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Abraham Verghese: Understanding the Complete World of Our Patients at the Bedside & on the Page.

It might be jumping the gun a bit to post this interview with one of my MD/writer heroes now–seeing as it won’t come out in a dead-tree version until the Summer H&P issue. But recently school seems to taking up all my capacity for delayed gratification. So then, here’s what I did with part of my break.

When first encountering Dr. Abraham Verghese—professor of medicine and chair for the theory and practice of medicine—one is most likely to focus on his unique medical background: political strife interrupted his initial training in Ethiopia and spurred him to become first an orderly in New Jersey and then a medical student in India. After earning his degree from Madras University, Verghese returned to the U.S. to practice infectious disease in East Tennessee just as the HIV/AIDS epidemic spread into the country’s rural areas. The resulting experience inspired him to describe America’s plague years in his first book, My Own Country, which was a finalist in the 1994 National Book Critic’s Circle Awards and won wide popular acclaim. His second book, The Tennis Partner, was hailed by the Boston Globe as “indelible and haunting, an elegy to a friendship found, and an ode to a good friend lost.” His scholarly work and shorter articles have appeared in The New England Journal of Medicine, The Wall Street Journal, New Yorker, Texas Monthly, and The New York Times Magazine. His first novel, Cutting for Stone, is scheduled for publication in 2009.

Remarkable as a background spanning medicine, literature, and three continents is, it does not convey the true sense of purpose one detects when talking to Dr. Verghese about clinical practice. His descriptions of the changing patient-physician relationship and the vanishing art of the physical exam illustrate that he is a clinician first, an author second. Recently, I sat down with Dr. Verghese to discuss the importance of literature and technology to our profession.

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What would you say is the value of studying literature to the medical profession?

I’ve spent the last five years teaching literature and humanities to medical students. And the goal has been to help students maintain their imagination for the suffering of people. The great danger of medical education, because we are so disease-oriented, is to see the diabetic foot in bed three and lose site of the whole. I think literature has two functions: one is that it allows medical students and physicians to continue to imagine the whole world, the complete world of their patient; second, it is an important way to keep hold of oneself. There are a lot of threats to being a physician—your selfhood, your patienthood, all these things are very crucially threatened and affected.

And how do you see the ‘medical narrative’, in which physicians retell their own and their patients’ stories, fitting in to the importance of literature to medicine?

We have become much more conscious of the medical narrative and physicians writing, but there was a lot of that kind of writing before—it just didn’t necessarily call itself that. I think we almost make too much of physicians being writers. For example, I don’t put a degree behind my name on any of my books because it shouldn’t be relevant. If the book has relevance, what does it matter if I have an MD or an MA or a Bachelor of Divinity or a Doctorate of Jurisprudence? When we use our status as physicians to justify our writing, then I wonder what we are really writing about. There has been a great emphasis—there should be and there always has been—on the words on the page and what are they doing for you. Do they work? But over the years, the emphasis has shifted too much onto who is writing and what their credentials are. And that’s not irrelevant, but the ultimate gold standard should be the words on the page.

So, other than an emphasis on credentials, have you noticed other changes in medical narratives?

What has become much more evident is consciously writing about the craft of medicine for the public. I think that’s very typical of what Jerry Groopman does and what [Atul] Gawande does, and they both do it very well. I think Oliver Sacks is the master of that genre. But I think as more colorful and diverse people come to medicine, we’ll see more writers of all sorts. I would hate to see them all fall into this narrow cone that’s called “physician-writing.”

Let’s change topic slightly and talk about the how we encounter our patient’s stories. One concern repeated to me by physicians who write is the fear that technology might be threatening the medical narrative in the clinic. Specifically the computerized history—with pull-down menus and cut-and-paste comments­—raises suspicions. Do you feel that technology endangers how we hear our patients’ stories?

