FULL RESPONSIBILITY
Sometimes a book finds you at the right time. I felt that way when I first read My Own Country: A Doctor’s Story. It was the second year of medical school, and I was feeling discouraged. I saw the book on the shelf of a classmate I admired; she said it had motivated her to become an infectious disease physician. I needed motivation, so when I saw a yellowed copy at the used bookstore, I picked it up.
I started reading it that night. The author, Abraham Verghese, wrote with impressive fluency and apparent passion. Verghese was a disheartened physician, but he still professed nothing but love for examining patients and teaching students. I quickly fell under his spell. In fact, all of medicine soon did as well, and Verghese became a leading physician-writer. Over the next two decades, Verghese developed an Osler-style proposal for renewing medicine through reading literature and carefully performing physical examinations, a proposal that began in the pages of My Own Country. So I reread it recently. For the second time, it was the right book at the right time. This time, I realized that the memoir’s peculiar magic is that it portrays a physician as the storyteller of his patients’ bodies, taking something like full responsibility for telling his patients’ stories.
My Own Country focuses on Verghese’s first job in the long white coat of an attending physician. Before taking the job, Verghese was an infectious disease fellow in Boston, a city renowned for its academic medical centers. As a fellow, Verghese had learned that infectious disease physicians could, with careful diagnosis and targeted treatment, cure people of their infections. After completing his fellowship, Verghese moved to Johnson City, Tennessee, a place removed from renown. About the same time, the AIDS epidemic arrived in Johnson City, and since there were as yet no effective treatments for the disease, Verghese found that he could care for his patients, but he could not cure them.
In moving to Johnson City, Verghese was living out Osler’s advice to the army surgeons. He had accepted a posting to a remote locale, with rural Appalachia substituting for Osler’s army outposts on the colonial frontier, and he made the most of it. As the only physician caring for persons with HIV and AIDS in the area, Verghese saw much. He rose before dawn to make rounds at the hospital, then slipped away to his laboratory to research pneumonia, and spent his afternoons seeing patients in an infectious disease clinic, where he became the primary physician for a group of people with HIV who had been shunned by the local physicians. After clinic ended, he often attended advocacy meetings or made house calls instead of returning home to his wife and young children. Verghese admitted that his work caused tension with his wife, but he could see no other way to be the kind of physician his patients deserved.
The book had everything the On Doctoring anthologists could wish for—the protagonist was reflective, the writing fluid, the message humanistic, the subject topical—while it endorsed the kind of work ethic every residency training director wants in his or her residents. Verghese was no critic of medicine; he was, rather, a disappointed idealist, whose highest compliment was that a colleague was “a careful and thorough physician.”1 I could see why his book was selected for the anthology; it instilled a useful hope in me.
Verghese’s hope for the renewal of medicine was that physicians would return to the bedside and personally engage patients through a physical examination. He wrote, “I loved bedside medicine, the art of mining the patient’s body for clues to disease. I loved introducing medical students to the thrill of the examination of the human body, guiding their hands to feel a liver, to percuss the stony dull note of fluid that had accumulated in the lung.”2 His descriptions of his patients were articulate and precise, if clinical, and as he shaped their stories, he portrayed physicians as the expert readers of the body, people who read the body like a familiar text.
To Verghese, the paradigmatic act a physician performs is to read the body through the physical exam, but the pleasure of being a physician lies in teaching trainees how to do the same. Verghese celebrated everything about the Oslerian teaching service—the authoritative examination, the detailed presentation, the learned discussion—and in this sense My Own Country was the perfect book for a medical student. It made my training, and my place at the bottom of Osler’s ladder, seem purposeful. I was learning to be the same kind of humane and skilled physician that Verghese became through his own training. If I followed the plan, I too would ascend the hierarchy of the teaching service. I too would become a humane physician.
