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.