Looking to the arts to keep compassion in patient care
From the March ACP Observer, copyright © 2006 by the American College of Physicians.
By Janet Colwell
The young man in the video documentary is horribly burned and has lost his eyes and hands to a natural-gas explosion. Although he pleads with his doctors to let him die, they do not.
At the end of the video, the audience—a group of fourth-year medical students—think the presentation is over, but it's not.
For Abraham C. Verghese, MACP (center), the skilled history and bedside exam are 'the basic language and grammar of medicine.'
"When the lights come on, there is the same patient, standing there looking kind of like John the Baptist with his long hair, prosthetic eyeballs, extensive burn scars and rudimentary hands," said Abraham C. Verghese, MACP. Suddenly, an academic debate—over patient autonomy and physician obligations—becomes very real, as the students literally come face-to-face with the pain, suffering and, at times, impossible consequences and decisions that are a part of medicine.
The patient, now a lawyer, explains clearly that he had the right to refuse treatment, even at the risk of death. "It is a moment the students will never forget," Dr. Verghese said. "Reading about patient autonomy in a textbook can't quite get this across."
The presentation is part of the curriculum of the Center for Medical Humanities and Ethics, which Dr. Verghese established at the University of Texas Health Science Center at San Antonio in 2002. Helping a new generation of physicians find that core of compassion and patient connection through literature, drama and the visual arts is one of the program's key goals.
"Our students come with all the right qualities of humanism, compassion and the ability to imagine the suffering of patients," he said. "I view the center as trying to preserve those qualities."
'The diabetic in bed three'
He cautions his students against becoming so immersed in science and technology that they start referring to patients as "the diabetic in bed three" or the "heart attack in bed four."
"At times I have the eerie sensation when walking the corridors that the patient in the bed has become an icon for the real patient in the computer," he said. "Everyone is looking to the computer for data, and students start to see that all the skills they were taught in their physical diagnosis course really aren't as important as scheduling a CT scan and getting back the results."
But that's not the way he sees it. Dr. Verghese, a renowned expert on infectious diseases, draws upon his extensive experience caring for AIDS patients to convey the importance of empathy. While acknowledging the value of technology, he laments that the careful bedside exam and traditional "laying on of hands" are becoming lost arts, to the detriment of patient care.
"I see the skilled history and bedside exam as the basic language and grammar of medicine, the first means by which we convey our attentiveness to the patient," he said. "Without them, a dialogue cannot begin."
In the humanities program, "we try to appeal to [students'] right brain in a way that most of their book reading and studies don't do," he explained. "You need that right brain stimulation to be creative as a clinician, to be imaginative."
It takes imagination, he added, to put yourself in the patients' shoes. "It takes a different kind of imagination to link the story they are telling you with your repertoire of clinical stories and come up with a diagnosis.It is not always linear or rational." When a diagnosis like nocardiosis or Still's disease comes to mind, he added, "I cannot always define in an 'evidence-based' way how I got there. That aspect of diagnosis I think is a right-brain phenomenon. "
Dr. Verghese serves as attending physician on the wards for three months of the year and sees patients weekly in the outpatient setting. He is most passionate about the bedside diagnosis rounds he conducts every Wednesday, seeing patients assigned to students rotating through internal medicine.
"I ask the student not to tell me or the other students what their patient has, to demonstrate how much the body can tell us if only we are looking and listening," he said. "It's a revelation to the students."
The center provides a four-year required program in humanities and ethics. The curriculum includes, among other works, "Wit", a movie directed by Mike Nichols; selections from author Kurt Vonnegut; and "The Spirit Catches You and You Fall Down," a nonfiction account of Hmong refugees in the U.S. by Anne Fadiman.
More than science
Writing has also intimately informed his own practice of medicine. The son of Indian immigrants, Dr. Verghese grew up in Ethiopia where his parents were both physics teachers. Now age 50, he received his medical calling at age 12 when reading "Of Human Bondage" by W. Somerset Maugham. He was captivated by the story of how Philip, the book's protagonist, sought to be an artist in Paris, but failed. Philip entered medical school almost by default and was surprised to discover a kinship between medicine and art.
"I began with a sense that I was not cut out to do science, but after reading [Maugham] I saw that doctoring was so much more," Dr. Verghese said. He particularly connected with the passage where Philip describes his first entry into the hospital world, seeing patients as "humanity in the rough," akin to raw materials for an artist. "The book made me feel that the qualities and aptitudes I had were just fine for this business."
He attended medical school in India and later finished a residency in Tennessee and an infectious diseases fellowship at Boston University. He returned to practice in a small town in Tennessee where he began treating AIDS patients in far greater numbers than had been predicted. In 1990, he attended the Iowa Writer's Workshop and in 1994 published the best-seller, "My Own Country: A Doctor's Story," relating his rural HIV experience. The book was later made into a movie.
'Writing is a clinical tool that helps make sense of the world and of oneself.'
—Abraham C. Verghese, MACP
He followed up on that success in 1998 with "The Tennis Partner," describing his friendship with a fourth-year medical student battling addiction. He remains one of very few scientific scholars—published widely in top medical journals—whose literary writing has also appeared in the New Yorker, the New York Times, the Washington Post, The Atlantic Monthly and elsewhere.
His own work amply illustrates his contention that writing helps make sense of life. "I am first and foremost a physician, an internist, that is my strongest point of identity and it transcends nationhood, gender, race or any other label," he said. "All my writing, whether fiction or non-fiction, is informed by and emerges from that stance. Writing is a clinical tool that helps make sense of the world and of oneself.
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