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