Dr Abraham Verghese: Calls for a return to the traditional one-on-one physical exam

An industry colleague sent me a link to this inspiring TedGlobal Talk given by Dr Abraham Verghese in Edinburgh over the summer. It’s 18 mins long but I’d strongly recommend you watch it all as this is an amazing man giving an inspiring performance that will give you some great life lessons:

He then asked me if services like 3G Doctor are just another part of this movement away from the traditional one-on-one medicine that is dismissive of the “powerful, old-fashioned tool of human touch”.

I think it makes for a great place to start a conversation about the issues and opportunities that present as care becomes ever increasingly informational (something that I’ve commented at length on before).

Here’s my thoughts on the talk:

Dr Abraham Verghese is a great communicator and Doctor but he’s not your primary care Doctor

Whilst I have no doubt that everyone involved in healthcare would do well to watch this video and learn the lessons in this important talk I think there will be a tendency for patients to think that the incredibly gentle emotive personality that we see expressed by this clinician is something that can be easily taught and then provided to every patient throughout every minute of a Doctors working life.

Facts are that half of all doctors must be below average and you’re watching a one off prepared presentation from by an exemplary high achieving medical educator. Unfortunately it’s not a Stanford Professor of Medicine who sits at the front line of primary care where the biggest diagnostic opportunity exists but a primary care GP with very limited hours in the day and a cue of expectant and sometimes demanding patients waiting outside their door.

Unless I missed it and this talk was advocating for the potential for women to self check or frontline nurses to learn the skills of breast examination I’m not really sure there’s anything in this talk that’s going to radically transform the primary care experience that is failing patients for whom the quality of care they receive is more directly related to the time and financial pressures faced by their carers rather than any personal unwillingness to engage in eye or physical contact.

Alternative ways of communicating with Doctors should not be considered as replacements for a family Doctor

At 3G Doctor we’re really clear about this: your family Doctor provides the best opportunity for you to recieve care.

BUT if you’ve got a family Doctor who doesn’t use the internet and you’ve just watched a brilliant YouTube video and have some personal questions about it and are considering your future treatment options because of it (4 years ago Pew Internet Research found that “75% of e-patients with chronic conditions say the information they found in their last online search affected a decision about how to treat an illness or condition”) what’s your alternative?

I think it’s obvious that the ability to share your history AND this digital informational experience with a registered Doctor can be very useful and it’s certainly more productive to appreciate that the internet hasn’t killed the conventional Doctor visit but provided us with the biggest opportunity to reform it.

It might also save you from inadvertantly risking a very valuable family Doctor relationship – something that research shows can be challenged by patients who bring information from the internet to a consultation.

The Real Tragedy

This is how Dr Verghese explained what’s going on in healthcare when a 40 year old patient in Northern California is being diagnosed with late stage breast cancer after being admitted to the emergency room:

the real tragedy is that she had been seen at 4 or 5 other healthcare facilities or institutions in the proceeding 2 years, 4 or 5 opportunities to see the breast masses, touch the breast mass, intervene at a much earlier stage than when we saw her… …Ladies and Gentlemen that is not a unusual story – unfortunately it happens all the time

I look at this very differently. I think the real tragedy here is that the sickcare industry is so accepting of such an insane system and continues to do the same thing over and over again expecting different results.

In this incidence it seems we’ve all learnt nothing. No one’s made accountable and the healthcare industry just continues to brush it off saying “unfortunately it happens all the time”.

I personally think this only continues to happen because no one has properly listened to and documented this patients history. I’m certain that this woman has either never told a Doctor of her concerns (probably because of access, time or cost limitations) OR that this revealing information has been shared but no Doctor has ever documented the patients concerns regarding breast changes in their notes.

I’m so confident of this because the converse (that the patient has reported it and the Doctor has it documented in their notes but has failed to do anything) would lead to one of 2 things that Dr Verghese would most likely have otherwise mentioned:

i) A medical negligence case against the Doctor(s) who ignored these symptoms for failing in their duty of care to their patient

ii) The issuance of a new set of clinical guidelines of things to look out for (eg. if you have these unique set of symptoms that Doctors don’t yet check for get checked for XYZ today)

Why waste time looking at your shoes when I could look at your Facebook profile?

I’d like to introduce you to the most important innovation I think in medicine to come in the next 10 years, and that is the power of the human hand to touch, to comfort, to diagnose and to bring about treatment

Yes it’s fundamental that Doctors appreciate their patients lives, where and how they work, and the challenges they face but the world today is fundamentally different to Edinburgh in the 1880′s (a time even before the sterile technique had been universally accepted) and I’m not so certain that the Joseph Bell’s approach is something that we should strive for today.

While it’s unlikely that we’ll be lucky enough to find distinctive clay on a patients feet (efficient modern Hospitals would quite rightly insist you remove your boots at the front door) the importance of appreciating information in 2011 is highlighted by the fact that a Doctor today could probably gather all this and more by glancing at your EHR and would get much more if they really wanted to by making a search of the various social media sites.

