TEDGlobal 2011
Abraham Verghese: A doctor's touch
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Modern medicine is in danger of losing a powerful, old-fashioned tool: human touch. Physician and writer Abraham Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam.
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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a 40 year-old woman came to an emergency room
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in a hospital close to where I live,
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and she was brought in confused.
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Her blood pressure was an alarming
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230 over 170.
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Within a few minutes, she went into cardiac collapse.
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She was resuscitated, stabilized,
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whisked over to a CAT scan suite
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right next to the emergency room,
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because they were concerned about blood clots in the lung.
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And the CAT scan revealed
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no blood clots in the lung,
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but it showed bilateral, visible, palpable breast masses,
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breast tumors,
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that had metastasized widely
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all over the body.
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And the real tragedy was, if you look through her records,
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she had been seen
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in four or five other health care institutions
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in the preceding two years.
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Four or five opportunities
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to see the breast masses, touch the breast mass,
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intervene at a much earlier stage
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than when we saw her.
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01:15
Ladies and gentlemen,
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that is not an unusual story.
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Unfortunately, it happens all the time.
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I joke, but I only half joke,
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that if you come to one of our hospitals missing a limb,
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no one will believe you till they get a CAT scan, MRI
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or orthopedic consult.
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I am not a Luddite.
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I teach at Stanford.
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I'm a physician practicing with cutting-edge technology.
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But I'd like to make the case to you
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in the next 17 minutes
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that when we shortcut the physical exam,
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when we lean towards ordering tests
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instead of talking to and examining the patient,
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we not only overlook simple diagnoses
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that can be diagnosed at a treatable, early stage,
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but we're losing much more than that.
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We're losing a ritual.
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We're losing a ritual that I believe is transformative, transcendent,
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and is at the heart
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of the patient-physician relationship.
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This may actually be heresy to say this at TED,
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but I'd like to introduce you
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to the most important innovation,
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I think, in medicine
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to come in the next 10 years,
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and that is the power of the human hand --
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to touch, to comfort, to diagnose
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and to bring about treatment.
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I'd like to introduce you first to this person
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whose image you may or may not recognize.
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This is Sir Arthur Conan Doyle.
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Since we're in Edinburgh, I'm a big fan of Conan Doyle.
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You might not know that Conan Doyle went to medical school
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here in Edinburgh,
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and his character, Sherlock Holmes,
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was inspired by Sir Joseph Bell.
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Joseph Bell was an extraordinary teacher by all accounts.
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And Conan Doyle, writing about Bell,
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described the following exchange
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between Bell and his students.
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So picture Bell sitting in the outpatient department,
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students all around him,
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patients signing up in the emergency room
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and being registered and being brought in.
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And a woman comes in with a child,
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and Conan Doyle describes the following exchange.
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The woman says, "Good Morning."
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Bell says, "What sort of crossing did you have
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on the ferry from Burntisland?"
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She says, "It was good."
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And he says, "What did you do with the other child?"
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She says, "I left him with my sister at Leith."
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And he says,
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"And did you take the shortcut down Inverleith Row
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to get here to the infirmary?"
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She says, "I did."
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And he says, "Would you still be working at the linoleum factory?"
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And she says, "I am."
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And Bell then goes on to explain to the students.
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He says, "You see, when she said, 'Good morning,'
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I picked up her Fife accent.
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And the nearest ferry crossing from Fife is from Burntisland.
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And so she must have taken the ferry over.
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You notice that the coat she's carrying
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is too small for the child who is with her,
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and therefore, she started out the journey with two children,
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but dropped one off along the way.
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You notice the clay on the soles of her feet.
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Such red clay is not found within a hundred miles of Edinburgh,
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except in the botanical gardens.
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And therefore, she took a short cut down Inverleith Row
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to arrive here.
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And finally, she has a dermatitis
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on the fingers of her right hand,
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a dermatitis that is unique
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to the linoleum factory workers in Burntisland."
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And when Bell actually strips the patient,
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begins to examine the patient,
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you can only imagine how much more he would discern.
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And as a teacher of medicine, as a student myself,
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I was so inspired by that story.
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But you might not realize
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that our ability to look into the body
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in this simple way, using our senses,
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is quite recent.
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The picture I'm showing you is of Leopold Auenbrugger
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who, in the late 1700s,
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discovered percussion.
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And the story is that Leopold Auenbrugger
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was the son of an innkeeper.
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And his father used to go down into the basement
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to tap on the sides of casks of wine
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to determine how much wine was left
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and whether to reorder.
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And so when Auenbrugger became a physician,
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he began to do the same thing.
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He began to tap on the chests of his patients,
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on their abdomens.
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And basically everything we know about percussion,
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which you can think of as an ultrasound of its day --
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organ enlargement, fluid around the heart, fluid in the lungs,
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abdominal changes --
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all of this he described in this wonderful manuscript
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"Inventum Novum," "New Invention,"
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which would have disappeared into obscurity,
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except for the fact that this physician, Corvisart,
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a famous French physician --
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famous only because he was physician to this gentleman --
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Corvisart repopularized and reintroduced the work.
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And it was followed a year or two later
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by Laennec discovering the stethoscope.
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Laennec, it is said, was walking in the streets of Paris
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and saw two children playing with a stick.
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One was scratching at the end of the stick,
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another child listened at the other end.
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And Laennec thought this would be a wonderful way
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to listen to the chest or listen to the abdomen
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using what he called "the cylinder."
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Later he renamed it the stethoscope.
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And that is how stethoscope and auscultation was born.
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So within a few years,
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in the late 1800s, early 1900s,
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all of a sudden,
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the barber surgeon had given way
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to the physician who was trying to make a diagnosis.
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If you'll recall, prior to that time,
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no matter what ailed you, you went to see the barber surgeon
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who wound up cupping you,
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bleeding you, purging you.
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And, oh yes, if you wanted,
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he would give you a haircut -- short on the sides, long in the back --
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and pull your tooth while he was at it.
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He made no attempt at diagnosis.
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In fact, some of you might well know
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that the barber pole, the red and white stripes,
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represents the blood bandages of the barber surgeon,
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and the receptacles on either end
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represent the pots in which the blood was collected.
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But the arrival of auscultation and percussion
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represented a sea change,
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a moment when physicians were beginning to look inside the body.
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And this particular painting, I think,
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represents the pinnacle, the peak, of that clinical era.
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This is a very famous painting:
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"The Doctor" by Luke Fildes.
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Luke Fildes was commissioned to paint this by Tate,
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who then established the Tate Gallery.
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And Tate asked Fildes to paint a painting
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of social importance.
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And it's interesting that Fildes picked this topic.
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Fildes' oldest son, Philip,
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died at the age of nine on Christmas Eve
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after a brief illness.
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And Fildes was so taken by the physician
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who held vigil at the bedside for two, three nights,
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that he decided that he would try and depict
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the physician in our time --
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almost a tribute to this physician.
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And hence the painting "The Doctor," a very famous painting.
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It's been on calendars, postage stamps in many different countries.
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I've often wondered, what would Fildes have done
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had he been asked to paint this painting
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in the modern era,
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in the year 2011?
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Would he have substituted a computer screen
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for where he had the patient?
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I've gotten into some trouble in Silicon Valley
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for saying that the patient in the bed
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has almost become an icon
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for the real patient who's in the computer.
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I've actually coined a term for that entity in the computer.
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I call it the iPatient.
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The iPatient is getting wonderful care all across America.
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The real patient often wonders,
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where is everyone?
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When are they going to come by and explain things to me?
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Who's in charge?
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There's a real disjunction between the patient's perception
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and our own perceptions as physicians of the best medical care.
