Health September 27, 2019
Of Empathy, Prejudice, and the Ritual of Exam
A conversation with physician and author Abraham Verghese

The first thing one senses in meeting Abraham Verghese—physician, educator, and best-selling author of both nonfiction and fiction works—is a calm humility. It is a humility that comes with seeing countless patients through harrowing disease and decline. And yet, it is a humility fortified by a firm belief in both the power of medical care, with an emphasis on care, and in the idea that triumph can come even as mortality may be imminent.

As a young doctor specializing in infectious disease, Verghese arrived in rural Tennessee—Johnson City—in October 1985, two months after the first HIV-infected patient appeared at the Johnson City Medical Center. While the first academic papers reporting the early cases of the disease appeared in 1981, the infections were all specific to port cities: Los Angeles, New York, and San Francisco. As Verghese wrote in his first memoir, “My Own Country”: “Everyone thought it had been a freak accident, a one-time thing in Johnson City. This was a small town in the country, a town of clean-living, good country people. AIDS was clearly a big city problem. It was something that happened in other kinds of lives.”

As it turned out, it was a storm that knew no boundaries, geographic or otherwise.

To read Verghese’s account of his five years treating AIDS patients in Johnson City is to understand what true empathy is. Though, in a long conversation I had with him during the recent Sun Valley Writers’ Conference, he, of course, waved that off. But I wondered if that profound empathy so evident in the book was just inherent to people who ended up in medicine or something learned. Verghese explained it this way: “I didn’t choose to specialize in AIDS. I actually went into infectious disease because … it was all about an astute diagnosis, and the patient rose like Lazarus, you know. And then AIDS just landed in our lap. So, a generation of us in infectious disease were suddenly treating people with a fatal condition, which is exactly what we had not wanted to do. We had gone into this field for a kind of hope, if you like. So, it was an education, and perhaps the empathy was also part of the education
for us.”

Verghese has written three books: “My Own Country,” “The Tennis Partner,” and “Cutting for Stone,” the latter of which is a novel. He has a new novel, “The Maramon Convention,” coming out soon.

The fact that there were no effective treatments for the disease until 1995—14 years after the first cases were described in medical papers—had a profound effect on Verghese and other doctors on the front lines of the epidemic. In a 2016 podcast titled, “The Importance of Being,” Verghese touches on a theme central to medicine: the distinction between healing and curing.

“I look back and think of patients long gone, particularly patients in the early AIDS era, young men for the most part … They were full of the ripening of life, full of desire, longing, ambition … I wanted to do for them, to fix what ailed them. I wanted to be busy with them in a medical way even though in those days we had no effective HIV medications, and there was nothing we could do to change the course … The absence of any treatments also taught us physicians powerful lessons. I learned from my physician’s assistant, Della, a warm and caring woman who felt less of the pressure to do and instead could just be … Once, as we walked in to visit a patient who was hours from exiting the world, I said, ‘What are we going to do here, Della?’ She said, ‘We are going to be with him.’”

Given all of the progress on the medical front with the disease—there are now real and effective treatments, as well as some promising vaccines in the pipeline—it is easy to forget the direness of the situation in 1985. Everybody was navigating in the dark. “No one knew what this was,” Verghese explained. “It was an unknown condition. It is hard to tell my medical students now [Verghese teaches at the Stanford Medical School] to imagine that time when we didn’t know causes, we didn’t know how it spread. Our best guess was that it was blood borne because it was the same risk groups popping up, namely intravenous drug users, blood transfusion recipients … and men having sex with men. But that wasn’t true in Africa … where the male-to-woman ratio [of infection] was one-to-one. In America it was more like 20-to-one … The epidemic in America was literally at the tip of the iceberg. The real epidemic was in Africa, and there it was a very different looking disease.”

