Revolutionizing Medicine With a Simple Touch and a True Exam

; Abraham Verghese, MD; Richard C. Horton, MD

Disclosures

May 20, 2020

This transcript has been edited for clarity.

Eric J. Topol, MD: For this Medicine and the Machine podcast, we're thrilled to welcome Dr Richard Horton, the editor-in-chief of The Lancet. We are going to explore his views about medicine in the AI and technology world. And I'm sure we'll get well beyond that. Richard, welcome.

Richard Horton, MD: Thank you. It's great to join you.

Topol: We go back at least 20 years, but you've been editor of The Lancet for 25 years. How is that?

Horton: It is an exercise in survival. That's exactly the right word. People say you should do a job for 5 years and then move on, but somehow that rule of life seems to have passed me by and I'm still here. Maybe that's a testament to the fact that The Lancet is still a pretty interesting place to be.

Topol: You caught our eyes and interest in your October essay, "Touch–The First Language." I'm going to turn this over to Abraham because this is a topic he's been actively writing about.

Abraham Verghese, MD: It's great to have you on the show, Richard. I am an admirer of your writing—not just your editorials in The Lancet but in many other venues. Thank you so much for joining us. As Eric said, the piece you wrote was quite touching. It was very personal and it gave us pause. Are we coming to a watershed moment where all that [we have loved in medicine] is nostalgia, or is this something that we need to recapture?

Horton: I started off as a medical student in 1980. Those years in medical school were all about developing fundamental clinical skills: taking a history, and the basics of a physical examination. We used to write pages and pages on the history and physical exam. We would draw pictures of the size and shape and layout of the rooms of the patient's home, and how far they were from the shops. It was the most detailed kind of social history you could have as a context for whatever their presenting complaint was. Similarly with the physical examination, we would examine every cranial nerve down to what felt like the very, very last neuron. It was a fantastic skill base to have going into the practice of medicine.

Roll forward 25 years and I found myself on the other side of the desk, so to speak. Last year I was diagnosed with stage IIIb melanoma, for which I had some pretty extensive surgery. During the course of this whole process, I saw an absolutely wonderful plastic surgeon and then was handed over to the oncologist. I have nothing but good things to say about the National Health Service (NHS) and the way the mechanics of the care were dealt with.

But through this whole process, not once, not once, did anyone do a physical examination. Since the melanoma lesion was on my skin, perhaps nobody thought I had a heart, lung, or abdomen that needed examining. I had all kinds of MRIs, CTs, PET CTs, and ultrasounds, but the idea that anyone was going to touch me with their hands to actually examine my chest or any other part of me was clearly not going to happen.

No one ever took a full history either. And this was all before a 7-hour surgical procedure. Then I was in hospital for a week, and honestly, even at the end of all that, nobody would have had a clue to who I was. I was the person who presented with this particular diagnosis. They did a great job, but in terms of me as a human being or an individual who had a place to go back to, to live and a life, there was nothing about that.

I thought, Well, you know, surgeons.... So then I was handed over to the oncologist and I believed it would be a different thing. And I saw this absolutely wonderful oncologist—fantastic technically, but when I went into her office and sat down, she never looked at me. She stared at the computer, looking at my lab tests or the latest scan results. And she asked me how I am while she's looking at these. I said, "I'm great!" And she said, "Great! Your lab results are fine and your scan was fine. So we'll see you in a month and here's your next prescription." So I said, "Great! And thanks." If the consultation lasted 2 minutes, that was quite a long consultation.

The whole process of this highly technical medicine with immunotherapy and all the things that are on offer, which is absolutely fabulous, leads me to conclude that I'm here, I'm happy, I'm strong, I'm well, but I feel like this system of medicine we've created has become the most depersonalized, dehumanized, automatic system and has lost its humanity completely.

I feel profoundly sad that the profession that I love and have nurtured throughout my life seems to have taken this turn away from humanity. I'm trying to understand what's gone wrong.

Verghese: I think it's helpful to parse your essay because you're not exactly saying that you think we're making major diagnostic errors by not examining, although we may well be doing that a lot. You're bemoaning something more fundamental in the relationship that has gone missing because of the absence of the physical exam. You speak of the exam and the history as being a ritual and that, in that ritual and in its execution, there was a bond that was created. You're bemoaning the absence of that ritual and that connection.

