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TEDGlobal 2011

Abraham Verghese: A doctor's touch

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Views 1,410,004

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.

- 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

A few months ago,
00:15
a 40 year-old woman came to an emergency room
00:17
in a hospital close to where I live,
00:20
and she was brought in confused.
00:22
Her blood pressure was an alarming
00:24
230 over 170.
00:26
Within a few minutes, she went into cardiac collapse.
00:29
She was resuscitated, stabilized,
00:32
whisked over to a CAT scan suite
00:35
right next to the emergency room,
00:37
because they were concerned about blood clots in the lung.
00:39
And the CAT scan revealed
00:42
no blood clots in the lung,
00:44
but it showed bilateral, visible, palpable breast masses,
00:46
breast tumors,
00:51
that had metastasized widely
00:53
all over the body.
00:55
And the real tragedy was, if you look through her records,
00:57
she had been seen
01:00
in four or five other health care institutions
01:02
in the preceding two years.
01:04
Four or five opportunities
01:06
to see the breast masses, touch the breast mass,
01:08
intervene at a much earlier stage
01:10
than when we saw her.
01:13
Ladies and gentlemen,
01:15
that is not an unusual story.
01:17
Unfortunately, it happens all the time.
01:19
I joke, but I only half joke,
01:22
that if you come to one of our hospitals missing a limb,
01:24
no one will believe you till they get a CAT scan, MRI
01:27
or orthopedic consult.
01:30
I am not a Luddite.
01:32
I teach at Stanford.
01:34
I'm a physician practicing with cutting-edge technology.
01:36
But I'd like to make the case to you
01:38
in the next 17 minutes
01:40
that when we shortcut the physical exam,
01:42
when we lean towards ordering tests
01:46
instead of talking to and examining the patient,
01:48
we not only overlook simple diagnoses
01:51
that can be diagnosed at a treatable, early stage,
01:54
but we're losing much more than that.
01:57
We're losing a ritual.
01:59
We're losing a ritual that I believe is transformative, transcendent,
02:01
and is at the heart
02:04
of the patient-physician relationship.
02:06
This may actually be heresy to say this at TED,
02:08
but I'd like to introduce you
02:11
to the most important innovation,
02:13
I think, in medicine
02:15
to come in the next 10 years,
02:17
and that is the power of the human hand --
02:19
to touch, to comfort, to diagnose
02:21
and to bring about treatment.
02:24
I'd like to introduce you first to this person
02:26
whose image you may or may not recognize.
02:29
This is Sir Arthur Conan Doyle.
02:31
Since we're in Edinburgh, I'm a big fan of Conan Doyle.
02:33
You might not know that Conan Doyle went to medical school
02:36
here in Edinburgh,
02:38
and his character, Sherlock Holmes,
02:40
was inspired by Sir Joseph Bell.
02:42
Joseph Bell was an extraordinary teacher by all accounts.
02:45
And Conan Doyle, writing about Bell,
02:48
described the following exchange
02:51
between Bell and his students.
02:53
So picture Bell sitting in the outpatient department,
02:55
students all around him,
02:58
patients signing up in the emergency room
03:00
and being registered and being brought in.
03:02
And a woman comes in with a child,
03:05
and Conan Doyle describes the following exchange.
03:07
The woman says, "Good Morning."
03:10
Bell says, "What sort of crossing did you have
03:14
on the ferry from Burntisland?"
03:17
She says, "It was good."
03:20
And he says, "What did you do with the other child?"
03:22
She says, "I left him with my sister at Leith."
03:25
And he says,
03:28
"And did you take the shortcut down Inverleith Row
03:30
to get here to the infirmary?"
03:32
She says, "I did."
03:34
And he says, "Would you still be working at the linoleum factory?"
03:36
And she says, "I am."
03:40
And Bell then goes on to explain to the students.
03:42
He says, "You see, when she said, 'Good morning,'
03:44
I picked up her Fife accent.
03:47
And the nearest ferry crossing from Fife is from Burntisland.
03:49
And so she must have taken the ferry over.
03:52
You notice that the coat she's carrying
03:55
is too small for the child who is with her,
03:57
and therefore, she started out the journey with two children,
04:00
but dropped one off along the way.
04:03
You notice the clay on the soles of her feet.
04:06
Such red clay is not found within a hundred miles of Edinburgh,
04:08
except in the botanical gardens.
04:12
And therefore, she took a short cut down Inverleith Row
04:14
to arrive here.
04:17
And finally, she has a dermatitis
04:19
on the fingers of her right hand,
04:21
a dermatitis that is unique
04:23
to the linoleum factory workers in Burntisland."
04:25
And when Bell actually strips the patient,
04:28
begins to examine the patient,
04:30
you can only imagine how much more he would discern.
04:32
And as a teacher of medicine, as a student myself,
04:35
