og for hende, var det en slags opmærksomhed,
som hun behøvede.
som hun behøvede.
10:50
I was very influenced by that anecdote.
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Jeg blev meget påvirket af den anekdote.
10:52
I was also influenced by another experience that I had,
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Jeg blev også påvirket af en anden oplevelse,
jeg havde,
jeg havde,
10:55
again, when I was in Texas, before I moved to Stanford.
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igen, da jeg var i Texas, før jeg flyttede til Stanford.
10:58
I had a reputation
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Jeg havde et ry
11:00
as being interested in patients
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for at være interesseret i patienter
11:02
with chronic fatigue.
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med kronisk træthed.
11:05
This is not a reputation you would wish on your worst enemy.
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Dette er ikke et ry man ville ønske for sin værste fjende.
11:09
I say that because these are difficult patients.
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Det siger jeg, fordi disse er svære patienter.
11:12
They have often been rejected by their families,
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De er ofte blevet afvist af deres familier,
11:15
have had bad experiences with medical care
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har haft dårlige erfaringer med sundhedsvæsnet,
11:17
and they come to you fully prepared
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og de kommer til en fuldt forberedt på,
11:20
for you to join the long list of people
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at man kan komme på listen over folk,
11:22
who's about to disappoint them.
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der snart vil skuffe dem.
11:24
And I learned very early on with my first patient
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Jeg lærte allerede fra min første patient,
11:27
that I could not do justice
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at jeg ikke kunne yde retfærdighed
11:29
to this very complicated patient
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for denne meget komplicerede patient
11:31
with all the records they were bringing
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med alle de journaler, de bragte
11:33
in a new patient visit of 45 minutes.
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ved et nyt patientbesøg på 45 minutter.
11:35
There was just no way.
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På ingen måde.
11:37
And if I tried, I'd disappoint them.
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Hvis jeg forsøgte, ville jeg skuffe dem.
11:40
And so I hit on this method
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Så jeg prøvede denne metode,
11:42
where I invited the patient
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hvor jeg bad patienten
11:44
to tell me the story for their entire first visit,
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fortælle mig historien i hele deres første besøg,
11:47
and I tried not to interrupt them.
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og jeg prøvede ikke at afbryde dem.
11:50
We know the average American physician
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Vi ved, den gennemsnitlige amerikanske læge
11:52
interrupts their patient in 14 seconds.
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afbryder deres patient inden 14 sekunder.
11:55
And if I ever get to heaven,
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Hvis jeg skulle komme i Himlen,
11:57
it will be because I held my piece for 45 minutes
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bliver det, fordi jeg holdt min mund i 45 minutter
12:00
and did not interrupt my patient.
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og ikke afbrød min patient.
12:02
I then scheduled the physical exam for two weeks hence,
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Så planlagde jeg den fysiske undersøgelse to uger senere,
12:05
and when the patient came for the physical,
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og da patienten kom for undersøgelsen,
12:07
I was able to do a thorough physical,
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kunne jeg foretage en grundig fysisk undersøgelse,
12:09
because I had nothing else to do.
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fordi jeg intet andet havde at gøre.
12:11
I like to think that I do a thorough physical exam,
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Jeg synes selv, jeg foretager grundige undersøgelser,
12:14
but because the whole visit was now about the physical,
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men fordi hele besøget nu handlede om den fysiske,
12:17
I could do an extraordinarily thorough exam.
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kunne jeg foretage en usædvanlig grundig undersøgelse.
12:20
And I remember my very first patient in that series
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Jeg husker min allerførste patient i den serie,
12:24
continued to tell me more history
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blev ved med at fortælle mig mere historie
12:26
during what was meant to be the physical exam visit.
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under, hvad skulle have været besøget for den fysiske undersøgelse.
12:29
And I began my ritual.
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Jeg begyndte mit ritual.
12:31
I always begin with the pulse,
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Jeg begynder altid med pulsen,
12:33
then I examine the hands, then I look at the nail beds,
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så undersøger jeg hænderne, så på neglelejerne,
12:36
then I slide my hand up to the epitrochlear node,
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så fører jeg hånden op til epitroklærkirtlen,
12:38
and I was into my ritual.
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og jeg var i gang med mit ritual.
12:40
And when my ritual began,
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Og da mit ritual begyndte,
12:42
this very voluble patient
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begyndte denne meget talende patient
12:44
began to quiet down.
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at tie stille.
