Is Caring the Rx for Medicine?
An interview with Dr. Abraham Verghese
“One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” — Dr. Francis Peabody
On May 8, 2017, Dr. Abraham Verghese gave the closing talk at Charting a Course for Uncertain Times, a health policy forum in San Francisco presented by the California Health Care Foundation. Author of three best-selling books, including the novel Cutting for Stone, Verghese is professor and vice chair for the Theory and Practice of Medicine at Stanford University School of Medicine.
In his address, “Telling the Story of What Matters to Patients,” Verghese ardently advocated for empathy and human touch in the healing process, part of what he calls “imagining the patient’s experience.” I caught up with him for a brief conversation, which has been edited and condensed.
SB: You argue that technology has become a major impediment to dealing with patients in an empathic way. Is the situation different in places where they have less technology? When you have more technology at your disposal, does it actually make things harder for doctors?
AV: I don’t really know because most places that don’t have technology are also quite resource-limited. That has its own problems, of course. The strange thing is that even in countries that pride themselves on the bedside exam, like England, they are essentially battling the same thing: an overreliance on technology. There’s something about technology that feels more comfortable — you get the printout of the sonogram as opposed to listening to someone’s story. I’m not against technology. I just think that we have only so much attention span, and we swallow so much of it with technology. It’s hard to have much left. The great promise of AI [artificial intelligence], another technology, is that it might free us up to be more human.
SB: How would it free us up?
AV: It could manage to do all the charting functions, billing, coding. That would be great.
SB: You said in your talk that medical students start out “pre-cynical” and eventually become cynical. When does that transformation take place?
AV: Well, the first two years, it’s all basic sciences, and they’re still itching to get to the wards. Then they get to the wards and realize that we’re not actually caring for patients so much as they had imagined. We’re just clicking boxes and doing the “4,000 keystrokes a day.” It’s very disillusioning for them.
SB: Is there a connection between the profit-driven focus of the American health care system and this sense of dehumanization experienced by patients and providers?
AV: Absolutely. The reason that we can’t scale back anything, or have a discussion about rationing care, is because we have all these people feeding at the $3 trillion trough. And anybody planning to take away their share of it, they’re going to lobby Congress and fight it. As long as there’s a profit motive, not to say that we shouldn’t all make a good living, but at what point does it become mercenary?
SB: Can you be on an even playing field when you don’t bring data to the table with your argument?
AV: The burden is on us to acknowledge that we do need data. Eminence-based medicine doesn’t work very well. Which is what it used to be: You went to the eminence and they pronounced. Clearly, we needed to make a shift, but it came with a hubris that suggested that everything else was meaningless. Particularly you see this in the American Board of Internal Medicine, my specialty, where we actually don’t examine doctors to verify that they can do anything at the bedside. It’s all multiple-choice tests. We don’t check to see that they can feel your spleen or your pulse. That’s a travesty. You wouldn’t fly on a plane where no one had actually seen the pilot fly a plane except theoretically. The public needs to hold us more accountable, and since they don’t quite know what we’re doing, we get away with a lot of stuff.
SB: Are you starting to attract medical students with liberal arts backgrounds?
AV: I’m not in the business of admitting them myself, but I think we need a mix. We clearly need the techie types who are going to revolutionize medicine and surgery. We need the Robert Gallos, who discovered the cause of HIV. We also need humanists. We need a physician versed in the human factors we’re dealing with. We have all this ontology for disease. We don’t have any ontology to capture who you are. Compared to the richness of your body fluids, you are this cipher. Maybe humanists will change that.
SB: The medical community has known the importance of the emotional connection with patients. The placebo effect, talking to patients. This is not a new thing.
AV: It’s not new. I’m not the only one, by any means, practicing this way. What’s happened is that we’re not enabled to do that. All our incentives, whether we work for Kaiser or anywhere else, is time and volume because reimbursement is limited. Without real reform none of this will make much difference. But we can’t do those things if the only way to make money is to see 25 patients a day. What happens is a lot of people go into concierge practice and become essentially shut off from the mainstream; they’re taking care of elite patients who can afford them.
SB: The California Health Care Foundation is heavily involved in addressing the opioid epidemic. What needs to be done regarding prescribing?
AV: I think it’s shocking. My second book, The Tennis Partner, was pre-opioid era but talking about addiction by a physician and addiction in general. And I must say I never saw this coming. That book came out in 1998, and it was about physicians with access to drugs. The irony that we created a lot of these problems shocks me. It’s an epidemic, it’s huge. I don’t think that most people outside of it have sufficient compassion for how hard it is to come off these things.
SB: And some of it was led by pharmaceutical marketing saying that you need to treat pain, how it’s the “fifth vital sign.” It went in the direction of being more compassionate by saying pain is a real issue, and that led people into this situation.
AV: Some of it is a steep learning curve. But even now, you go to surgery, and you’ll get Tylenol with codeine, three refills when you only need six tablets. You’re going to walk away with 30 and three refills.
SB: End of life is an area where it seems like the culture is starting to change, and people are starting to say, “I want to have control over my life,” and doctors and the rest of the team are trying to accede to that. Do you feel like that could be a starting point for bringing more humane care to the rest of the health care system?
AV: You think you’re seeing that?
SB: Many people die without having their wishes met, or they don’t know what their wishes are. But I do think more people are dying out of the hospital, though it’s still skewed by income and education.
AV: My mom died at home, but it was a major effort for us to make that happen. At every turn mundane things could have landed her in the hospital, if it hadn’t been for me and my other family members who are also physicians. I think that the sophistication of home health care has not been achieved yet.
SB: When people come up to you after these talks, are they there to talk about your writing, medicine, or both?
AV: It’s a bit of both. I’m surprised how much novels strike a chord. I love the quote, “fiction is a great lie that tells the truth.” A lot of those people want to tell me their story. It’s an urge people have.