Abraham Verghese, MD, believes that AI has the potential to advance medicine, if physician leaders can band together to successfully advocate for a reversal of the prevailing model of health care in which physicians seem to be working for technology—instead of the other way around.
“With every one hour with patients cumulatively, we spend up to two hours entering data, and not to mention email in the evenings,” he said in his keynote address at the AMA State Advocacy Summit. “We are basically the highest paid clerical workers in the world.”
In his remarks, Dr. Verghese focused on the importance of physicians conducting bedside exams and establishing a human connection with their patients, one that transcends AI or the EHR.
“Something has to change, and it has to change because there are better tools out there,” he said. “The Stone Age did not end because people ran out of stones. It ended because there was better technology.”
Dr. Verghese is well positioned to make the case on the importance of human connection in medicine, given that his work as a writer has touched the hearts of millions. An infectious diseases physician, he is now professor and vice chair for the Theory and Practice of Medicine at the Stanford University School of Medicine. He has written two nonfiction books and two novels, one of which—Cutting for Stone—has sold more than 1.5 million copies. His latest, The Covenant of Water, debuted on The New York Times bestseller list and was selected by Oprah Winfrey for her book club.
Diagnostic model’s shift over time
In his address at the AMA summit, Dr. Verghese discussed the history of medical diagnosis, saying that, before about the year 1819, most medical care came from barber-surgeons who made no attempt at diagnosis.
“Instead,” he said, “they would cup you, bleed you and purge you. And while you were there, cut your hair short at the back, long in the sides, pull a tooth if you wanted to.”
With the invention and adoption of percussion, followed soon by the stethoscope, though, Dr. Verghese said that medicine quickly adopted the process of physical examination to make an anatomic diagnosis.
“The skills at the bedside reached incredible heights,” he said. “People were very, very good at reading the body and coming up with pretty astute observations.”
That has changed, however, as physicians have been required to spend more time with technology and less in the presence of those they are treating. Lost in the tsunami of electronic demands on physicians, he said, is an emphasis of a holistic understanding of the patient—one in which the physical examination plays a key role.
“It’s very clear that a great part of our attention, a great part of our knowledge about the patient, is no longer on the patient’s body. It is actually in the computer,” Dr. Verghese said.
That results in the misperception that the digital record offers the most important information in determining diagnosis, treatment and management. He mentioned a study in which he participated that collected stories from physicians about oversights in the physical exam that led to consequences such as diagnostic delay or therapeutic misadventure. The majority of these errors were caused simply by the patient not being examined.
“Yet, if you biopsy the chart, especially the electronic medical record the exam appears complete—my goodness, every drop-down box is filled,” he said.
He said that, in addition to lowering the risk of misdiagnosis, physical examinations also communicate to patients that their physician is attending to their individual bodies, not just interacting with their digital records.
“The ‘iPatient’ gets wonderful care all across America. The real patient often wonders: Where is everyone? When is anyone going to explain things to me?” he said.
Learn more with the AMA about augmented intelligence (AI) in medicine. That is the term physicians use to emphasize AI’s assistive role, enhances human intelligence rather than replacing it.
The AMA recently updated its principles (PDF) on the development, deployment and use of health care AI, and has long provided research, resources and advocacy to reduce the burdens of EHRs and remove other obstacles to patient care.
A physician’s most valuable tool
Dr. Verghese used the famed 19th century painting “The Doctor,” by Luke Fildes, to illustrate the immense value patients put on the attention of their physicians. The painting shows a doctor leaning over the bedside of a very sick child, displaying empathy for, and intense concentration on, his patient. Dr. Verghese discussed how when the painting was shown in 1891, it created a public sensation, and soon across the world it became a beloved, iconic depiction of the care physicians show their patients.
“Even though it the era of the stethoscope, the ophthalmoscope, the blood pressure cuff, the reflex hammer, the thermometer, you don't see any of those instruments depicted in the picture—very deliberately, I think, because Fildes did not want to distract from the singular attentiveness of the physician to the patient,” he said.
Not only do patients value those types of personal interactions, but they can be fulfilling for physicians as well, Dr. Verghese told the hundreds of physician leaders and medical society staffers in attendance. Conversely, the lack of such meaningful patient interaction can be frustrating and a factor in the disturbing data on physician burnout.
“Burnout, very simply, is a syndrome of depersonalization, emotional exhaustion, a sense of low accomplishment. And it happens slowly. It happens one keystroke at a time.”
In Dr. Verghese’s view, physicians must push back against being chained to clumsy EHRs and should advocate technology that reduces their burden instead of increasing it. And he said that no matter what, there must remain space in medicine for observation and examination, for physical touch.
“One needs to examine the abdomen post-surgery, not just to see if there are problems or tenderness or abscess forming, but also because the patient expects it,” he said in answer to a question from the audience. “The fact that your follow-up CT didn't show anything isn't information conveyed to them. Things that reside on images and reports are not personal to the patient, compared to your touching.”
He said the physician’s physical examination of a patient has all the hallmarks of a ritual, one that transcends cultural, ethnic and language barriers, and all rituals are characterized by some sort of transformation, which in the case of the exam is, “that the disease process is localized on their body, as opposed to a distant MRI or a biopsy report,” he said. “The transformation is trust. It's the sealing of the patient-physician relationship. It is the transition from ignoring a symptom to doing something about it, hopefully a transition from illness to wellness.”
