Abraham Verghese. (Photo: Peggy McInerny/UCLA.)
Using stories, pictures and citations from literature to illustrate his points, writer-physician Abraham Verghese emphasized the way in which literature can help physicians cultivate the humanist, healing aspect of medicine.
“I remind my students that there's always story, there's always drama, when a patient comes to hospital or the doctor's office. Even if it's routine for you, it's not at all routine for the patient.”
UCLA International Institute, November 12, 2013 — Doctors can borrow from the writer’s toolbox to make themselves better physicians and clinicians, said author-physician Abraham Verghese at an October 25th lecture at UCLA.
Held in Korn Convocation Hall of the UCLA Anderson School of Management, the event was cosponsored by the UCLA Center for India and South Asia, UCLA Department of English, UCLA David Geffen School of Medicine, UCLA Division of Social Science, the UCLA Mellon Postdoctoral Fellowship Program: Cultures in Transnational Perspective, and Friends of English at UCLA.
The speaker began with two stories, one about the death of fellow physician-writer Anton Chekov and one about the work of John Sassall, the English country doctor depicted in John Berger’s “A Fortunate Man.” Both emphasized the gift that physicians give patients when they recognize the latter’s humanity.
In addition to teaching better listening skills, said Verghese, literature promotes the use of both the imagination and of metaphor. All, he said, are crucial for communicating with patients at a deeper level that recognizes their individual uniqueness.
Verghese is Senior Associate Chair for the Theory and Practice of Medicine at the Department of Medicine of Stanford University, where he is also clerkship director. In addition, he teaches for the Stanford Health Policy program of the Freeman Spogli Institute and Stanford’s Center for Biomedical Ethics. He is board certified in internal medicine, pulmonary diseases and infectious diseases.
A renowned writer and graduate of the Iowa Writers Workshop, Verghese has published three books to date, with a new novel in the works. The memoirs, “My Own Country” (Vintage, 1995) and “The Tennis Partner” (Harper Collins, 1998), received critical acclaim, and the novel “Cutting for Stone” (Vintage, 2009) spent over two years on the New York Time’s bestseller list.
"Story,” said Verghese, “is fundamental to medicine. In fact, when we see a patient, we take a history — the word ‘story’ is actually embedded in ‘history.’” In fact, the noted, doctors often act as the “spokesperson” for a patient’s illness.
Every patient has a story, said Verghese, defining the term to mean the narrative of a conflict or obstacle that is overcome to reach a resolution.
“Most of people’s daily activities do not involve story. But the moment someone shows up to see a physician in his office,” he observed, “there is inherent drama, because most of us in this room will get the news that our lives will be shortened, or affected, or changed in some fashion in a doctor’s office.
“I remind my students that there’s always story, there’s always drama, when a patient comes to hospital or the doctor’s office. Even if it’s routine for you, it’s not at all routine for the patient.”
Listening well to a patient’s story, said Verghese, can produce an epiphany (an “ah hah” moment), when he suddenly sees things in a different light. He said his own epiphany as a doctor came during the early days of the AIDS crisis, when he realized that healing and curing were not the same thing.
Then working in rural Tennessee, he decided to visit a very ill AIDS patient who had not come to his weekly clinic, intuiting that he would not otherwise see the young man again. To his astonishment, his visit proved very meaningful to both the patient and his family, helping them come to terms with the man’s illness and impending death.
When he left their home, said Verghese, “I thought, this is what the horse-and-buggy doctor of 150 years ago did so well. In the absence of any cure, they were able to heal — by which I mean, helping people come to terms with things — even if they could not cure.”
Relating the difference between healing and curing to disease, Verghese compared disease to coming home and finding one’s door open, the lock in splinters and all one’s valuables taken. Even if all your things are eventually returned (i.e., you are cured), he observed, you will remain devastated by the violation of your privacy (i.e., the fact of the disease needs healing).
All illness, he emphasized, has these two elements of curing and healing: there is a physical loss and a sense of violation— why me? why now? This is, he emphasized, especially true with illnesses such as HIV and cancer.
Verghese urged doctors not to “medicalize” a patient’s story to the point where they fail to see the individual. As doctors turn a patient’s description of symptoms into concise medical notes, he remarked, “The great danger is that it can strip the patient of everything that makes [him or her unique], that makes them a ‘character.’”
To illustrate his point, he recounted the story of a rather gruff, elderly surgery patient from Tennessee who developed a deep infection that went to the bone. Beloved by the nurses, the patient had a playful sense of humor and referred to the catheter that delivered his antibiotics as his “watering hose.”
The long treatment for the infection became, to the patient’s delight, the focus of a medical article by Verghese. “Here I was, confirming the uniqueness of his illness,” noted the speaker, “by writing an article about it.”
When he showed the man the galleys of the article, however, the patient started reading and looked up disappointed. “‘But Abraham, he said,’” recounted Verghese, “’there’s nothing about me in here.’ It was a great reminder to me that even though it is the voice of medicine that we record in the chart; we have to find a way to keep the patient’s voice alive to remind us of their uniqueness and who they are.”
In the age of the electronic medical record (EMR), said the speaker, the problem of “medicalization” is magnified by need to record notes on a computer. Quoting from his recent article on the “I-patient,” Verghese observed, “The patient in the bed keeps wondering, where is everyone? What the hell is going on? When will they come and talk to me?”
While Verghese lauded the rich metaphors that medicine has created in the past (e.g., “strawberry tongue,” “peau d’orange,” “apple core lesion”), he bemoaned their absence in contemporary medicine.
“There is not a single metaphor I can think of that is of our generation. Yet in my career, I have lived through so many new diseases, so many new ways of looking at the body,” he commented, “Where are the metaphors of our age?,” he asked, “What has happened to medicine that we’re not making metaphors?“
“We have become so scientifically oriented,” he continued, “that we don’t know how to use metaphor as we should.” Metaphors capture the imagination, he said, and reading fiction keeps the imagination alive in a deep way.
Excavating the human from the medical
Verghese related the lack emphasis on the humanist aspect of medicine to the research orientation of medical schools and their current preference for students with bioengineering backgrounds. “There is something about medical school that is capable of stripping people of all their good qualities,” he commented.
“Basically, people come to medicine able to imagine the suffering of their patients. . . [yet we teachers] are so focused on disease, that they become disconnected from the very emotion that brought them to medicine.” The good news, he noted, is that the best students rediscover this emotion.
Verghese concluded by saying that physicians would be of great service to their patients if they remain attuned to story, character, epiphany and metaphor. Repeating his argument that listening deeply to a patient helps the physician see him or her differently, Verghese again cited John Berger (“A Fortunate Man”):
"An unhappy patient comes to the doctor to offer him an illness in the hope that this part of him, at least — the illness — may be recognizable. His proper self he believes to be unknowable. In the light of the world he is nobody. By his own lights, the world is nothing. Clearly, the task of the doctor is to recognize the man. If the man can begin to feel recognized, then such recognition may well include aspects of his character which he has not yet recognized himself. The hopeless nature of his unhappiness will have been changed; he may even have the chance of being happy."