A doctors touch Abraham Verghese

a few months ago a 40 year old woman

came to an emergency room in a hospital

close to where I live and she was

brought in confused her blood pressure

was an alarming 230 over a hundred and

seventy within a few minutes she went

into cardiac collapse

she was resuscitated stabilized whisked

over to a cat-scan suite right next to

the emergency room

because they were concerned about blood

clots in the lung and the cat scan

revealed no blood clots in the lung but

it showed bilateral visible palpable

breast masses breast tumors that had

metastasized widely all over the body

and the real tragedy was if you look

through her records she had been seen at

four or five other health care

institutions in the preceding two years

four or five opportunities to see the

breast masses touch the breast mass

intervene at a much earlier stage than

when we saw her ladies and gentlemen

that is not an unusual story

unfortunately it happens all the time I

joke but I only half joke that if you

come to one of our hospitals missing a

limb no one will believe you till they

get a cat scan MRI or orthopedic consult

I am NOT a Luddite I teach at Stanford

I’m a physician practicing with

cutting-edge technology but I’d like to

make the case to you in the next 17

minutes that when we shortcut the

physical exam and we lean towards

ordering tests instead of talking to an

examining the patient we not only

overlook simple diagnosis that can be

diagnosed at a treatable early stage but

we’re losing much more than that we’re

losing a ritual we’re losing a ritual

that I believe is transformative

transcendent and is at the heart of the

patient-physician relationship this may

actually be heresy to say this at Ted

but I’d like to introduce you to the

most important innovation I think in

medicine to come in the next 10 years

and that is the power of the human hand

to touch to comfort to diagnose and to

bring about treatment I’d like to

introduce you first to this person whose

image you may or may not recognize this

is Sir Arthur Conan Doyle since we’re in

Edinburgh I’m a big fan of Conan Doyle

you might not know that Conan Doyle went

to medical school here in Edinburgh and

his character Sherlock Holmes was

inspired by Sir Joseph Bell Joseph Bell

was an extraordinary teacher by all

accounts and Conan Doyle writing about

Bell described the following exchange

between Bell and his students so picture

Bell sitting in the outpatient

department students all around him

patients signing up in the emergency

room and being registered and being

brought in and a woman comes in with a

child and Conan Doyle describes the

following exchange the woman says good

morning Bell says what sort of crossing

did you have on the ferry from burnt

Island she says it was good and he says

what did you do with the other child she

says I left him with my sister and leave

and he says and did you take the

shortcut down invar light throw to get

here to the infirmary she says I did and

he says would you still be working at

the linoleum factory well she says I am

and Bell then goes on to explain to the

students he says you see when she said

good morning I picked up her five accent

and the nearest ferry crossing from Fife

is from burnt Island and so she must

have taken the ferry over you notice

that the coat she’s carrying is too

small for the child who was with her and

therefore she started out the journey

with two children but dropped one off

along the way you noticed the clay on

the soles of her feet such red clay is

not found within a hundred miles of

Edinburgh except in the Botanical

Gardens and therefore she took a

shortcut down in relay throw to arrive

here and finally she has a dermatitis on

the fingers of her right hand a

dermatitis that is unique to the

linoleum factory workers in burnt Island

and when Belle actually strips the

patient begins to examine the patient

you can only imagine how much more

were discern and as a teacher of

medicine as a student myself I was so

inspired by that story but you might not

realize that our ability to look into

the body in this simple way using our

senses is quite recent the picture I’m

showing you is of Leopold on Ruger who

in the late 1700s discovered percussion

and the story is that Leopold

ellenberger was the son of an inn keeper

and his father used to go down into the

basement to tap on the sides of casks of

wine to determine how much wine was left

and whether to reorder and so when all

Ruger became a physician he began to do

the same thing he began to tap on the

chests of his patients on their abdomens

and basically everything we know about

percussion which you can think of as a

ultrasound of its day organ enlargement

fluid around the heart fluid in the

lungs abdominal changes all of this he

described in this wonderful manuscript

inventive novum new invention

which would have disappeared into

obscurity except for the fact that this

physician Corvis art a famous french

physician famous only because he was

physician to this gentleman Corvus art

repopulate and reintroduced the work and

it was followed a year or two later by

lennick discovering the stethoscope

lennick it is said was walking in the

streets of Paris and saw two children

playing with a stick one was crashing at

the end of the stick another child

listened at the other end and lenok

thought this would be a wonderful way to

listen to the chest or listen to the

abdomen using what he called the

cylinder later he renamed with the

