Time lines

A simple dignity envelopes writer Abraham Verghese, MD . A calm quietness about this Stanford professor of medicine conveys both strength and vulnerability. You have a sense as soon as you meet him, and especially when you get to know him, that there’s great depth here.

He’s written two searing works of nonfiction: My Own Country, a paean to the men he treated for HIV/AIDS as a young physician in eastern Tennessee, and The Tennis Partner, a lyrical eulogy to a fellow physician and best friend whose life went off the rails and skidded into the abyss.

His third book, the novel Cutting for Stone, found a huge new audience and the response was rhapsodic. Its first page jolts you. A Roman Catholic nun gives birth to twins and dies on the operating table in a hospital in Ethiopia. From that point on you are swept into a beautifully detailed world that comes alive through Verghese’s skills as a physician and a writer.

Novelist John Irving said of the book, “That Abraham Verghese is a doctor and writer is already established; the miracle of this novel is how organically the two are entwined. I’ve not read a novel wherein medicine, the practice of it, is made as germane to the storytelling process, to the overall narrative, as the author manages to make it happen here.”

As the School of Medicine’s commencement speaker last spring, Verghese talked about the timeless qualities of practicing medicine. Here he continues this line of thought in a discussion with Stanford Medicine executive editor Paul Costello.

Paul Costello: In your first book, My Own Country, you wrote so eloquently about HIV as an illness that takes people before their time.

Abraham Verghese: That was certainly true of HIV in that era, but of course there are many diseases like that. Still, at that time, that one disease dominated my experience and affected young men, in most cases, who had every reason to think they had plenty of time left. Instead, they found themselves in this crucible, where there was only so much enzyme and substrate left before the whole thing ground to a halt. It made them acutely conscious of time and the fact that it was running out.

I remember taking my kids to memorial services for my patients. I wanted my children to understand the fact that this, our time here, is not guaranteed and that time is precious. John Irving says in one of his books, “life is a terminal condition.” It’s about to run out on all of us. But it’s a shock when you learn it will run out sooner. And there are no exceptions to the fact that it all ends. I think in a way that’s what makes life poignant and beautiful … and sad.

Costello: As you are crafting narrative and characters, do you often think about time?

Verghese: It’s hard not to think about it, but especially in fiction, time is almost like a character. In Cutting for Stone, I experimented with time in so many ways, ultimately settling on the idea of the narrator being an older individual looking back at the moment of his birth. The great power of a novel is that you can leap 10 years in the course of a page. At the end of one chapter, you’ve left one character. In the next chapter they are 10 years older — or 100 years older. I love that.

One hopes that a good novel also distorts the reader’s sense of time: You hope to pull the reader into your story and by page two make them suspend disbelief, make them forget they’re reading words on a page but instead have them enter a new world, one you created, and you allow them to live vicariously through several lives playing out over several generations, hundreds of years going by, and when they come to the last page they look up and realize, wow, it’s only Tuesday. I was always attracted to a novel that could do that, and it was my ambition to write like that.

Costello: How has time changed you as a physician?

Verghese: I remember as a young physician feeling almost immune, as if there were a contract we had just made: In return for my hard work and acquiring all this huge knowledge, I would be spared these ghastly things that I saw every day. As you get older you begin to realize, first of all, you’re not immune, and secondly, only the grace of God and tremendous luck spares you from being in that bed, and being the one looking up and speaking to the grisly crew around your bed.

I think it just takes the passage of time to arrive at the perspective of one’s own vulnerability and the fact that you are not immune. I get impatient with physician essays that revolve around a physician encountering medicine as a patient, often for the first time. And with it comes suddenly this epiphany about life and the nature of medicine. And I always think, “Really? It took that experience for you to understand this? All those years of watching the suffering weren’t enough?” I am sure I am being unfair, because it is hard to be in someone’s shoes till you are, but still.

Costello: When you cross that threshold and enter a patient’s room with physicians in training, what are you telling them is important?