I was so inspired by that story.
04:38
But you might not realize
04:40
that our ability to look into the body
04:42
in this simple way, using our senses,
04:44
is quite recent.
04:46
The picture I'm showing you is of Leopold Auenbrugger
04:48
who, in the late 1700s,
04:51
discovered percussion.
04:53
And the story is that Leopold Auenbrugger
04:55
was the son of an innkeeper.
04:58
And his father used to go down into the basement
05:01
to tap on the sides of casks of wine
05:04
to determine how much wine was left
05:06
and whether to reorder.
05:08
And so when Auenbrugger became a physician,
05:10
he began to do the same thing.
05:12
He began to tap on the chests of his patients,
05:14
on their abdomens.
05:17
And basically everything we know about percussion,
05:19
which you can think of as an ultrasound of its day --
05:21
organ enlargement, fluid around the heart, fluid in the lungs,
05:25
abdominal changes --
05:28
all of this he described in this wonderful manuscript
05:30
"Inventum Novum," "New Invention,"
05:32
which would have disappeared into obscurity,
05:35
except for the fact that this physician, Corvisart,
05:37
a famous French physician --
05:40
famous only because he was physician to this gentleman --
05:42
Corvisart repopularized and reintroduced the work.
05:45
And it was followed a year or two later
05:49
by Laennec discovering the stethoscope.
05:51
Laennec, it is said, was walking in the streets of Paris
05:54
and saw two children playing with a stick.
05:57
One was scratching at the end of the stick,
05:59
another child listened at the other end.
06:02
And Laennec thought this would be a wonderful way
06:04
to listen to the chest or listen to the abdomen
06:06
using what he called "the cylinder."
06:08
Later he renamed it the stethoscope.
06:10
And that is how stethoscope and auscultation was born.
06:12
So within a few years,
06:16
in the late 1800s, early 1900s,
06:18
all of a sudden,
06:20
the barber surgeon had given way
06:22
to the physician who was trying to make a diagnosis.
06:25
If you'll recall, prior to that time,
06:28
no matter what ailed you, you went to see the barber surgeon
06:30
who wound up cupping you,
06:33
bleeding you, purging you.
06:35
And, oh yes, if you wanted,
06:37
he would give you a haircut -- short on the sides, long in the back --
06:39
and pull your tooth while he was at it.
06:42
He made no attempt at diagnosis.
06:44
In fact, some of you might well know
06:46
that the barber pole, the red and white stripes,
06:48
represents the blood bandages of the barber surgeon,
06:51
and the receptacles on either end
06:54
represent the pots in which the blood was collected.
06:56
But the arrival of auscultation and percussion
06:59
represented a sea change,
07:02
a moment when physicians were beginning to look inside the body.
07:04
And this particular painting, I think,
07:07
represents the pinnacle, the peak, of that clinical era.
07:10
This is a very famous painting:
07:13
"The Doctor" by Luke Fildes.
07:15
Luke Fildes was commissioned to paint this by Tate,
07:18
who then established the Tate Gallery.
07:21
And Tate asked Fildes to paint a painting
07:23
of social importance.
07:25
And it's interesting that Fildes picked this topic.
07:27
Fildes' oldest son, Philip,
07:30
died at the age of nine on Christmas Eve
07:33
after a brief illness.
07:36
And Fildes was so taken by the physician
07:38
who held vigil at the bedside for two, three nights,
07:41
that he decided that he would try and depict
07:45
the physician in our time --
07:47
almost a tribute to this physician.
07:49
And hence the painting "The Doctor," a very famous painting.
07:51
It's been on calendars, postage stamps in many different countries.
07:54
I've often wondered, what would Fildes have done
07:57
had he been asked to paint this painting
08:00
in the modern era,
08:02
in the year 2011?
08:04
Would he have substituted a computer screen
08:07
for where he had the patient?
08:11
I've gotten into some trouble in Silicon Valley
08:13
for saying that the patient in the bed
08:15
has almost become an icon
08:17
for the real patient who's in the computer.
08:20
I've actually coined a term for that entity in the computer.
08:23
I call it the iPatient.
08:26
The iPatient is getting wonderful care all across America.
08:28
The real patient often wonders,
08:31
where is everyone?
08:33
When are they going to come by and explain things to me?
08:35
Who's in charge?
08:38
There's a real disjunction between the patient's perception
08:40
and our own perceptions as physicians of the best medical care.
08:43
I want to show you a picture
08:46
of what rounds looked like
08:48
when I was in training.
08:50
The focus was around the patient.
08:52
We went from bed to bed. The attending physician was in charge.
08:54
Too often these days,
08:57
rounds look very much like this,
08:59
where the discussion is taking place
09:01
in a room far away from the patient.
09:03
The discussion is all about images on the computer, data.
09:06
And the one critical piece missing
09:09
is that of the patient.
09:11
Now I've been influenced in this thinking
09:13
by two anecdotes that I want to share with you.
09:16
One had to do with a friend of mine who had a breast cancer,
09:19
had a small breast cancer detected --
09:22
had her lumpectomy in the town in which I lived.
09:25
This is when I was in Texas.
09:27
And she then spent a lot of time researching
09:29
to find the best cancer center in the world
09:32
to get her subsequent care.
09:35
And she found the place and decided to go there, went there.
09:37
Which is why I was surprised a few months later
09:40
to see her back in our own town,
09:43
getting her subsequent care with her private oncologist.
09:46
And I pressed her, and I asked her,
09:49
"Why did you come back and get your care here?"
09:51
And she was reluctant to tell me.
09:54
She said, "The cancer center was wonderful.
09:56
It had a beautiful facility,
09:59
giant atrium, valet parking,
10:01
a piano that played itself,
10:03
a concierge that took you around from here to there.
10:05
But," she said,
10:08
"but they did not touch my breasts."
10:10
Now you and I could argue
10:14
that they probably did not need to touch her breasts.
10:16
They had her scanned inside out.
10:18
They understood her breast cancer at the molecular level;
10:20
they had no need to touch her breasts.
10:23
But to her, it mattered deeply.
10:25
It was enough for her to make the decision
10:28
to get her subsequent care with her private oncologist
10:32
who, every time she went,
10:35
examined both breasts including the axillary tail,
10:37
examined her axilla carefully,
10:40
examined her cervical region, her inguinal region,
10:42
did a thorough exam.
10:44
And to her, that spoke of a kind of attentiveness that she needed.
10:46
I was very influenced by that anecdote.
10:50
I was also influenced by another experience that I had,
10:52
again, when I was in Texas, before I moved to Stanford.
10:55
I had a reputation
10:58
as being interested in patients
11:00
with chronic fatigue.
11:02
This is not a reputation you would wish on your worst enemy.
11:05
I say that because these are difficult patients.
11:09
They have often been rejected by their families,
11:12
have had bad experiences with medical care
11:15
and they come to you fully prepared
11:17
for you to join the long list of people
11:20
who's about to disappoint them.
11:22
And I learned very early on with my first patient
11:24
that I could not do justice
11:27
to this very complicated patient
11:29
with all the records they were bringing
11:31
in a new patient visit of 45 minutes.
11:33
There was just no way.
11:35
And if I tried, I'd disappoint them.
11:37
And so I hit on this method
11:40
where I invited the patient
11:42
to tell me the story for their entire first visit,
11:44
and I tried not to interrupt them.
11:47
We know the average American physician
11:50
interrupts their patient in 14 seconds.
11:52
And if I ever get to heaven,
11:55
it will be because I held my piece for 45 minutes
11:57
and did not interrupt my patient.
12:00
I then scheduled the physical exam for two weeks hence,
12:02
and when the patient came for the physical,
12:05
I was able to do a thorough physical,
12:07
because I had nothing else to do.
12:09
I like to think that I do a thorough physical exam,
12:11
but because the whole visit was now about the physical,
12:14
I could do an extraordinarily thorough exam.
12:17
And I remember my very first patient in that series
12:20
continued to tell me more history
12:24
during what was meant to be the physical exam visit.
12:26
And I began my ritual.
12:29
I always begin with the pulse,
12:31
then I examine the hands, then I look at the nail beds,
12:33
then I slide my hand up to the epitrochlear node,
12:36
and I was into my ritual.
12:38
And when my ritual began,
12:40
this very voluble patient
12:42
began to quiet down.
12:44
And I remember having a very eerie sense
12:46
that the patient and I
12:49
had slipped back into a primitive ritual
12:52
in which I had a role
12:54
and the patient had a role.
12:56
And when I was done,
12:58
the patient said to me with some awe,
13:00
"I have never been examined like this before."
13:02
Now if that were true,
13:05
it's a true condemnation of our health care system,
13:07
because they had been seen in other places.
13:09
I then proceeded to tell the patient,
13:12
once the patient was dressed,
13:14
the standard things that the person must have heard in other institutions,
13:16
which is, "This is not in your head.
13:19
This is real.
13:21
The good news, it's not cancer, it's not tuberculosis,
13:23
it's not coccidioidomycosis or some obscure fungal infection.
13:26
The bad news is we don't know exactly what's causing this,
13:29
but here's what you should do, here's what we should do."
13:32
And I would lay out all the standard treatment options
13:35
that the patient had heard elsewhere.
13:38
And I always felt
13:41
that if my patient gave up the quest