stethoscope and that is how stethoscope

and auscultation was born so within a

few years in the late 1800s Early 1900s

all of a sudden the barber surgeon had

given way to the physician who was

trying to make a diagnosis if you recall

prior to that time no matter what ailed

you you went to see the barber surgeon

who wound up cupping you bleeding you

purging you and oh yes if you wanted he

would give you a haircut short on the

sides long on the back and pull your

tooth while he was at it he made no

attempt at diagnosis in fact some of you

might well know

that the barber pull the red and white

stripes represent the bloody bandages of

the barber surgeon and the receptacles

on either end represent the pots in

which the blood was collected but the

arrival of auscultation and percussion

represented a sea change a moment when

physicians were beginning to look inside

the body and this particular painting I

think represents the pinnacle the peak

of that clinical era this this is a very

famous painting the doctor by Luke

Fields Luke Fields was commissioned to

paint this by Tate who then established

the Tate Gallery and Tate asked fields

to paint the painting of social

importance and it’s interesting that

fields picked this topic feels as older

son Philip died at the age of nine on

Christmas Eve after a brief illness and

fielders were so taken by the physician

who held vigil at the bedside for two

three nights that he decided that he

would try and depict the physician in

our time almost attribute to this

physician and hence the painting the

doctor very famous painting it’s been on

calendars postage stamps in many

different countries I’ve often wondered

what would Fields have done had he been

asked to paint this painting in the

modern era in the year 2011

would he have substituted a computer

screen for where he had the patient I’ve

gotten into some trouble in Silicon

Valley for saying that the patient in

the bed has almost become an icon for

the real patient who’s in the computer

I’ve actually coined a term for that

entity in the computer I call it the eye

patient the eye patient is getting

wonderful care all across America the

real patient often wonders where is

everyone when are they going to come by

and explain things to me who’s in charge

there’s a real disjunction between the

patient’s perception and our own

perceptions of the best medical care I

want to show you a picture of what

rounds looked like when when I was in

training the focus was around the

patient we went from bed to bed the

attending physician was in charge too

often these days rounds looks very

much like this where the discussion is

taking place in a room far away from the

patient the discussion is all about

images on the computer data and that one

critical piece missing is that of the

patient now I’ve been influenced in this

thinking by two anecdotes that I want to

share with you one had to do with a

friend of mine who had a breast cancer

had a small breast cancer detected had

her lumpectomy in the town in which I

lived this was when I was in Texas and

she then spent a lot of time researching

to find the best cancer center in the

world to get her subsequent care and she

found the place and decided to go there

went there and which is why I was

surprised a few months later to see her

back in our own town getting her

subsequent care with her private

oncologist and I pressed her and I asked

her why did you come back and get your

care here and she was reluctant to tell

me she said you know the Cancer Center

was wonderful it had a you know

beautiful facility giant atrium valet

parking a piano that played itself

concierge that took you around from here

to there but she said but they did not

touch my breasts my you and I could

argue that they probably did not need to

touch her breasts they had her scanned

inside out they understood her breast

cancer at the molecular level they had

no need to touch of rest but to her it

mattered deeply it was enough for her to

make the decision to get her subsequent

care with her private oncologist who

every time she went they examined both

breasts including the axillary tail

examined her exilic carefully examined

her cervical region her inguinal region

did a thorough exam and to her that

spoke of a kind of attentiveness that

she needed I was very influenced by that

anecdote I was also influenced by

another experience that I had again when

I was in Texas before I moved to

Stanford I had a reputation as being

interested in patients with chronic

fatigue this is not a reputation you

would wish on your worst enemy

I say that because these are difficult

patients they have often been rejected

by their families have had bad

experiences with medical care and they

come to you fully prepared for you to

join the long list of people who was

about to disappoint them and I learned

very early on with my first patient that

I could not do justice to this very

complicated patient with all the records

they were bringing in a new patient

visit of 45 minutes there is just no way

and if I tried I would disappoint them

and so I hit on this method where I

invited the patient to tell me the story

for their entire first visits and I

tried not to interrupt them we know that

the average American physician

interrupts their patient in 14 seconds

and if I ever get to heaven it will be

because I held my peace for 45 minutes

and did not interrupt my patient I then

scheduled the physical exam for two

weeks hence and when the patient came

for the physical I was able to do a

