http://www.stanfordalumni.org/news/magazine/2009/janfeb/features/verghese.html
The Human Whisperer
Whether practicing medicine or literature, Abraham Verghese teaches how to pay full attention at a patient’s bedside.
BY SUSAN COHEN
PHOTOGRAPHY BY MICHAEL SUGRUE
IT TAKES ABRAHAM VERGHESEonly a few minutes to stroll from his public office to his secret one. His main office in the department of medicine contains the medical handbooks, the imposing desk, the ready assistant who copes with the physician’s complicated schedule. His secret office bears someone else’s name outside. It’s only slightly more personal than a motel room, a space devoted to nothing but writing. He jokes that he’ll be forced to eliminate anyone who uncovers its location.
Stanford promised Verghese the dual offices and two days a week to write when it hired him last year as senior associate chair for the theory and practice of medicine and put him in charge of training third- and fourth-year students as they rotate through internal medicine. It was, department of medicine chair Ralph Horwitz readily acknowledges, an unusual tenured appointment for an institution that typically evaluates a paper trail of research grants and publications to hire or promote. Verghese’s paper trail included, instead, a long list of essays, short stories and two much-praised memoirs, one of which was made into a movie starring Naveen Andrews of Lost.
Verghese’s summary of research interests remains blank on his faculty web page.
His list of publications, on the other hand, continues to grow. The newest is an epic novel, set over five decades in Ethiopia and America; Cutting for Stone will be published by Knopf on February 6.
Even more unusual than these literary accomplishments are the personal history Verghese brings to Stanford, and the ways it has led him to practice and teach medicine. Modern medicine can be high-tech, research-oriented, data-driven and time-crunched in ways that are alienating to both patient and physician. Examining a patient can come as an afterthought, neglected in the onslaught of laboratory test results, medical scans, numbers on the computer screen. These days, as Verghese puts it, “If you’re missing a finger, you have to get an X-ray to be believed.”
‘To him the physical exam is a beautiful and worthwhile art that benefits both patient and doctor.’
He is a link to an older healing tradition: devoted to medicine not just as science, but as calling and craft. Verghese doesn’t neglect modern laboratory tests; he’s board-certified in three specialties—internal medicine, pulmonary medicine and infectious diseases. But he loves nothing more than teaching students who are focused on the image of an organ on a piece of film to also look at the person in the hospital bed. And not just look, but touch, listen, even smell, with a writer’s attention to detail and a physician’s intention to discover the story of someone’s suffering.
“I loved introducing medical students to the thrill of the examination of the human body, guiding their hands to feel a liver, to percuss the stony dull note of fluid that had accumulated in the lung, to be with them when their eyes shone the first time they heard ‘tubular’ breathing . . . and thereby diagnosed pneumonia,” Verghese has written. To him, the physical exam is a beautiful and worthwhile art that benefits both patient and doctor.
Horwitz recruited Verghese after being struck by the power of his commitment to patients and bedside medicine “at a time when technology is so seductive.” The first time he heard Verghese speak, he watched this man with the soft voice electrify a boisterous audience of medical students who grew quieter and quieter so that they would not miss a word. Horwitz found in Verghese a scholar and master clinician who represents medicine’s “most enabling and enduring values.” There’s no irony in his voice when Horwitz insists that Verghese is “cutting edge” precisely because “he promotes bedside medicine and its meaning to both patients and practitioners.”
“Stanford needs that,” Horwitz argues, so that with all its emphasis on science and technology “we don’t lose sight of the value and meaning of that science and technology.”
ABRAHAM VERGHESE DESCRIBES HIMSELF as a perennial outsider. His parents were teachers from a Christian region of India, who raised him in Ethiopia. The expatriate life in Africa made him an acute observer of cultures and a seeker of connections. He believes that doctors are often wounded people attracted to medicine in an attempt to heal themselves, people who’ve sought “a way to be in this world” from the margins, and that literature, too, is a way to connect with the human condition. As a boy, he was drawn to both these passions by the stories of doctor-turned-writer Somerset Maugham.
Verghese, 53, began his medical education in Ethiopia, but fled in 1973 as civil unrest turned the country against both intellectuals and foreigners. He had witnessed so much brutality that when he reached New Jersey, where his parents and younger brother had settled a few years before, his only remaining life’s ambition was safety. He worked as a hospital orderly and assumed he’d live a blue-collar life.
