10/28/2008
Dr. Abraham Verghese on medicine and his literary career
Abraham Verghese, MD and MACP, is Professor in Stanford's Department of Medicine, and Senior Associate Chair for the Theory and Practice of Medicine. He previously served for five years as Director of the Center for Medical Humanities and Ethics at the University of Texas. He is the author of two bestselling books: My Own Country: […]
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>> This is KZSU Stanford.
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Welcome to entitled opinions.
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My name is Robert Harrison, and we're coming
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to you from the Stanford campus.
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[ Music ]
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>> When I'm asked to describe what kind of radio program I host,
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I usually just say that entitled opinions is a literary talk show.
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But most of you in the E.O. brigade know it's much more than that.
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You remember all the shows we've done on biology,
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cosmology, psychiatry, psychoanalysis, evolution,
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and even corporations to say nothing of philosophy and religion.
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Almost assume, ne'il umani ami alianum puto.
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I am a man, nothing human can be alien to me.
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That phrase from the Latin comic poet Terencius is the motto
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of entitled opinions, and since there is very little
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in the whole domain of knowledge that is unrelated
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to the human, there's very little that we won't talk
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about on entitled opinions, given world enough and time.
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[ Music ]
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>> In the human, ne'il umani ami alianum puto, that applies
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to entitled opinions, but it applies equally well.
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In fact, even more so to the medical profession, we'll be talking
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about that profession today because in keeping with our motto,
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we are vowed to the human, and no one is more directly exposed
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to, locked into and challenged by the human than the physician.
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Physicians are steeped in it all, they find themselves at the center
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of the tragic comedy of the human condition.
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In all, it's essential dimensions, physical, psychological,
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spiritual, scientific, social, cultural, sexual, and racial.
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They don't always take full cognizance of the intrinsic humanism
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of their vocation, and sometimes they adopt practices,
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attitudes, or techniques that actively
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are being limited against it.
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It seems that these days many physicians prefer to think of themselves
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as hardcore scientists, rather than humanists trained in the science of healing.
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Medicine is a science, yes, but it is also an art, and even more importantly,
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it is a quintessentially human practice predicated on intimacy, whether one likes it or not.
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Intimacy in medicine is often uncomfortable and unsettling on both sides,
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and one cannot blame the physician who seeks to minimize or neutralize its reality.
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But whenever a physician goes so far as to erect a barrier of impersonal abstraction
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between himself and the patient, he or she strays from the humanism of the calling.
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That humanistic calling is under intense pressure these days from the all-pervasive role
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that technology now plays in the diagnosis and treatment of patients.
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More and more it seems that internists succumb to the temptation to identify their patients
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with their data files rather than the human beings in the wards.
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Or as my guest today once put it, "It's almost as if the patient in the bed is a mere icon
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for the real patient in the computer."
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And now that I've quoted him, let me introduce my very special guest to you.
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His name is Abraham Vergazi, MD, and M.A.C.P.
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He is a professor in the Department of Medicine at Stanford University.
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He was recruited at Stanford in 2008 by the chair of the Department of Medicine,
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Ralph Horowitz, to head the medical school's new theory and practice of medicine program
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and to be a leading voice in the national and international debates about the future of medicine.
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A crusader for the re-humanization of the physical exam, Dr. Vergazi is board certified in
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three major areas, internal medicine, pulmonary diseases, and infectious diseases.
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He is widely published in scientific journals, but I first came to know him in his other capacity as
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a literary author. His first literary work, a select autobiography, came out in 1994 under the title
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"In My Own Country." In 1999, he published the tennis partner, a truly impressive book that
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will also be talking about with him today. But first, let me welcome Dr. Vergazi to the program.
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Abraham, it's a real pleasure to have you on entitled opinions today.
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Thank you for having me. Can we begin with your personal biography, if you don't mind,
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because you have a very interesting background. Can you just tell us where it begins?
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I was actually born in Africa and Ethiopia, but of Indian parents, my parents were school
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teachers hired from India by the emperor to populate his new schools and teach there. So they
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were one of hundreds of Indians from a particular part of India, the south of India, which is,
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as you know, predominantly Christian. Hence, my name, Vergazi. And I had most of my education there,
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and actually began medical school in a new medical school that had just been started by the
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British Council, with the emperor's blessings. And then in my third year of medical school,
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the emperor was deposed, civil war broke out. And I, as an expert, was told that the college was
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being closed and to make my own way in the world, essentially. And I came here to America.
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I worked in a succession of hospitals as an orderly. And I always looked back on that as the most
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important medical training of my life. And since I had no undergraduate degree in the Commonwealth,
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people often go straight from school to medical school, I would have had to start from scratch. And
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as I was trying to figure this out, the Indian government ironically took me in as a displaced
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person. And so I went back to India, finished medicine there. And then eventually came back to
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America to do my further training. For the many listeners of this program, given that it's
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literary intellectual, they might not know what an orderly is. What is it to be an
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orderly? So an orderly is basically someone who assists the nurse. And it's the most mundane and
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mini-ultas, if you will, bed pans and giving baths. And yet, you know, I found it to be
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a very important function. I recognized that the doctor was perhaps there only for a short time.
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And for the remaining 23 hours and 55 minutes, the patient's entire hospital experience
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was predicated on people like myself, and the order leads and the nurses. And you know, to be able to
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bring them comfort, to be able to save them from their embarrassment about sharing their bodily
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functions in front of us, you know, all that, you were in a great place to put them at ease or not.
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Right. And this served you well when you went back to medical school to finish your degree,
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you say, yeah, I think it humbled me. I think I was a cocky medical student the first time around.