But Verghese also alerted me to what would happen if I did not follow the plan. Throughout his memoir, he criticized peers for performing careless and perfunctory physical examinations. He lamented that most contemporary physicians aspire to be exquisite technicians who perform specialized procedures with consistency and speed without engaging their patients. Since those procedures were much better reimbursed than bedside medicine, cardiologists and surgeons earned more money than infectious disease physicians like Verghese, and their higher income accorded them greater status among medical students, hospital administrators, and their neighbors. Verghese faulted healthcare’s financial hierarchy for discouraging humane encounters with patients.
I welcomed this kind of justification during my preclinical years, when I spent most of my days being examined or lectured to. My work seemed absurdly distant from the goal of caring for real people. Reading Verghese gave me the hope that if I submitted myself to the seemingly pointless rituals of medical school, I would become something approximating the physician Verghese described.
Verghese also gave me hope that I could be a good physician by attending carefully to the body through the physical examination, organizing signs and symptoms into revealing clues. When you rolled up sleeves to take a patient’s blood pressure and found raised purple patches, they signified Kaposi’s sarcoma, and when they were accompanied by symptoms like fatigue and weight loss, they suggested an HIV infection; such signs and symptoms could be organized into a compelling story. As the physician in a remote region, Verghese told these stories, stories of particular ill bodies but also of a group of “prodigal sons,” young men who grew up closeted in rural Appalachia, left to live openly as gay men in urban centers, contracted HIV/AIDS, and returned home to die.3 Their stories were powerful medical science and humane literature.
I aspired to be such a physician and writer, so I appropriated Verghese’s commitment to internal medicine along with his frustrations about procedural medicine and his hopes for the renewal of medicine. The hope I borrowed from Verghese helped me through the preclinical years of medical school. I endured lectures and exams while waiting for the third year, when the clinical training would begin. When the day arrived, I was eager for the hospital and gratified to be assigned a teacher who reminded me of Verghese. Dr. Samuel Cykert could describe the results of dozens of studies and the efficacy of hundreds of medications from memory.
He ran his hospital service according to the Oslerian rhythm. We students would arrive before dawn, gather data, and then pass it along to the residents, who corrected and organized the data into presentations. When Dr. Cykert arrived, we would make rounds. We examined the patient’s parts in order, from head to toe, and then by rank, students first, then the interns, the residents, and the chief resident. Afterward, Cykert would complete the portions of the exam we had missed. Together, we percussed the liver searching for dull sounds, flashed penlights in pupils to assess for light reflexes, and listened to lung fields for whispered pectoriloquy which could indicate to the ears of an experienced physician the presence of cancer or pneumonia. Then Cykert would ask a student to name the finding, assemble a differential diagnosis, and venture a treatment plan. He questioned, or “pimped,” the student until he or she reached the end of his or her knowledge. Then he would move hierarchically through the rest of the group, asking more difficult questions of the intern, then the resident, and finally the chief resident. When the knowledge of the entire group had been exhausted, a rhetorical space would have been created out of the gaps in our knowledge, and within that space Cykert would teach us, filling in those gaps. Cykert pimped us mercilessly. I feared his questions because they revealed my ignorance, but they also inspired me. I wanted to understand my patients so well that I could answer Cykert’s questions. It was a worthy goal, but it also meant that every patient became a test, an opportunity to assess my own ability and worth.
My chance to prove myself came late one afternoon when I admitted a young man who reminded me of Verghese’s prodigal sons. Demetrius was a thirty-two-year-old gay man who had returned to his mother’s house two months earlier. He was thin and colorless, like a picture book faded by the sun, and his mother thought it odd that, even in the thick heat of a southern summer, he wore long sleeves to cover his arms. But she looked the other way because her son was home, whatever the reason, after a decade away. When he did not come downstairs one morning to pick at his breakfast, she opened his bedroom door and found him unconscious on top of sheets stained with blood.
When his ambulance arrived at the hospital, he was already receiving his second liter of normal saline through an eighteen-gauge intravenous needle. The Emergency Department nurses and physicians stabilized him, but it was clear that he could not return home, so they paged the admitting team, Cykert’s team. We were on call, responsible for following the patients already admitted and for admitting new patients overnight. It was early in the afternoon, and there was still time for teaching, so the resident encouraged me to take the lead.