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I want to show you a picture
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of what rounds looked like
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when I was in training.
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The focus was around the patient.
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We went from bed to bed. The attending physician was in charge.
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Too often these days,
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rounds look very much like this,
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where the discussion is taking place
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in a room far away from the patient.
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The discussion is all about images on the computer, data.
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And the one critical piece missing
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is that of the patient.
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Now I've been influenced in this thinking
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by two anecdotes that I want to share with you.
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One had to do with a friend of mine who had a breast cancer,
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had a small breast cancer detected --
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had her lumpectomy in the town in which I lived.
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This is when I was in Texas.
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And she then spent a lot of time researching
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to find the best cancer center in the world
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to get her subsequent care.
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And she found the place and decided to go there, went there.
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Which is why I was surprised a few months later
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to see her back in our own town,
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getting her subsequent care with her private oncologist.
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And I pressed her, and I asked her,
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"Why did you come back and get your care here?"
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And she was reluctant to tell me.
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She said, "The cancer center was wonderful.
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It had a beautiful facility,
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giant atrium, valet parking,
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a piano that played itself,
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a concierge that took you around from here to there.
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But," she said,
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"but they did not touch my breasts."
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Now you and I could argue
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that they probably did not need to touch her breasts.
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They had her scanned inside out.
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They understood her breast cancer at the molecular level;
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they had no need to touch her breasts.
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But to her, it mattered deeply.
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It was enough for her to make the decision
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to get her subsequent care with her private oncologist
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who, every time she went,
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examined both breasts including the axillary tail,
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examined her axilla carefully,
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examined her cervical region, her inguinal region,
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did a thorough exam.
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And to her, that spoke of a kind of attentiveness that she needed.
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I was very influenced by that anecdote.
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I was also influenced by another experience that I had,
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again, when I was in Texas, before I moved to Stanford.
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I had a reputation
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as being interested in patients
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with chronic fatigue.
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This is not a reputation you would wish on your worst enemy.
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I say that because these are difficult patients.
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They have often been rejected by their families,
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have had bad experiences with medical care
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and they come to you fully prepared
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for you to join the long list of people
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who's about to disappoint them.
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And I learned very early on with my first patient
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that I could not do justice
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to this very complicated patient
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with all the records they were bringing
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in a new patient visit of 45 minutes.
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There was just no way.
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And if I tried, I'd disappoint them.
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And so I hit on this method
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where I invited the patient
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to tell me the story for their entire first visit,
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and I tried not to interrupt them.
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We know the average American physician
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interrupts their patient in 14 seconds.
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And if I ever get to heaven,
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it will be because I held my piece for 45 minutes
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and did not interrupt my patient.
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I then scheduled the physical exam for two weeks hence,
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and when the patient came for the physical,
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I was able to do a thorough physical,
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because I had nothing else to do.
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I like to think that I do a thorough physical exam,
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but because the whole visit was now about the physical,
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I could do an extraordinarily thorough exam.
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And I remember my very first patient in that series
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continued to tell me more history
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during what was meant to be the physical exam visit.
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And I began my ritual.
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I always begin with the pulse,
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then I examine the hands, then I look at the nail beds,
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then I slide my hand up to the epitrochlear node,
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and I was into my ritual.
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And when my ritual began,
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this very voluble patient
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began to quiet down.
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And I remember having a very eerie sense
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that the patient and I
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had slipped back into a primitive ritual
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in which I had a role
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and the patient had a role.
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And when I was done,
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the patient said to me with some awe,
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"I have never been examined like this before."
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Now if that were true,
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it's a true condemnation of our health care system,
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because they had been seen in other places.
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I then proceeded to tell the patient,
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once the patient was dressed,
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the standard things that the person must have heard in other institutions,
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which is, "This is not in your head.
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This is real.
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The good news, it's not cancer, it's not tuberculosis,
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it's not coccidioidomycosis or some obscure fungal infection.