12:46
And I remember having a very eerie sense
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Jeg mindes at have en sælsom fornemmelse,
12:49
that the patient and I
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at patienten og jeg
12:52
had slipped back into a primitive ritual
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var gledet tilbage i et primitivt ritual,
12:54
in which I had a role
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i hvilket jeg havde en rolle
12:56
and the patient had a role.
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og patienten havde en rolle.
12:58
And when I was done,
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Da jeg var færdig,
13:00
the patient said to me with some awe,
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sagde patienten til mig med ærefrygt,
13:02
"I have never been examined like this before."
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"Jeg er aldrig blevet undersøgt sådan før."
13:05
Now if that were true,
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Hvis det var sandt,
13:07
it's a true condemnation of our health care system,
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er det en sand fordømmelse af vores sundhedssystem,
13:09
because they had been seen in other places.
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fordi de var blevet tilset andre steder.
13:12
I then proceeded to tell the patient,
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Jeg gik da videre til at fortælle patienten,
13:14
once the patient was dressed,
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da patienten var blevet påklædt,
13:16
the standard things that the person must have heard in other institutions,
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standardtingene, som personen må have hørt
i andre institutioner,
i andre institutioner,
13:19
which is, "This is not in your head.
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hvilket er, "Dette er ikke i dit hoved.
13:21
This is real.
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2000
Det er virkeligt.
13:23
The good news, it's not cancer, it's not tuberculosis,
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Det gode er, det er ikke kræft,
det er ikke tuberkulose,
det er ikke tuberkulose,
13:26
it's not coccidioidomycosis or some obscure fungal infection.
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det er ikke coccidioidomycosis eller en underlig
svampeinfektion.
svampeinfektion.
13:29
The bad news is we don't know exactly what's causing this,
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Det dårlige er, vi ved ikke præcis, hvad forårsager dette,
13:32
but here's what you should do, here's what we should do."
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men nu skal du høre, hvad du skal gøre,
hvad vi skal gøre."
hvad vi skal gøre."
13:35
And I would lay out all the standard treatment options
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Jeg ville lægge alle standard-
behandlingsmulighederne ud,
behandlingsmulighederne ud,
13:38
that the patient had heard elsewhere.
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som patienten havde hørt andre steder.
13:41
And I always felt
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Og jeg følte altid,
13:43
that if my patient gave up the quest
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at hvis min patient opgav søgningen
13:45
for the magic doctor, the magic treatment
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efter den magiske læge eller behandling
13:48
and began with me on a course towards wellness,
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og begyndte med mig på en kurs mod velvære,
13:51
it was because I had earned the right
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var det, fordi jeg havde fortjent retten
13:53
to tell them these things
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til at fortælle dem disse ting
13:55
by virtue of the examination.
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i kraft af undersøgelse.
13:57
Something of importance had transpired in the exchange.
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Noget vigtigt var kommet frem i udvekslingen.
14:01
I took this to my colleagues
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Jeg tog dette til mine kolleger
14:03
at Stanford in anthropology
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på Stanford i antropologi
14:05
and told them the same story.
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og fortalte dem den samme historie.
14:07
And they immediately said to me,
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De fortalte mig straks,
14:09
"Well you are describing a classic ritual."
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"Jamen, du beskriver et klassisk ritual."
14:11
And they helped me understand
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De hjalp mig med at forstå,
14:13
that rituals are all about transformation.
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at ritualer handler om forvandling.
14:16
We marry, for example,
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Vi gifter os, for eksempel,
14:18
with great pomp and ceremony and expense
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med pomp og ceremoni og udgifter
14:21
to signal our departure
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for at markere vores udtræden
14:23
from a life of solitude and misery and loneliness
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2000
af et liv i ensomhed og ulykkelighed
14:25
to one of eternal bliss.
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3000
til et af evig lyksalighed.
14:28
I'm not sure why you're laughing.
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Jeg ved ikke, hvorfor I ler.
14:30
That was the original intent, was it not?
345
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Det var det oprindelige formål, ikke sandt?
14:32
We signal transitions of power
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Vi markerer overgivelse af magt
14:34
with rituals.
347
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med ritualer.
14:36
We signal the passage of a life with rituals.
348
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Vi markerer, at et liv er forbi, med ritualer.
14:38
Rituals are terribly important.
349
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Ritualer er frygteligt vigtige.
14:40
They're all about transformation.
350
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De handler alle om forvandlinger.