I pulled back the curtains surrounding Demetrius’s bed and conducted the history and physical exam. He would start a conversation and then, overcome by fatigue, lose the thread and fall silent. Meanwhile, the resident physicians wrote orders to admit Demetrius to the hospital. It took them five minutes to write the orders. It took me two hours to complete my assessment, because I was determined to stitch together the right story, to assess Demetrius in a way that would pass Cykert’s examination while being as articulate as one of Verghese’s stories. Even as I examined Demetrius, I was startled by the way his experience resonated with Verghese’s memoir—the patient had identified as gay from a young age but remained closeted until he left his rural North Carolina hometown for Washington, D.C., where he lived openly as a gay man, contracted HIV and hepatitis C, buried his partner, and then, in grief, stopped the antiretroviral medications that checked his infection. Over the previous year the infection had progressed until he could no longer work, so he had returned to his mother’s attic to die. He told me all this as I percussed his liver, auscultated his lungs, and examined his eyes. I evaluated him in between interruptions for more urgent interventions: phlebotomists drew blood, nurses hung additional bags of saline, and aides cleaned his periodic bouts of bloody vomitus.
When Demetrius was transported to the intensive care unit, I organized my notes into a story. We paged Cykert, and I presented Demetrius to him.
“The patient is a thirty-two-year-old male with HIV, CD4 count unknown, and HepC brought in by ambulance with hypotension.”
Cykert interrupted. “How low was the BP?”
I shuffled through my notes. “97/64.”
“Go on.”
“. . . and vomiting blood.”
“What blood type?”
“Um, not sure.”
“Find out. Go on.”
So I went on. On and on, Cykert stopping me at every one of my many mistakes. Finally, the chief resident came to my aid, telling us we were being paged to examine Demetrius on the floor. As we walked, Cykert told me to correct the presentation. He examined Demetrius in three minutes, efficiently resolving all the questions my presentation left unanswered. He suggested a few changes to our orders and went home.
I spent the night at the nurse’s station in the ICU, writing and rewriting my presentation. I hunted through the unit’s tattered copies of Harrison’s Principles of Internal Medicine and the Washington Manual of Medical Therapeutics for clues on how to improve my presentation. Again and again, I rewrote the presentation, but it never seemed Cykert-worthy. I could not get the story right, and I began to perceive my situation as desperate.
Fifteen feet away, Demetrius was experiencing a truer kind of desperation. He was still bleeding. He had esophageal varices, pathologically dilated veins, from the blood backing up from his faltering liver. His varices loosened, and with every beat of Demetrius’s heart, blood leaked into his esophagus. The nurses hung bag after bag of blood—it was O positive—throughout the night. A visiting gastroenterologist fellow threaded an endoscope through the burbling blood, looking for a place to cinch up a varix band or inject a clotting agent. She could not find one. She called in the attending gastroenterologist from home. Bleary-eyed, but with experienced hands, he fared no better. Meanwhile, the nurses kept hanging bags of fluids and medicines until Demetrius was surrounded on either side by IV poles that were propping him up.
When Cykert returned early the next morning, I presented the patient again. There were no interruptions this time. While Cykert sipped his cup of coffee, his experienced eyes scanned the unit. Halfway through my presentation, Demetrius vomited blood again. Cykert walked briskly into Demetrius’s room, the group following. Receiving no answer to the questions he posed to Demetrius, Cykert called the code, the hospital-wide announcement that a patient was in mortal distress. The unit awoke in unison. Physicians, nurses, and respiratory therapists worked to save the dying prodigal.
They all failed. Demetrius died a frantic death, alone in a crowd. I felt dispirited, both for my patient, the second person whose moment of death I had witnessed, and for my hopes of becoming a particular kind of physician. Verghese had convinced me that the physical examination, the performance and presentation of it, would allow me to see the patients before me clearly, to be present to them in their suffering. Instead, I had spent Demetrius’s dying hours trying to write the best description of his body.
I never read Verghese the same way after that night.
