In the October issue of Health Affairs, Abraham Verghese had a wonderful essay about the practice of medicine entitled “The Importance of Being,” in which he straightforwardly states: “I want to teach the art of being present.” He aptly points out that, as physicians, “we are chained to the [electronic] medical record, and every added keystroke adds another link in the chain.” He calls for us to break that chain. Indeed, the intrusion of health information technology has led to a serious erosion of doctor-patient communication during visits, often with frank dissociation between both. But, as Dr. Verghese points out, what patients really want and need is for their doctors to be present, listening, caring, and totally connected with them during an encounter. Most doctors would like that, too. That’s why they went into medicine in the first place, not to type on keyboards or keep their eyes peeled on electronic screens. The last two words of Verghese’s piece nailed the essential missing component: Presence. Period.
I was quite impressed with the message of this essay, and Dr. Verghese and I sent a few messages back and forth about it on Twitter:
— Eric Topol (@EricTopol) October 7, 2016
Eric thanks! Folks often assume our views must b in opposition (& I'm a Luddite!) Far from it! Shared core values! So pleased u like this. https://t.co/DUWAdHwP6e
— abraham verghese (@cuttingforstone) October 7, 2016
There is some backstory here. Dr. Verghese and I met several years ago when he came to Scripps Health for a conference. We were on a panel together, pitted against each other, with him standing up for human touch and I for technology. But no such “showdown” occurred, as each of us fully recognized the value of both aspects of health care. We discussed a technology called hand-held echocardiography, also known as pocket ultrasound, which was new at the time. While Dr. Verghese is one of the masters of teaching the bedside exam, he duly acknowledged the technological edge this tool provided beyond the stethoscope, allowing physicians to see the heart via ultrasound. He had already adopted this tool for his physical exam and for teaching students and physician trainees. That surprised me since most physicians then—and still today—have been reluctant to use the pocket ultrasound in place of the 200-year old stethoscope, the icon of medicine.
We discussed how the technology of hand-held ultrasound can actually make the office visit more intimate. Many consider that an impossible paradox. But the ability to do an echocardiogram of the heart and immediately show it to the patient provides a kind of “presence.” Here, technology is connecting the doctor and patient in a unique way: Acquiring the images requires touching the patient, just as one would with a stethoscope. But instead of the patient having no ability to know what the doctor is hearing, there are video loops to share and discuss. In a formal echocardiogram, the findings are not discussed with the patient at the time of the scan, but are typically only obtainable days later when the study has been officially read by the cardiologist. The patient never gets to see his or her ultrasound images. In my own practice, I do a smartphone electrocardiogram rhythm strip for each patient I see in clinic and review the results in real time. Whenever possible, I email the results to patients right away so that they will have their data to review and for future reference. These are just a couple of examples of how technology can promote connectivity with patients. They don’t in any way substitute for empathy and caring, but they foster closeness and a sense of unity of purpose and sharing of information.
Since our initial encounter in 2010, Dr. Verghese and I have become friends. I interviewed him for Medscape in 2014, and it turned out to be one of the most watched and acclaimed interviews I have done over the past decade. Not surprisingly, Dr. Verghese was awarded a National Humanities Medal by President Obama this past September, recognized by the National Endowment for the Humanities “for reminding us that the patient is the center of the medical enterprise.”
I can assure you that Dr. Verghese is no Luddite. He recognizes, as I do, that some technologies are humanistic. Like Dr. Verghese, if a new technology doesn’t substantively improve the patient-doctor relationship and outcomes, I have no interest in it. As physicians I think we can all agree that we desperately need to restore and maximize human touch in medicine. When technology helps us achieve that, we should embrace it.