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And I'm probably too young to appreciate all the nuances of illness and, you know, I had not really
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been seriously ill myself. But I think that experience made me so much more conscious of, you know,
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how the science and the medicine and the prescription and diagnosis was such a small part of the
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patient's experience. The overwhelming feeling the patient has is of not being well of being
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and discomfort of being uneasy of wanting to get out of there, wanting someone to say you're now
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mended and you can leave. And you know, I'm not sure that we've kept track of that desire of the
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patient's very much. We've almost lost sight of it, I would say. I'm not sure. So after you've completed
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your degree, you came back to the United States and you began your practicing. Am I correct in
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Tennessee? Well, so I began as a resident intern and resident in Tennessee. I did three years of training
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there. Then went to Boston for my fellowship training in infectious disease, special training,
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right at the time when HIV was sort of appearing in America. And then I returned to Tennessee to
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Johnson City to join the faculty of the young medical school there East Tennessee State University.
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And hence this book of yours, we want to talk about your literary career in the second half of
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the show and without getting into the literary aspect. But the first book in my own country
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is a fascinating account of your experience in rural Tennessee at the time when the HIV
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epidemic was just making itself felt. And the extraordinary reticence of people to admit that there
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was such things claiming some of their neighbors and the embarrassment. And you also being an outsider
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from your background. Can you redescribe just for our listeners a little bit what that was like in
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the 80s? Sure. So when I trained in Boston, HIV was felt very much to be an urban disease,
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very unlikely to be ever seen in rural America. And so when I left Boston for Johnson City,
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the pundits told me I could expect to see perhaps one or two HIV infected patients every year
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or every other year. And that turned out to be horribly wrong. Within a short time,
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I had accumulated almost a hundred patients with HIV. And I felt that I had stumbled onto
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some extraordinary things. For one thing I realized that the illness HIV was actually two diseases
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that traveled under the same umbrella, if you will. One disease was the virus and what it does to
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the immune system and all the stuff we know about it. But the second disease that traveled with
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the virus, which was huge in rural America, was what it meant to have HIV. The metaphor of HIV,
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and it was a metaphor of shame and secrecy. And in many instances, at least in one very distinct
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instance, I felt as if the metaphor had killed the patient. It's just a knowledge that he had
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HIV made him take his life in a very dramatic fashion, almost as though he wanted to go out in a
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blaze of glory and erase the metaphor. But the other part of the story was the great mystery of
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why a town of 50,000 should have a hundredfold more HIV than anyone predicted. And in a nutshell,
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I discovered that I'd stumbled onto an elaborate paradigm of migration, which I was convinced was
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playing out all over America. And the paradigm goes like this. A young man grows up in a small town
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and leaves for all the same reasons you and I leave small towns, jobs, education, opportunities.
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But in his case, in his case, he was also leaving because he was gay and could not contemplate
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living that lifestyle under the scrutiny of his family and relatives. And so went to the big city,
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found himself, but tragically, some years into this story, the virus found him. And so now he
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was returning. They were returning to their hometown roots for different reasons. One, because they
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had sort of a magical thinking that maybe if I go back to a simpler existence, I'll escape this
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plague. In other cases, because they were sick themselves or because they were, they lost their jobs.
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There were various reasons, but there I was at the tail end of this migration, witnessing this
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incredible story of HIV in rural America, which is quite different from anywhere else.
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You might imagine that they all some of them had decided that they wanted to die in their own homeland.
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I think that was very much part of it. But for the most part, I think there was a sense of
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tragedy about this voyage, having to end up from the very place they escaped from, if you will.
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There was a lot of joy. There was a lot of wonderful families that received them, but I always thought
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that for the individual, in a sense, to die in the same room they grew up in, in their particular
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case, was ironic and not satisfying. Since you were recruited here to stand for because of
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past experience such as that and other sort of attitudes or philosophies that you have about the
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practice of medicine, I believe, that Ralph Horwitz saw a new, when you visited Yale in 2001.
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And so forth. And I'd like to talk a little bit about this philosophy and what you, what plans you have
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here at Stanford in order to. I think reform is too strong a word because
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one doesn't presume to reform even aspects, particular aspects of the medical profession,
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like the physical exam. However, I do know that the physical examination is something that you are