14:42
Well I would submit to you
351
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Jeg vil sige jer,
14:44
that the ritual
352
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at ritualet,
14:46
of one individual coming to another
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hvor en person kommer til en anden
14:48
and telling them things
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2000
og fortæller dem ting,
14:50
that they would not tell their preacher or rabbi,
355
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3000
som de ikke ville fortælle deres præst eller rabbi,
14:53
and then, incredibly on top of that,
356
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2000
og så, utroligt nok derudover,
14:55
disrobing and allowing touch --
357
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3000
afklæder og tillader berøring --
14:58
I would submit to you that that is a ritual of exceeding importance.
358
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jeg vil sige jer, at det er et ritual af
stor vigtighed.
stor vigtighed.
15:02
And if you shortchange that ritual
359
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Og forkorter man det ritual
15:04
by not undressing the patient,
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2000
ved ikke at afklæde patienten,
15:06
by listening with your stethoscope on top of the nightgown,
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3000
ved at lytte med sit stetoskop uden på natkjolen,
15:09
by not doing a complete exam,
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2000
ved ikke at foretage en fuld undersøgelse,
15:11
you have bypassed on the opportunity
363
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har man forspildt muligheden
15:13
to seal the patient-physician relationship.
364
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4000
til at forsegle patient-læge-forholdet.
15:17
I am a writer,
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2000
Jeg er forfatter,
15:19
and I want to close by reading you a short passage that I wrote
366
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og jeg vil afslutte med at læse en kort tekst,
jeg skrev,
jeg skrev,
15:23
that has to do very much with this scene.
367
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som omhandler dette scenarie.
15:25
I'm an infectious disease physician,
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Jeg er infektionsspeciallæge,
15:27
and in the early days of HIV, before we had our medications,
369
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3000
og i HIVens tidlige dage, før vi havde vores medikamenter,
15:30
I presided over so many scenes like this.
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4000
overværede jeg så mange lignende forløb.
15:34
I remember, every time I went to a patient's deathbed,
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Jeg husker, hver gang jeg gik til en patients dødsleje
15:37
whether in the hospital or at home,
372
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2000
på hospitalet eller i hjemmet,
15:39
I remember my sense of failure --
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4000
husker jeg følelsen af fiasko --
15:43
the feeling of I don't know what I have to say;
374
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2000
følelsen af, jeg ved ikke, hvad jeg skal sige;
15:45
I don't know what I can say;
375
930000
2000
Jeg ved ikke, hvad jeg kan sige;
15:47
I don't know what I'm supposed to do.
376
932000
2000
jeg ved ikke, hvad jeg bør gøre.
15:49
And out of that sense of failure,
377
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2000
Ud af den følelse af fiasko,
15:51
I remember, I would always examine the patient.
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936000
3000
husker jeg, jeg altid ville undersøge patienten.
15:54
I would pull down the eyelids.
379
939000
2000
Jeg ville trække øjenlågene ned.
15:56
I would look at the tongue.
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2000
Jeg ville se på tungen.
15:58
I would percuss the chest. I would listen to the heart.
381
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3000
Jeg ville banke på brystet, lytte til hjertet.
16:01
I would feel the abdomen.
382
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2000
Jeg ville føle maven.
16:03
I remember so many patients,
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Jeg husker så mange patienter,
16:06
their names still vivid on my tongue,
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deres navne stadig levende på min tunge,
16:08
their faces still so clear.
385
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2000
deres ansigter stadig tydelige.
16:10
I remember so many huge, hollowed out, haunted eyes
386
955000
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Jeg husker så mange enorme, udhulede,
hjemsøgte øjne,
hjemsøgte øjne,
16:14
staring up at me as I performed this ritual.
387
959000
3000
der stirrede på mig, mens jeg udførte dette ritual.
16:17
And then the next day,
388
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Den næste dag
16:19
I would come, and I would do it again.
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ville jeg komme og gøre det igen.
16:21
And I wanted to read you this one closing passage
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Jeg vil gerne læse denne afsluttende passage
16:24
about one patient.
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om en patient.
16:26
"I recall one patient
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"Jeg husker en patient,
16:28
who was at that point
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som på det tidspunkt
16:30
no more than a skeleton
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blot var et skelet
16:32
encased in shrinking skin,
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omsluttet af skrumpende hud,
16:34
unable to speak,
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ude af stand til at tale,
16:36
his mouth crusted with candida
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hans mund skorpet af trøske,
16:38
that was resistant to the usual medications.
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der var resistent over for normal medicin.
16:41
When he saw me
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Da han så mig,
16:43
on what turned out to be his last hours on this earth,
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i hvad der skulle blive hans sidste timer på denne jord,
16:45
his hands moved as if in slow motion.