Verghese published another memoir and then a novel, but I did not read them. They were not the right books for those moments in my life. Then, a few years ago, my inbox started filling up with essays, op-eds, and commencement speeches written by Verghese. Physicians who were frustrated with the practice of medicine were passing around these writings like samizdat. I received them, often with subject lines imploring me to “READ THIS!,” from former classmates and from our hospital’s chief medical officer.
When I did so, I was reminded of the appeal of Verghese’s writing. He wrote well and cited great literature with medical themes. He diagnosed the ills of medicine. He prescribed a treatment.
In his medical journal essays, Verghese wrote for his fellow physicians, sharing his regrets that technology now dominates the field of medicine. Verghese lamented that instead of attending to a patient at his or her bedside, we attend to technological abstractions of a patient, the electronic medical record or the lab values or imaging studies.
I sympathize with his complaint. Most days, I spend more time documenting patient care than being with my patients. I wonder how much more I could learn about patients if I spent my days with them instead of their charts. As an attending, I frequently tell medical students and residents to ignore their smartphones while speaking with a patient, only to find myself distractedly looking at my own electronic minders. Even when we spend more of our time with our patients, even when we put away our devices, we often pay more attention to a patient’s blood work than to the body from which the blood was drawn.
Verghese understands this, and like Osler he recommends reading certain texts. Unlike Osler, he specifies literary fiction with medical themes. Verghese advises physicians that such texts can help them understand their patients through the literary tools of narrative, character, and metaphor. This advice appeals to me; I read constantly and find that narratives offer me a way to understand my life and the lives of the people I meet as patients. Verghese, however, extends the argument, asking physicians not just to read the tale, but to become the teller. When he spoke to a national gathering of internists a few years ago, he argued that physicians could renew medicine by understanding themselves as “storytellers, storymakers, and players in the greatest drama of all: the story of our patients’ lives as well as our own.”4 For Verghese, these kinds of close readings refocus the physician on the patient.
Verghese believes that the physical exam also leads to such refocusing. He discourages physicians from performing the kind of cursory physical examination I watched on my first day with Gloria’s rural physician: The doctor spends a few moments assessing what he or she suspects will be the diseased parts of a patient’s body, then checks “WNL,” an abbreviation for “within normal limits,” in the medical record. In such cases, the doctor may never know what he or she missed. (Privately, physicians joke that “WNL” actually means “we never looked.”) Verghese wants more physicians to be like him and Dr. Cykert, and like Osler before them—careful performers of the physical examination. To this end, Verghese, now a professor at Stanford, and his colleagues have developed the Stanford 25, a list of twenty-five physical examination techniques they teach to students, trainees, and attending physicians. They are offering not only a diagnosis and prescription for contemporary medicine but also a compelling hope: that physicians can renew medicine if they refocus their attention on the individual patient through the physical examination. This diagnosis, prescription, and hope are captured in the slogan of the Stanford 25: “An initiative to revive the culture of bedside medicine.”
. . .
So what happens when a physician practices medicine in this fashion, when he or she stays at the bedside to read the diseased body and tell its story? It was when I had progressed in my medical training and started thinking more deeply about this question and the larger questions of how we see our patients that I returned to My Own Country. Much of the memoir still inspires, because Verghese rendered the suffering of his patients as compelling case histories of men and women infected with a virus that stigmatized them before it killed them. Since no cure was available, Verghese learned to care for his patients with HIV/AIDS by carefully attending to them. In doing so, Verghese developed a clear hope that attending carefully to what the body has to tell will allow a physician to see the suffering person on the hospital bed clearly, and thus become a “good” physician.
But My Own Country also transmits an implicit warning. While rereading it, I found passages inappropriate for our aspirational anthology, passages where the light fades fast. These sections show the alienation Verghese experienced through the stigma of AIDS, the loneliness he felt as an outsider in Appalachia, the strains his work inflicted upon his marriage, his anger at the greater pay and social status afforded physicians who perform procedures instead of sitting with patients, and most of all the difficulty of facing his patients’ deaths.