Verghese: I am not sure I say anything. I think I am mostly trying to model a kind of interaction. I make rounds with third-year medical students on Wednesdays and Fridays at Stanford and at the Palo Alto VA hospital. And in each case I want to convey to them, without saying anything per se, a sense of this being hallowed ground. You’re entering sacred space and given the great privilege to see people in distress and to treat.

I try to teach students concrete and simple things: such as the fact that the two most important buttons in medicine are not the left and right mouse button but the button to raise the bed up so that you can do a decent job of examining the patient; and secondly, the task light button (which is often hidden or out of sight) so that you can see and study the patient.

A mechanic does that for a motor, so it is the least we can do for our patients. I’m also trying to convey the skill of a quick exam and the need to read the body as a text. Why open a book if we can’t read the words, and the patient’s body abounds with words. If I’m lucky, I’ll connect with the patient in a particular way that makes them forthcoming. I’ll bring out stories from them. I’ll tell them stories. And in the process I am hoping that students will see there is this great privilege and satisfaction in these interactions — and joy in teaching and modeling it and seeing the student respond.

Costello: I know you’re not a Luddite when it comes to technology in medicine, yet you are concerned that technology often overrides spending time focused on the patient.

Verghese: Do we think we can deliver good patient care by spending all of our time in front of a computer screen, hours and hours and hours away from the patient? All of this perverse clicking we do: It’s estimated we click about 4,000 times a day. A great percentage of that has to do with billing. But I’m an eternal optimist. And I am also sensing that we have a different breed of students today. They are incredibly motivated.

I have great hopes that today’s students will be the ones to set it all straight. I think they’re in medicine for all the right reasons. I think they are more altruistic than ever before. I also think they have the knowledge and skills to solve this present dilemma we’re in. I am not against technology by any means. But the reams of data that are in the computer and that we understand very well, a symphony of facts and theories, mean nothing if the patient only registers that people rarely come by. We are dealing with humans, not data points.

Costello: Why do you think it’s important for young physicians to understand the lineage of medicine?

Verghese: It’s to help understand time. The lineage is a sense of connection. The technology isn’t timeless, the understanding of disease isn’t timeless — it changes logarithmically. But the desire of humans to serve the sick is timeless; the sense of vulnerability one feels when ill is timeless. So, in that sense, there is a lineage whose function is constant, and that is “to love the sick, each and every one of them as if our bodies were at stake,” to quote Galen.

I think to understand that lineage — and you can go back to Hippocrates, Galen, Paracelsus and Harvey, and in America go to Osler, and at Stanford to Shumway, Kaplan — the sense of sacredness emerges when you realize that you are the latest iteration of a long, long tradition. It makes the everyday, the humdrum bearable to know that. It does for me.

Costello: What have you taken away from your patients as you’ve watched them face significant illnesses?

Verghese: Early on in my career I had a hemophiliac patient who had the misfortune to contract HIV from the blood products he got for hemophilia. I got to know him well. Toward the end of his life he remained incredibly stoic and brave, dealing with one HIV-related crisis after another. When I asked him how he coped, he shared with me that as a young boy he often would wake up in the middle of the night and feel a joint swelling up and know that he was starting to bleed in that joint. He knew what lay ahead for him and his parents if he were to wake them — that they would have to go to the hospital and get a Factor 8 infusion. He also knew his parents were working two jobs, driving an old car, mostly because of all his medical needs. He knew how they needed their sleep. So instead of disturbing them and despite his pain, he would wait a few hours till dawn so they could get a full night’s sleep. Next to his bed was a little record player and he would play the hymn Joy Comes in the Morning.

You know, sometimes I think our illusion in medicine is that we fix things forever. We don’t make people immortal. If we’re lucky we get to minimize the impact of disease, sometimes reverse it. To me, it’s all about hope. It’s the desire to hang in there, to just keep it going. There’s a saintliness I saw in so many of my patients. There’s a certain attitude and powerful lessons for the rest of us. What a privilege.

Online extra: