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RELATED LINKS

• Dr. Verghese's official site
• Excerpt from Cutting for Stone
• "Physician returns to the art of healing in medicine"

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Physician-turned-author talks about the destructive pressure put on doctors. (:53)
 

Full interview. (19:42)
 

Tavis: Dr. Abraham Verghese is a professor and senior associate chair for the theory and practice of medicine at the Stanford University School of Medicine. He was the founding director of the Center for Medical Humanities and Ethics at the University of Texas Health Science Center. He's also an acclaimed author whose latest book is called "Cutting for Stone." It is his first work of fiction. Dr. Verghese, nice to have you on the program.

Dr. Abraham Verghese: Great to be here, Tavis.

Tavis: Why fiction this time around?

Verghese: Fiction was always my first love, and I actually believe that fiction is a great way of telling the truth. Dorothy Allison says, "Fiction is the great lie that tells the truth about how the world lives." So if you do it right, there's a lot of truth in there.

Tavis: Tell me what you mean when you say - I hear the quote, it's a beautiful quote - with regard to this particular text, "Cutting for Stone," this fiction piece, how does writing this story in fiction allow you to get to a level of truth-telling that you and the reader, I hope, will appreciate?

Verghese: Well, I have a great love for medicine, and I was hoping that the reader would capture what I think is the romance and passion that is inherent in medicine, and that in a technological age sometimes get lost. I think students don't often see what the potential for medicine is.

I also have a great desire to see a style of medicine not disappear. The great danger of technology is that it tends to replace physicians, and I actually worry that the patient in the bed has almost become an icon for the real patient, who's in the computer.

Everybody's fussing around the computer, around the i-patient, I call it, and the great danger, I think, is that we're not paying enough attention to the patient.

Tavis: Both of these issues are raised in the text, and I'll come back to them separately. Let me start with the first, because I like the way you phrased it but I want to explore a little bit more.

When you refer to the romance and the passion in medicine, you mean by that what, specifically? Because I can imagine a number of folk, with all due respect to the healthcare industry, who've had experiences of late don't see much romance or much passion in how they're being treated. So what do you mean by the romance and passion in medicine?

Verghese: Well, my sense is that people should not go into medicine seeing it as just a science. I think you really have to feel a calling. You almost have to feel like this is a ministry.

I think there's an important priestly function, Samaritan function, to being a physician that never goes away. And so if you're going to come into this just for the science, at some point that'll get jaded, perhaps, and the whole business of medicine will get jaded.

If you keep alive the Samaritan function, the priestly function, I think you'll stay sane even as these other things such as healthcare or financing and all that goes up and down. You'll still have your calling; you'll still have your ministry. That's what I meant - a sense of calling, a sense of purpose.

Tavis: I get it now. And your second issue, this issue of not treating people like i-patients when they are in these institutions - how much of that has to do with the bedside manner that physicians practice?

Verghese: Well, I think the great danger is that the bedside manner is disappearing. It's become possible to see the insides of the patients much better with a machine than by going by and examining them, and for that reason people are short-changing the bedside exam. But I've come to feel that the ritual of examining the patient is like any ritual - like marriage, like installing a president.

Rituals are about transformation, and if you examine the patient well, if you do justice to their baring their soul and then their body to you, if you take that privilege of being allowed to touch them and do it well, you develop a patient-physician relationship. That's where it happens.

If you just sit behind a desk and send them to this test and that test and then bring them back and say, "Here's what I found," they may never buy it from you because they haven't bonded.

Tavis: What are the main culprits, if I can put it that way, for this demise in the physician-patient relationship? Is it the physicians themselves? Is it the institutions? Is it the insurance industry that has people doing more with less? Tell me what the culprits are for that demise in that relationship between patient and physician.

Verghese: Well, I think we're all culpable, honestly. I think medicine should definitely take the share of the blame. But what's happened is the way our healthcare reward system works is you get paid for doing. There's a lot of money in doing stuff to people. There's a lot of money in sending people for tests. And so not surprisingly you have all these heart centers, cancer centers, imaging centers building up, because that's where the money is.

And I don't think it's possible for a physician to own an MRI facility or a CAT scan facility and say that they're being objective about which patients of theirs they send to their own facility. So I think we've been really corrupted by the money and this is the time, Tavis, for a one-payer system. It really is. The time has come.