Toward the end of the book these tensions culminate at the bedside of Luther, a man with AIDS whom Verghese knows well. Luther has been hospitalized, and Verghese is examining him, accompanied by a full teaching team. He usually describes examinations of patients with students and trainees as his happiest moments, but in this instance he is annoyed with the students for being more impressed by “numbers from a Swan-Ganz cardiac catheter” than by the physical examination of a patient. Their attention is consumed by technological abstractions. Verghese ultimately faces his own limitations at Luther’s bedside:
The medical students and residents are quiet, hovering around the bed, uncomfortable because death is staring at them. I am uncomfortable too, and I am angry all the time now. This is what I think when I lie awake at night: I want to start all over again. . . . When I began in Johnson City, I was ambitious, fascinated by the [HIV] virus and by my patients. I maintained no distance, denying to myself that this was a fatal illness. The future, when all my patients were dying, seemed remote and vague. I convinced myself that I could handle that. But I simply did not understand how devastating it would be to watch. All the stories that I have painfully collected have come to haunt me with their tragic ending, as if I am the author and must take full responsibility. In a new place I can begin again from a wiser and more careful vantage. The students and residents are waiting on me. I have been lost in thought. What am I supposed to do here, at this bedside?5
I was startled by this passage. As a practicing physician, I now know how devastating it is to know someone, care for that person, and then watch the person die. The truth about medicine is not that some patients die despite our efforts but that every patient eventually does so. What I missed when I read this passage as a student was that part of the anguish for Verghese was that he had made sense of a dying person’s suffering through his own actions. As Verghese put it, the physician can become, in a moment like this, an author who “must take full responsibility” for the deaths of his patients. By accepting that responsibility, Verghese crossed the line between reader and writer, and he felt as though he had in some way created Luther’s body and brought about Luther’s death. Under the weight of such responsibility, Verghese fantasized about quitting his job, leaving the state, and starting over. In the moment, though, he remained at Luther’s bedside, surrounded by students waiting, like children eager for a bedtime story, for him to read the text of this dying person to them. Was he the reader or the author of the text? What was a physician to do, here at the deathbed?
For Verghese, the answer was clear. In his next line he wrote, “I have, for which I will always be thankful, the ritual of the examination.” He put his hand on Luther and examined his dying patient. Although Verghese insightfully asked what physicians were supposed to do at the deathbeds of patients like Luther, the answer he offered in his memoir, the answer he has repeatedly offered over the ensuing two decades, is that they should return to the ritual of the physical examination. And yet a physical examination is surely, like the numbers from a Swan-Ganz catheter and the reports in the electronic medical record, an abstraction of the body, albeit in a different degree. In each instance, a physician takes on the responsibility of interpreting the meaning of a patient’s body, a responsibility that can stagger even our most skilled physicians.
And what about Luther? What solace could he take from being expertly examined, from being read well, by a physician and his trainees? I do not know, and Verghese provided me with only an indirect answer. In My Own Country, Verghese wrote that a physician’s diagnostic power, which made a patient visible to the physician, allowed him to interpret seemingly unrelated signs and symptoms as part of a single disease. By naming signs and symptoms as disease, a physician could reduce the stigma experienced by many of his patients. Many of Verghese’s patients with AIDS were shunned by friends and family; what a relief it must have been to meet a physician who would see and touch them despite their illness.
However, by seeing them in the manner he did, Verghese also took on a fearsome responsibility. In his memoir, he tabulated the cost of undertaking such intimate readings of his dying patients. These responsibilities so alienated him from himself, his family, and his work that he did ultimately leave Johnson City. Rereading Verghese’s memoir at a later stage in my own career, I clarified the misgivings about his prescriptions that I had experienced at Demetrius’s death: his proposal to renew medicine advocates seeing much because it reinforces the role of physicians in contemporary life as the people with full responsibility for reading and interpreting the body, for determining its meaning.
There are, of course, humane proposals to renew medicine that do not place full responsibility on physicians. Some shift the authority in a physician-patient relationship entirely to patients or their caregivers. Some propose reviving medicine by engaging humane disciplines—art, history, literature, music—other than science.
