Pulling Back the Curtain: Abraham Verghese, MD

In this edition, Abraham Verghese, MD, describes his childhood in Ethiopia, lessons learned from patients during the HIV/AIDS epidemic, and the roots of his second career as a writer.

Tell us about your childhood. Did you always know you wanted to go into medicine?

I grew up in Ethiopia, though my family is Indian. After Ethiopia was liberated from Italy during World War II, a large community of Indian teachers were hired by the new high schools all over the country. My mother and father emigrated to Ethiopia, met there, taught physics and chemistry, and started their family.

Middle-class Indian parents see three career options for their children: doctor, lawyer, or failure. So, it was clear to my brothers and me where our career paths were headed.

Ironically (because I am now an author as well), a book brought me to medicine: Of Human Bondage by Somerset Maugham. The medical element in the book is minor, but there’s a moment when the protagonist, Philip, finds that he can’t make it as an artist in Paris. He’s an orphan, but his parents left him money to pursue professional studies. He decides to return to London and study to become a physician. When he finally arrives on the wards, Maugham writes, “Philip saw humanity there in the rough, the artist’s canvas, and he said to himself, ‘This is something I can be good at.’”

That sentence made me feel that, while not everyone could be a math whiz or a brilliant artist, anyone with a curiosity about the human condition and a willingness to work hard could be a good physician. I still agree that it requires those two qualities, and I had both.
I began my medical training in Ethiopia, in one of four or five then-new schools established by the British Council throughout Africa. It was a wonderful education, because our professors had just retired from eminent positions in England and had come to complete a year of service. However, during my third year, the Ethiopian emperor was deposed and a brutal military regime took over. One of the first things they did was close the university and send all students to the countryside to educate the masses.

Did you remain in Ethiopia after the coup?

My parents had seen the writing on the wall. By the time the university closed, they had already moved to New Jersey. When I joined them 2 years later, they were teaching. They had each earned postgraduate degrees – a master’s in education for my mother and a master’s in nuclear physics for my father.

Were you able to start medical school in the U.S.?

The medical education process in Ethiopia is different from that in the U.S.; instead of getting an undergraduate degree, I went straight from high school to medical school. When I got to the U.S., I was stuck, – unable to enter medical school there and unable to complete my medical training in Ethiopia. While I contemplated my next step, I worked as an orderly, first in a nursing home and then in a hospital. Eventually, through the great efforts of one of my aunts, the Indian government took me in as a displaced person in 1974, and I was able to resume my medical schooling in Madras. The Indian training system was similar to Ethiopia’s – based on the British system – so I was able to earn my medical degree and complete my internship there. I returned to the U.S. in 1980 to begin my residency.

How did your experiences as an orderly shape your career?

Looking back, that was the best medical education I could have had, because I saw what happened to the patient in the 23 hours and 58 minutes the doctors were not in the room.
I also attribute that experience to my great appreciation for my colleagues in nursing, because they are spending the most time taking care of patients. I feel a sense of solidarity with nursing staff. To this day, when I round, I try to check in with the nurse because that is who the patient “belongs to” in my mind.

Working in the nursing home was truly an eye-opening experience. It was quite a shock to see the warehousing of the elderly happening there. I was responsible for 5 or 6 patients who were completely bedridden. My job was to get them cleaned up and fed in the morning, then take them to the recreation room where they would sit in front of the television all day. At the end of the day I’d reverse the process. I thought it was very sad, very discouraging.

The humanity of medicine later became a focus of your career. Did witnessing the care in the nursing home spark that interest?

It was part of it, but the other big moment for me was the arrival of HIV in the early 1980s. Prior to that, I was caught up in what I call the “conceit of cure” – the idea that doctors could fix anything. If you made an astute diagnosis, you could have a patient rise like Lazarus and walk out of the hospital. When the HIV/AIDS epidemic hit, it was ironic that such a fatal illness should land on the laps of people like me, who were caught up in this delusion. HIV humbled me, because I was watching young men my age succumb to a fatal disease for which we had absolutely no treatment.

An entire generation of infectious disease clinicians were humbled by this disease. We learned what it meant to heal when we could not cure. We realized how much our presence and caring mattered. A cure wasn’t within our reach, but we were making a profound difference by indicating to the patient that we would be there, that we were not running away.

Witnessing the devastation of HIV also was the genesis of my becoming a writer. After training in infectious diseases in Boston, where I saw so many HIV cases, I took a faculty position at a hospital and medical school in a small town in Tennessee in 1985. We expected to see, at most, a couple patients with HIV every other year. Instead, in a fairly short time, I encountered almost 100-fold more patients with HIV than anyone predicted for that rural population.

I wanted to tell that story, which, as it turned out, was the story of young men who had left that small town to pursue education or better opportunities, but also because they were gay and did not want their lifestyle to be evident to their friends and relatives. Years later, the virus had found them, and they were trying to come back to their hometown roots, either because their lovers had died and they had no one to care for them, or because they hoped that, by retreating to a small town, they would escape the plague that had decimated bigger cities.

I wrote a scientific paper about that phenomenon of migration, but my sense was that a scientific paper could not begin to capture the tragedy of the men’s voyages or the heartache of their families – and it could not captured my own grief, having watched it happen again and again.

I was accepted to the Writers’ Workshop in 1990 and my initial idea was to tell the story of the small town through fiction. One story I wrote while at Iowa, “Lilacs,” was published in The New Yorker and I thought it was my big break.

I then submitted a proposal for a nonfiction piece about treating patients with AIDS in a small town in the rural South, from the perspective of a foreign heterosexual physician. The New Yorker passed on the piece, but my agent realized that I had essentially crafted a book proposal, and I signed a contract to write a nonfiction book, My Own Country, which was published in 1994 by Simon and Schuster.