thorough physical because I had nothing

else to do I like to think that I do a

thorough physical exam but because the

whole visit was now about the physical I

could do an extraordinary thorough exam

and I remember my very first patient in

that series continue to tell me more

history during what was meant to be the

physical exam visit and I began my

ritual I began I always begin with the

pulse then I examined the hands then I

look at the nail beds and I slide my

finger up to the epic rocker node and I

was into my ritual and when my ritual

began this very voluble patient began to

quiet down and I remember having a very

eerie sense that the patient and I had

slipped back into a primitive ritual in

which I had a role and the patient had a

role and when I was done the patient

said to me with some all I have never

been examined like this before now if

that were true is a true condemnation of

our healthcare system because they had

been seen in other places I then

proceeded to tell the patient one that

once the patient was dressed the

standard things that the person must

have heard in other institutions which

is this is not in your head

this is real the good news it’s not

cancer it’s not chipper Colossus it’s

not coccidia mycosis or some obscure

fungal infection the bad news is we

don’t know exactly what’s causing this

but here’s what you should do or here’s

what we should do and I would lay out

all the standard treatment options that

the patient had heard elsewhere

and I always felt that if my patient

gave up the quest for the magic doctor

the magic treatment and began with me on

a course towards wellness it was because

I had earned their rights to tell them

these things by virtue of the

examination something of importance had

transpired in the exchange I took this

to my colleagues at Stanford in

anthropology and told them the same

story and they immediately said to me

while you are describing a classic

ritual and they helped me understand

that rituals are all about

transformation we marry for example with

great pomp and ceremony and expense to

signal our departure from a life of

solitude misery loneliness to one of

eternal bliss I’m not sure why you’re

laughing that was the original intent

was it not we signal transitions of

power with rituals we signal the passage

of a life with rituals rituals are

terribly important they’re all about

transformation what I would submit to

you that the ritual of one individual

coming to another and telling them

things that they would not tell their

preacher or rabbi and then incredibly on

top of that disrobing and allowing touch

I would submit to you that that is a

ritual of exceeding importance and if

you shortchange that ritual by not

undressing the patient by listening with

your stethoscope on top of the night

gown by not doing a complete exam you

have bypassed on the opportunity to seal

the patient-physician relationship I am

a writer and I want to close by reading

you a short passage that I wrote that

has to do very much with this scene I’m

an infectious disease physician and in

the early days of HIV before we had our

medications I presided over so many

scenes like the

I remember every time I went to a

patient’s deathbed whether in the

hospital or at home I remember my my

sense of failure I think the feeling of

I don’t know what I have to say I don’t

know what I can say I don’t know what

I’m supposed to do and out of that sense

of failure I remember I would always

examine the patient I would pull down

the eyelid I would look at the tongue I

would perk us the chest I would listen

to the heart I would feel the abdomen I

remember so many patients their names

still vivid on my tongue and their faces

still so clear I remember so many huge

hollowed-out haunted eyes staring up at

me as I perform this ritual and then the

next day I would come and I would do it

again and I wanted to read you this one

closing passage about one patient I

recall one patient who was at that point

no more than a skeleton encased in

shrinking skin unable to speak his mouth

crusted with Candida that was resistant

to the usual medications when he saw me

on what turned out to be his last hours

on this earth his hands moved as if in

slow motion and as I wondered what he

was up to his stick fingers made their

way up to his pajama shirt fumbling with

his buttons I realized that he was

wanting to expose his wicker basket

chest to me it was an offering an

invitation I did not decline I per cust

I palpated I listened to the chest I

think he surely must have known by then

that it was vital for me just as it was

necessary for him neither of us could

skip this ritual which had nothing to do

with detecting roles in the lung or

finding the gallop rhythm of heart

failure no this ritual was about the one

message that physicians have needed to

convey to their patients although God

knows of late in our hubris we seem to

have drifted away we seem to have

forgotten as if with the explosion of

knowledge the whole human genome mapped

out at our feet we are allowed into

inattention forgetting that the rich

it’s cathartic to the physician

necessary for the patient forgetting

that the ritual has meaning and a

singular message to convey to the

patient and the message which I didn’t

fully understand then even as I

delivered it I wish I understand better

now is this I will always always always

be there I will see you through this I

will never abandon you I will be with

you through the end thank you very much

you