“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists held this year in Orlando, Florida. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”
Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”
Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.
“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.
“The electronic health record was never designed for us to use,” Dr. Verghese said. “It was designed for billing. The current electronic health record is a mistake of ‘EPIC’ proportions. We are the highest-paid clerical workers in the world!”
The physician who inspired Sherlock Holmes
Dr. Verghese opened his talk with a story he loves to tell medical students about Dr. Joseph Bell, a surgeon who was the instructor of Arthur Conan Doyle when Doyle studied medicine in Edinburgh, Scotland. Dr. Bell was the apparent inspiration for Doyle’s famous character, Detective Sherlock Holmes. Seeing a patient in clinic for the first time, Dr. Bell could tell by her accent what part of Scotland she had traveled from, by the clay on her shoes that she had walked through the Botanical Gardens on the way to the clinic, and by the dermatitis on her hand that she worked at a linoleum factory.
With Dr. Bell’s remarkable observation skills, Dr. Verghese said, “can you imagine how much the body is going to speak to him after the patient has disrobed?”
Dr. Verghese traced the art of physical diagnosis back to the early 18th century, when Dr. Josef Leopold Auenbrugger, a physician in Vienna, conceived the idea of tapping on a patient’s chest to assess fluid levels around the heart and lungs just as wine merchants would tap on casks of wine to check their fullness. He invented the art of percussion, and in 1816, Dr. Rene Laennec invented the stethoscope.
“The day when physicians began to carry the stethoscope in their pockets was the moment where we were no longer in the tradition of the barber-surgeons,” Dr. Verghese explained. The barber-surgeons made no attempt at diagnosis, they merely “cut, purged, and burned,” no matter what the underlying disease happened to be.
Though our ability to diagnose and treat disease has advanced exponentially, and we can amass staggering amounts of “Big Data” about patients, Dr. Verghese made the case that the heart of practicing medicine is in danger of being lost because of disconnection between physician and patient.
Dr. Verghese showed a photograph of the great physician and teacher, Sir William Osler, sitting at a patient’s bedside, clearly in deep contemplation. Next, he showed a famous 1891 painting by Luke Fildes called “The Doctor,” which shows a physician watching at the bedside of a dying child. Fildes painted from his own experience, after a physician kept vigil with his nine-year-old son for two days and two nights before the child finally died from an untreatable illness.
“Even though this was the era of the stethoscope, Fildes did not include any of those in the painting,” Dr. Verghese noted. “Why this painting has such public appeal — we identify with the child. This is the singular attentiveness we want from our physicians.”
Dr. Verghese quoted a verse from the Gospel of St. Matthew 25:36, “I was ill and you cared for me,” to underscore the importance of what he termed “the Samaritan function of being a physician.”
The peril of “loss of ritual”
Today, clinical rounds are conducted too often around a table or a mobile computer workstation instead of at the bedside, Dr. Verghese noted
Since the advent of the electronic health record, “more and more people are only trusting their numbers,” Dr. Verghese said. In times past, “the entire data set was in the intern’s head and on the patients body,” whereas today “if you came to the hospital missing a leg, no one would believe it until you got an orthopedic consult and an MRI.”
Dr. Verghese and his colleagues collected hundreds of vignettes about instances where the inadequacy of the physical examination was the cause of medical errors and adverse events. Examples included vomiting due to a testicular torsion that was misdiagnosed as gastroenteritis, and a patient with severe chest pain from shingles who was sent for cardiac catheterization.
“This is a moral erosion that undercuts everything we try to teach students,” Dr. Verghese said.
Rituals of all kinds — opening ceremonies, weddings, funerals — are about connecting in the process of transformation, he explained. Examining the patient is a ritual too. “The patient tells you things that they would never tell anyone else. And then, the individual disrobes and allows touch. It is a profound moment. It is part of our responsibility to the patient. In the context of reading the body as a text, we have that privilege.”
“They know when you’re doing it well, and they know when you’re doing it poorly,” Dr. Verghese continued. “You can’t learn these skills online; you can only learn them one on one. Part of our obligation is to pass down this craft of ours, this calling, one on one.”
In closing, Dr. Verghese quoted Sir William Osler, “Patients will form an estimate of you by the way in which you conduct yourself at the bedside. Skill, whether in the simple act of feeling the pulse, will establish more confidence in you than any diploma.”
And to my delight as an English major, he also quoted from E.M. Forster’s famous novel, Howards End: “Only connect.”
This article was originally published on aPennedPoint at www.apennedpoint.com.