Cutting for Stone's Verghese Talks Prose, Patients With Topol

; Abraham Verghese, MD

Disclosures

October 09, 2014

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Abraham Verghese: An Introduction

Eric J. Topol, MD: I am Eric Topol, Editor-in-Chief of Medscape. I am thrilled to be joined today by Dr Abraham Verghese, professor and vice chair at Stanford in internal medicine, and professor of the theory and practice of medicine. Dr Verghese adds to our cadre of the most interesting people in the world of medicine. It is wonderful to have you, Abraham, to have a chat about your philosophy and your background.

To begin, you were born in Ethiopa, of Indian parents, and then emigrated to the United States, where you worked as an orderly?

Abraham Verghese, MD: Yes. I was in the middle of medical school when a civil war broke out in Ethiopia, so I came to America and found myself adrift and became an orderly. The Indian government, paradoxically, took me in to finish medical school, and then I came back to America for the rest of my training.

Dr Topol: You had an interesting lineage of training. You were at Madras, and then you went to, of all places, Johnson City, to Eastern Tennessee University. What was that like?

Dr Verghese: It was wonderful. Most foreign medical graduates at the time went to the big, urban hospitals—the traditional foreign graduate mills. I was looking for something slightly different, and I heard of a new program in an old Veterans Administration hospital, and it turned out to be wonderful. It was a real college setting, a small community, but very interesting medical problems, largely neglected, so it was great training.

Dr Topol: Then you went on to Texas?

Dr Verghese: I went on to Johnson City Hospital for my fellowship. My mentor in Tennessee was an infectious diseases specialist. We had written a couple of papers together, and he inspired me to go into infectious diseases.

I went to El Paso and headed the infectious diseases division at a county hospital, which was literally a stone's throw from the border. So we saw the most fascinating acute conditions in relatively young people—acute brucellosis, acute rheumatic fever—third-world conditions in a first-world hospital. It was just wonderful.

Dr Topol: Before you went to Iowa, you went to San Antonio?

Dr Verghese: I went to San Antonio from Texas Tech University, and I ran something called the Center for Medical Humanities and Ethics. I then eventually made my way to Stanford in 2007, and I have been there for 7 years.

A Detour to Iowa on the Road to Writing

Dr Topol: When did you take a detour to Iowa for a writer's workshop?

Dr Verghese: When I went back to Tennessee after my fellowship, I lived through an extraordinary period in the history of HIV. In rural America, I would expect to see one HIV-infected person every other year, but I was seeing 100 people with HIV infection. It turned out that it was a paradigm in which gay men were coming home after acquiring the infection during prolonged residence in the big cities. It was a very moving story—a very American story—and I was moved to try and tell that story beyond the scientific paper I wrote on it.

In 1990, after 6 years of working in that town, I took a sabbatical. I went to Iowa and joined the Iowa Writers' Workshop, for which the only admission criteria were two short stories. I told myself that if they took me, I would go. They did, and I went.

Dr Topol: You got a master's degree in fine art?

Dr Verghese: Yes, and then I had to go back to earning a living, because I cashed in my retirement and my tenure to take the Iowa position. That is when I went to Texas Tech.

Dr Topol: You probably could write pretty well before you even got that extra training, I would imagine?

Dr Verghese: I was very interested in writing. I have always been a good reader. The incredible thing about Iowa is that no one sat there and taught you how to write. We met just once a week, and our stories came up once or twice a semester, but the rest of our time was gloriously ours to develop our writing and to read. We had taken such pains to get there that we were forced to take ourselves seriously as writers and try to develop our voices. The kind of stuff that your wife thinks is cute or your mother thinks is precious doesn't fly there. You quickly get a sense of what real American writing can be about.

Authoring Novels and Short Stories

Dr Topol: I want to take on these two different sides of you: the author, Abraham, and the doctor. You have written three books already, two of them being nonfiction: My Own Country and Tennis Partner. The book that hit it big in terms of your reach was Cutting for Stone (a fiction novel). Tell us about those books, and how you evolved to become a novelist.

