Listening and Touching

My daughter forwarded me this TED talk that was given several years ago, and I'm sure some of you may have already seen it.

The speaker is Dr. Abraham Verghese, a practicing infectious disease physician, writer and teacher at Stanford University.

It's about medicine losing the human touch and how important psychologically to the patient a simple physical examination is.

"We're losing a ritual that is at the heart of the relationship," he says, referring to the ritual of the physical examination.

It is RITUAL , i.e. routine, that makes us good at what we do and that's why it's called "practice" as in the practice of medicine or the practice of law or any other professional "practice."

While I don't really agree with his statement that the next big thing to come to medicine in the next "10 years is the power of the human hand to touch, comfort, diagnose and bring about treatment," Verghese in my opinion makes some powerful argument about the ritual, the practice, of medicine and it is particularly applicable to workers' compensation cases.

Workers' compensation, as we all unfortunately know, is all about numbers and volume. It is discount medicine. It is all about economies of scale. The basic economics of workers' compensation almost dictate this reality.

Verghese talks about how technology has come to dominate the "practice" of medicine - how physicians are quick to order tests, MRIs, x-rays and other technologically advanced diagnostic assists, and that we now have two patients: the one on the examining table and the one in the ether world.

The "iPatient" (the patient in the computer) is "getting wonderful care all across the country," Verghese says. But the REAL patient is left wondering "where is everyone? when are they going to come by and explain things to me? and who's in charge?"

Physician rounds used to be held bedside with the lead physician taking a troupe of others to each patient's bed and conducting inquisition and seeking answers, he notes.

Rounds now a days take place in private rooms far away from the patient - everyone looking at computers and data, but the one critical component missing is the patient.

Verghese gives an early practice anecdote about an experience he had with chronic fatigue syndrome.

He said, "they come to you thinking you will be joining the long list of people that are about to disappoint him."

Verghese thought he would do something a little different in the 45 minutes allotted for the initial exam - just listen.

So he invited the patient to tell his entire story and would try not to interrupt ("we know that the average physician interrupts his patient within the first 14 seconds"). He just listened to the patient give his entire life's history and set a return appointment for 2 weeks hence for the actual physical exam.

In the second visit, to Verghese's surprise, the patient continued to tell more of his story and voluntarily provide more of his history. But when Verghese started with the ritual of exam this "very voluble patient began to quiet down."

"And when I was done, the patient said to me with some awe, 'I have never been examined like this before.'" 

Verghese proclaims this a condemnation of the medical system, but really it is recognition that communication is probably one of the most important parts of the physician's role - and not communicating what the doctor knows, but listening to what the patient has to say.

It may not be profound and it may not lead to actually figuring out what is going on physically, but the psychological impact of a caring individual taking the time to HEAR what the patient has to say had remarkably powerful implication.

Verghese said he told the patient, "This is not in your head. This is real. The good news, it's not cancer, it's not tuberculosis, it's not coccidioidomycosis or some obscure fungal infection. The bad news is we don't know exactly what's causing this, but here's what you should do, here's what we should do." 

It was about wellness, about taking responsibility for one's own condition, regardless of the outside influences of illness, disease or injury. The doctor earns the TRUST of the patient by virtue of listening, and then conducting the ritual of the physical examination, which allows the patient to FEEL that there is a caring person in that smock.

Someone gives a damn...

As youngsters we are taught to trust our doctors - they have the gentle hand, know how the body works, have superior intellect.

Most of all, at least when I was growing up (and remember I was on a first name basis with my childhood orthopedist since I was such a frequent visitor!) we could tell the doctor things we would not tell anyone else.

Verghese says that the act of listening deeply first, and then conducting the actual physical examination, laying hands on the patient, palpating, rubbing, feeling, provided a transformative exchange:

"Rituals are terribly important. They're all about transformation. Well I would submit to you that the ritual of one individual coming to another and telling them things that they would not tell their preacher or rabbi, and then, incredibly on top of that, disrobing and allowing touch -- I would submit to you that that is a ritual of exceeding importance. And if you shortchange that ritual by not undressing the patient, by listening with your stethoscope on top of the nightgown, by not doing a complete exam, you have bypassed on the opportunity to seal the patient-physician relationship."

Verghese tells a story about a terminally ill patient who, even in his last hours of life, willing submitted to the ritual of the physical examination, that it was so important to that person.

"And the message, which I didn't fully understand then, even as I delivered it," Verghese says, "and which I understand better now is this: 'I will always, always, always be there. I will see you through this. I will never abandon you. I will be with you through the end.'"

Most of modern medicine misses this important message and certainly in workers' compensation that message is eviscerated.

The work comp system does not reward patience or communication. We look at numbers, lots of numbers, that we think describe different things to help us try and understand what is going on in this complex world and system.

But we do a miserable job of listening and performing necessary rituals that would gain trust, that would say "we'll be there for you."

Like Dr. Verghese, I submit that if we just listened more we could reduce the amount of unnecessary disability, reduce the expense of workers' compensation, and have a better, more robust, more credible role in the lives of injured workers, their employers and society.

Our challenge is how to reward positive behavior and allow physicians to listen, and injured workers to trust.