Abraham Verghese
Bedside Manners
I was taught to tap and thump my patients and listen for the sounds of sickness and health. But this is fast becoming a lost art, and that’s bad for everyone.
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In Auenbrugger’s time, physicians focused largely on symptoms and had no great need to touch the patient (which some would argue is where we are now). Knowing what ailed you made little difference, because as far as treatment went, you could only be cupped, purged, scarified, or bled. Bleeding was to that era what antibiotics are to ours: abundant and overused. At the barber-surgeon’s establishment, you held on to a pole as he sliced you and collected your blood in a basin. While there, you could also get a tooth pulled, an abscess drained, and finish up with a shave and a haircut. The barber-surgeon was nothing if not versatile. At the end of the day, the barbers washed long strips of bandage and hung them outside to dry. Medical students are often surprised when I tell them that the familiar red-and-white barber’s pole has its origins in bloodletting, with the stripes representing the bloody bandages and the ball on the top of the pole representing the basin. If you had a chance to live, these treatments might nevertheless do you in; if you were destined to die, they mercifully hastened the end.
When Auenbrugger became a physician, he started thumping and tapping on his patients and painstakingly cataloging the sounds of health and disease they produced. The book he wrote about this practice, Inventum Novum, published in 1761, had the impact on medicine that X-rays would have 150 years later. For the first time a doctor could “see” beneath the intact skin into the innards of the body. Percussion allowed (and still allows) a physician to get evidence of a dilated heart, an enlarged liver, fluid around the lung, fluid in the belly, a perforated stomach ulcer, and many other conditions. I think of present-day ultrasound as the child of percussion, the ultrasound transducer generating a sound wave that bounces off the tissues and comes back to a sensor.
Like any new method, percussion had its overenthusiastic practitioners. The famous Pierre Piorry percussed while sitting on a high stool next to the patient’s bed and then used colored crayons to outline the organs. Known as the “medical Paganini,” Piorry claimed each organ had its own note and the body held a musical scale. An apocryphal story has Piorry going to see the king and, on being told that the king was out, proceeding to percuss the chamber door and declare that the king was in.
I attended medical school on two continents. My first clinical professor in Addis Ababa, Ethiopia, was a spiritual descendant of Auenbrugger’s named Charles Leithead. He taught us how to place our fingers on the wrists of patients with rheumatic heart valve disease and recognize the slapping, “water hammer” pulse of a leaky aortic valve or the plateau pulse (pulsus parvus et tardus) of a narrowed aortic valve. He marched us to the heart, taking the blood pressure along the way, studying the sinuous waveforms of the neck veins, which mirrored the happenings in the heart’s upper chamber. He carefully inspected the patient’s chest and felt for the thrust of the heart between the fifth and sixth ribs on the left, though in an enlarged heart, the impulse could wander down and out to the armpit. At this point in an exam he had us pause and try to put the clues together. His teaching was “Before you pull out your stethoscope, you should know what you are going to hear.” It was heady, marvelous stuff. When I finally heard the soft, rumbling, low-pitched, mid-diastolic murmur of mitral valve narrowing that is caught only with the bell of the stethoscope lightly applied, I was ecstatic. I heard it because I knew it would be there.
Displaced from Africa by civil strife, I went to Madras, in South India, to finish my studies. My teacher was the legendary K. V. Thiruvengadam, known to all as KVT. KVT is the Ravi Shankar of percussion. He enjoined us to “percuss to feel and not to hear.” The vibration we received in the pleximeter finger laid flat against the chest was, he said, more important than the sound. You can recognize KVT’s progeny from our near-silent percussion; if I percuss audibly, it is only to teach, or to demonstrate, say, to a skeptical brother-in-law or spouse.
For sleuths of the caliber of Leithead or KVT, a diagnosis could be lurking in something as simple as a facial expression. Not the dull and coarse facies of a sluggish thyroid or the masklike expression of Parkinson’s disease, which are evident to laypeople, but the risus sardonicus (sardonical smile) of tetanus or the facies latrodectismica (a grimacing, flushed, jaw-clenching, puffy-eyed expression) of a patient affected by the toxin from a black widow spider or the Madonna facies and transverse smile of a type of muscular dystrophy.
My final exam at the medical school in Madras included a rigorous clinical test with real patients carefully selected for signs and symptoms of a disease. In America, final-year medical students face no such clinical test. Even for specialists in internal medicine, testing with real patients and live examiners was done away with in the mid-seventies, after it was deemed too subjective. Recently, the powers that be put in place a national Clinical Skills Assessment Exam for final-year American medical students, for which the student has to cough up $1,000 and travel to one of a couple of centers in the country. In my opinion and the opinion of many academics I talk to, this exam tests everything but clinical skills. It tests the student’s ability to make eye contact, to interact with a person acting the role of a patient, to follow the appropriate leads in his fictional story. Does it test whether the student can detect an enlarged liver? Or hear the diastolic sound of heart failure? To get a driver’s license or a pilot’s license, it is axiomatic that an examiner must watch you drive or fly to confirm you have the skill. Not so in medicine.
I recognize that I am an incurable romantic. I teach bedside skills because I hear the ghosts of Auenbrugger; of the celebrated physician Sir William Osler, who took us out of the classroom a century ago; and of the old horse-and-buggy doctors in South Texas who could divine their patients’ maladies by touch, smell, sight, and sound. I hear them say, “Thou shalt not break the chain.”
For the past few years in San Antonio, I have spent Wednesday afternoons on “professor’s rounds” with six or seven third-year medical students, seeing patients they have worked up. Each week, when I round with a new group, I ask them not to tell me or the other students what the patient’s diagnosis is, so that we can see how much the body alone might reveal. The students love these sessions. They often say that this is what they envisioned medicine would be about: time spent in the hallowed space around the patient’s bed, time spent with the patient, probing the body for clues. I preach that it is a skill they should cultivate, not to replace technology but to allow them to use technology judiciously and to ask better questions of the tests.
At a recent Wednesday afternoon session, our patient, an elderly veteran, was thrilled by the attention from the flock of students, particularly their percussing of his chest. “My doctor used to do that when I was a boy,” he said with a smile. “He sure knew what he was doing.”
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