day
good morning everyone
lovely introduction and what a rousing start to the morning I'm really
privileged to be the first speaker,
privileged to be with you and with my colleagues from Stanford. I want to talk to
you about the body
as text and I wanna tell you that our ability
to look at the body and diagnose diseases and
tell all the myriad things that are going on is very recent.
Until the mid-1800s or so, no matter what ails you
pain cough fever you would go see
a barber surgeon and the barber surgeon would
cup you, bleed you, purge you and if you want it also pull a tooth and
cut your hair long at the sides and short at the back,
but would make no attempt at diagnosis. My medical students
always surprised to learn that our first ability to read the body as a text,
a super power if you will, began because of
a man called Auenbrugger, who I'll mention to you in a second. I just want to point out to you
probably already know this
that the famous barber pole with the red and white stripes
represents this legacy of the barber surgeon. The red and white stripes represent
the bloody bandages
the brush receptacle at the bottom represents where the blood was collected.
It was this man and the late eighteen hundreds
who got us started and our ability to read the body this text. His name was
Leopold Auenbrugger
in Vienna and his father was an innkeeper.
And one of his early memories was going down to the basement
of the in with his father and watching his father
tap on the sides up the kegs wine
to determine where the meniscus was and whether it was time
to reorder or not. And when Auebrugger became a physician
he begun to tap on bodies. He began to what we call percuss
and effectively my part the size of the heart, the presence of fluid in the lungs
the size with the liver and so on. Everything we know about percussion,
which was the
of the ultrasound of its day, was discovered by
Auenbrugger. It was really a huge moment in medicine.
Followed very shortly by this gentleman, Laennec,
here in Paris, who discovered the stethoscope. Until then,
as you can imagine if you want to listen to the patients just you had to apply
your ear
to the chest wall or the abdomen, which as you can imagine from time to time
presented some aesthetic difficulties,
and Laennec came up with the stethoscope. And all of a sudden by the early
1900s
we had this phenomenal ability to read the body as text.
Not just because of the stethoscope and percussion, but also
the opthalmoscope, the blood pressure cuff and we began to have
magnificent clinicians who could really read the body. And just to show
you an example,
I'm gonna tell you a little anecdote that involves this person. This is actually
Arthur Conan Doyle. He's the author of the Sherlock Holmes series as you know very
well.
What you might not know is that Conan Doyle's
inspiration for the character of Sherlock Holmes was his professor
at Edinburgh,a man by the name of Joseph Bell.
Bell was an extraordinary clinician, but probably not that different from
many
extraordinary clinicians who existed on both sides of the Atlantic,
especially in France, which was the epitome of this kind of
clinical skill.
About Conan Doyle writing in The Lancet some years later,
describe what it was like to be a student of Joseph Bell.
You can imagine Bell seated in the outpatient department
students all around him and the woman comes walking in with the child.
She says good morning Dr. Bell.
and Dr. Bell says, "Good morning and what sort of a crossing did you have on the
ferry from Burnt Island." She's shocked, she said said it's a good crossing. "And what did you
do with the other child?"
She said, "Well, I dropped my other child of
with my sister in Leith." And he says, "Did you take a shortcut
down INvewrleith Row to come here today to the infirmary?"
She said, "Yes I did." And he says, "Would you still be working at the linoleum factory?"
She said, "Yes I am."
Mind you this is before she's taken off clothes or been examined, Can imagine how
much more
Bell would deduce. And he goes on to explain to the students,
"You see when she said good morning I picked up for fife
accent and the nearest crossing from Fife
is Burnt Island. Secondly, you observe that the coat
she's carrying is too small for the child who's with her
and therefore she started this journey with two children, dropped one off
along the way. Third, you notice that the clay
on the soles of her feet is a kind of clay that's not found with a hundred
miles
of Edinburgh except in the Botanical Gardens and Inverleith row
is her closest shortcut through the Botanical Gardens.
And finally you notice the dermatitis on the fingers on her right hand,
which is characteristic of the linoleum factory workers
of Fife." I don't know about you, but my medical students
love that story. I love that story. It's the kind of superpower
I came to medical school to acquire.
I have to share with you a different story.
This is an individual, not this particular individual, but this is
an exemplar of a kind patient that shows up in North American hospitals
fairly regularly, usually complaining in this case of left hand.
And tragically many months will often go by while the primary care physician
X-rays the hand finds nothing.
Sends the patient to an orthopedist, who examines the hand and the shoulder finds
nothing.
It may take some months for people to diagnose what Joseph Bell
and any number of positions a hundred years ago would have diagnose an instant, that
this patient has Horner syndrome. He has
a little lag the left pupil and he has a smaller pupil on that side on that side,
And they might have picked up that he was a little horse and they would have
said instantly without even looking at hand
that he has a tumor at the apex of the lung. To find out why you have to come to the
breakout session, it's not important. What's important know though,
that for some reason, this fairly common well describe condition
is something we miss now with regularity
where someone like Joseph Bell would never have missed it. I would consider it
a major ever for us to delayed diagnosis
because we failed to pick up something that people a hundred years ago
picked up fairly regularly. And the reason
might be captured by this diagram I really like. It was drawn by a patient
who had gone to see her pediatrician. And she drew
a little sketch of her, to her, a wonderful visit.