13:43
for the magic doctor, the magic treatment
13:45
and began with me on a course towards wellness,
13:48
it was because I had earned the right
13:51
to tell them these things
13:53
by virtue of the examination.
13:55
Something of importance had transpired in the exchange.
13:57
I took this to my colleagues
14:01
at Stanford in anthropology
14:03
and told them the same story.
14:05
And they immediately said to me,
14:07
"Well you are describing a classic ritual."
14:09
And they helped me understand
14:11
that rituals are all about transformation.
14:13
We marry, for example,
14:16
with great pomp and ceremony and expense
14:18
to signal our departure
14:21
from a life of solitude and misery and loneliness
14:23
to one of eternal bliss.
14:25
I'm not sure why you're laughing.
14:28
That was the original intent, was it not?
14:30
We signal transitions of power
14:32
with rituals.
14:34
We signal the passage of a life with rituals.
14:36
Rituals are terribly important.
14:38
They're all about transformation.
14:40
Well I would submit to you
14:42
that the ritual
14:44
of one individual coming to another
14:46
and telling them things
14:48
that they would not tell their preacher or rabbi,
14:50
and then, incredibly on top of that,
14:53
disrobing and allowing touch --
14:55
I would submit to you that that is a ritual of exceeding importance.
14:58
And if you shortchange that ritual
15:02
by not undressing the patient,
15:04
by listening with your stethoscope on top of the nightgown,
15:06
by not doing a complete exam,
15:09
you have bypassed on the opportunity
15:11
to seal the patient-physician relationship.
15:13
I am a writer,
15:17
and I want to close by reading you a short passage that I wrote
15:19
that has to do very much with this scene.
15:23
I'm an infectious disease physician,
15:25
and in the early days of HIV, before we had our medications,
15:27
I presided over so many scenes like this.
15:30
I remember, every time I went to a patient's deathbed,
15:34
whether in the hospital or at home,
15:37
I remember my sense of failure --
15:39
the feeling of I don't know what I have to say;
15:43
I don't know what I can say;
15:45
I don't know what I'm supposed to do.
15:47
And out of that sense of failure,
15:49
I remember, I would always examine the patient.
15:51
I would pull down the eyelids.
15:54
I would look at the tongue.
15:56
I would percuss the chest. I would listen to the heart.
15:58
I would feel the abdomen.
16:01
I remember so many patients,
16:03
their names still vivid on my tongue,
16:06
their faces still so clear.
16:08
I remember so many huge, hollowed out, haunted eyes
16:10
staring up at me as I performed this ritual.
16:14
And then the next day,
16:17
I would come, and I would do it again.
16:19
And I wanted to read you this one closing passage
16:21
about one patient.
16:24
"I recall one patient
16:26
who was at that point
16:28
no more than a skeleton
16:30
encased in shrinking skin,
16:32
unable to speak,
16:34
his mouth crusted with candida
16:36
that was resistant to the usual medications.
16:38
When he saw me
16:41
on what turned out to be his last hours on this earth,
16:43
his hands moved as if in slow motion.
16:45
And as I wondered what he was up to,
16:48
his stick fingers made their way
16:50
up to his pajama shirt,
16:52
fumbling with his buttons.
16:54
I realized that he was wanting
16:57
to expose his wicker-basket chest to me.
16:59
It was an offering, an invitation.
17:02
I did not decline.
17:05
I percussed. I palpated. I listened to the chest.
17:07
I think he surely must have known by then
17:10
that it was vital for me
17:12
just as it was necessary for him.
17:14
Neither of us could skip this ritual,
17:16
which had nothing to do with detecting rales in the lung,
17:19
or finding the gallop rhythm of heart failure.
17:22
No, this ritual was about the one message
17:25
that physicians have needed to convey to their patients.
17:28
Although, God knows, of late, in our hubris,
17:31
we seem to have drifted away.
17:33
We seem to have forgotten --
17:35
as though, with the explosion of knowledge,
17:37
the whole human genome mapped out at our feet,
17:39
we are lulled into inattention,
17:42
forgetting that the ritual is cathartic to the physician,
17:44
necessary for the patient --
17:47
forgetting that the ritual has meaning
17:49
and a singular message to convey to the patient.
17:51
And the message, which I didn't fully understand then,
17:55
even as I delivered it,
17:58
and which I understand better now is this:
18:00
I will always, always, always be there.
18:03
I will see you through this.
18:06
I will never abandon you.
18:08
I will be with you through the end."
18:10
Thank you very much.
18:12
(Applause)
18:14

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About the speaker:

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.

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.

More profile about the speaker
Abraham Verghese | Speaker | TED.com