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particularly interested in and that you believe that perhaps technology has gotten too much in the way
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or has insinuated itself with excessive sort of domination into the physical exam and that you
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are envisioning a rehumanization somehow of this, of this key crucial moment in the diagnosis of
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patients. Would you like to say something about physical exam? Let me just say that I've
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always felt that medicine is really a romantic and passionate pursuit. It should be,
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it should be a calling, a one that in my case I arrived at very early on in life and
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actually was from a book, maybe I should mention this because it's sort of significant,
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I remember reading of human bondage when I was quite young and I was attracted to the book by the
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title which promised something quite racy and turned out to be quite otherwise and there was a line in
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the book where Philip the protagonist who has tried his way in Paris to become an artist finally
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arrives in London to begin being a medical student giving up his artistic dream and there's a
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moment where he arrives in his third year on the wards and he sees quotes humanity there in the
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rough, the artist's canvas, close quotes and I remember that line just really attracting me the sense
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that this could be one's job as to sort of deal with one's fellow human beings in an imaginative
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way and so I've always loved that and I think the other thing that I should mention sort of
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you know, explaining this bent of mind towards physical exam and the bedside is one of the most
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humbling lessons I learned in that period of HIV care and rural Tennessee was the fact that when I had
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nothing to offer these patients, you know here I was a Western trained caught up in what I called
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the the conceit of cure and the irony was here I was saddled with the disease for which there was
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no cure and I discovered that at the very moment that I had nothing to offer the patient,
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I was stumbling on to the fact that I had everything to offer the patients and what I was doing was
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I was leaving the comfortable threshold of the medical industrial complexes within which we
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practice and I was going to the patient's house out of desperation out of a sense of not knowing
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what else to do and to my great surprise I found that in going to the house I was acknowledging
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the patient in a very special way I was helping the family, the patient come to terms with
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the illness and I suddenly realized that I had stumbled on to the essential difference between
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healing and curing and the example I use with my students I tell them you know if you're to go home
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today and find that someone's kicked down your apartment or and all your valuables have been stolen
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and you know the places in disarray you would be devastated and then if the police came by
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an hour later and said we caught the person who did this here's your stuff back you would be cured
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but you would not healed your sense of having been violated would linger for for many many
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months and weeks and you might even leave the apartment so I think all illness has those two aspects there is
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a physical element which signs does a great job of addressing but I think every patient also has a
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sense of being violated I mean something as trivial as hurting your knee or you know or breaking a
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finger your first reaction is often why me why now you know and I think there's a role of the
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physician in helping one to come terms to terms with that sense of violation that we've kind of
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slipped away from a western medicine and my other bias is that one of the ways that you convey your
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attentiveness to the patient one of the ways that you you sort of acknowledge the special trust
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that they're putting in you is you you must learn to examine the patient very well and do it in a
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very fluid and and a careful and thoughtful way and in the process I think you convey something to
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the patient you convey your attentiveness you convey your care more importantly I think from my point of
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view is that you also you know you also wind up ordering your test more judiciously you sort of immediately
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know well this is not important but this is terribly important I'm not to minimize any of the you
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know diagnostic capabilities we have I'm not a luddite by any means but I do think we act as though
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we're in a as as one of my colleagues but it we're in a restaurant with a menu that has no prices on it
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I mean you come into the hospital you know well let's get the MRI and send you for a cat and do
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yes you know and I think that that practice has come about a large part I suspect you know because
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we're ignorant on how health care is funded but also because we've lost our faith in our bedside
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skills so but is it faith Abraham or is it something that it's part of a tradition that is
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passed on through proper pedagogy and observation and even a certain philosophy of medicine so
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you have you've spoken about these inspirational professor you had in medical school Charles Light
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Head is that how am I pronouncing it correctly and this anecdote that the least useful instrument in
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for the physician is the is the stethoscope why because the physical exam begins with inspection
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then palpation per cushion and then finally oscultation which means that you look then you feel then you
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so by the time you and then when he asks why is it the least important instrument for the exam it's