Horton: Well, Abraham, you use the word "relationship," and I think I would reply, what relationship? The relationship doesn't exist. I believe that there is something deeply powerful about the therapeutic relationship that a patient should have with the physician or the specialist nurse, whoever the healthcare provider is. I certainly remember, as I'm sure you do, experiences when we were literally living in hospital and we had deep connections with the patients. Our lives became entwined with their lives in the context of the clinic. And that affected you and you affected them. And that was all part of the therapy or part of the treatment, of the management, of the support you were giving to the person in their particular predicament.

I pay tribute to the technical progress of medicine, which has been so phenomenal in the past 20 to 30 years. But the result of that progress is that those very fundamental skills that are about building that therapeutic relationship appear to have been lost. I've checked with colleagues and friends to see whether this is an "N of 1" experience that I'm describing, and I don't believe it is. I think this is an experience that may be amplified across medicine in the Western world. I believe that's a serious reason for concern. Because medicine is not just about the disease—and I know this is a cliché—it's about the dis-ease of the patient. The medicine that we're offering needs to attend to the dis-ease of the patient as much as the disease. I don't think we are thinking in that way as much as we should.

[T]he medicine that we're offering needs to attend to the dis-ease of the patient as much as the disease.

Topol: I couldn't agree more, Richard. It's one thing to read your essay but quite another to get your personal account. It's gut-wrenching for a global leader in medicine to have experiences like this firsthand. In your essay, you talked about touch building trust, reassurance, a sense of communion. You quoted Margaret Atwood in The Blind Assassin: "Touch comes before sight, before speech. It is the first language and the last, and it always tells the truth." That humanity has been lost. I couldn't agree more with you.

One of the reasons we got this podcast going is because Abraham and I both think this is a pervasive problem. It's tied to the global epidemic of burnout that you have written about in The Lancet. We need to return to the touch, the trust, the presence, all these things. Do you have any ideas of how that could happen?

Horton: That's a really good question. It's very hard for a patient to take control of a consultation, to be able to do that on a one-to-one basis. In order to get that touch going so I feel that there's a connection, I actually have to ask for it: "Would you mind examining me?" I feel nervous when I ask for that, and yet, I'm a doctor and I know how the system works. Can you imagine what it's like for someone who doesn't understand how the system works? It must be frightening.

In terms of changing, it has to begin during medical school. I have a daughter who is in her first year of medical school now, and I hope that as she is being exposed to patients and learning these fundamental skills, that there is an emphasis on the humanity of medicine and the notion of a personal physician—that this is not just a list of to-do's after the ward rounds; this is about developing a set of personal skills that are about rehumanizing the scientific medicine we've created. That has to begin in medical school, and then it has to be reinforced throughout the practice culture.

The metrics we've instituted that measure the success of medicine today do not take account of these humanizing dimensions of patient care, partly because there might not be an index or a metric or a number, a quantity that we can apply to that. We've created a medical profession that's driven by metrics and quantification. That should also be a concern to us. We should be thinking about the continuous professional development of a physician, the support for that physician throughout their lifetime, in a way that recognizes and rewards their professionalism—not just as a scientific doctor, but their professionalism as a personal doctor, as someone who's there side by side with patients, sharing this journey and being their partner in that journey. That's a difficult thing to put a number on, I will agree, but it's something we should take more seriously.

Verghese: I'm going to push back a little just for the sake of taking the devil's-advocate role. First, I think a patient would say, "What took you so long? We've been experiencing this for so many years. It's hardly news for patients." Second, I want to advocate for our young physicians—your daughter, for example. I had the pleasure of teaching medical students in their first 2 years. They're so excited to pick up the ophthalmoscope and the stethoscope and all the things we teach them. But then, when they come to the wards, they experience a crushing disappointment that the currency on the wards does not revolve around these things. It revolves around the screen, the computer. That's our doing, not their doing. And that's the pushback you'll hear.

You're in a wonderful position as a spokesperson for medicine. I think we have to be realistic. I love that you use the word "touch" in the title of your article. Realistically, given the pressures of time and reimbursement, how easily can we demand this of our junior physicians without putting structures in place that, as you say, reward that behavior? I'd like you to think about that in terms of the practicality of what we might do tomorrow.