Again, I know there’s a whole sort of industry around ‘the medical narrative’—breaking it down, deconstructing it. And that doesn’t interest me at all. It keeps people busy, but does it change the way I think about medicine? No. And the threat of technology in terms of the history—the real threat is that the precious patient-physician interaction can’t take place very well when the physician has got his back half-turned to the patient so he can enter data. Recently, my son saw a pediatrician, not at Stanford but in Texas. And you know how critical it is to bond with the child with all the tips and tricks we are taught as students. Well, this pediatrician had his back to my wife and our son as he worked on the computer. And maybe that’s what his system requires, but I thought, “We’re never going to come back here.” I just don’t see how he could form a bond with the child. That’s the threat, not the computerized medical record per se. In fact I think the computerized records have saved many lives by reducing medical errors and increasing access to vital information.

So would you say that technology has been an overall boon to clinicians?

I don’t want to sound like a Luddite because I’m not. I think we have great technology. But it should have made us a lot better at the bedside. Sir William Osler was a phenomenal physician. How much more phenomenal would he have been if he had had ultrasounds, angiograms, and all the things that allow us to instantly see what’s going on? You could argue, “What does it matter? Times have changed; we don’t need to do what Osler did.” But I think patients recognize our drift away from the bedside. They see it as inattentiveness; they’re not privy to the conference rooms where we have these wonderful conversations and discuss their images in detail. All they know is the physician came by for three minutes when they have been there for twenty-four hours. We can focus so much on technology that a patient in a bed can become an icon for the real patient in the computer; whereas, a good physical exam really conveys our attentiveness to the patient. My best medical education came when I was an orderly and saw what happens in the twenty-three hours and fifty-five minutes when the physician is not there. And so much of that is missed now—not that doctors can be there all that time, but we can certainly be respectful that the patient has to be there all those hours. And we can be more conscious that patients are unaware of everything we learn about them and how busy we are with their concerns.

Do you think new technology or new applications of the technology might remove this danger of displacing the patient-doctor relationship?

I think we can do more with technology in ways that we might not think the technology is for. For example, in El Paso, I had a patient with an amoebic liver abscess. He was very sick, so we were delighted to make the diagnosis. We started him on treatment and things were getting better, but he wasn’t looking any better. There was no medical reason for this, and there was also a language barrier, as my Spanish was not that good. So, finally, I went down and got the CT scans and showed him “el absceso en su higado” and how it was shrinking. And it made all the difference; he was a much better patient the next day. That represents the kind of technology information transfer that we don’t make.

I wonder if we can shift gears now and talk briefly about your forthcoming novel, Cutting for Stone. Could you sketch the outlines of the story for us?

It is very much an epic medical story, beginning in Africa and ending here in America. It has in it all my love of medicine and to some extent the underbelly of medicine, which we all encounter. There are characters who are saved by becoming physicians, and characters for whom giving their life to medicine was, in a way, their biggest mistake. The story really affirms to me what I love most about medicine, which is that medicine is life. If you go to it hoping to flee the rest of the world, as many of us do, it doesn’t always work. At some point you have to pay the piper. So it is sort of an old-fashioned novel in that sense.

What would you say are your aspirations for this book? Is there a particular area you hope to explore or particular readers you hope to reach?

My first goal, of course, is a good story well told, which is no small feat. For the second goal, I want the book to do for the reader perhaps what certain books did for me, which was to make me feel that medicine was a worthwhile and romantic pursuit that involves a lot of sacrifice but which affords a special insight into life. It involves the idea that in treating patients’ pain, you can heal your own. And I don’t know if we convey that idea very well today. I don’t know how people come to medicine anymore. I wonder if it’s from “Scrubs” or “Gray’s Anatomy” or the Discovery Channel. And maybe that’s how it should be, but I like the notion of falling in love with medicine. And that’s what I’ve tried to write about: loving the mystery of it, the danger of it, the grief of it. I don’t know if I’ve succeeded, but that’s what I’d like to convey.