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the the answer that you students would give us by the time you have all you have looked felt and
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per cussed you should know what you will hear but is that something one can teach as part of the
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regular curriculum of medical school or is it that's it requires a certain intuition a certain
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state of mind in order to be that sensitive to the human body through touch and here actually you
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know I think we do teach this in the first two years before the students wind up coming to the
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clinical words and we teach it in the abstract unfortunately we don't really teach it you know with
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patients so when they come to the words and when there's an opportunity for them to sort of confirm
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this what they find is that the whole scheme of medicine now revolves around the computer and it
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revolves around ordering tests and all these instruments that they bought and carried in their pockets
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the reflex hammer and vibrating tuning fork and so on really aren't being used and so they sort of
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spot the hidden curriculum and I must say that one of the things that's happened is you know if you
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get an echo cardogram on the of the heart you you got a much more accurate picture of the heart
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than you can with you know just your senses although you can do pretty well and what has happened
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as a result of that is that because these technologies that provide such an accurate picture
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people have lost the habit of getting any sort of picture on their own and they're sort of
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distrusting of the of the senses and it guesses into big trouble I think sometimes we
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wouldn't even recognize if a test was switched and we're looking at the wrong test because we have
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nothing to confirm with um so I think that the traditional way that Leethead taught us was first of
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all it was incredibly exciting and when I take students around and we do this sort of old-fashioned
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bedside rounds uh you know I get various reactions from them uh first of all I think they're
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they it's almost like they're witnessing magic because in their heart of hearts they didn't actually
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believe this stuff could be helpful and for us to show them that I think is very exciting
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but the second reaction I get interestingly from them is uh one of slight annoyance almost a sense
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of why am I only getting this at this little session now this is what I thought medicine was going
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to be all about was to be at the bedside so I think our our task is really to allow technology to
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service but not allow it to distance us from the patient and and I find that people are becoming
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less comfortable on rounds at the bedside uh you know more inclined to sort of treat that as a
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a social visit as though most of the information is coming from elsewhere and I think the more
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experience clinicians clearly when you watch them they they invest so much in that bedside visit
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there's so much you know of making sense of the patient that happens there and it's a quality
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that I think you can only teach and convey one person at a time you know at the bedside you can't
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teach this in the abstract you have to do it by examples I'm really one student at a time
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one student at a time but because you have a couple of students with you you have a team with you
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and I think that you know my share route forwards uh and I share the same philosophy how
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you know medicine is very much a calling there's a tremendous fiduciary responsibility we have
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with the patient and all of that necessitates you know direct engagement with the patient at the
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bedside with the family we do a lot of these things you know I'm not implying by any means that
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we have not done this in the past but I think it's easy to think that I'm taking great care of
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| 00:24:01.560 |
the patient because I've got all their facts lined up and in my mind I really understand the order
|
| 00:24:06.040 |
of things and this next test is crucial because the evidence space shows us that you know rasch
|
| 00:24:11.320 |
studies have shown that this is what I need to do next well the patient doesn't know any of that the
|
| 00:24:15.320 |
patient only knows that they barely saw the doctor he or she was in for two minutes and then disappeared
|
| 00:24:20.280 |
that's I think what we're trying to make an impact on not just at Stanford by the way
|
| 00:24:26.120 |
nationwide I think this is the great threat in the tennis part of which you want to speak about
|
| 00:24:32.120 |
in a few minutes the there's a passage about taking the pulse and how much can be actually
|
| 00:24:40.680 |
learn from this if taken with great patients and with certain kind of techniques and you describe
|
| 00:24:48.840 |
it in a way that you know that leads led me to believe that it's almost like an oracle that you know
|
| 00:24:54.600 |
sees into into you know the very future health or lack thereof in a patient how much of these
|
| 00:25:04.200 |
techniques did you personally learn in India where there might be a different sort of emphasis on
|
| 00:25:12.200 |
things like the very patient taking of a pulse and so forth and how much can one again I
|
| 00:25:24.440 |
that's a different form of the same question can one make it a part of the training of medical
|
| 00:25:31.960 |
students today here in a way I did learn a lot of this in India and Africa very old fashioned
|
| 00:25:37.160 |
sort of way of being taught and frankly many physicians in this country above a certain age
|
| 00:25:42.280 |
we're also taught that way yeah but we still teach the students those methods the only difference
|
| 00:25:47.560 |
is that when they get to the wars they don't see that being used day after day they don't see
|
| 00:25:52.680 |
anyone putting great weight on it and in that piece in the tennis partner that I that you talked about
|
| 00:25:58.440 |
I talk about how that moment of shaking the patient's hand when I'm about to begin the exam I hold
|
| 00:26:02.680 |
their hand and then I use my left hand to put my fingers on the pulse and you know that is the
|
| 00:26:07.880 |
beginning of this you know mass like ritual that begins where I examine the patient and there's
|
| 00:26:13.000 |
something about feeling their pulse which has a sense of walking in their shoes in a sense your
|
| 00:26:19.080 |
