“We desperately need physicians to feel happy in what they do,” said Abraham Verghese, MD, senior associate chair of the Department of Internal Medicine at the Stanford University School of Medicine and New York Times bestselling author. Dr. Verghese sat down earlier this month with AMA President Steven J. Stack, MD, to discuss the current state of medical education, the ritual of the physical exam, overtesting and what it means to be a physician who writes fiction.
How future physicians are educated
Dr. Verghese is an internist but also specializes in infectious disease and pulmonary medicine. He is very involved in medical education at Stanford University School of Medicine, where he runs the student clerkship. He has written several books, one of which, Cutting for Stone, was on the New York Times bestseller list for well over two years.
Dr. Stack: “Do you see changes over the course of your career in the way medical students are educated and how that impacts our incoming physicians?”
Dr. Verghese: “There have been some striking changes. For one thing, the model that you probably trained under and certainly I trained under—an intense focus on the patient and the bedside and rounds going from bed to bed—I think it’s been sort of kidnapped in a sense by the workstation.”
“One of the great disappointments students have when they come on the wards is … in the first two years they’re learning physical diagnosis, and they’re so excited to learn how to read the body as a text. And they arrive on the wards, and their moment of awakening, almost disillusionment, is to find that the currency on the wards does not revolve around the patient. It revolves much more around the computer. For many of them, it’s a moment of crisis. I think it actually leads many of them away from primary care, which is not a good trend.”
Learn how the AMA is collaborating with med schools throughout the country to accelerate change in medical education by creating a system that trains physicians to meet the needs of today's patients and to anticipate future changes.
The ritual of the physical exam
Dr. Stack pointed to the conflicting aspects of the current practice environment. Citing his own specialty of emergency medicine, he pointed to the fast-paced nature of interactions with patients and the need to focus on information. At the same time, it’s important to still try to “connect in a very human way with patients.”
Dr. Stack: “As an emergency physician, … I use human touch as an important part of what I do. I would not pretend to be as thorough as an internist, but I certainly use communication and human touch to establish a rapport and build that trust, which I think is unique to the patient-physician bond and therapeutic relationship. How has the physical exam become so important to you?”
Dr. Verghese: “When you examine a patient after listening to them, you’re inevitably participating in a very important ritual. First, it’s a very unequal relationship. You’re a physician with your diplomas on the wall, and a stranger is coming to you.”
“Even though we might have the illusion that this is a simple business transaction—an exchange in fact (I think that many of the hospital administrators tend to view it as that)—it’s actually much more loaded and complex. You’re wearing a white, shamanistic outfit with special tools in your pocket. The patient is in a paper gown. They’re expecting something to happen.”
“In society we’re conditioned for rituals all the time. There’s a ritual when you go to church or the synagogue or mosque. A ritual when you graduate, when you marry, when you baptize. [The physical exam] has all the trappings of ritual, and I think to that degree that we shortchange it. We shortchange the product of a ritual. Rituals are about transformation. The result of the ritual of the exam, I think, is the sealing of the patient-physician bond.”
Patient and physician satisfaction
What’s the flip side of performing the ritual of the physical exam for physicians and patients?
Dr. Verghese: “There’s also the very important thing of patient satisfaction. That is clearly affected by the absence of a physician’s touch. Another thing that’s very important is that physician satisfaction is clearly tied to being connected with the patient. For most of us, that’s why we came to medicine. We didn’t come to sit in front of a screen.”
Dr. Stack: “I describe it simply as finding out what makes doctors happy and sad. I think patients should be reassured and physicians should feel good to know that, overwhelmingly, the leading finding [of a 2013 study by the AMA and the RAND Corporation] was that physicians are most fulfilled professionally when they feel they did good work at the end of the day to help their patients lead healthier, happier lives and were supported in that work by the health system, rather than interfered with and obstructed in that work.”
“I think it’s a modern-day, research-based affirmation of the Hippocratic Oath, at least one facet of it: Putting your patients’ needs ahead of your own.”
“Though [many technologies] have promise to make care available to more people, [they] are real challenges to the human connection. With technology causing distance between a physician and a patient, how can we, as physicians, keep the balance?”
Dr. Verghese: “Remember the times when we had to go hunt the paper chart all over the hospital? I’m not in any way looking to go back, but I think that when we try to codify the encounter into being some sort of factory line, we are actually making more errors.”
“If we were to invest more time in listening to the patient, if we were to invest more time in training people to examine the patient well and make good sense of that information, I think the downstream effect would be that we would be ordering less tests, ordering fewer consults.”
Interested in additional insights?
- Read what Dr. Verghese said to physician leaders at the AMA State Legislative Strategy Conference earlier this month regarding technology, the future of medicine and the ritual of the physical examination.
- Learn more about this and other conversations around developing #AHealthierNation via Twitter and Facebook.