Ritual of the bedside exam

SALMAN KHAN: This is Sal again. I'm here at Stanford Medical School with Doctor Abraham Verghese and what are we going to talk about? ABRAHAM VERGHESE: We're going to talk about the ritual of the physical exam, the bedside exam. SALMAN KHAN: The physical exam, the ritual-- why do you call it a ritual? That's interesting that you call it a ritual. ABRAHAM VERGHESE: Yeah, I think the lesson I've learned from hanging around with my anthropology colleagues here at Stanford is that rituals are all about transformation. A ritual signals the crossing of a threshold. You baptize to signal the crossing of a threshold, we marry to signal our departure from a life of solitude, loneliness, and misery to one of eternal bliss. SALMAN KHAN: Yes. ABRAHAM VERGHESE: So our lives are full of-- You shouldn't be laughing Sal. SALMAN KHAN: No. It resonates so strongly with me. ABRAHAM VERGHESE: So crossing a threshold is why we have a ritual. And I would say that the act of one individual coming to another, and telling them things they wouldn't tell their rabbi or their preacher, and then incredibly disrobing and allowing touch, I would say that that signals a ritual of incredible importance. And the fact that we, in the postmodern sort of medical world, have stopped seeing it that way and just see it as another data gathering tool may work for us, but I don't think it works for the patient. And I think that a major disconnect between us and our patients is our failure to see what they see, which is a profound ritual in which they're highly invested. And we then come and just stick our stethoscope on top of the shirt, or don't examine them thoroughly, we are sort of short changing ourselves of an important ritual. SALMAN KHAN: Yeah, and I'll feel short changed. I'm kidding. Sorry. ABRAHAM VERGHESE: But I'd love to list for you, if I may, those aspects of what makes this a ritual. So if you look at it, first of all there's always a specialized space. You don't examine a patient out in the corridor. It's always a special room, a ceremonial room if you will. Mysterious looking objects on the walls, a very specialized bed that you sit on. These are all signals that this is a virtual. Then when the physician walks in the physician often is wearing a ceremonial garb, which happens to be a white coat. SALMAN KHAN: Fascinating. This is interesting just from an anthropological point of view. ABRAHAM VERGHESE: The physician is wearing ceremonial garment. The patient is also instructed to disrobe and gets a patient garment. SALMAN KHAN: Which seems specially designed to put patients in a position of weakness. ABRAHAM VERGHESE: I know. It's quite unfortunate. We should be rethinking the [INAUDIBLE] garments [? major. ?] And then the physician then begins a systematic exam, which at some level is mysterious to the patient. It's not always clear to the patient why the physician is thumping on their chest or why the physician is saying take a deep breath, or cross your arms, or stand on tiptoe, or take your hand and touch your nose rapidly. So there's mysterious and ritualistic aspects to it. And very often the physician is using terms that are somewhat Latinate and arcane, and utterly mysterious to the patient such as fremitus, and percussion. SALMAN KHAN: What does fremitus mean? ABRAHAM VERGHESE: Fremitus means you ask the patient to say 99, and you listen, you put your hand on their chest. You pick up the vibration, and if they have consolidation or collapse the fremitus is not what it should be compared to the other side. SALMAN KHAN: The fremitus, so was it the sound or the-- ABRAHAM VERGHESE: It's more like the vibration. Sound being transmitted through and being picked up by your hand. SALMAN KHAN: Interesting. ABRAHAM VERGHESE: So the thing that's most interesting to me about the ritual is that the person coming in might be a policeman, a teacher, an entrepreneur, but in the process of putting on that gown, and sitting on that ceremonial chair, they have sort of been stripped of all that identity, and they are taking on the identity of being the patient. But conversely, I think there's something very important that happens, which is that just before this the patient has been vocalizing all their symptoms and their complaints, and at that point the physician could order ten tests, and go and look at images, but there's something about the physician then laying hands on the patient, that sort of gives weight to what the patient just talked about. You talk about your belly hurting, and then this individual carefully examines your belly. It's sort of validating your soma. Your body is being