starting to get the measure of them no pun intended there or pun intended I suppose you know and
|
| 00:26:23.800 |
the pulse has all kinds of diagnostic value but at its heart it's about this tremendous privilege
|
| 00:26:31.240 |
of being able to touch someone who is disrobing for you and I think to be equal to that trust of
|
| 00:26:38.040 |
theirs you have to approach them with great skill I don't think you can be clumsy about it and
|
| 00:26:42.680 |
you know patients pick up on that I think I may have mentioned this to you that I developed a
|
| 00:26:48.680 |
reputation for being interested in patients with chronic fatigue which wasn't quite true I saw one
|
| 00:26:53.480 |
patient did let to another and these are very difficult patients in the sense that they've
|
| 00:26:57.640 |
got a lot of baggage they've been rejected by their families often who think they're
|
| 00:27:02.600 |
malingering and you know physicians have not often treated them well and I began to realize that I
|
| 00:27:07.880 |
could not do justice to these patients in in one quick office of visit so I would give them one hour
|
| 00:27:14.040 |
on a new visit just to tell me their story and bring them in for a second visit a week later to do
|
| 00:27:19.400 |
the physical exam and I I remember feeling as I examined these patients very carefully having an hour
|
| 00:27:25.560 |
to do it now since I'd already taken the story that these these very valuable patients would
|
| 00:27:30.600 |
quiet down and I had a sense early on with one patient of how we were we had both regressed and we
|
| 00:27:37.720 |
were taking part in some primitive ritual that had symbolic importance as most rituals
|
| 00:27:44.120 |
as you know they have a transformative quality they have you know they have new answers to them that
|
| 00:27:49.240 |
make them important that's why you have rituals and I suddenly became very conscious of this ritual
|
| 00:27:54.040 |
and when the patient at the end of this set to me I have never been examined this way she seemed to
|
| 00:28:00.680 |
be affirming something that had been playing in my mind and and and and so that became my goal
|
| 00:28:05.880 |
with these patients that they should feel that no one had ever examined in this way and then when
|
| 00:28:10.920 |
I gave them the recommendations to you know do all the things that they'd already heard at Mayo or
|
| 00:28:15.880 |
Scott and White or wherever else they'd been which is you know I would say this is not in your
|
| 00:28:21.320 |
head this is this is real the good news it's not cancer it's not this it's not that you know
|
| 00:28:26.920 |
that if they accepted these recommendations and give up the quest for the magic doctor the magic
|
| 00:28:32.200 |
bullet the magic tests I always thought it was because I had earned that right by virtue of the
|
| 00:28:38.040 |
exam well in America today we're really saddled with issues related to chronic illness you know
|
| 00:28:44.200 |
I mean there is so much chronic illness out there where I think the physician's role is
|
| 00:28:49.000 |
very much one of sort of helping the patient cope and how do you do that I think you do that by
|
| 00:28:55.880 |
earning the right to say these things to them you can't just pat them on the shoulder and say you
|
| 00:29:00.040 |
know it'll be all right you have to earn that right and I think you earn it in this fashion so
|
| 00:29:05.320 |
there's a description of our profession that calls it the ministry of healing and I like that
|
| 00:29:09.960 |
term because of its implications that there were were ministering to these patients were not just
|
| 00:29:14.680 |
diagnosing them and sending them for the right test we're ministering to them this is a very
|
| 00:29:19.800 |
different notion of the art or science appealing than a heroic kind of
|
| 00:29:32.520 |
aspect of things like surgery in the tennis partner again there's of the main character and again
|
| 00:29:39.560 |
we'll talk about it in a minute but nevertheless you're trying to praise the virtues of being a
|
| 00:29:46.040 |
internist practitioner of you know internal medicine rather than surgery whereas this character
|
| 00:29:54.760 |
in the book feels that if he can't go out and be on the front lines of surgical intervention and
|
| 00:30:01.720 |
saving lives and in moments of sheer emergency then somehow he's going to be a failure according to his
|
| 00:30:09.080 |
own standards and what you're saying seems to confirm this notion of a kind of heroism of the
|
| 00:30:19.560 |
everyday dimension of your practice so absolutely I mean we need both kinds clearly but
|
| 00:30:29.800 |
you know for everyone student going into surgery or emergency medicine what this country also needs is
|
| 00:30:36.600 |
you know more and more people going into primary care who can minister to the patient and
|
| 00:30:41.240 |
currently it's not for everybody but I think what is not advertised well enough is that tremendous
|
| 00:30:47.880 |
rewards of that kind of care it may appear that fixing something abruptly and getting the
|
| 00:30:54.440 |
patient on their feet is rewarding in and of itself and it certainly is but there's another kind of
|
| 00:30:59.560 |
reward in my case say for you know being with a patient over the course of a decade or so and seeing
|
| 00:31:05.400 |
them and their family through and in this for which there is no cure in that culminates in death
|
| 00:31:09.800 |
and my pride in having been there with them for that is I would like to think the equivalent of
|
| 00:31:15.800 |
you know fixing something on day one and sending them out of there it's a different kind of pride
|
| 00:31:20.360 |
you have on your the web page for the new program of theory and practice of medicine that you have
|
| 00:31:28.600 |
been asked to lead a quote from Tinsley Harrison who wrote a book in 1950 called Harrison's text book
|
| 00:31:39.400 |
of internal medicine where you where you think that this paragraph is still very relevant
|
| 00:31:44.440 |
and if you don't mind I'll read it please and I love that paragraph and of course on the web page
|
| 00:31:51.720 |
the quote you re-gendered someone re-gendered it so you did so that all the masculine pronouns are
|
| 00:32:02.200 |
now feminine but I'm going to read it in the original because I'm a literary scholar and I have
|
| 00:32:05.880 |
I think that you know the original text is my it's the philologist in me that fair enough that
|
| 00:32:11.720 |
likes that but Harrison writes a following no greater opportunity responsibility or obligation
|
| 00:32:19.000 |
can fall to the lot of man than to become a physician in the care of the suffering he needs technical
|
| 00:32:27.720 |
skill scientific knowledge and human understanding he who uses this with courage humility and
|
| 00:32:35.880 |
wisdom will provide a unique service for his fellow human beings and build an edifice of character
|
| 00:32:42.680 |
within himself isn't that lovely I mean I just you know I just get through every time I read that
|
| 00:32:49.400 |
the sense of you know how doing does back for you you know this is this is the great secret of
|
| 00:32:56.760 |
medicine is that as much as we might give of ourselves and ours and our time and you know it's
|
| 00:33:02.600 |
unpleasant it can be a times this is the great reward the enduring edifice of character that you
|
| 00:33:08.520 |
build in yourself and something that I think we've not done a great job of conveying and those
|
| 00:33:13.720 |
words are really timeless they are okay because I was asking myself whether the medical profession
|
| 00:33:22.680 |
and you know we've all had experience there where as a patient I have felt
|
| 00:33:31.720 |
very one-way relationship where I am the receiver of the care attention and expertise of the
|
| 00:33:40.120 |
physician or the doctor of the surgeon whatever and that there's nothing really that I can give
|
| 00:33:45.880 |
back in that moment I can you know send a beautiful bottle of wine after the fact but there is not
|
| 00:33:54.840 |
a reciprocity and I've often asked myself whether the fact that it's the physician who is always the
|
| 00:34:02.360 |