Dr Verghese: I always wanted to be a novelist. I have a great faith in fiction. I thought that I would tell the AIDS story through fiction. There is a great quote by Dorothy Allison. She says, "Fiction is the great lie that tells the truth about how the world lives." I published a short story titled "Lilacs" in the New Yorker,[1] a very dark story, and when that was accepted, I thought, "This is my ticket to writing this fictional book about AIDS."

But they were interested in my background and asked me to write a nonfiction piece about AIDS in rural America, and for many reasons, they didn't publish it. The editor was leaving. Tina Brown was coming on board. I would do other work for her, but we were left with a book proposal, and so I stumbled into nonfiction and wrote my first book. I had to learn how to write nonfiction. It is a very different genre from fiction.

While I was writing that book, I was living through an extraordinary experience with a young medical student who was a former tennis professional who became one of my best friends. I watched him fall under the spiral of addiction, so that became a natural subject for the second book, Tennis Partner, about the phenomenon of doctors and drugs as told through this very personal experience with David.

Finally, I was ready to come back to my first love, which was writing fiction. Cutting for Stone represented the book I always wanted to write. I am glad I didn't write it right away, because I needed years, and maturity and perspective, to write the book I did.

Dr Topol: Are you going to write another novel?

Dr Verghese: I am working on a novel.

Dr Topol: Can you tell me anything about it?

Dr Verghese: It is about a spinal surgeon, a woman, who discovers spinal surgery in the 1940s when the spine was considered the zone that no one touched. You might drain an abscess, but the thought of correcting the spine would have been quite foreign then. I see her as a pioneer. Making the crooked straight is the operating metaphor for the book. It is more than the spine; obviously, it is other aspects of life.

Spurning the iPatient

Dr Topol: Let's talk about the doctor side. You gave an extraordinary commencement address at Stanford in May. What caught my ear was the quote that you have framed on your wall.Can you tell us who said that and your philosophy about medicine?

Dr Verghese: This is a quote that hangs in my bedroom. It is by Paracelsus, a very interesting person. His full name was Wilhelm Paracelsus Bombastus. In fact, the word "bombastic" comes from Paracelsus. He was a larger-than-life character, and he thought that no one else, including Celsus, knew what was going on.

Incredibly, he was also very focused on the patient/physician relationship in a way that it would behoove us to be reminded of. Among the many things he said was this quote: "To love the sick, each and every one of them, as if they were our own." I always think, when I hear that "they are our own," that there isn't anything that separates you and I from the people we are taking care of in the hospital. It is the same fabric, the same humankind.

It bears bringing up again and again because in this marvelous age, with all the wonderful advances that we have seen, there is a slight danger that our attention is subtly shifting from the human being in front of us to the representation of the human being on the screen—the lab. I call that entity the iPatient, like the iPhone or iPad.

Dr Topol: I remember your New York Times op-ed[2] on that.

Dr Verghese: The iPatient gets wonderful care, but the human being often is in desperate need of a human connection. This is a way of reminding myself that all our tremendous science has to be delivered through the mechanism of one individual to another.

Preserving Hands-on Medicine

Dr Topol: You have the Stanford 25 for physical exam here, and you oversee the third-year clerkship. You really emphasize the physical exam. Can you tell us about that?

Dr Verghese: There is much to be gained by speaking to the patient and examining the patient. Clearly, my hand cannot replace a CT scan when I am examining the abdomen, but only my hand can say where it hurts. Only my hand can say that pressure over the cyst seen on the CT scan doesn't cause any of the symptoms that we are worried about. There is so much that remains for the body to tell us, and our peers of 100 years ago did it so well. It would be a shame if we pick up less than they did, given all of our opportunities to confirm what is going on with MRI or PET scan.

I am not an old throwback; I'm just saying that we should percuss, because it is what we used to do. I am also impressed by the fact that when I examine a patient well—I am the attending right now with very complicated patients, working with 15 different teams on one patient with a brain abscess, having his second liver transplant. But patients often remember. They may not know my name (it is too many syllables), but they will say, "I want to talk to that doctor—the one who examined me."