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bevægede hans hænder sig som i slowmotion.
16:48
And as I wondered what he was up to,
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Og som jeg funderede over, hvad han ville,
16:50
his stick fingers made their way
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nåede hans tændstikfingre
16:52
up to his pajama shirt,
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op til hans pyjamasskjorte,
16:54
fumbling with his buttons.
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fumlende med knapperne.
16:57
I realized that he was wanting
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Jeg indså, at han ville
16:59
to expose his wicker-basket chest to me.
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vise sit pilekurvsbryst til mig.
17:02
It was an offering, an invitation.
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Det var et tilbud, en invitation.
17:05
I did not decline.
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Jeg afslog ikke.
17:07
I percussed. I palpated. I listened to the chest.
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Jeg bankede, palperede, lyttede til brystet.
17:10
I think he surely must have known by then
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Jeg tænker, han vel må have vidst dengang,
17:12
that it was vital for me
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at det var vigtigt for mig,
17:14
just as it was necessary for him.
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som det var nødvendigt for ham.
17:16
Neither of us could skip this ritual,
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Ingen af os kunne undvære dette ritual,
17:19
which had nothing to do with detecting rales in the lung,
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som intet havde at gøre med at finde rallen i lungen
17:22
or finding the gallop rhythm of heart failure.
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eller finde galloprytmen ved hjertesvigt.
17:25
No, this ritual was about the one message
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Nej, dette ritual handlede om den ene besked,
17:28
that physicians have needed to convey to their patients.
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som læger behøver at viderebringe til deres patienter.
17:31
Although, God knows, of late, in our hubris,
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Selvom, ved Gud, på det seneste i vores hybris,
17:33
we seem to have drifted away.
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lader vi til at være drevet væk.
17:35
We seem to have forgotten --
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Vi lader til at have glemt --
17:37
as though, with the explosion of knowledge,
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som med videnseksplosionen,
17:39
the whole human genome mapped out at our feet,
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hele menneskegenomet kortlagt for vores fødder,
17:42
we are lulled into inattention,
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bliver vi lullet ind i uopmærksomhed,
17:44
forgetting that the ritual is cathartic to the physician,
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glemmer, at ritualet er rensende for lægen,
17:47
necessary for the patient --
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nødvendig for patienten --
17:49
forgetting that the ritual has meaning
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glemmer, at ritualet har betydning
17:51
and a singular message to convey to the patient.
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og en enestående besked at bringe til patienten.
17:55
And the message, which I didn't fully understand then,
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Og beskeden, som jeg ikke fuldt forstod dengang,
17:58
even as I delivered it,
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selv mens jeg leverede den,
18:00
and which I understand better now is this:
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og som jeg forstår bedre nu, er denne:
18:03
I will always, always, always be there.
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Jeg vil altid, altid, altid være der.
18:06
I will see you through this.
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Jeg vil hjælpe dig gennem dette.
18:08
I will never abandon you.
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Jeg vil aldrig forlade dig.
18:10
I will be with you through the end."
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Jeg er hos dig til det sidste."
18:12
Thank you very much.
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Mange tak.
18:14
(Applause)
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(Bifald)
ABOUT THE SPEAKER
Abraham Verghese - Physician and authorIn our era of the patient-as-data-point, Abraham Verghese believes in the old-fashioned physical exam, the bedside chat, the power of informed observation.
Why you should listen
Before he finished medical school, Abraham Verghese spent a year on the other end of the medical pecking order, as a hospital orderly. Moving unseen through the wards, he saw the patients with new eyes, as human beings rather than collections of illnesses. The experience has informed his work as a doctor -- and as a writer. "Imagining the Patient’s Experience" was the motto of the Center for Medical Humanities & Ethics, which he founded at the University of Texas San Antonio, where he brought a deep-seated empathy. He’s now a professor for the Theory and Practice of Medicine at Stanford, where his old-fashioned weekly rounds have inspired a new initiative, the Stanford 25, teaching 25 fundamental physical exam skills and their diagnostic benefits to interns.
He’s also a best-selling writer, with two memoirs and a novel, Cutting for Stone, a moving story of two Ethiopian brothers bound by medicine and betrayal.
He says: “I still find the best way to understand a hospitalized patient is not by staring at the computer screen but by going to see the patient; it's only at the bedside that I can figure out what is important.”
In 2011, Verghese was elected to the Institute of Medicine, which advises the government and private institutions on medicine and health on a national level.
Abraham Verghese | Speaker | TED.com