giver in that relationship with the patient what is the physician getting back when he or she
|
| 00:34:10.360 |
goes home or you know looks back on a lifetime of that sort of commitment and responsibility and
|
| 00:34:17.640 |
so it heartens me to say that it is its own reward because otherwise at times you know it
|
| 00:34:24.760 |
it can appear that it's a completely saintly you know suspension of all egoism in the
|
| 00:34:31.960 |
name of altruism no no that's all in fact I would argue that you are giving them one extraordinary
|
| 00:34:36.840 |
thing which you have the right to withhold and that is your trust I mean you're not obliged to go
|
| 00:34:43.400 |
to this physician or that physician you invest this individual with your trust you let this one
|
| 00:34:48.360 |
human being into secrets that you might not tell your spouse you bear your soul and your body to them
|
| 00:34:55.640 |
it's a tremendous gift that you're giving them and and they have to be worthy of it and I think the
|
| 00:35:01.960 |
great thing about medicine is that people rise to be worthy of that kind of investment of trust
|
| 00:35:07.880 |
I think that's what that paragraph is getting at is on the one hand you you know you become this
|
| 00:35:13.960 |
student of human behavior in return you build this enduring edifice of character yeah beautiful
|
| 00:35:21.400 |
can we talk uh Abraham about your literary career sure now because with all that's on your plate
|
| 00:35:28.200 |
in terms of coming to Stanford the new theory and practice of medicine the uh taking students on
|
| 00:35:35.080 |
the ward showing them that you know the bedside exam and for all that you also have a very
|
| 00:35:43.640 |
rigorous and thriving career as a writer and an extraordinary one at that with these two books that you've
|
| 00:35:51.400 |
published and a third one do out which is already finished a novel as I understand it which is
|
| 00:35:57.160 |
do out in a couple of months in January no February rights in February when when did you
|
| 00:36:04.280 |
get involved in this other venture of yours which is to become a literary author
|
| 00:36:11.480 |
well if I if I may qualify that first Robert by saying that I really um don't think of it as two
|
| 00:36:16.760 |
professions or two cultures you know I'm I really I feel incredibly privileged to be a physician
|
| 00:36:21.800 |
I'm in love with medicine and all it's sort of wonderful history and the romance around it the kind
|
| 00:36:28.360 |
of thing that you described with Charles Lee Ted and Tinsley Harrison and to me they're writing
|
| 00:36:34.040 |
bubbled out of that passion you know I think that we're right to try and be a writer without my
|
| 00:36:40.440 |
day job I think I would not succeed clearly all the writing emanates from this and during that
|
| 00:36:46.520 |
AIDS experience I began to write as a way of you know almost as an escape I remember a wonderful
|
| 00:36:52.520 |
definition of poetry or fiction that I stumbled on to around that time which said that
|
| 00:36:57.000 |
poetry is one means of achieving success at the limits of the ability of the will to express itself
|
| 00:37:04.280 |
by other means can you can you have you know really again yeah so poetry is one means of achieving
|
| 00:37:09.960 |
success at the limits of the ability of the will to express itself so in other words I think what they're
|
| 00:37:16.840 |
trying to say is that in our day-to-day life we can't cross over into death and come back we can't
|
| 00:37:22.200 |
make the voyage to to the inferno of hell and describe you know all the stages along the way
|
| 00:37:27.560 |
but through the vehicle of fiction and poetry you can get into someone else's head you can turn
|
| 00:37:32.280 |
back time and in my case I felt that this was the one way I could sort of overcome the
|
| 00:37:39.160 |
inexorable sort of death and destruction that was happening all around me and so I began writing and
|
| 00:37:45.080 |
began writing more and more seriously I love fiction and I love a quote by Dorothy Allison she
|
| 00:37:51.720 |
says that fiction is the great lie that tells the truth about the about how the world really lives
|
| 00:37:57.080 |
and you know take of human bondage a fictional story by summers at mom was enough to draw me to
|
| 00:38:03.000 |
medicine talk about the power of fiction so to me the writing always always has seemed like
|
| 00:38:09.000 |
an extension of my love for medicine and my first one of my first published stories was a short story in
|
| 00:38:16.280 |
the New Yorker called lilacs of a dark AIDS story and it was that story that led to my being
|
| 00:38:23.880 |
asked to do this nonfiction book on HIV but I never thought of myself as a nonfiction writer I
|
| 00:38:30.120 |
had to sort of learn that craft I had to relearn the craft I had gone to Iowa to the Iowa writers
|
| 00:38:36.760 |
workshop about five years after being in practice as my means of sabbatical if you will and I'd
|
| 00:38:42.600 |
gone to Iowa to write fiction came out of their writing fiction published at New Yorker's story
|
| 00:38:47.720 |
but I never knew that I'd wind up writing the kind of nonfiction I have and I actually made a
|
| 00:38:53.960 |
decision to go to alpassal texas the sort of the last outpost of American medicine that you can be
|
| 00:39:00.520 |
part of and still be in America but I went there very consciously one because I love something
|
| 00:39:05.720 |
about that area when I went to visit and secondly because I knew I could write there that the demands of
|
| 00:39:10.440 |
that medical school would not extend too much too much to my nights and weekends and the two books
|
| 00:39:16.360 |
that came out of there are really very much the reason I'm here Robert so ironically something in
|
| 00:39:21.480 |
them struck a chord with young kids in college you're heading to medical school struck a chord with
|
| 00:39:27.080 |
people in medical schools who are trying to teach something in those two books in me and those two
|
| 00:39:31.960 |
know and you know so I the reason I met Ralph Horowitz when he was chair at Yale is because I'd been
|
| 00:39:38.520 |
invited to speak again in the context of this books and so I've come to feel that you know that
|
| 00:39:44.600 |
this writing as it emanates from medicine is still utterly serious in that it's connected to
|
| 00:39:51.640 |
medicine and you know and coming to Stanford I have this dream job right now where my I have 40%
|
| 00:39:58.520 |
protected time which should be typical for a researcher and but my research equivalent is my writing
|
| 00:40:04.680 |
a sense that you know reflecting on the medical experience in any form fiction or nonfiction
|
| 00:40:10.680 |
is as critical to experiencing the medical experience you know we have to put it in context we
|
| 00:40:17.320 |
have to interpret it we have to react to changes that all that needs a voice and I feel
|
| 00:40:23.720 |
privileged to be given a chance to try that well you know it's one thing to see the relations between
|
| 00:40:29.080 |
fiction and medicine it's another to have the talent and the intrinsic talent to write the way you
|
| 00:40:36.520 |
do because a lot of people presume to be able to write fiction and it's quite bad in your case
|
| 00:40:42.360 |
there is something there's an endowment there that you know that's very obvious so if you don't
|
| 00:40:49.080 |
mind let can we talk about the tennis partner sure and this book I'd like to recommend it you know
|
| 00:40:55.480 |
very enthusiastically to all the listeners who may be tuning in to because it deals with medicine
|
| 00:41:04.520 |
again with the practice of it internal medicine but it's a lot more than that it also deals with
|
| 00:41:11.720 |
a young man who is a medical student third or fourth year who was an ex-professional tennis player
|
| 00:41:20.600 |
and there is a clear passion for tennis in your case that I'm presuming that this book by the
|
| 00:41:31.400 |
way is not a fiction that it's actually it's a true story it's a true story so it's a
|
| 00:41:38.360 |
so it's it's the story of among other things you're encounter and experience with this young man
|
| 00:41:45.080 |