Touching Medical Care

Dr Topol: You said in your commencement speech that patients would complain that they never were touched.

Dr Verghese: I think it is significant.

Dr Topol: You captured many things in that speech, such as how physicians spend too much time at the computer, and the CPT (Current Procedural Terminology) codes. You mentioned there is a CPT code for things that can happen in a mobile home. I didn't know there was a CPT code for how you can be hurt by a turkey. This crazy stuff takes us away from actual hands-on medicine.

Dr Verghese: It is taking us away, and society will judge us poorly about 20 years from now. They'll look back and say, "You were complicit. Why did you let EPIC and all these electronic medical records rule your life? You actually signed up to learn the new ICD codes and plug them in. Exactly what did this do for patient care?" And the answer is that it did nothing for patient care.

It did everything for billing. I feel like the lone piper saying this, but it is clear that we are all feeling the frustration of being forced to do things that have nothing to do with patient care. They are all about billing.

Hanging Up the Stethoscope?

Dr Topol: When you were visiting Scripps a couple of years ago, we had a debate about technology as part of the physical exam. You became interested in the VScan, a hand-held ultrasound device. Are you using that now?

Dr Verghese: We are using that. When I met you, we had already purchased the device, so I am not a Luddite, I assure you.

Dr Topol: I thought you were at the time.

Dr Verghese: I want to assure your readers that I am not. At Stanford, I am happy to embrace the cutting-edge tools. The things we do for cancer or for cardiology are just astonishing. Nevertheless, there is an element of the ritual of examining a patient that is profoundly important. If you pay attention to the metaphors that patients use when they talk about us, it is amazing how often the metaphor is, "He or she didn't touch me," or "He or she didn't put a hand on me."

Clearly, this is profound to them. If we step back for a moment, we have gotten so used to it that perhaps we stop seeing it. But the idea that someone comes to you or I, a stranger, and tells us things that they wouldn't tell their spouse or their rabbi—and then, incredibly, disrobes and allows us the privilege of touch, which in any other context would be assault—has all the trappings of a ritual.

We are wearing a ceremonial outfit, and the patient is wearing a paper outfit. The furniture in the room doesn't look like anything in your house or mine. This is a ritual, whether we like it or not, and we set the patient up to expect it. If we walk in and shortchange them, we have lost something.

Dr Topol: I agree with you. Would you use a smartphone electrocardiogram and an ultrasound during your exam?

Dr Verghese: I use the pocket ultrasound. I don't use the smartphone electrocardiogram because the ECGs are ubiquitous. They are multiplying on the bed as we walk by.

Dr Topol: So you use some technology. You are not ready to give up the stethoscope yet?

Dr Verghese: I can see myself getting better at the VScan, so it would be redundant, but for the sake of history, it would be nice every now and then to instruct someone about a widely split second sound and why this is going to predict the bundle branch that we are going to see.

Dr Topol: I used to spend a lot of time talking about this second heart sound splitting, but I haven't been doing that so much lately. What about the recent Deloitte recent survey[3] that says by the end of this year, 1 in 6 office visits between doctors and patients will be virtual, and the projection is that with all of these telemedical entities, most visits will be virtual. Do you think that is going to lead to substantial degradation of medicine?

Dr Verghese: I am not sure. I would love to see what that ultimately looks like. Do I think that there are a lot of visits where we can spare the patient the hassle of parking and climbing up to the clinic? Certainly, many things can be transacted not just on telemedicine, but also with the wonderful team we have of nurse practitioners and physician assistants. I am a big believer in that, and often they do the very things that we don't do, which is listen and touch and spend time.

For many patients, however, there will be a moment in the trajectory of the illness where a face-to-face visit will be performed and be of importance.

A Good Mix: Medicine and Humanity

Dr Topol: There is no question about preserving those times. You have this unique blend of master author who transcends fiction and nonfiction, and the doctor's doctor. How do you put this all together in one package?