Most of the medical humanities proposals that, like Verghese’s, are embraced by healthcare practitioners, adopted by medical schools, and circulated over email by physicians are not so radical. They represent what the physician Jeffrey Bishop calls the “dose effect” of humanities, the idea that we ought to “give medicine and medical students a dose of humanities so that medicine can become (once again?) humanistic.”6 Many of the most popular dosing regimens, like the white coat and the anthologized book of wisdom, subsume humanism into professionalism. At the hospitals at which I have trained and worked, one of the most popular proposals along these lines is Schwartz Center Rounds.
Schwartz Center Rounds are funded by the Schwartz Center for Compassionate Healthcare. The center’s inviting motto, “Join us in Transforming Medicine,” indicates the scope of its goals. It wants to renew medicine by increasing compassionate care for patients, a move that it believes will reduce burnout among care providers. Schwartz Rounds began at Massachusetts General Hospital in 1997 but now take place regularly at hundreds of hospitals across the country. Schwartz Rounds are confidential, multidisciplinary gatherings in which physicians, nurses, and other healthcare professionals reflect on the burdens, challenges, and gifts of caring for the ill. The meetings, usually occurring over lunch in a hospital auditorium, are open to practitioners but not to patients and their families. They typically begin with a narrative summary of a case and are followed by an open discussion of how it felt to participate in the case. In an article reviewing a decade of Schwartz Rounds at Massachusetts General Hospital, the oncologist Richard T. Penson and his colleagues observed that Schwartz Rounds were very well received, writing, “Caregivers yearn for an opportunity to express themselves openly in a situation in which it is safe to do so and . . . they derive great benefit from the feedback and support they receive from colleagues.”7 As Penson suggested, Schwartz Rounds are designed to offer a place where caregivers can express themselves, in order to relieve the weight of full responsibility placed upon them by contemporary medicine.
When I first attended Schwartz Rounds, I did experience the relief that comes from sharing a burden to which one had become accustomed, but there was also a surprising feeling of familiarity. It felt like grand rounds, the weekly lunchtime meetings in hospital auditoriums where members of a clinical department gather to discuss a difficult case and listen to an eminent physician share the latest research associated with the patient’s condition. As in grand rounds, senior practitioners usually framed the conversation. As in grand rounds, practitioners at Schwartz Rounds told stories about patients in order to teach a lesson. As in grand rounds, practitioners at Schwartz Rounds discussed, rather than engaged with, patients. In both settings, the patient’s story is told by practitioners for the edification of practitioners. As Penson wrote, “The Rounds focus on caregivers’ experiences, and encourage staff to share insights, own their vulnerabilities, and support each other.”8 I appreciated the relief, but Schwartz Rounds struck me as something much less than the transformation of medicine. Later, when I read more about Schwartz Rounds, I saw that the Schwartz Center understands them as the humane version of grand rounds; the familiarity I experienced is intentional.
At least part of the success of Schwartz Rounds is due to that familiarity for medical practitioners who are already accustomed to learning Osler-style lessons from the bodies of patients. It was Sir William himself who popularized the grand rounds tradition while teaching at Johns Hopkins. I could not escape the great physician and his influence; he kept showing up unexpectedly. In the Schwartz Rounds, it was the use of patient stories for the education of practitioners. Even when the message was quite different—I find it impossible to imagine a contemporary Schwartz Round speaker advocating for coerced autopsies—the form is the same. Physicians see much, therefore we see wisely. In Osler’s model, and in the model of the medical humanists like Verghese who followed him, the physician determines the meaning of an illness. We now see quotidian events of human existence—conception, childbirth, adolescence, pregnancy, old age, death—as events in which a physician should intervene. Even the proposals, like the Stanford 25 and the Schwartz Rounds, that set humanism at the heart of medicine do not unseat physicians from their place as the people with something approaching full responsibility for interpreting the body.
We may be able to renew medicine through stories, because we all make meaning through stories, but we will not do so if the stories are told by physicians for the use of other physicians, if we continue to imagine physicians as having full responsibility for their patients’ bodies and lives. Perhaps the solution lies in the opposite direction—preventing physicians from taking on full responsibility by regulating the bodies and time of physicians themselves.