And she depicts herself as you see sitting on the exam
table her mother and sister are sitting
beside her and the sisters playing with a doll and the doctor
is pictured as having his back turned to the patient.
I have to tell you about this physician because he was traumatized by this
picture.
This was an individual who loved pediatrics.
This is an individual spent one year in the US carrier
in the Mediterranean taking care of 250
on Navy corpsmen and every emergency that could
happen to them. And then came back and because he loves children
engaged in a pediatric residency, Had three children of his own
during the residency, and when he saw this diagram
he was crushed. In the stimulus package
that the government put together one of the major expenditures was to create
electronic medical records and
one phrase that he said caught my attention, he says
we spent however many million dollars on the electronic medical record I wonder
what this will really cost in terms of the
face to face interaction in terms of patient care. So we have this paradox
where
we have the wonderful ability to see things in the body that I could never
have imagined I was in training. It's a wonderful time
to be a physician, the kinds imaging that I can access daily,
remotely, it's quite incredible. But it has come
with an a our declining abilities to pick up
very simple things that Joseph Bell,
Laenneck, and Auenbrugger would have picked up 100 or more years ago.
And we st Stanford think that this is not right and we have taken the lead
on doing something about this. We think that
although we can't have rounds totally be like this around the bedside, this is
from from
Boston City Hospital where I trained some time ago.
Rounds have increasingly become like this where the most important person in the
room
is missing, namely the patient. Instead it becomes a discussion
of date. It becomes a discussion of what I call the i-patient, you know like your
iPhone or iPad.
We have i-patient gets wonderful care all across America,
the real patient often suffers just a little bit.
Now I think that we can't afford to lose these wonderful clinical skills
for two reasons. One is we
have to be able to pluck the low-hanging fruit. If you come to visit me in my
office, you'll notice these
strange plastic fruit dangling from under my desk and on my bookshelf.
It's because I want to make this our metaphor that we
will not let any of our trainees walkout.
never have it in our conscious that they missed the low-hanging fruit/
That someone who has a diagnosable, treatable condition
is picked up three months later when they're no longer treatable.
That should not be on our conscience. That's one good reason I think,
to examine the patient well, to listen well, to get not too caught up in
technology where we stop seeing the patient.
But the other reason is perhaps even more interesting my wonderful
interactions with colleagues in anthroplology, including Dr. Kupur,
have taught me that the ritual of examining a patient
is an important one. It's a ritual think about it. Someone comes to you who
you don't know. They tell you things that they wouldn't tell the rabbi or their
preacher
or their priest. And then incredibly
they disrobe and they allow touch,
which in any other context could be assault.
That is an exceedingly important ritual. Patients have certain expectations of it
and if you don't fulfill that ritual they walk away feeling
my doctor didn't pay attention, something was missing.
Rituals are all about transformation, we engage in rituals to signify
a crossing of a threshold, be it marriage or
death or transition of power.
The ritual of examining a patient also has a transformation. What is it?
Well it validates the personhood of the patient and it locates the illness on
their body,
not remotely on some screen. It takes their symptom
and you put your hand on where it hurts and you validate that.
You affirm your connection, commitment and trust. And finally
where this very interesting phenomena that's really wrapping me up in terms of
the
data that's coming out on the phenomenon of placebo without placebo.
We've known for some time that placebo is not about tricking people with a
sugar pill,
that you can actually prove produce profound neurobiological affects with
the placebo.
You give a Parkinson's patient the placebo not only do
two-thirds of them stop shaking, but you can also measure
in the ones we stop shaking a surge in dopamine levels in the brain.
You give a patient who's in pain a placebo and in one to two-thirds of them
the pain will vanish. If you use a morphine antagonist
the pain will come rushing back. Placebo produces real
neural biological effects.And we're learning that you can have placebo
without placebo.
Meaning context, tone of voice, the ritual examination,
all these things a profoundly important in
the biology of disease. I can only begin to highlight this in the
eight minutes I have. I want to close with a little anecdote.
I'm infectious disease specialist and in the early years my practice,
I took care of many young men, predominantly, who were my age who were dying of AIDS.
And I remember my sense of futility going back there
by their bed sides: as they were dying towards the last stages. And I remember
in particular
one young man who was dying. Day after day, I would go by to visit him and I'd see
his family there
and I would never know quite what to do. And out of a loss for
knowing what else to do, I would do my ritual.
I would begin to examine him. I would percuss the lung,
I would listen to the heart, feel the belly, not that there was any information I was
going to gather at this point
that will change for much but it was my ritual
And I remember this one particular young man on the very last day of his life,
hours before he died as I came to his bed his mother told me that he had not
responded at all
for the last 12 hours. And as I was just standing there talking to her,
we saw his hands come fluttering up
we wondered what is he gonna do. And they went to his pajamas and he began to
fiddle and I realize he was going to expose his chest to me.
He was wanting me to examine him. That this ritual,
which was in a sense meaningless to medicine at that moment, was
incredibly meaningful to him. It meant,
for one thing, I will never abandon you. I will see you through this.
I will be with you through the very end. I'm very proud to tell you that we at
Stanford
consider our technology paramount, but we consider
the sanctity the physician-patient relationship the superpower of
being a great clinician to be equally important.
Thank you very much.