Dr Verghese: Honestly, I don't make the separation of writer and physician that many people make. I am not being coy, but my great passions for medicine and the humanities are intermingled. I came to medicine because I saw it as a romantic and passionate pursuit, and my desire to write about it is very much because I am enamored by the tremendous privilege of being with another human being at their greatest moment of vulnerability and distress. Why would it be surprising that I choose to write about that for my themes, both fiction and nonfiction? What is medicine but "life plus," if you like, or what is life but "medicine plus"? They are intermingled. I don't see much of a separation and I write very slowly. Three books in 20 years is a very slow production. Joyce Carol Oates has written three books since breakfast this morning.

Dr Topol: She is quite prolific, on the other end.

Dr Verghese: I enjoy my life and I try, with the time I have, to write, but it is a slow process.

Dr Topol: Do you constantly rewrite and strive for perfection? Is that why it takes you a while?

Dr Verghese: It takes a while mostly because of my day job—things I am unwilling to give up, such as my time with the students, my time on the wards, and my time with my great young colleagues who inspire me.

My writing process is first composing on the screen and then printing it out. It is ironic. The computer offers an illusion of freedom, but it is only when you print out and you have several hundred pages that you can say, well, these 50 pages go here, these 20 pages go there, and these 100 pages go into the round file under the desk. I love the tactile sense of the pages, and you can't quite do that with a computer.

Inspiration and Irony

Dr Topol: Speaking of inspiration, you touch a lot of young physicians. How do you provide such an inspirational force for them?

Dr Verghese: I am not sure that I am consciously doing that. I went to Texas Tech El Paso, certainly not the premier medical school in the country, precisely because I wanted to be able to teach medical students at the bedside and practice in the county hospital, but be free on my weekends and nights off. I didn't want to be writing grants or papers, which I was quite capable of doing, but I wanted to write what I wrote. The great irony is that because I wrote the books largely in obscurity in Texas, here I am at Stanford. Had I come to Stanford in the first place, just about now I might be losing my tenure and heading back to Texas.

Dr Topol: You are right in the midst of Silicon Valley; you are in the tech world. Some people call it "Start-up U" here, but it isn't exactly the capital of humanistic medicine. Do you feel like you are somewhat of an antiforce in this environment?

Dr Verghese: No, I feel very well supported. A nice thing about Stanford is that for all its emphasis on the cutting edge and technology, there is a great consciousness that is reflected in their hiring me. They also very much need the values that I espouse and that we all share. These are not my values; these are our values, and I am perhaps better known for espousing them and repeating them and championing them in print, but they are certainly not my values. They are our values, and it has been great fun to be here.

I cut my teeth on the county hospital in El Paso, Texas, and I remember the yeoman service that we all provided there. I often wonder how many other unheralded physicians are providing wonderful care all across the country, not to mention across the world. I am privileged to be able to write about what I do and to have it spotlighted.

Dr Topol: You are very modest. We are privileged to be able to read it. You are interesting because as a physician you are on Twitter, although not many physicians are.

Dr Verghese: I know somebody else is on Twitter who has a pretty big following.

Dr Topol: What do you think of Twitter?

Dr Verghese: I am still trying to understand the forum. For someone whose books are fairly long by most standards, Twitter is slightly foreign to me, but I do think I get it. I find myself much more interested in other people's Twitter feeds and what they lead me to—the variety of things that one stumbles onto because of Twitter and Facebook and other social media. It is quite fascinating, but I am not as facile as some people.

Dr Topol: I have always thought that if we all shared, we would get smarter faster, and it is a nice medium for doing that.

I know we have interrupted you from attending rounds, and we are very grateful to you for taking the time to join us. It has been wonderful to understand your background and philosophy and what you are doing to take medicine to the highest level, not just here at Stanford but elsewhere. We are anxious to see your next book and hope that not so many years will separate each of these works, because they are a great contribution.

This has been a great session with one of the most interesting people I know in medicine. I would be interested in your feedback and comments on what we had to say today. Thanks very much for joining us.

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