Perhaps attributable to the lack of understanding of the disease at the time and partly due to the specific etiology of the disease, patients not only suffered the ravages of a horrendous disease, they also endured tremendous prejudice. Verghese described the milieu at the time: “Along comes a plague that’s unknown in how it spreads and that is affecting a group for whom society as a whole had a lot of distaste. And it was easy to blame them for it. ‘This was brought on by you’ is what they were saying … So, the metaphor of AIDS was one of shame and secrecy. It was one of blame: ‘You got this for your actions.’ That got in the way of everything, my treating them, my getting help to treat them. There were doctors who would [treat them] and others who would have nothing to do with it.”

He described taking an X-ray to a radiologist to get his opinion on the scan. “He says to me, ‘Why do you take care of these f****** fags, they deserve to die.’ People were willing to talk like that in that era.”

While the AIDS epidemic is by no means over, huge advances have been made, not only in attitudes, but also in treatments and outcomes. But what lessons have been learned that are applicable to current epidemics, or those still to come? Verghese notes two. “We too often underestimate the impediments that society can put in the way of public health management … It’s happening as we speak with Ebola in the Democratic Republic of Congo (DRC). We actually have now both a vaccine and a treatment that can effectively prevent or control the spread of the disease. But the bigger disease in the DRC now is suspicion of foreign workers, suspicion of any kind of treatments, and, as a result of so much secrecy around Ebola, people are dying. It has become a huge problem … and it’s not a scientific problem. It’s a social problem.”

The other lesson Verghese notes, this one positive, concerns prejudice. “Given all of the prejudices non-Southerners associate with the Deep South, not necessarily true, and given the prejudices around this disease, I think the real marvelous lesson … It was a truism that family trumped prejudice. Any bias you had, any dogma you subscribed to, went out the window when it was your son, your brother. That was reassuring to see … Family was such a strong value, even though they didn’t talk about it,
it was.”

Today, Verghese spends less time in the HIV setting than on general medicine wards, and he remains an educator and a writer. After his intense experience in Tennessee, he took a break from medicine and attended the prestigious University of Iowa Writers’ Workshop. He has subsequently published three critically acclaimed, bestselling books: two nonfiction works, “My Own Country” and “The Tennis Partner,” and one novel, “Cutting for Stone.” He has an upcoming novel, “The Maramon Convention,” that will be published by Scribner.

And if that were not enough to consume his time, Verghese teaches at the Stanford Medical School. There he focuses much of his energy and time on training new doctors. He is the Linda R. Meier and Joan F. Lane Provostial Professor at the Stanford Medical School, and vice-chair of the Department of Medicine.

One of his passions in medical education concerns what he terms “the ritual of exam,”—the process both objective and subjective—of interviewing and doing a hands-on, bedside evaluation of the patient, a skill and value he worries may be overlooked by some physicians.

“Too often, I feel, there is a knee-jerk response—‘Let’s order a test. Oh, you’ve got this symptom, let’s get this test,’” Verghese told me. “It is a great luxury of our medical world that we have all of these ways of affirming things. The exam is far from precise, but nevertheless … I mean, what does a CAT scan of the head show you? It only shows you the skull and the brain. But to understand what’s the deficit the patient is left with … The CAT scan won’t tell you that they are profoundly weak on the right side or can’t speak. You have to do a skilled exam.”

And that exam, Verghese maintains, with its unusual setting with odd furniture, patient gowns and white doctors’ coats, with the instruments there, “… has all the trappings of a ritual … People are used to rituals. Society is full of them: baptisms, graduations, bah mitzvahs … Anthropologists teach us that rituals are all about transformation.

“What is the transformation in this ritual? One, it is the sealing of the doctor-patient relationship. That privilege of touching—in any other context in society—that’s assault. So, you need to bring to it a great deal of gravity … Secondly, the localizing of the illness on the body—not on some CAT scan, not on some biopsy specimen … but on your person. It is sort of acknowledging your personhood. We sort of need that, you know.”

 

This article appears in the Fall 2019 - The Habitat Issue Issue of Sun Valley Magazine.