A few years later, I wrote The Tennis Partner, based on my friendship with a medical student during my time as Chief of the Division of Infectious Diseases at Texas Tech, which is where I went after Tennessee and Iowa. But all along, I wanted to write fiction. So, after finishing my second book, I was determined to write my novel, which became Cutting for Stone. The book brought me back to fiction – my first love.

How do you make time to write without taking a sabbatical?

It is hard. My writing takes a long time. The novel I just finished writing has taken 7 years, and before that, Cutting for Stone took 6 or 7 years to complete. Fortunately, I’m not in any great hurry. The publishers might be, but I want to get it right. Also, I enjoy my day job. Of all the places where I have worked, Stanford was the first to treat my writing as a research equivalent and to build in protected time. Before that it was mostly done – and still is – on evenings, weekends, and whenever I get a spare moment.

What are the biggest changes you have witnessed since you started your career in medicine?

The most dramatic change has been the overwhelming progression of science – the way science has blossomed. Treatments that were inconceivable just 10 years ago are now nearing FDA approval. The change was most dramatic in the treatment of HIV, but has now been seen in so many arenas, especially oncology.

There was a point in time when most of us felt that there would never be anything to help patients with HIV. During that early era, I felt most aligned with my hematology colleagues. I was seeing so many patients with HIV and hemophilia, and I think both the hematologist and I got to know these individuals well in the course of managing their diseases. These patients have already been through a lifetime of hardship managing their hemophilia, and now, on top of that, they contract HIV. They took it in stride, getting used to living with these diagnoses even though it’s not what they bargained for. Today, advances in science and technology have brought about treatments for both conditions that were once unimaginable.

Another change – not necessarily for the better – is the amount of patient data now available to us. With so much data, we are in great danger of losing sight of the patients. For some time now, that has become the focus of what I study and practice: finding ways to keep the human element of medicine alive, even as we embrace technology and data science.

Every day, new patients come to see a physician, and if the physician and the patient don’t connect on a human level on that first meeting, it affects everything that follows, including compliance and treatment outcomes. Despite this, there hasn’t been a systematic study of that precious first moment, so our research group at Stanford, which focuses on the art and science of human connection in medicine, decided to do an extensive literature survey on that sense of patient-physician connection and how to better foster that relationship. We interviewed physicians, patients, and people from nonmedical professions that involve intense interpersonal interactions (like firefighters and social workers) to find the most effective practices for fostering physician presence and connection with patients.

Results from the study were recently published in JAMA, where we reported on five practices to enhance physician presence: preparing with intention, listening intently and completely, agreeing on what matters most, connecting with the patient’s story, and exploring emotional cues.

The paper is a culmination of a lifetime interest in what I call “the human factors of medicine.” Ultimately, the patient-physician interaction is one human being coming to another in distress. All the data in the world can’t substitute for one’s desire to be comforted by another human being. However, clinicians also need to deliver evidence-based care. We struggle with cultivating physician presence because of volume.

I think the best stories are those that speak some element of truth that resonates inside of you. The writer Dorothy Allison defines storytelling as “the great lie that tells the truth about how the world lives.” That idea resonates with me. When you read a great story, you’re transported into another world. If you’re lucky, you’re not just being entertained, but also deeply educated about human behavior. I love that feeling. I think it’s the greatest kind of escapism there is.

I also try not to look at the news too much. The novel that I just finished celebrates values that were especially rich in my mentors and the people I looked up to when I was coming up in medicine, which was just common decency and commitment to values that seem to be so lacking when you look at the nature of public discourse today.

One of the hematologists I knew who embodied this is the legendary late Stanley Schrier, MD. He was a founding member of the Division of Hematology at Stanford in the 1960s and he was still coming to teach us about peripheral blood smears in his 90s. My best friend Anand Karnad, MD, at the University of Texas San Antonio, is also a hematologist, writer, and great influence. He wrote Intrinsic Factors, about the life of William Castle, MD, who was a pioneer in understanding hemoglobin physiology and pernicious anemia at Boston City Hospital, where Anand and I were fellows together. I try to find ways to embody the beautiful values and the silent heroism I saw in individuals like Dr. Schrier and that I see in my friend. Their words influence my work and my writing.

What stories are you escaping with these days?

I’m enjoying reading Fyodor Dostoyevsky now. He is a writer with powerful messages. As a young man, he was arrested by the Russian tsarist police for circulating antigovernment propaganda and imprisoned along with his “co-conspirators.” After months of imprisonment, the men were sentenced to death. They were lined up in front of a firing squad, prepared to die, when the execution was halted by a last-minute reprieve from the tsar. The tsar actually had pardoned the men the previous day; the mock execution was held to scare anyone who dared to criticize the Russian government. Instead, the men were exiled to Siberia for years. But, on that day, for about 45 minutes, standing in front of a firing squad, Dostoyevsky believed that he was about to be killed.

While in exile, he wrote to his brother, “Life is everywhere life, life in ourselves, not in what is outside us. … Life is a gift, life is happiness, every minute of my life might have been an age of happiness.” You can see that captured in his characters. Even with his most hateful characters, he somehow manages to find their internal humanity. He gives you the rationale for why they are the way they are.

I believe there’s a lesson there that applies to medicine: As clinicians, we are told not to judge, and we have to go a step further and find the goodness and humanity in every patient. That’s not something that can be taught. As one gets older, though, it’s easier to appreciate that wisdom. I mean, what’s the alternative? Looking for bad things in people?