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A few months ago a talk was posted by Dr. Abraham Verghese, “A Doctor’s Touch...” You can view it here. It is an amazing talk. In it he relates a wonderful story of an experienced physician of the late 1800’s, who exercises his power of observation and history taking to deduce the social history and probable complaint of a patient. He then relates a tragic story about a woman who had her cancer undiagnosed because of the lack of a specific part of a physical exam. It is an engrossing talk, and Dr. Verghese is an amazing story teller.
After I watched it, I marveled at his ability to weave a narrative and tie it to the point he was trying to make…which is an important one. Certainly, in the developed world, and in the US in particular, physicians in many ways rely too much on diagnostic tests and imaging, and not nearly enough the history and physical exam. It is also true that a well performed physical exam is a wonderful diagnostic tool of its own. I took the time to watch the talk again, shared it with my friends, and then began to feel a little disquieted by Dr. Verghese’s message. I could not think of exactly why I was unnerved.
The next morning I went into my clinical assignment. At the time I was working with a team of four general internal medicine physicians. Generalists, but specialists in the complex interplay of chronic disease in their patients. I did a lot of learning on this rotation, the value of being thorough, the current evidence regarding the long term management of heart failure, diabetes, lung disease. Every day I was challenged in my history taking and physical exam skills…and my disquiet grew.
I was very lucky on this rotation to have four wonderful mentors who challenged me. One was a very experienced physician whose wisdom with dealing with generations of patients who were acutely ill focused me on basics of diagnosis (and prognosis), another was a physician respected for his breath of knowledge and skills as a diagnostician, the next had an incredible empathy and connection with her patients that was instructive to watch.
The fourth was a wonderful physician who models thoroughness and compassion with each interaction, even with the most trying of chronically ill patients, patients that are desperately trying control their disease, to get control of their very life. At a break, I asked him about Dr. Varghese’s talk, and he replied that he has watched it. I then asked him what he thought of it. He replied “It was fantastic…but” and went on to explain that he was a little unsettled as well. As we talked, it was clear that we respected Dr. Varghese’s thoughts, and the values he discusses were our values.
Where we disagreed (if you can even call it that) was in the goal that he stated of building connection through ritual, and of the History and Physical being, in a way, sacred. The reality is that the only thing that is sacred is the humanity of the patient and physician walking together, sharing a path, writing and telling their story together. We can do that in a lot of different ways, and we might use a lot of different tools and technologies to write and tell that story. The touch of a physician is just one, of many tools that we can use.
But without heart, without empathy, that touch is empty and meaningless. In a physician, just like in any other relationship, an empty gesture is worse than no gesture at all. Build up the heart of a physician, then you will not have to worry about the hands, mouth and ears. They will be filled with purpose.
So, in the end, I would say that the heart of a physician is the most important tool.