David Smith and Australian beautiful tennis player ex-professional player and you know your love of the
|
| 00:41:52.360 |
game and the way in which at a moment of crisis in both of your lives with your separation from
|
| 00:41:59.240 |
your wife and his recovering drug addiction that tennis served a therapeutic purpose and also
|
| 00:42:07.960 |
served in the book as a series of lessons not just about life but also the practice of medicine somehow
|
| 00:42:14.200 |
it's quite remarkable how all these things are interwoven and can you can you just say a word about
|
| 00:42:22.680 |
that book sure I'd love to you know one of the dark secrets about medicine is that the highest
|
| 00:42:28.360 |
suicide rate in this country is amongst doctors and dentists and lawyers and it's about 20 fall
|
| 00:42:36.120 |
higher than any other profession an extraordinary statistic and as I tell my students I say
|
| 00:42:41.720 |
every year it takes two complete classes of medical students to replace the number of physicians
|
| 00:42:48.920 |
who committed suicide that year and the great majority of those deaths are linked to drug addiction
|
| 00:42:55.720 |
or overdose or in-temper-juice of drugs so clearly there's a story there and I befriended this
|
| 00:43:01.560 |
young man David Smith and you know it was very interesting and strange relationship because on the
|
| 00:43:07.720 |
wards I was the teacher and he was the student and on the courts he was clearly the professor and
|
| 00:43:13.560 |
either student and in between we found this middle ground of two men trying to sort of find their
|
| 00:43:19.320 |
way in the world and when David relapsed and succumbed to a very serious intravenous cocaine
|
| 00:43:26.840 |
addiction when it was all said and done I wanted to pay tribute to that friendship for two reasons
|
| 00:43:33.000 |
one I felt that heterosexual men were notoriously reluctant to talk about their deepest friendships
|
| 00:43:40.200 |
with other men in a gay man right about it so eloquently women right about their friendships so
|
| 00:43:46.120 |
eloquently we often couch our friendships in sporting metaphors you know my golf buddy my tennis partner
|
| 00:43:53.960 |
in this case and so I wanted to try and paint a friendship and point out to my to my readers that
|
| 00:44:03.720 |
these sort of friendships are not incidental to our lives they're really key to our to our health and
|
| 00:44:09.480 |
our our well-being and that when you lost them you lost so much more than somebody which is
|
| 00:44:16.200 |
disappeared from the planet you lost a part of yourself some essential part of yourself and so
|
| 00:44:21.800 |
and I also I thought I felt tennis was a wonderful metaphor I think all sports are metaphors for life
|
| 00:44:27.240 |
but tennis in this context was a wonderful metaphor for life I mean the difference between David and
|
| 00:44:33.560 |
me is that at some point I suppose he was no longer willing to get the ball back over the net that
|
| 00:44:38.680 |
one last time whereas you know here I am I'm alive I'm plotting on dark days at times and you know
|
| 00:44:46.520 |
days of despair but that sense of get the ball back over the net one more time and for David it was
|
| 00:44:52.440 |
much more complex than that his his addiction his disease which is what I came to understand it really
|
| 00:44:58.600 |
is a disease was really really severe and no one knew more about it than he did and at some point
|
| 00:45:04.680 |
he just wasn't willing to to do what was necessary right so part of the pathos also of the book is
|
| 00:45:12.520 |
that you talk about male friendship and it's true it's a very eloquent count of a male friendship
|
| 00:45:19.080 |
but also maybe perhaps typical of a male friendship which is not homosexual or female friendships
|
| 00:45:25.800 |
which are another thing there is in this case a complete opacity in David of a region of himself
|
| 00:45:35.880 |
which is unknowable or closed off which when it revealed itself in the end of the book he
|
| 00:45:43.320 |
he becomes unrecognizable to you it's not that David you knew on the tennis courts that there's this
|
| 00:45:48.440 |
there's this other side that is shut off isolated completely no one can reach it no one can he's
|
| 00:45:58.120 |
he's he also has sexual obsessive behavior and and a kind of serialization of relationships with
|
| 00:46:05.560 |
women but even the women can can get to it so there there's this core of of remote inaccessibility
|
| 00:46:14.440 |
you know and god knows Robert that might be all of us you know all of us at some level have a place
|
| 00:46:20.360 |
that's unreachable perhaps and and I think what I found most poignant was how parallel this was
|
| 00:46:27.000 |
with physicians in general you know they say about addiction that addiction is a disease of secrecy and loneliness
|
| 00:46:34.760 |
you could use those two adjectives about so many of us in the medical profession so much of
|
| 00:46:40.360 |
what we do we can't talk about so there's a secrecy there's a loneliness of you know not even
|
| 00:46:45.560 |
your spouse can quite walk your experience for you you have to get up in the night and do it yourself
|
| 00:46:52.040 |
and they say if a works it works because it forces you to shed your secrets and repopulate your
|
| 00:46:58.440 |
world you can't be lonely anymore so I think I saw in David aspects of myself I saw in David
|
| 00:47:05.480 |
the worst aspects of the medical profession and there was a wonderful sort of study of
|
| 00:47:10.440 |
the very thing you mentioned that that dark secret part of ourselves and you know he had gone
|
| 00:47:16.680 |
two years of rehab and as you pointed out there was a core that he didn't let go and they say in
|
| 00:47:24.200 |
your secret slide your addiction and you know I don't think he quite got to the core of it yeah
|
| 00:47:29.720 |
well the other thing that appealed to me a great deal about the book given that I'm a huge tennis
|
| 00:47:38.200 |
fan and also a tennis player and and have learned so much from the game about other things but
|
| 00:47:46.520 |
nevertheless the game itself is a very literal source of you know a pleasure is that it's doesn't serve just
|
| 00:47:55.640 |
as a metaphor for these things that you have a a deep passion for the actual playing of it
|
| 00:48:04.040 |
and also the spectator ship of it no what is it about tennis in particular that fascinates you
|
| 00:48:09.640 |
at at a player and a no no watcher of the professionals I think you know there's some great
|
| 00:48:15.240 |
parallels between the tennis that you and I used to watch and and the way the tennis has changed you
|
| 00:48:20.200 |
know the technology has also distorted the tennis in a funny way the the television has made it
|
| 00:48:27.080 |
on the one hand more accessible on the on the other hand you know put such money and sponsorship
|
| 00:48:32.680 |
into it that it's become almost unrecognizable but I think which what you and I both perhaps like
|
| 00:48:38.280 |
about tennis is that this is truly a sport where two contestants are going at it you know
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| 00:48:43.800 |
Mano Amano if you like unlike say golf or unlike other things and there is no time limit this is
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| 00:48:50.520 |
really all about who conquers the other person and I think there's an element of grace and beauty to
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| 00:48:56.840 |
it that especially visible in the old fashion game and now it's much more power some of that
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| 00:49:02.440 |
finesse is not not as clearly seen I think that that's aspect that I really enjoyed lovely
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| 00:49:09.240 |
characters behind it you know the stories of labor versus rose wall and we have characters in the modern
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| 00:49:16.520 |
game as well it's slightly different but again one one finds all the archetypal figures popping up
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| 00:49:22.920 |