One night, while working, Verghese found a copy of Harrison’s Principles of Internal Medicine on a table where a med student had left it. The book revived his calling. With the help of an aunt, he finished medical school in India, which took him in as a displaced person.
Medical training in Madras was “intense at the bedside every day,” Verghese recalls. “I loved it. Those Indian teachers were incredibly skilled. They’d identify all these diseases you’d never find in Western textbooks.” He watched them almost with a sense he was witnessing “wizardry.” He admired not just their ability to diagnose, but also the way they dealt with patients, “the gentleness of the way they taught us” and the love for medicine they conveyed. Many of the physical signs he was taught to notice at the bedside were named after great doctors of the past. His teachers were passing along a grand tradition, and he found himself “not wanting to break the chain.”
When it came time to do his residency, Verghese chose a newly fledged program in internal medicine at East Tennessee State University in the foothills of the Smoky Mountains. He chose internal medicine partly because he saw that foreign-trained students who wanted to be surgeons were recruited to the poorest American hospitals, worked around the clock, and rarely were promoted afterward by the top-ranked medical centers, places the students jokingly called “Mecca.”
Johnson City and the rural towns and hollers around it were a long way from any medical Mecca, but they turned out to be the opportunity of a lifetime for Verghese as both doctor and writer. People grew to depend on this foreign doctor with the brown face, slightly British diction and unplaceable accent. After a two-year fellowship in infectious diseases at Boston University, where he tried and disliked laboratory research, Verghese returned to Tennessee and joined the faculty, choosing to focus on caring for patients and teaching.
THAT’S WHERE HE FOUND HIMSELF in 1985, when young gay men began to return to their small towns and families to die. The HIV/AIDS clinic Verghese established saw more than 80 patients in five years, by which time Verghese felt burned out. It had been humbling. He’d been forced to give up what he called the physician’s “conceit of cure.” But though no one had a cure for the new disease, Verghese had found a lot to offer in the way of care—so much that he had little time to spare for his own family, which by then included a wife and two young sons, Jacob and Steven. He filled journals with his observations and his thoughts, and the details of his patients’ stories, in an attempt to learn as much about himself as about them. He thought he’d prepared himself for so much death. He hadn’t.
In a bold move, Verghese gave up his tenured position in Tennessee to attend the famous Writer’s Workshop at the University of Iowa. He realized later how hard that was on his family. “It was very selfish on my part. To me, it felt like survival.” A year and a half of intensive writing later, money running out, Verghese turned down several traditional academic positions that would have required him to chase grants and publish research papers. He took a clinical position instead—as professor of medicine and chief of infectious diseases at Texas Tech Health Sciences Center in El Paso. “I really liked the sense of being on the edge of America,” he explains. It was a “first world hospital—just barely—taking care of third world disease.” Without the pressure to do research, he wrote fiction.
After the New Yorker ran a short story based on his experiences in Tennessee, Verghese was offered a contract to write a memoir—one of the earliest books by a doctor working from the AIDS front line. He’d never considered writing nonfiction, but My Own Country: A Doctor’s Story of a Town and Its People in the Age of AIDS was a finalist for the National Book Critics Circle Award in 1994. Director Mira Nair filmed it for Showtime TV. My Own Country was, another physician comments, “a really brave book.” His second was even braver. The Tennis Partner: A Doctor’s Story of Friendship and Loss, in 1998, described his bond with a medical resident in El Paso who died of drug addiction. The heavily autobiographical book interwove many themes: his passion for tennis, the failure of his first marriage, his enduring love of medicine in spite of the isolating effect it can have on its practitioners.
He attributes some blame for the appalling levels of suicide and drug abuse among doctors to this isolation. “Medicine is so beautiful, and yet it has its seamy underbelly,” Verghese says. “Most of us in medicine end up being far better doctors than fathers or husbands.” Although it’s his compassion—as well as his vivid and often lyrical writing—that wins praise, Verghese thinks what draws medical students to his work is that he exposes himself as a flawed human being rather than an all-knowing physician.