Horton: You're absolutely right to say, "Where have you been?" And it's true—this is not something I had seen. It was a surprise, even a shock. But I do think something has changed in the past generation. The technology of medicine has advanced so rapidly, and because of the pressures young doctors are under today, that means that the time you used to have to sit on the edge of a patient's bed and spend an hour just shooting the breeze is gone. Who has that time now? So I accept that. But I think there is a halfway point.

One of you mentioned burnout. Why is it that doctors have become so despondent, disillusioned, and discontented about their careers? We're working in the most inspiring, visionary, wonderful profession. We should be excited every single day we go to work about the privilege we have to practice medicine. There's nothing better in life than a career in medicine. I still believe that. But a lot of doctors don't believe that. A lot of doctors get to their 50s and they think, I don't want to do this anymore because it has crushed me. It's destroyed me. I need to get out before it kills me. What have we created to lead a doctor to feel like that? I believe that part of it is that we've lost the connection from one human being to another, and what we've become are bureaucrats in an administrative system, where it is the screen, the paperwork, the reimbursement. It is the pushing around of the administration of medicine and not why we went into medicine.

Most doctors love people. But we've created a medicine culture where there's no opportunity to express that love of people anymore. That has to be what we bring back into medicine. Challenging though it is, this has to come from the top—that means our clinical leaders and the people who are responsible for running our clinics and our hospitals. It has to include the leadership of medicine in every setting. And it has to come from the bottom, by which I mean the values in medical school and the way we assess doctors throughout their careers. We are talking here about igniting a revolution in the way we live and practice medicine to, in a sense, revivify medicine with those fundamental values.

I'm not talking about going back to a golden era of [William] Osler. That's not what I'm talking about. I love the technology of medicine. I'm alive thanks to the technology of medicine. I owe everything to it. But I want medicine to be the humanistic discipline that I know it can be. Because if we don't make medicine part of our humanity, then the benefits that we have given to the public through the power of our therapeutics are not going to be sustained. If we want sustainable improvements in health, in well-being, in the lives, purpose, and meaning for individuals, we have to rehumanize medicine. That needs to be part of the project of medicine in the 21st century, that revivification of the values of the medicine that we all love.

Topol: I want to reaffirm everything you just said. But I also want to point out that this is a crisis, and it can't wait. You alluded to this earlier when you talked about a 2-minute appointment and the hour you used to have to spend at a bedside. The idea is that the gift of time could get us back now. The other thing you touched on is the administrators. Administrators rather than physicians largely run things. The Geisinger Health System at one point was run by David Feinberg, a physician who started this program where he locked the patient and doctor in a room for 40 minutes. They couldn't leave the room. It led to an incredible sense of fulfillment in both patients and doctors throughout the system. They couldn't continue that practice because that 40 minutes wasn't highly productive and efficient. This is partly because of the big business model, especially in the United States. Perhaps the NHS is not quite the same in terms of incentives. But do you think the gift of time could be the foundation for this rehumanization of medicine?

Horton: Absolutely. I profoundly agree with the idea of the importance of time, being able to just sit back in your chair and put your hands together and sit with someone and say, "Let's talk." You know: "You go first. Tell me, how are things?" and just let the conversation roll. That takes time. If we need to speak in a language that is understood by hospital and clinic management these days, maybe we need to talk about prescribing time, if we're going to operationalize this. Maybe we can't always have a 40-minute consultation. But I'm going to prescribe a 40-minute consultation—not every month, but perhaps every 2 months or every 3 months. "We are just going to sit back and we're going to let time roll. We're going to talk." I think we could introduce that in a way that would be perfectly possible in a busy clinic.

And again, it doesn't have to always be the doctor. The people who mattered to me on a daily basis, more than the physician, were the specialist nurses. Those specialist nurses know how to navigate everything in the hospital. If I was able to sit down with one of them for 40 minutes once a month, and shoot the breeze about what's going on in life, thoughts and fears and anxieties, that would be enough for me. But I don't have that opportunity. So a prescription for time might be the way to actually address it.