Tavis: Since you went there, I'll go there first and then I'll come back to the text. Your thoughts about that more expressly, and what makes you think the time is right for that? A lot of talk about this, obviously, during the presidential campaign, but why do you think the time is right, and are you hopeful that the time can be redeemed?

Verghese: Yeah, I'm very hopeful. I think in a funny way the bad economic crisis that we're in now really forces us to look hard at practices that we allow to just keep going the way they were. Medicare has an overhead of about 3 percent. All the other insurance companies together, their overhead is something like 33 percent.

If we put everyone under that Medicare umbrella, what we would save, about $33 billion, would be more than enough to cover everyone else. Now, that doesn't underestimate the forces that will struggle hard to keep things the way they are, because there's money in what's being done right now. People are making a lot of money.

Tavis: How do you wrestle that animal to the ground, then? I ask that, to your point now, about all the money and the president's convened, what, one meeting so far in the White House, as he promised he would when he ran, and not 24 hours after that meeting a couple of people walked away from the table, after the first meeting.

They walked away and said, "No, we can't do this." So what does this - how do you wrestle this demon down?

Verghese: Well, I hope that he's got enough stamina to deal with this. I think it was Machiavelli who said, "Just because something's the right thing to do, never underestimate the forces that will keep doing it the same old way." And in this case, I think this is a very powerful industry that's making a lot of money and knows how to lobby to keep things the way they are.

So I think it takes more than willpower. It also takes a great deal of forces willing to take on the powers that will keep things the way they are. I'm certainly not an expert in those sorts of things, but I know the will is there among the medical population. I think we were as guilty as anybody else of wanting things to just stay the way they are. There's a sense now that this is inevitable - it has to come.

Tavis: Wrestling with the issues that you wrestle with, I can see why ever now and then you might want to steal away and write a fiction book - if for no other reason, escapism into another world.

Verghese: Absolutely.

Tavis: And yet there's a slight part, a very slight part of this book that is autobiographical. Tell me that part first; then I want to get more deeply into the book itself.

Verghese: Well, I was born in Ethiopia. My parents were teachers there. I grew up, I had my whole education in Ethiopia, including the first couple of years of medical school. And then civil war broke out and actually the present prime minister was one year my junior in medical school. He became a guerilla fighter. Many of my other classmates died; I went on to India and finished medicine.

So the first part of the book really uses the geography that I know. There's a saying that geography is destiny, and I really wanted to capture the lovely, lovely countryside that I knew so well, the people that I knew so well, because I think people have the wrong sort of impression that comes to mind when you say Ethiopia. They don't ever see what I saw.

Tavis: So we get the autobiographical sketch of what is this book. Before I get into it, tell me what "Cutting for Stone" represents. Why "Cutting for Stone" as the title?

Verghese: So there's a phrase in the Hippocratic Oath that says, "Thou shalt not cut for stone." Because in medieval times, stones were epidemic - even in Victorian times - and there were these charlatans who would go from city to city and they would cut and take out your bladder stone, your kidney stone, and relieve you of your suffering, but the next day you would die of infection. And so the oath said do not cut for stone.

I like the title because it had a certain resonance and because my main character's name is Stone. They are surgeons; hence "Cutting for Stone."

Tavis: Dr. Thomas Stone.

Verghese: That's right.

Tavis: All right. We don't want to give too much away, but tell me what "Cutting for Stone" is.

Verghese: It's really a medical epic, a medical saga. I was hoping to show that medicine can save you; medicine can also be your downfall. Many a doctor goes into medicine and gets so caught up in it that their family life suffers, their personal life suffers.

I don't know if you know this, Tavis, but the highest suicide rates in this country are among doctors, lawyers, dentists. Twenty-five fold higher than any other profession.

Tavis: More than police officers?

Verghese: You know, I don't know the data for police officers, honestly. I'm sure that's pretty high, too. But I think it's striking that people go into this profession and they almost feel that since they're dealing with other people, they themselves are spared from anything that might happen to them.

And therefore, they're very intemperate in their use of drugs, alcohol, and that is often the genesis for their slipping into addiction.

Tavis: That seems weird, though, that those who choose professions to save lives end up taking, in a variety of ways, their own lives.