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The bad news is we don't know exactly what's causing this,
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but here's what you should do, here's what we should do."
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And I would lay out all the standard treatment options
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that the patient had heard elsewhere.
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And I always felt
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that if my patient gave up the quest
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for the magic doctor, the magic treatment
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and began with me on a course towards wellness,
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it was because I had earned the right
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to tell them these things
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by virtue of the examination.
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Something of importance had transpired in the exchange.
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I took this to my colleagues
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at Stanford in anthropology
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and told them the same story.
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And they immediately said to me,
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"Well you are describing a classic ritual."
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And they helped me understand
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that rituals are all about transformation.
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We marry, for example,
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with great pomp and ceremony and expense
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to signal our departure
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from a life of solitude and misery and loneliness
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to one of eternal bliss.
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I'm not sure why you're laughing.
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That was the original intent, was it not?
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We signal transitions of power
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with rituals.
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We signal the passage of a life with rituals.
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Rituals are terribly important.
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They're all about transformation.
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Well I would submit to you
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that the ritual
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of one individual coming to another
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and telling them things
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that they would not tell their preacher or rabbi,
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and then, incredibly on top of that,
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disrobing and allowing touch --
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I would submit to you that that is a ritual of exceeding importance.
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And if you shortchange that ritual
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by not undressing the patient,
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by listening with your stethoscope on top of the nightgown,
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by not doing a complete exam,
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you have bypassed on the opportunity
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to seal the patient-physician relationship.
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I am a writer,
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and I want to close by reading you a short passage that I wrote
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that has to do very much with this scene.
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I'm an infectious disease physician,
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and in the early days of HIV, before we had our medications,
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I presided over so many scenes like this.
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I remember, every time I went to a patient's deathbed,
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whether in the hospital or at home,
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I remember my sense of failure --
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the feeling of I don't know what I have to say;
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I don't know what I can say;
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I don't know what I'm supposed to do.
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And out of that sense of failure,
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I remember, I would always examine the patient.
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I would pull down the eyelids.
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I would look at the tongue.
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I would percuss the chest. I would listen to the heart.
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I would feel the abdomen.
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I remember so many patients,
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their names still vivid on my tongue,
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their faces still so clear.
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I remember so many huge, hollowed out, haunted eyes
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staring up at me as I performed this ritual.
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And then the next day,
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I would come, and I would do it again.
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And I wanted to read you this one closing passage
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about one patient.
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"I recall one patient
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who was at that point
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no more than a skeleton
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encased in shrinking skin,
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unable to speak,
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his mouth crusted with candida
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that was resistant to the usual medications.
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When he saw me
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on what turned out to be his last hours on this earth,
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his hands moved as if in slow motion.
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And as I wondered what he was up to,
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his stick fingers made their way
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up to his pajama shirt,
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fumbling with his buttons.
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I realized that he was wanting
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to expose his wicker-basket chest to me.
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It was an offering, an invitation.
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I did not decline.
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I percussed. I palpated. I listened to the chest.
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I think he surely must have known by then
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that it was vital for me
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just as it was necessary for him.
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Neither of us could skip this ritual,
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which had nothing to do with detecting rales in the lung,
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or finding the gallop rhythm of heart failure.
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No, this ritual was about the one message
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that physicians have needed to convey to their patients.
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Although, God knows, of late, in our hubris,
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we seem to have drifted away.
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We seem to have forgotten --
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as though, with the explosion of knowledge,
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the whole human genome mapped out at our feet,
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we are lulled into inattention,
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forgetting that the ritual is cathartic to the physician,
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necessary for the patient --
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forgetting that the ritual has meaning
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and a singular message to convey to the patient.
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And the message, which I didn't fully understand then,
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even as I delivered it,
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and which I understand better now is this:
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I will always, always, always be there.
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I will see you through this.
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I will never abandon you.
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I will be with you through the end."
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Thank you very much.
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(Applause)
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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