Verghese believes in the curative power of literature for physicians. Writing is a way to explore what they see every day and can’t share. Reading is a way for students to revive the empathy that gets lost in the process of medical training. Modern training “takes lovely people and converts them into bottom-line, somewhat cynical, disease-oriented people,” Verghese insists. “We teach them to convert into our language, which we need for diagnosis. We rob the story of everything human about it.” After a while: “Imagining suffering is a struggle. The danger is we begin to talk about the diabetic in bed three.” Literature, on the other hand, is full of suffering. He likes to teach his students Chekhov, and is apt to recite a poem off the top of his head by William Carlos Williams—two other writer/physicians.
Six years ago, Verghese created the Center for Medical Humanities & Ethics at the University of Texas Health Science Center in San Antonio, one of an increasing number of programs—like Stanford’s arts, humanities and medicine program—that encourage medical students to explore the arts. He also worked on Cutting for Stone. The novel’s title plays on a phrase in the Hippocratic oath and the name of a central character, Thomas Stone. Stone is a surgeon who’s missing from much of the narrative, just as he’s missing from his twin sons’ lives: a symbol of the wounded doctor who distances himself from people even as his hands render miracles on the operating table. Much of the rich, sprawling story is set in Ethiopia at a mission hospital that the locals call Missing. It’s an ambitious book filled with characters who, in their different ways, reveal Verghese’s view of what medicine does best and worst. Some of its most powerful scenes occur at a decrepit hospital in the Bronx where a newly arrived foreign medical student assumes the helicopter pad on the roof represents the richly endowed American medicine he so envied from afar. But the landing pad exists so doctors from an elite medical center can touch down just long enough to harvest organs for transplant from the trauma patients who flood the inner-city emergency room.
Though Verghese is ambitious for his writing, medicine remains its source. “I’d love to practice medicine until my last day,” he says. There are other physicians who combine the two, of course: surgeons Atul Gawande, ’87, and Richard Selzer, and pediatrician Perri Klass. But there are more of those like novelist Ethan Canin, ’82, a Harvard Medical School graduate who found he had to choose. Canin, a friend who has been familiar with Verghese’s writings for years, says: “I’ve always been amazed at his ambition and attainment in both. Plenty of people are ambitious in both, but few—if any—have attained such distinction in the two fields at once.”
When Verghese received Stanford’s offer to return to teaching at the bedside, an offer that included time to write, plus tenure, it struck him that Stanford valued his books and essays as highly as research. The realization was “precious.”
ON A DAY IN AUGUST, as he walked down a corridor at Stanford’s medical center, Verghese gestured to a glass wall that looks onto a wildly colorful garden, a glorious riot of flowering plants that achieve their profusion with massive—and expensive—tending. “Mecca,” he laughed. As though he had to pinch himself.
Verghese wants Stanford students to see medicine as a historic calling the way he does. He wants them to see a patient not as a diseased liver or a spleen, but as a man or woman in a bad situation. Young doctors may be brilliant at analyzing tests, but he finds many “incompetent” at diagnosing and treating at the bedside. Verghese also wants students to understand that there’s a “huge therapeutic effect” in offering someone hopeful words. Especially, and only if true, the words: “I think you will get better.”
What Verghese seems to have tapped into, even in the scant year he’s been here, is a hunger not just from patients for doctors with a human touch, but also from doctors for the kind of satisfaction many no longer get from medicine. Verghese, who lives with his wife, Sylvia, and their 11-year-old son, Tristan, hosted a speaker’s evening with an expert on evidence-based physical diagnosis. A medical resident grew so enthusiastic about learning more on how various skin conditions might help her diagnose patients that she blurted: “We get to be doctors! Not just order tests!”
Lisa Shieh, an assistant professor who specializes in internal medicine and in-patient care, says she’s found a mentor in Verghese. After hearing him speak, she invited him to instruct second-year students how to take a history and conduct a physical exam. She also followed him on rounds like a student, to see how he interacted with patients and taught. “There’s just so much data now in medicine, and keeping that straight is very challenging. Sometimes with all the technology, the physical exam takes a back seat.”
Verghese is organizing a major conference on bedside medicine that will take place at Stanford next September. Department chair Horwitz sounds like a proud parent when he talks about his successful recruit: “I now live in the shadow of Abraham!” He notes that, instead of the eight or nine graduating students who typically choose a career in internal medicine over other specialties, this year 21 students out of 90 made that choice.