Verghese: I want to ask you both a question. Eric has written eloquently about physicians taking power back, the whole idea of physicians as a labor movement. What is the sentiment in Britain? Clearly here, in the United States, it's not that physicians or future physicians don't want to be with patients. Rather, it's that they are overwhelmed with data. The care of a patient has become so complicated, and nothing else is taken away, so it's just untenable. I think that until there is a revolution and people say that this is untenable, nothing will change. This is my great fear. I'd like you both to speak about that.

Topol: I had a remarkable experience with the NHS in that planning for the future effort. I learned the advantages of the single-payer system. But both systems, ours in the United States and yours in the United Kingdom, have a common problem of very limited charge. That is, physicians are not calling the shots in any way. I remember the doctor shortage and the strike by the young doctors in the United Kingdom, but that's what it is like every day in the United States in terms of dissatisfaction and having these administrative overlords who are not at all sympathetic to more time and the ability to do the proper history and physical—the fundamentals; not just of medicine but also of the human essence of medicine.

I believe that we do need a revolution, at least here in the United States and perhaps more broadly, to take back medicine. We lost it along the way. Too many things happen and doctors have been passive. Activism has largely been missing. Richard, you've been an activist throughout your career on many, many topics. Sometimes that makes for challenges, but it has largely been missing in the world of physicians and the medical community at large, don't you think?

Horton: Oh, absolutely. I believe that doctors have lost their confidence. And I believe that we've lost our confidence because we've been attacked by lawyers. We've been attacked by governments who want to overregulate us. We've been attacked by the media, when there's a scandal of some sort, and it's blown up into some enormous systemic problem with medicine. We have utterly failed to communicate to the public and to governments about the tremendous successes that medicine delivers to the public every minute of every day, up and down our respective countries. The result is that we've become overly defensive. We're far too quiet, and we need to be much more activist in what we do.

I would point to the 19th century. The 19th century in the United Kingdom was a century of medical activism. This was the time when science was beginning to have a huge impact on patient care. It was a time when Dickensian conditions in society were leading to powerful social reformers standing up and saying that this is unacceptable. The Lancet was born in 1823, at a time when medicine was discovering its voice in society, and not just its scientific voice but its political voice. I think we have lost that political voice. We've lost our activism to take our case for what we believe in to decision-makers, policymakers, and political leaders. We need to find that voice again.

Unfortunately, the institutions that represent us, certainly in my country, have utterly failed to hold governments accountable for what they've done to medicine. They've been far too concerned about having their place at the table in discussions and not being activist enough to make the case for medicine. I look at the American Medical Association, I look at the American College of Physicians, and I see much the same problem in the US.

We have had this awful situation in Britain called Brexit. I hate Brexit. But the phrase that became the defining idea of Brexit was summed up in three words: Take. Back. Control. Those should be our words. Every doctor up and down the country should take back control of his or her profession. It's the profession we love and we've lost it. We need to win it back again.

Verghese: That's just wonderful, and so well said. That's the siren call. Perhaps we will be in the front of this movement on both coasts. I want to bring us back to the poignant message we began with. We started this conversation with your essay that has this wonderful title: "Touch—The First Language." And that word, "touch," keeps recurring. I think we in America, when we talk about the bedside exam, we focus a lot on the medical errors, the simple kinds of errors you can make when you don't do the exam—when we're called by the radiologist the next day and told that there's a strangulated hernia or scrotal gangrene we didn't see. But there is an element to touch that you really have honed in on, and it's about caring. It's about expressing your care for this individual.

At the end of the last paragraph of your paper, you say, "The impersonalisation of the clinical encounter has been a severe setback for medicine. Underestimation of the importance of touch denies the universal need for physical connection in human relationships, of whatever kind. Touch, expressed through the physical examination, communicates comfort and concern. Touch encourages cooperation. It's time to bring back touch into medicine." I want to salute you, because many of us have circled around that and you were brave enough to come out and say it, just as you're brave enough to say that we should all lead this revolution to take back control. I'm delighted that you were able to join us for this session.

Topol: Thanks, Richard. You've inspired us, and I know you're going to do the same for all the people listening. It's great to have your voice about this vital topic.

Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.

Richard Horton, MD, is editor-in-chief of The Lancet, contributor to The Times Literary Supplement and The New York Review of Books, and author of Health Wars: On the Global Front Lines of Modern Medicine.

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