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Checking In With Dr. Abraham Verghese On The Importance Of The Bedside Manner

Sep 15, 2009

Dr. Abraham Verghese, a professor and senior associate chair at Stanford University’s School of Medicine and a best-selling author, often writes about the magic of the doctor-patient relationship. In the health care debate, he offers a distinct voice that champions the art of medicine. His voice is shaped by his experiences as a practicing physician, medical educator and storyteller.

His perspective is also influenced by his unique background, which includes growing up in Ethiopia to Indian parents and completing his medical training in East Africa and India. Verghese came to the U.S. through a special visa program that places foreign medical graduates in underserved communities, and he has practiced medicine from Johnson City, Tenn., to El Paso, Texas.

His first book, "My Own Country," was drawn from his work with terminal AIDS patients. His recent novel "Cutting For Stone" explores the decline of doctor-patient interactions in a high-tech era.

KHN reporter Jessica Marcy spoke with Verghese recently about how medical educators are addressing the shortage of primary care physicians and the "battle of stories" in the health care reform debate.

Q: The U.S. now faces significant health care workforce challenges especially regarding primary care physicians. How could Congressional efforts to expand access to nearly 50 million uninsured Americans add to this shortage?

A: It’s a critical shortage. I am right now writing letters of recommendations for students who are deciding what to do with their lives after medical school -- whether to be primary care physicians or specialists. There’s no question that the way reimbursement is set up, even the most eager and committed student has to really reexamine why they would possibly go into primary care medicine... Students are heading off into things like ophthalmology and surgery not because they don’t like primary care, but because they sense that’s the only way to make a living that recoups their [medical school] investment. They really can’t stomach the idea of being in medicine ten years down the road and watching their classmate make twenty times… more than they do. [The shortage] has to be addressed in the very radical fashion by changing reimbursement. That, I’m not sure we have the willpower to do.

Q: What do you think about how the pending legislative proposals address the shortage? Do you think it’s enough? What advice do you offer to solve this problem?

A: I don’t think it’s enough frankly. Our students don’t have their medical school education subsidized by the government – and I think it would be nice for us to take away the burden of student loans. ... One way to do that would be to require of all students a year of public health service in return for which their loans are eliminated. If they choose not to... they will get a lower priority when they apply for specialty positions and residencies.

It would mean that automatically -- every year -- we would have 13,000 graduated students serving in a primary care [setting]. In one stroke, you can solve the primary care shortage. You can also introduce people [to this type of medicine] who would never find out about primary care. It could change their lives.

Q: How did your own medical training abroad shape the way you practice medicine in the U.S.? What unique perspective does this training enable foreign physicians to bring to the practice of medicine here?

A: Foreign doctors have all kinds of different forms of training. But many are united by one common factor that seems to be operative especially in the Commonwealth countries -- a great emphasis on the bedside exam and on clinical skills. In part, [this approach] was driven by the lack of ready access to all the kinds of sophisticated testing that we have now. But I think that kind of clinical training still serves me very well. It’s almost embarrassing to see how little emphasis we put on that here where the most glaring finding, one that could have been discovered by either a good history or by a discerning exam, instead requires this $2,000 MRI and interpretation to discover something that was really there for everyone to see and recognize had they only learned how to do that.

Q: How can professors and medical schools help address the primary care shortfall and influence health care reform?

A: It’s a struggle … but if you’re going to do it, you’re going to do it only by showing them the charm and the magic of being at the bedside. There is no passion and romance that you can illustrate to them in front of a computer, which is where a lot of care takes place these days. The only way to excite students about medicine is to do it one by one, by them seeing you being the kind of physician that they’d like to be.

Q: Is there anything else you want to add about health care reform as it stands right now?

A: My sense is that we’re at a really exciting point in American history where we have a real option to bring about change. The one alternative that I don’t hear being discussed very much is that we could also do nothing and allow the system to implode, which I think is a real possibility. The other thing that strikes me as terribly important ... is this is incredibly complicated for people to understand. Even when you have all the facts, there are more facts. ... People are extremely sensitive about their health.

As a story-teller, I’m struck by the power of stories. President Obama has this wonderful story about his grandmother. Stories are the metaphors around which so much revolves. The stories that counter his -- the alarmist stories that talk about someone in the Canadian health system who has a brain tumor and goes [untreated] for months-- those stories are patently false very often, but it doesn’t matter. They have the same powerful influence. ... This [health care reform debate] is a kind of a battle of stories.

Q: Is that alarming to you?

A: No. It’s naïve to think facts alone will change things. If facts alone would change things, then we would all eat healthy and wouldn’t smoke. Stories change things. Pain changes things. Suffering changes things. In many ways, that’s what I’m saying is happening in medicine. If it’s all about facts and numbers, it doesn’t move patients. Medicine is an art and not a science. The science part is the numbers. But we can’t abandon the art part. It’s so important.

Q: Anything else?

A: It’s important to point out that every dollar in that $2.1 trillion [health industry] represents a dollar of income for somebody. ... The power of lobbies to influence what should be the American people’s decision should not be underestimated. If anything, the president has been too deferential to these forces, which have tremendous power but perverse interests. … They’re not the best interests of the patients. They’re the interests of their own pocket.

By the way, I include myself in that group. I think that we in medicine, had we been the august institutions that we claim to be, would not have allowed the kind of perverse practices -- the conflicts of interests -- that are almost routine now to exist. Since we allowed them, I think we’re also not in a great position to say "this is what we should do."

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