ONE TUESDAY as Verghese led students on weekly rounds, they entered a hospital room where an elderly woman lay moaning, her eyes closed, her mouth open. Her husband, wearing a blue baseball cap and an exhausted look, sat in a chair at the foot of her bed, eyes fixed on her face for any signs she might respond.
“Come closer, she won’t bite,” Verghese called to his students, who hung back by the door while he greeted the man in the cap. “He won’t bite either.”
Verghese examined the patient, ending by lifting her arms and noting the very different rate at which her hands drifted down the sheets. At the small hospital where she’d first been hospitalized, a central venous catheter had been placed in the course of treating her for a possible infection. In transferring her to Stanford, there had been talk of an exotic diagnosis. But Verghese’s exam suggested she had suffered a stroke. When questioned, her husband recalled that she had become confused on the afternoon when the catheter was inserted. Verghese postulated that event had triggered a “cascade of catastrophes”: a drop in pressure, along with her history of irregular heart rhythms, had caused a clot to break loose and disrupt blood flow to the brain.
Verghese explained his concern to the husband in understandable terms, and said that he hoped to have more news later after getting the results of a brain scan. He asked where the family was staying and whether they were comfortable.
In another room, a white-haired woman with pneumonia eyed the gaggle of students, interns and residents with bright-eyed good humor, even as her grown daughter immediately launched into a litany of complaints about the room and the hospital care. Verghese took these complaints for what they were: a caring daughter’s anxiety over her mother’s illness. He moved right up to his patient, put his hand on her thin wrist, percussed her back and listened to her chest with his stethoscope. He left his hand lightly resting on her arm. “There’s something very comforting about the human hand. That’s very nice,” the patient commented.
‘Modern training “takes lovely people and converts them into bottom-line, somewhat cynical, disease-oriented people”’
Verghese smiled. “I’m trying to teach them that,” he said, and turned to his students: “I always take a patient’s hand and then pulse.” He told the ill woman that she looked as if she’d been getting plenty of fluids.
“Oh, good,” she said, laughing, “keep me up!” She raised her arms to indicate he’d lifted her spirits. Her daughter continued to ask questions, but seemed more relaxed. Before leaving, Verghese told the woman in the bed not only that he’d like to send her home, but that she was lucky to have a daughter who took such good care of her.
Before rounds ended, the students gathered around Verghese in the hall and talked about a patient who seemed better but whose CT scan looked worrisome. Verghese reassured them that in this case they could trust their observations. He praised a nurse who stopped to ask about a patient. “That was good nursing care,” he said. “We appreciate that care.” He singled out an intern who’d received a compliment from a patient for smiling and being helpful in the emergency room the night before.
The students trooped after Verghese to radiology to look at the brain scans of the nonresponsive woman they saw earlier. Sure enough, the radiologist pointed out evidence of small bleeds in her brain.
When Verghese and one resident returned to give the husband this news, the man in the blue baseball cap was exactly where they’d left him, at the foot of his wife’s bed and staring at her face. Verghese explained that the MRI seemed to confirm his suspicion that she had suffered a series of small strokes. He would ask the neurologists for some help, Verghese said, but he thought there was a chance the man’s wife would gain back a good part of her function. “One day at a time,” he told the husband, who clung to each word as hard as he was grabbing onto Verghese’s hand. Each day would bring a little more information. Verghese took time to thank the man for describing how his wife became unresponsive, and said the information had played an important role in leading them to their diagnosis. In a way, Verghese had welcomed the husband to the team, and invited him to be part of her healing, even while delivering bad news.
On the walk back to his office—the official one at the department of medicine—Verghese once more expressed his amazement at where he, the perennial outsider, had landed. Directly in Mecca. The trade-off he made decades ago, to spend whatever time he didn’t spend at the bedside writing, brought him here. A career trajectory no one could dream, let alone plan.
At Stanford, Verghese started out feeling as if he didn’t fit in, even though he found everyone extremely welcoming. But then he walked out into the hospital and led his first rounds. He felt immediately at home at patients’ bedsides. That was the evening Verghese told his wife: not only did he feel comfortable at Stanford, he knew he had something to offer.