Doctors, patients, ritual and showing up

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Ritual is a big part of life; this is especially evident at universities at this time of year. I recently took part in the ritual of attending convocation at another university to watch my daughter receive her Bachelor of Health Sciences degree. In addition to the parental joy of seeing my daughter on stage for about six seconds of hooding and handshaking, I had the pleasure of hearing the convocation speaker, Dr. Abraham Verghese, a physician, author and professor at Stanford School of Medicine.

The importance of ritual, both in life and in particular in the doctor-patient relationship, is something Dr. Verghese is passionate about. He’s written about this, presented TED talks, and, late last month, incorporated this message into his convocation address at McMaster University.

Dr. Abraham Verghese (Screenshot from webcast)

Dr. Verghese noted that it’s possible to get your degree without attending the ceremony, but “rituals matter.” He added: “It says something about you that you believe in this ritual, that you showed up, because showing up for rituals that matter is perhaps the best advice I can give you.”

He acknowledged that he was speaking from “the vantage point of a window of practicing medicine” but hoped his message about ritual would resonate with everyone. He pointed out that the very ritual of convocation itself makes no sense in other contexts: “You’re dressed in a way that you otherwise never dress like. And I’m dressed as I rarely dress. With distinguished faculty on the stage, you marched in proceeded by a beadle carrying the mace, an instrument of battle that’s also a metaphor of power.”

“Our anthropology colleagues teach us that rituals are all about crossing a threshold,” he explained. “They represent a transformation, whether it’s a baptism, or a bar mitzvah, an inauguration, a funeral, a graduation.”

He challenged the graduates to consider what the rituals are in their lives, in their work, before sharing insight into his own understanding of ritual in his medical practice:

“If you think about the usual clinic visits, two strangers are often coming together, one person in the room will be wearing this white shamanistic outfit with tools in their pockets, and the other individual will be wearing a paper gown that no one knows how to tie or untie. The furniture in the room looks nothing like the furniture in your house or mine. The individual in the paper gown will then begin to tell the other one things that they would never tell their rabbi, or their preacher, and in my specialty of infectious disease, they will tell me things they would never tell their spouse. And then, incredibly, they will disrobe and allow touch, which in any other context in society would be assault, but the physician gets the privilege in the setting of this ritual.”

He further explained that this is not unique to any one culture. “I care for people from all kinds of ethnic groups, and I’m struck by how many different beliefs they have about illness, about disease, about treatment, but they all know about ritual,” he said. “And you put them in that room with all its setup and they know they’re about to embark in a ritual and if you do it poorly, if you just do a prod of their belly, and stick your stethoscope on the gown, they’re on to you, they can tell when you’re doing it well just as you can tell when you’re in the hands of a thoughtful barista, a good chef, a good hairdresser, a good mechanic.

“Rituals, done well, signify people who are doing their jobs well.”

Rituals can also be transformative, he said. “I learned this firsthand in the early years of the AIDS epidemic before we had any treatment,” he said, recalling a young man who he had followed for months at the clinic and who was now dying in the hospital.

“Each day I would come to his bedside and I’d visit him and I’d talk to his mother, and not knowing what else to do in this sacred hallowed space that surrounded him with his mother holding vigil, after a while, I would begin to examine him, albeit briefly. I would listen to his heart, I would percuss his lungs, feel his abdomen, feel his spleen, even though it was very unlikely I would discover anything that would change what we did,” he said.

“I engaged in this ritual out of habit, relieved that it gave me something to do, some purpose at the bedside.”

“One day, when I came by, his mother, that eternal figure there, told me that he’d not spoken or come to consciousness since the previous noon. It seemed certain that he was about to die, and in fact, he did pass away a few hours later,” Dr. Verghese continued. “But strangely, at that moment, as he heard us talking, as he heard my voice, we saw his hands begin to move. She was astonished, ‘cause she had not seen anything before. And I was astonished, and we’re wondering what is he gonna do? And we saw his skeletal fingers flutter up and then move to this wicker basket of a chest of his. And it took us a while to understand that he was fumbling with his pajama buttons. He was trying to unbutton his shirt, he was reflexively allowing me the privilege of examining him, giving me permission. I tell you, I did not decline the gift.”

“I percussed, I palpated, I listened to his heart, his lungs. I felt connected to the timeless message the physician conveys, the same message the horse and buggy doctor, riding out to towns on the western edge of Lake Ontario 150, 200 years ago, conveyed to his or her patients of that era, when there was so little to offer,” he said.

“The message is that beyond the data, beyond the evidence or lack of evidence, beyond the medicines that stop working, here I am and no matter what, I care, I will be there with you through thick and thin, I will not stop coming, I will show up.”

Dr. Verghese then spoke about emerging artificial intelligence and how it will change medicine.

“Here’s what’s not going to change, is the need for human beings to care for each other,” he said.

“We all need it in every walk of life, but especially in the care of the sick. I’m hoping that in my field, artificial intelligence will free us from some of the drudgery of medical record keeping and allow us to fulfill the Samaritan function of being a physician, to minister to those who suffer,” he added.

He exhorted the graduates to “embrace the rituals of your life, be conscious of them.”

“Be in charge and be cognizant of those human values and rituals that you want to preserve,” he added. “Remember that fluttering hand of the dying patient, I remember it every single day.”

Unlike machines, he said, “You can care, you can love, you can preserve the rituals that showcase these things. And you can show up. Always show up.”


You can watch Dr. Verghese’s full address here. It begins around 29:05.

 

 

 

 

 

 

 

 

One Response to Doctors, patients, ritual and showing up

  1. Peter Bryson says:

    Great post Tony. Thank you.
    Enjoyed reading every word, and then again.

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