Almost all of us have been, at one time or another, a patient or the caregiver to a patient. And perhaps one of the enduring memories (good or bad) of that experience may be that of the doctor who treated. From the days of Hippocrates, known as the Father of Medicine, the ‘doctor’ is one of the key actors in the story of life and death.
There was a time, not all that long ago, when the “family doctor” was the first and last word in attending to every member of the family, from babies to the elders. Most of these are still remembered, not so much for their specialized skills, as for their comforting presence and availability, and their personal engagement with the patient. In most cases, the patient was known to the doctor from childhood onwards. Thus the diagnosis and treatment was closely linked not just to the physical, but also to the psychological aspects. Often it was ‘much less about specific diagnosis than it was about knowing the person in front of you and the illness they have, and sometimes the outcome depended much less on the nature of the illness than on the nature of the patient.’
Over time, with advances in the science of medicine, and the new developments in technology that enables more accuracy and depth of diagnostic tests, the medical profession started becoming more and more dependent on these tools. So much so, that in recent times, the first visit to the doctor results in returning with a list of “tests”, based on the results of which, the doctor would begin, at the next visit, to even “look at” the patient, let alone proceed further in diagnosis and treatment. No doubt these advances have led to a deeper understanding of disease and medical conditions, and have hugely benefitted their treatment. But such advances have made modern medicine so high-tech, research-oriented, data-driven and time-crunched, that somewhere along the way, this has led to the ebbing of the “human touch”, as it were, in the relationship between doctor and patient.
There is however, a section of the medical profession which is promoting the revival of the practice of this ‘human touch’. They believe that physical examination is a key to developing trust between patient and physician. Dr Abraham Verghese is a passionate and leading advocate of this school of thought.
Dr Abraham Verghese is perhaps better known as an author. He became known for his book Cutting for Stone, and his recent book The Covenant of Water has been acclaimed. What is perhaps less widely known is that Dr Verghese is a practicing physician and teacher of medicine, who strongly endorses as well as practices what he calls ‘the ritual of the physical exam’ as the most important aspect of developing trust between patient and physician. He believes that the physical exam is a humanistic ritual that builds trust and creates the crucial bond between physician and patient—a bond that is at the core of quality health care
Abraham Verghese started his medical education in Ethiopia and completed it in India at the Madras Medical College, both places which followed the British system of medical education that put great emphasis on learning to read the body as a text. In an interview he recalled that he had the most wonderful teachers who were incredibly skilled at reading the body as a text. He feel that this is a dying art today. We are getting so enamoured with the data and the images, the CAT scan and the MRI. But sometimes we can lose sight of the human being. …When what patients really need is something simpler and they need to be listened to, they need to be cared for.
Even as he follows this practice as a sacred ritual, Dr Verghese has been working to institutionalize this in the United States where he has worked for several decades. He founded the Center for Medical Humanities and Ethics at the University of Texas, San Antonio where the motto was ‘Imagining the Patient’s Experience’. He is now a professor for the Theory and Practice of Medicine at Stanford, where his old-fashioned weekly rounds have inspired a new initiative, the Stanford 25, teaching 25 fundamental physical exam skills and their diagnostic benefits to interns. Verghese feels that doctors spend an astonishing among of time in front of the monitor charting in the electronic medical record, moving patients through the system, examining tests results. In short, bedside skills have plummeted in inverse proportion to the available technology.
The objective of this initiative is to emphasize and improve bedside examination skills in students and residents in internal medicine, and advocating for a similar national effort at all medical schools. Verghese himself teaches students at patients’ bedsides instead of around a table. As he says: I still find the best way to understand a hospitalized patient is not by staring at the computer screen but by going to see the patient; it’s only at the bedside that I can figure out what is important. A part of you has to be objective and yet you have to sort of try to imagine what the patient is going through.
This approach has sparked a movement of Bedside Medicine which believes that the bedside encounter between a patient and physician is central to the practice of medicine. There is also The Society of Bedside Medicine, a mission-based global community of clinician educators dedicated to bedside teaching and improving physical examination and diagnostic skills. Its purpose is to foster a culture of Bedside Medicine through deliberate practice and teaching to encourage innovation in education and research on the role of the clinical encounter in 21st-century medicine.
For many of us who wish for the return to the ‘family doctor’ in an age when this is almost an extinct species, the Bedside Medicine movement spells a ray of hope. This week is celebrated in America as National Physicians Week. In India also we mark Doctor’s Day on 1 July. While this day is marked by thanking doctors, it may also be a good time for physicians to remind themselves of the sacred bonds between the patient and the healer. In the words of Dr. Verghese At its very nature, the experience of medicine, the experience of being a patient, is very much a human experience—patients require the best of our science, but they don’t stop requiring the Samaritan function.
–Mamata