Similarly to my post discussing “What if Sir William Osler had tweeted” let’s consider how Dr Joseph Bell of the Edinburgh Royal Infirmary would be amazing his students in 2011:

“Where are your other 4 children? I notice you got drunk last night in Fife because of the recent break up with the husband you lived with in London for 12 years, but it’s good to see you managed to get up and travel here on the 7.10 am from Fife, grabbed a breakfast at McDonalds and are all set to meet with an exboyfriend when you’re finished here to talk about his recent divorce and house sale. I’ve fired off an email to social services as I’m just a little concerned you might be spending some of your childs income support on the ‘whacky backy’ you’re probably buying as I’ve seen all that smoking paraphernalia you shop online for… …oh and thank you for reminding me to give a call to the public health team in Fife as it’s great to see a linoleum factory worker who doesn’t have dermatitis since we asked them to enforce the Health and Safety at Work Directive to ensure you were supplied with gloves and barrier cream”
Student: “Wow… how did you gleam this information Dr Bell?”
“Why Arthur Conan Doyle I simply looked at her Electronic Health Record and then I took the liberty of friending her on Facebook with my new Android Smartphone and Googling her on my iPad! You’d be amazed what you can discover about a patient by searching on Facebook, Twitter, Groupon, HousePrices.co.uk, their ebay profile… oh and aren’t the promotional early bird mid week fares on ScotRail amazing?”

Be under no doubt that had he lived in 2011 Joseph Bell would inspire a very different Sherlock Holmes as he’d almost certainly be one of those consultants I know who sends his junior house officers into town to buy up the latest tablets and smartphones.

He’d also be (quite rightly) anticipating some very serious disciplinary action from the Medical Council for invasion of his patients right to privacy (but that’s another conversation altogether).

All the same I think this makes the point very well that we live in a different world in which the informational opportunities are enormous and transformational, they now start BEFORE the patient walks in the door, but they are far from straightforward…

The chronic fatigue patient

and they come to you fully prepared for you to join the long list of people who’s about to disappoint them. And I learnt very early on with my first patient that I could not do justice to this very complicated patient with all the records they were bringing in a new patient visit of 45 minutes. there is just no way. And if i tried I’d just disappoint them. And so I hit on this method where I invited the patient to tell me the story for their entire first visit and I tried not to interrupt them. We know that the average American physician interupts their patient in 14 seconds and if I ever get to Heaven it will because I held my peace for 45 minutes and did not interrupt my patient

This is one of the best articulations of the problem that Instant Medical History provides the solution to. In Dr Verghese’s heaven I think he’s going to be waiting on the table of the team behind Primetime Medical – because this is exactly what the software they’ve developed can offer to every single patient the world over – without consuming the patience or time of their Doctors. If you’re unfamiliar with this please watch the following video of Dr John Bachman MD, Professor of Primary Care at the Mayo Clinic, explaining how he uses this simple tool to enhance the Patient Doctor relationship in ways that a patient freestyling without interruption for 45 minutes has little chance of ever achieving:

The importance of listening to the patient

Much as I admire the deductive talents of Joseph Bell I can see inherent problems with guess work in modern medicine after all any smarty pants student in 2011 would have reminded him there were also plenty of linoleum workers in Kirkcaldy! The same is true today – no matter how much detailed information we add to EHR’s the lesson of Sir William Osler will continue to bring results:

“listen to the patient — he or she is telling you the diagnosis”

As Dr Verghese obviously achieved with his first chronic fatigue patient and their 45 minute uninterrupted history giving appointment, here at 3G Doctor we start every single consultation with the patient being given the opportunity to share their full history without any time limitations. We’ve not only given the patient as much time as they need to tell us their information but we’ve also provided questions for them that will help probe their feelings so that they can reveal the important information.

Doing this electronically also means we document it all and it can be presented in one coherent patient record that the Doctor and patient can review before they meet, and which can be edited to provide a persistent and detailed record of the consultation once it has finished.

So how can 3G Doctor help patients who need a physical examination when it can’t offer the touch of a clinician?

I’ve summarised here some of the benefits a video connection can offer patients when consulting with a registered Doctor but I think it’s also worth explaining the value the 3G Doctor service can offer to a patient who needs a physical examination.

First of all you need to accept that some patients don’t have a family Doctor. Some patients have a family Doctor they know very well but have unmet educational and informational needs that prevent them from presenting to a family Doctor for a physical examination.

I’m reminded of the EveryMan campaign Director at Cancer Research UK who told me of the problems they’ve seen with young males when they’re faced with having to go to their family Doctor to get a lump on their testicles checked out. It was clear that an anytime/anywhere reassuring video consultation and the written documentation of the advice of an informed remote Doctor could help such patients overcome the embarrassment and uncertainty issues that may be preventing them from presenting to their Doctor for a physical examination.

