Physician returns to the art of healing in medicine
The guest speaker, Abraham Verghese, MD, looked in with surprise at the dozen people seated in the public affairs office. "I thought this was a one-on-one meeting," said the professor of medicine, who was newly recruited to raise the profile of clinical training.
Then he walked around the room and shook hands with each person, quietly introducing himself. So no, it was not a one-on-one meeting—but Verghese made it seem like one for a moment.
Verghese's department chair, Ralph Horwitz, MD, said he had worked to recruit Verghese ever since the physician-writer spoke at Yale University grand rounds in 2001. Horwitz, now chair of Stanford's Department of Medicine, heard Verghese read from his first book, My Own Country, about his experiences as a young doctor in rural Tennessee at the beginning of the AIDS epidemic.
Verghese's stories lay bare the daily intensity of medical work along with large swaths of his own personal life.
"Abraham speaks quietly. The auditorium became quieter and quieter as people were straining to hear," said Horwitz. "It was an example of the power of talking softly but with great meaning and importance."
Horwitz, at that time chair of Yale's department of medicine, was also impressed by Verghese's clinical skills during that visit. "Abraham is a master clinician. And he speaks very powerfully about the craft of medicine and reminds us of its importance," said Horwitz.
Verghese is accomplished in multiple ways. Board certified in three specialties—internal medicine, pulmonary diseases and infectious diseases—he is widely published in scientific literature and also writes for the popular press. My Own Country was a finalist in the 1994 National Book Critic's Circle Awards and made into a movie; his second book, The Tennis Partner, was a bestseller. It traces his friendship with a medical student dogged by drug addiction.
"One of my goals is to position us as the most intellectually vibrant department of medicine in the United States. I want this department to be engaged in a noisy but civil discourse on the future of medicine and I think that Abraham will be an important contributor," said Horwitz.
Verghese arrived at Stanford in December to serve as professor of medicine and senior associate chair for the new program in the theory and practice of medicine. His previous position was at the University of Texas in San Antonio, where for five years he directed the Center for Medical Humanities and Ethics.
"Though I enjoyed setting up the center, I found I most enjoyed being a clinician. It's clear that is my first love," he said. "There really is no greater privilege for me than caring for patients at the bedside, and it is the place to convey to students the excitement of internal medicine," he said.
This one-on-one between physician and patient should be at the heart of medical care, said Verghese. At the University of Texas, he encouraged students and doctors to use writing to bring their feelings about these relationships to the surface. In his own writing he has described his distress that in modern medicine these relationships get short shrift.
"Medicine's never been more potent, and yet we have this paradox—I don't think patients have ever been more dissatisfied," he said. "To the patient, it can seem impersonal. It's almost as if the patient in the bed is a mere icon for the real patient in the computer. I'm not a Luddite but I do think technology and fragmentation of care can get out of hand."
He told a story of an acquaintance in Texas. The woman had breast cancer and left town for treatment at a world-class center. Then Verghese discovered she was back and asked why. "She said, 'Everything was fabulous, valet parking, beautiful grounds, the latest protocols....But no one really examined my breast. At best it was cursory.' You could argue they hardly needed to examine her breast at that point; they had her scanned inside and out. But it was important to her. It reflected a kind of inattention," said Verghese. "This is the problem we are up against. If we don't exercise the privilege of putting our hands on people and examining them carefully we lose something therapeutically, and we lose credibility."
Verghese began his medical education in Ethiopia, where he was born in 1955 to South Indian parents. Leaving Ethiopia in the wake of a coup d'etat, he moved to the United States, where he worked in New Jersey as an orderly, and then to India where he finished his medical education at Madras Medical College. He returned to the United States in 1980, entering a residency program at East Tennessee State University in Johnson City, and completed infectious disease training at Boston City Hospital. In 1985, he returned to Johnson City for a position at the Veterans Administration hospital and an appointment as assistant professor at East Tennessee State University School of Medicine.
As a medical student, Verghese dreamt of a "glamorous" career. "…I harbored secret fantasies of specializing in heroic neurosurgery, high-risk perinatology, surgery of the open-heart-and-transplant kind…" he wrote in My Own Country. But Charles Leithead, MD, one of his professors in Ethiopia, hooked him on perfecting the craft of physical examination and inspired him to be an internist.
In My Own Country, Verghese also wrote about training under Leithhead:
"Never forget," he [Leithead] would say, "inspection, then palpation then percussion, finally auscultation." He would look at us curiously and ask: "Which is the least important instrument in our armamentarium?"
"The stethoscope, sir!" we would bark out.
"And why is that, pray?"
"Because, sir," we would chant, "by the time you have looked, felt and percussed, you should know what you will hear!"
At Stanford, Verghese hopes to imbue students and physicians with this respect for the physical examination, and the power of a touch. He's planning a seminar series to celebrate this approach, including hands-on demonstrations.
"For too long, as physicians we've couched our dependency on tests and technology in the notion that we must practice defensive medicine in a litigious era," said Verghese.
"Technology is wonderful. But the 'art' part of healing still requires that you interact with that patient to the maximum possible. It's somewhat mysterious what transpires there, but it's necessary. Your presence is still terribly important for the therapeutic effect," he said.
He's serious about medicine, but also about writing. His appointment earmarks 40 percent of his time to writing and comes with a second office, away from the department of medicine, where he can give writing his full attention. "I'd tell you where it is," he said. "But then I'd have to kill you."
His next book, Cutting for Stone, will be published in January 2009. It's a novel, and begins with a nun giving birth to twins in an operating room in a mission hospital in Africa.
It has all of his passions in it, said Verghese. "It shows that a career in medicine can both save you and lose you."