validated in this ritual. And then when you finally have the tests all sent off they become sort of-- what follows intuitively on the ritual of first having it validated on your body. One of the things that I bemoan sometimes is that at times the patient in the bed, I feel, in hospitals around America, has almost become an icon for the real patient who's in the computer. SALMAN KHAN: Right. It's just something to interface with to get to that data structure in the computer. It's interesting. ABRAHAM VERGHESE: I've coined a term for that entity in the computer. It's the iPatient. When the iPatient is getting fabulous care the real patient I think has a need to feel their complaints validated. To feel it validated on their soma, and to engage in a ritual for which there's a transformation. And you might well ask me, what is the transformation that takes place in this ritual? And, I think the transformation is the sense of the patient has delivered the story, the physician in the process of the ritual has validated that they've heard the story and tried to locate it on the soma, and the transformation is really the ceiling of the patient physician relationship. And so I think what has happened Sal, unfortunately, is that because we have so much technology we've become very sloppy in the way we examine patients. I think that we should be a hundredfold better at examining people given that we have real-time feedback with echocardiograms, angiograms, and all that. Instead of which, I think people have never been less certain of their bed side skills. SALMAN KHAN: What about this phenomenon, just talking to physicians I know in my own family, that there's so much time pressure. They have to see so many patients, one every 15 minutes, and all of this, and they wish they could do this, but they'll say that I have so many other things to worry about, and the paperwork, and all that. Is it realistic? ABRAHAM VERGHESE: No, I think that's a very real concern. But I think if you can do this well. And our goal at Stanford is to teach our students to do it very well. You actually save time. Because if you do a quick exam and you find that they're tender in a certain spot you can order the test that sources just that out, rather than, which I think is much more common, which is I don't really know what's going on, I'll tick off every box, and maybe something will fall out of the sky. So I think a directed exam, not only fulfills the ritual, but if you're any good at it, it actually allows you to ask better questions of a test you order and minimize the patient's exposure to radiation. And I think the trouble is we get all these tests, and we get back results we don't know what to do with, we stumble onto what we call incidentalomas. Have you heard that term? SALMAN KHAN: Incidentaloma. Well, I have heard that VIP's often get worse medical care because they do everything for them. ABRAHAM VERGHESE: Yeah, exactly and they wind up with finding things they don't know what to do. SALMAN KHAN: Exactly yeah over diagnosing things. ABRAHAM VERGHESE: But to come back to a ritual, I think we at Stanford are very proud to feel that, as much as we represent this great bastion of technology and advancement, we also celebrate the fundamental ritual aspects of the patient physician relationship, which is best symbolized in the physical exam. SALMAN KHAN: I think this is why a lot of physicians originally want to enter the field. It sometimes gets lost, but this is why they wanted to do it. ABRAHAM VERGHESE: And you're right. I think they often get disappointed when they learn to do this and arrive on the wards and find that no one's carrying a stethoscope, and no one's carrying-- I mean they carry the stethoscope. I think it's like a mating symbol. SALMAN KHAN: No you gotta carry one to look legitimate. ABRAHAM VERGHESE: But they don't carry the knee hammer, and they don't carry all the other tools. SALMAN KHAN: I once visited my wife at the doctor and I wore her coat, and I felt very good. ABRAHAM VERGHESE: Did you drape your stethoscope around the neck too? SALMAN KHAN: Oh I did. Yeah, I looked very authoritative. ABRAHAM VERGHESE: That's a great signal that you arrived. So I think that we have so much to learn from our anthropology colleagues about the importance of ritual. I think sometimes we operate as though medicine is all about reason, but it's really reason, ritual, emotion. They all tie in together. This is art and science. SALMAN KHAN: No. This is fascinating. I'm going to reflect on some of the rituals I do now to see if they are. Very cool. Well, thank you for this. ABRAHAM VERGHESE: Thank you so much.