Verghese: Isn't that ironic? And I think it's because for too long we've underestimated the dysphoria of medical training. Medical training is pretty intense. You see some really gruesome things, and until recently, the macho culture of medical training didn't encourage you to talk about what you felt having just seen this terrible scene play out.

And in fact, the macho culture invited you to just take it like a man and go on. I think in doing that, in shutting ourselves to the emotional content of what we see, we begin to shut ourselves to our own emotional distress. And when physicians get ill, they're the last to recognize it. They deny their patienthood. They focus on a symptom, but they don't focus on their distress.

Tavis: So the storyline, beyond Dr. Thomas Stone, is?

Verghese: Well, it begins with a nun by the name of Sister Mary Joseph Praise giving birth to twins in a mission hospital in Africa. Unfortunately she succumbs in labor. One of her sons becomes the narrator for the story. And eventually, he winds up in America and he winds up being one of several thousand foreign medical graduates who come to America every year to fill the needs of inner city hospitals all over this country.

Now, that's no fiction - that is the truth. We need about 25,000 new doctors a year to fill our residency positions, and we only have about 15,000 American medical graduates. So all the rest are filled by foreign graduates, and I wanted to capture that world - the sort of very different conditions under which they work, and yet the very important service they provide in situations where no one else seems to be willing to go.

Tavis: We keep bouncing back, as I suspect we will until this conversation ends - we keep bouncing back and forth between the fiction in the book and the nonfiction, the real life, of medicine in this country. Here I go again, doing that in asking this question - tell me what you make of the fact that we need in this country about 25,000 doctors a year to fill the residency spots, as you mentioned a moment ago, while do we only have 15, and how those foreign physicians who come here are treated once they engage the system?

Verghese: Well, it's very interesting. There's a real schizophrenia about the whole business of physicians from abroad. On the one hand, the AMA has insisted for the longest time, until very recently, that there are too many doctors. I think a sense of protectionism.

And yet every year we have all these unfilled positions, which if they didn't go filled, inner city hospitals that rely on those physicians to provide service would really suffer.

Medicare, in fact, invented this business of funding internships and residencies as a way to get manpower in places that no one else would go. So I think we clearly need to turn out more physicians and we need to open the gates on medical schools - allow new ones to be built, fund more, increase class size. Clearly, that's what it takes.

But I think like anything else in America, Tavis, when America has a need, whether it be basketball players or, forgive me, cocaine or whatever it is - corn de-tasslers, labor workers, chicken cleaners - the rest of the world provides. Well, America has a huge need for physicians every year, and the rest of the world provides.

Tavis: And how are those persons treated by our system? Are they trusted by the system, are they maltreated by the system, are they welcomed by the system?

Verghese: I wouldn't say they're exactly welcomed. There clearly are two strata of training. There's the upper-crust places that one can apply to which foreign graduates never even go looking at. In the settings that they're received, I think they're very well received, well trained. I myself look at it as a great blessing in my life that I actually trained in a situation like that.

I think I got more attention than I suspect people might get in a better place. Nevertheless, it's a fact that the choices open to them are very different from the choices open to the American trained graduate. So there's a two-tiered system that over time becomes a little more even, and I think for the physicians who come, there clearly is a tremendous opportunity for them.

But they wouldn't be coming were there not this big, gaping need every year which we've done a poor job addressing.

Tavis: So clearly, there is this need for physicians. But how does the training stack up? How does training for physicians in the U.S. stack up, rate, or not with medical training around the world?

Verghese: I think the U.S. post-graduate training system is really wonderful. I think one of the reasons people come - they don't come just to fill a position, they come because the United States has clearly been the leader in innovative medical teaching and training. So it's wonderful training. It's also fairly standardized all across the country.

Nevertheless, there are some hospitals that you can't get American medical graduates to step into, and these are the places that have to have their ranks filled by foreign graduates. And I think they provide yeoman's service - they provide yeoman's service, and they get something very special out of it. They're proud of the service they gave to Cook County, Chicago, or wherever it is they went. They look back and they're proud of the service they gave.