in tennis just as they do in life I found it really ironic that when this book was reviewed in
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| 00:49:29.080 |
England by a very famous radio host who's a psychiatrist we spent he spent very little time no time
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| 00:49:37.640 |
talking about the you know the suicide and the friendship issues in England it was all about the tennis
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| 00:49:43.720 |
right I've had a few people here tell me well you know I couldn't get into that part because I'm
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| 00:49:48.040 |
not a tennis player and I felt then I must have failed them because I'm not a golfer and I love reading
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| 00:49:53.640 |
John Uptike on golf I think you know there's something about sports being described by someone who's
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| 00:49:59.160 |
passionate about it that if they do it well then you're hooked in the reading at least if nothing else
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| 00:50:06.200 |
well I guess I can't judge for those people because I know it from the inside but I would imagine
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| 00:50:10.920 |
it's a failure of imagination on their part if they can't let's go let's go let's go but there's
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| 00:50:15.720 |
also it makes me think that when you speak about the grace and beauty of the game the way it's
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| 00:50:21.320 |
played by certain a certain style of game there's no doubt that David in your book being Australian
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| 00:50:29.480 |
was almost like the pure Australian one-handed backhand slice you know the servant the the net game
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| 00:50:38.120 |
and he had a movement on the court which was so so beautiful and graceful and so transcend and
|
| 00:50:46.520 |
and by the end of the book my experience of it was well you know after his suicide and after this very
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| 00:50:55.720 |
ugly revelation of him down and out just prior to his suicide
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| 00:51:01.800 |
after that there's the invocation is a memory of him on the tennis court and it seemed like
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| 00:51:07.880 |
everything is redeemed through the sheer almost platonic beauty of his game and that it's like
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| 00:51:17.000 |
something other than life maybe it's belongs to another order of truth or reality and that you
|
| 00:51:23.320 |
have a description of a woman in the in the wards of a Mexican woman who used to be very beautiful but
|
| 00:51:31.960 |
two years later is a complete wreck she's shooting up and her body has become completely
|
| 00:51:37.960 |
deformed but when she gets her her dose she probably just leaves this world all together and
|
| 00:51:46.200 |
her body's not even around it's almost like it's another realm it's almost if there's a plate
|
| 00:51:50.200 |
this is a work there I think there's very well said I remember you telling me that and I think that
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| 00:51:55.400 |
that's a wonderful description of I think what was in fact operative there you know when you
|
| 00:52:00.600 |
think of Roger Federer a modern day player who has that quality to to his game where when you watch
|
| 00:52:08.120 |
him play you're sort of transported when he's in the zone there's something so fluid it's almost
|
| 00:52:13.560 |
this ideal version of ourselves that we're drawn to because you know we all we all want to reach
|
| 00:52:20.040 |
that we never will but here's someone who comes close right well in fact I've always said that if I
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| 00:52:25.720 |
ever were to believe or ever become a plateness it would be because of tennis because on the tennis court
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| 00:52:32.280 |
I know just in my body what is the perfect backhand shot at a per at a specific moment and I know
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| 00:52:41.480 |
just how far I fall short of the perfect shot it's almost like the ideal super temporal perfect shot
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| 00:52:49.880 |
and every now and then when you hit that perfect shot you feel that there's a coincidence between
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| 00:52:53.720 |
the reality of your bodily execution and this other ideal thing and those are moments of transcendence
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| 00:53:00.600 |
those are almost a transcendence absolutely Abraham you're you're a new book coming out in February
|
| 00:53:10.680 |
called cutting into stones cutting force stone cutting cutting force stone okay that's a
|
| 00:53:15.240 |
makes it a very different title indeed do you do you feel like sharing any thoughts about that
|
| 00:53:21.080 |
with us happy to talk about so my first love has always been fiction and I I really wanted to
|
| 00:53:27.400 |
write the kind of novel that would do for a young college student what of human bondage did for me
|
| 00:53:34.440 |
that it would really make them say you know I don't care what money lies ahead in medicine or
|
| 00:53:40.440 |
you know what medicare does or this or that I I can't imagine another kind of life and so the book is
|
| 00:53:46.840 |
it begins with a nun by the name of sister Mary Joseph praise giving birth to twins in an operating
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| 00:53:54.200 |
room in a mission hospital in Africa and she actually dies in childbirth and one of the kids
|
| 00:53:59.800 |
becomes the narrator for the story and I think it's a sort of a roller king medical saga of a family
|
| 00:54:07.160 |
it takes place over many years over two continents and I think I've left nothing out of it
|
| 00:54:14.120 |
Robert I put all my heart and soul and all my love for medicine all the dark underside of medicine
|
| 00:54:20.200 |
the great things about it the terrible things about it the fact that medicine can save you
|
| 00:54:25.320 |
the medicine can make you lose your soul all of that is in there and I think it's a satisfying
|
| 00:54:32.920 |
story I've been really grateful that Canof is just really cheated it like a big book and they've
|
| 00:54:40.280 |
championed it and there's a lot of excitement building so I'm excited it took me a good seven
|
| 00:54:46.760 |
eight years to be done so it's lovely to see the reaction well I'm also excited I can tell you and
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| 00:54:53.160 |
I want to mention again to the readers we're talking about three books now by you one is the first
|
| 00:54:58.920 |
one in in my own country my own country the tennis partner and cutting for stone and we've been
|
| 00:55:07.400 |
speaking with Dr Abraham Bergeza here on entitled opinions KZSU and it's been a fascinating
|
| 00:55:14.440 |
discussion indeed I want to encourage all the listeners out there who want to access our previous
|
| 00:55:19.960 |
shows that they can go online and hear them all over 70 hours of it just log on to the French
|
| 00:55:25.880 |
Italian departments webpage and click on entitled opinions and there you can listen either on our
|
| 00:55:31.560 |
webpage or through iTunes the iTunes music store or Stanford iTunes and well it's been a
|
| 00:55:39.240 |
pleasure Abraham we'll have you on again in the future thank you Robert thank you for having me we
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| 00:55:43.880 |
look forward to the book so we'll be with you our listeners next week bye bye
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| 00:55:58.600 |
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