Are the clinicians of tomorrow learning to treat an"
I-Patient," a computerized, virtual model of the real, breathing,
Clinician and author Abraham Verghese, M.D., extols the healing rituals
of being with a patient, listening to the patient, and offering the comforting
Credit: David Hathcox
Clinician and author Abraham Verghese, M.D., reminded psychiatrists that
they are the foremost practitioners of an ancient approach to healing that
relies on being with the patient—the real one, not the one on the
computer readout—listening to the patient and rendering the efficacious
therapy of a comforting word.
His remarks came in a stirring address as he presented the William C.
Menninger Memorial Convocation Lecture at APA's 2009 annual meeting last month
in San Francisco.
But against that traditional approach has evolved a new, more expedient one
brought on in part by a revolution in technology and biological sciences, but
also by "a byzantine reimbursement system that makes reimbursement for a
single 45-minute session of psychotherapy 40 percent less rewarding than three
15-minute medication-management visits," Verghese said.
"This new, expedient way is not formally taught, but residents seem
to learn it no matter where in the United States they train," he said."
The patient is still at the center, but as an icon for another identity
clothed in binary garments that I call the I-Patient.
"Often the ER personnel have already scanned, tested, and diagnosed
so that our interns meet a fully formed I-Patient long before they see the
real patient," Verghese said. "The I-Patient has been counted and
tracked and trended, while pop-up flags remind us when to feed and bleed. The
I-Patient is handily discussed in the bunker room while the real patient keeps
the bed alive and ensures that there is a folder bearing his or her name still
extant on the computer."
The problem with this approach, Verghese said quoting the Polish-American
philosopher and father of semantics, Alfred Korzybski, is that "the map
is not the territory."
Verghese is the senior associate chair and professor of the theory and
practice of medicine in the Department of Medicine at Stanford University. He
is board certified in internal medicine and has gained a reputation as an
inspired teacher of medicine at the bedside.
Verghese has published extensively in the medical literature, and his
writing has appeared in the New Yorker, Atlantic, Esquire, and
Sports Illustrated, among other publications. His first book, My
Own Country, was about his experiences treating AIDS patients in rural
Tennessee and was a finalist for the National Book Critics Circle Award in
1994. His newest book is also his first novel, Cutting for Stone,
released earlier this year.
As an internist, Verghese said he feels a strong affiliation with
psychiatric colleagues because, he said, internal medicine is "second
only to your specialty in the attention we pay to patients' stories and on the
importance and salutary effects of being with the patient."
He added that those core values that have attracted psychiatrists and
internists to their specialties are "the very things that are being
Verghese was speaking in place of friend and Stanford colleague Atul
Gawande, M.D., also an author and clinician. Gawande had to cancel due to
scheduling conflicts related to his appointment as director of the World
Health Organization's Global Challenge for Safer Surgical Care.
Verghese cited Gawande when he remarked that the trend toward tending to
the I-Patient—as opposed to the real patient—invariably results in
an overreliance on technology and tests that are often unnecessary. He also
quoted Gawande as calling the American health care system "a menu
without prices from which you can order filet mignon every day."
Verghese urged psychiatrists to stand by the real patient and to make the"
argument of ritual," stating that examining, being with, and
listening to the patient were transformative rituals.
He cited his own experience working as a clinician in Texas where he was a
professor of medicine at the Texas Tech University Health Sciences Center in
El Paso from 1991 to 2002. There he gained a reputation as a clinician who
would treat patients with chronic fatigue syndrome.
On the patient's first visit, he said, he simply listened for an entire
hour to the patient's history and story without interrupting. On the second
visit he performed a physical examination so rigorous and thorough that one
patient told him in awe, "I have never been examined that way
Later, he said, he could tell the patient the standard things—that
the disorder wasn't in his or her head and that it wasn't life threatening,
but that it wasn't well understood—and prescribe the standard of
exercise and supportive psychotherapy.
"I always felt that if my patients gave up the quest for the magic
test or the magic treatment, it was only because I had earned the right to say
this to them by virtue of the ritual of the exam," he said."
Rituals are about transformation. And what could be a more powerful
ritual than individuals baring their soul to you and baring their body and
giving you the extraordinary privilege of touching them."
Verghese said that tending to the I-Patient "can't begin to compare
with the joy, the excitement, the intellectual pleasure, the disappointment,
and the lessons in humility that trainees experience by learning and treating
the real patient.
"When residents don't witness the bedside aspect of your discipline
or mine, when they don't see the craft and wisdom at work, its underlying
romance and passion, they may come to view what we do as a trade practiced
before a computer screen with a prescription pad," Verghese said."
Such trends in my field and yours have implications for the identity of
our respective disciplines."
He closed by quoting Karl Menninger, M.D., who said, "Listening is a
magnetic and strange thing, a creative force. The friends who listen to us are
the ones we move toward. When we are listened to, it creates us, makes us
unfold and expand."
He reminded his audience that the one treatment administered in an
emergency via the ear is the comforting word.
"As you debate the future of the profession, I hope you will keep the
patient and their needs front and center," Verghese said. "If you
do that, you can't go wrong. What the patient needs most of all from you is
your presence, your active listening, your translation of what they say, and
most of all your words of comfort." ▪