Tavis: I'm not naïve in asking this question, but I want to make sure we put it out front because it's been talked about twice now and I want to go right at it, which is why those persons, those 15,000 who do, in fact, fill these residency slots every year, do not look to, en masse, I should say, en masse, do not look to, don't feel the need, aren't interested in filling these slots in inner city hospitals.

Verghese: Well, I think given that there's such a surplus of positions, I think it's sort of natural that they gravitate to the best places. Now, I should have a caveat that some of the best places are inner city hospitals, but they're university-affiliated; university city hospitals. That's a completely different cup of tea.

We're talking about inner city hospitals that are not affiliated, have no university umbrella, no fancy logos, as I say in the book. No logos on every piece of paper, but just a place that provides service. Why go there when you can go to a place that's more prestigious and will set you on your way to your next step, whatever it is. So that's the reason. I think that's just human nature.

Tavis: I was in a conversation about this some time ago, and one of the persons in the conversation was making the point to me, Dr. Verghese, that sometimes, oftentimes, these inner city hospitals, given what they are dealing with, are the best places for training.

If you're really trying to learn about dealing with catastrophic illnesses and traumatic illness - if you consider what these inner city hospitals are and what they're dealing with and the challenges they face, there's a lot of learning that goes on there.

Verghese: I completely agree. I think it's a wonderful learning environment. Whether in that learning environment we're doing the best justice to those patients is a different question. I really think that even though it might be the best learning environment, better resources could have made it a safer experience all around, could have made it a better experience all around.

But it's clear that this is a wonderful place to train. It's a bit overwhelming, too, and you must know that something is falling through the crack when you have that kind of numbers coming at you and only a certain number of people to deal with it.

Tavis: One of the things you do a great job of in the book - Holly and I were talking about this earlier - is really for the reader describing quite well what it's like when the character arrives in America. The sights, the sounds, the smells, the noise, even as compared to Ethiopia. I'll let you explain it, though.

Verghese: Well, I think I was clearly harking back to my own experience of landing in Kennedy and in a few minutes I was on the freeway, and all these lanes of traffic, and lights as far as you could see, and another six lanes coming this way.

And sort of the scale of it was so huge I had the sense, almost, that everything I had done in my life prior to this didn't count anymore. Everything I thought was big was actually small; everything I thought was grand was actually nothing. That I would have to re-frame this all over again. And I also had the sense, which I still do around Kennedy airport, that there was some super-organism in charge to keep this all flowing smoothly, and but for their intervention it would all be catastrophe.

So I think the scale is overwhelming when you first land. We take for granted, you and I at this point - at least I do - the scale of America. But you compare it to any other country and we are really blessed.

Tavis: Tell me about your early experience when you got here, particularly your early HIV/AIDS experience.

Verghese: Yeah, I was fortunate to train around the time when HIV was coming, and I was in Boston, training at Boston City Hospital. But then I moved to rural Tennessee to take a job when I finished my training, and I assumed that I would see no HIV. But in a very short time in that town I began to see almost eventually a hundred people with HIV in a town of 50,000 - something no one would have predicted.

And that was really the story of my first book, "My Own Country." The explanation was it was hometown boys coming back to their home because they were ill, and they had left because primarily they were gay and did not want to live that lifestyle under the scrutiny of their family and relatives. And so there'd been this quiet exodus, and with HIV, we became very aware of them because they were now coming back.

Tavis: Let me close by asking - and we touched on this a bit, I think, in this conversation, but more directly and more expressly, what do you want, what do you hope the take-away will be for those who read "Cutting for Stone?"

Verghese: I'm hoping that they will appreciate that if they're in medicine that medicine can save you but medicine can also destroy you. I hope for the young reader out there, someone in college, they'll see medicine as a worthwhile career. No matter what the money situation turns out to be, they will see this as a career that'll be so fulfilling that they don't have to ask, "What is the meaning of my life?" They will find meaning in what they do. I'm hoping that would be the message that goes out there.

Tavis: So I suspect that when this comes out in paperback somewhere down the road, you'll be sitting in the doctor's office with a copy of this in paperback that says, "Do not remove from the doctor's office." (Laughter) His new book - his first cut, pardon the pun, at fiction - "Cutting for Stone," by Dr. Abraham Verghese. Doc, nice to have you on the program.

Verghese: Thank you so much for having me.

Tavis: My pleasure, good to see you.