In the instance of a female patient I think the history documentation process reminds us of the importance of documenting a history BEFORE a Doctor physically examines a patient. With young patients increasingly presenting to Doctors that they don’t know very well (eg. because they live away from home and their family Doctor, because their family Doctor employs salaried/locum Doctors, etc, etc) Doctors are being discouraged from conducting physical exams as a result of fear of litigation or accusations of inappropriate behavior – issues that are similar to those associated with difficult questions.

A patient presenting to a Doctor in a clinic for the first time holding a copy of the consultation documentation recommending a physical examination provided by another Doctor who they’ve already consulted with makes for an entirely different patient experience than they might get otherwise eg. a time pressured Doctor hurriedly requesting a patient to strip 1 minute into a 5 minute consultation.

The opportunities for discussions to take place far away from the patient when time and space can be collapsed

Dr Verghese criticises the current approach that is taking clinical decision making “far away from the patient, the discussion is all about images on the computer, clincial data and the one critical piece missing is that of the patient“.

When you appreciate the poor design of a lot of Healthcare IT solutions you’d probably agree with this but I see one of the biggest opportunities for mHealth to tansform eHealth initiatives into something that make an invaluable difference to patients and medical science. One things for certain: The opportunity to collapse time and space and have decisions made when they need to be made by informed experts regardless of their physical location is too big an opportunity to miss.

I think we already see the success of this today when we have clinical decisions being made in remote hospitals by pulling together geographically dispersed informed clinical experts on a Saturday night rather than having to transfer a patient to a central hospital and then wait again until Monday morning for an on duty consultant to visit the patient on their ward round. The success of telestroke services here in Ireland are a very good early example of this emerging opportunity.

I think it’s also important to appreciate the ability mHealth has to transform cold impersonal eHealth practices and the patient experience by connecting the last patient mile. Rather than a crowd of students at my bed each seeking their 5 mins in the spotlight on a ward round I would much rather a remote expert clinical team supported by the data and clinical guidelines where making informed decisions and rationally discussing my care in private away from my bedside (and visitors) – so long as they video recorded it all and filed a copy in my health record that I could access on my mobile if I wanted to:

Could you spare me the ritual, please?

I like to think I have a very good appreciation of the value of rituals and routines. I always look in the eye and shake a persons hand when I greet them (obviously Doctors increasingly face issues with this due to issues with facility and community acquired infections). Due to a very odd bit of folklore here in Ireland I was familiar with laying hands on people to provide healing more than a decade before I went to Medical School so I’m also not blind to the massive benefits, connection and relief it provides to the ill. I’m also lucky enough to also understand first hand the transformation it can provide when you’re experiencing it as someone who is dying.

But have you ever watched a Doctor or nurse being treated? I know one friend who was going to put up a “I’m a Doctor” sign on his bed because he couldn’t stand the sympathetic “patient experience” they were receiving. A nurse I know said she would summon all her strength to slap a certain medical student across the face if they ever attempted to pull one of those sympathetic tilted head expressions at them again.

Touch has incredible value but I think it’s also worth saying that the thick brush of paternalistic care isn’t something that every patient wants.

As with touch: don’t underestimate the value of connectivity

Whilst it’s easy to appreciate that we’re sensitive to touch it’s worth appreciating that we don’t always get to choose either/or as there are lots of times when touch is not wanted or even possible.

I remember providing life support to a seriously injured patient a decade ago and I can still feel the enormous connection that I had with the emergency operator – that’s someone I’ve never seen or met with (never mind touched) in my life and it was made over a 14.4 Kbps mobile voice call.

In a similar way patients with infectious diseases, who are intoxicated, who have immune difficiencies or live remotely can find incredible value in touch-less experiences and connectivity extends the potential for us to deliver these to ever more times and places that conventional healthcare practices cannot reach.

But the best evidence I’ve got for the value of connectivity would be with a very senior patient who independently lives alone near me. You could not give him all the tea in china to give up his mobile and unlike the 45 minute uninterrupted history giving sessions with a medical school Professor that Dr Verghese describes the value of this is before we even try and calculate the value for money a healthcare system is getting because this citizen is happy to be paying for his mobile with his own money.

3 Responses to Dr Abraham Verghese: Calls for a return to the traditional one-on-one physical exam

  1. [...] heard this over and over (here’s an interesting post on the subject) but whilst I wouldn’t say physical exams are over rated I think it’s fair to say that [...]

  2. David Gimlett, M.D. says:

    You just don’t get it–care, love, healing, existential authenticity-whatever you want to call it. 3G has no soul.

  3. Hi David,

    Thanks for sharing your opinion.

    For the record we don’t look to technology (eg 3G) to provide any of these important human qualities.

    Instead we look to the opportunity it provides to collapse time and space so that patients have better access to Doctors who can provide care, love and healing in a way that is documented.

    Best wishes,

    David Doherty

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