The Good Doctor

With a third book set to arrive in stores next year, Abraham Verghese has established himself as one of the most gifted writers ever to make Texas his home. Then again, writing is just a hobby compared with his somewhat more ambitious day job: Changing modern medicine as we know it.

December 2004By Comments

“FIRST IMPRESSIONS CAN point to the most important diagnoses,” said Abraham Verghese, leading the way through a warren of drab hospital corridors in San Antonio this summer. We were hustling toward an appointment with medical students of the University of Texas Health Science Center, and the 49-year-old doctor was explaining his belief that American medicine has become too enamored of its lavish technology. An Indian born in Ethiopia, Ver­ghese was trained in the British tradition, which relies heavily on bedside diagnoses, and he still approaches curing and healing like a detective. “When I’m in a crowded elevator, I feel like I’m not paying attention unless I recognize at least three symptoms in the people around me,” he said. “And if there’s nobody else in the elevator, then I need to be studying the mirror, looking at myself.” We had just emerged from an elevator, and his remark had an unsettling effect on me. I felt scrutinized at a glance, and I was momentarily jolted into an acknowledgment of that ever-lurking shadow—sickness and dying—that we try to whistle past in the alleyways of life.

Verghese has an athletic build and bearing, thinning dark hair, and a rich brown complexion. A woman friend of mine recently exclaimed, “I saw Abraham make a speech, and he made me want to take my clothes off.” The setting of her fantasy did not seem to be a medical examining room. A naturalized U.S. citizen and a specialist in infectious diseases, Verghese exudes a soft-spoken charisma. He is a pioneer in the treatment of rural patients infected with the HIV virus, who came into the profession in the eighties, a time when American doctors felt all but invincible; only cancer was truly feared, and its cure was considered just a matter of time. But the dread plague of our era shattered the illusion that research physicians, laboratories, and pharmaceutical companies had all the answers, and Verghese remains a careful doubter in search of telling clues.

HIS APPROACH TO MEDICINE is also shaped by his other passion: Verghese is one of the most gifted writers ever to live and work in Texas. At nights, after he’s had dinner with his wife and their seven-year-old son has gone to bed, he regathers his energy and focus and slips into his other cloak. He’s already written two highly acclaimed memoirs, My Own Country (1994) and The Tennis Partner (1998), both of which achieved a delicate balance of tragedy and transcendence, themes that run through his personal life and his philosophy of medical practice. And sometime this spring he hopes to finish his much-anticipated first novel, Cutting for Stone. The new book draws on the remarkable odyssey that finally made Texas his own country, but the title goes back to medieval times, when traveling monks hacked and sliced on people without disinfectants or anesthesia to remove their kidney—and gallstones. Most patients died of infection as these forebears of modern medicine moved on, plying their crude trade.

For all the plaudits he’s earned as a writer, Verghese is still foremost a doctor, and a highly sought-after one. Two years ago, after entertaining an offer from Yale, he went to the medical school in San Antonio to take on yet another challenge: to found its Center for Medical Humanities and Ethics. For more than two decades, medical students have been pondering ethical quandaries such as disconnecting a respirator and allowing an unknowing patient to die; Verghese and his colleagues have designed a four-year curriculum that requires a literary approach to ethics coursework and case studies. “Students come to medicine with a great capacity to imagine the suffering of others,” he says. “Then, as they enter their clinical years, they’re taught to take the patient’s unique story of illness and translate it into the formal language of a chart. The student may hear a patient say, ‘The pain started at four in the morning and immediately reminded me of my father, because he died of cancer and it began with a similar pain.’ But what the student records in the chart is not the voice of the patient but the voice of medicine, a formal language that sounds like this: ‘This forty-seven-year-old white female developed the acute onset of left flank pain eight hours prior to admission.’ This language is essential for diagnosis, but the danger is great that students may depersonalize their patients and begin to think of them as simply ‘the diabetic foot in bed two,’ ‘the myocardial infarction in bed three,’ or ‘the chronic renal failure in bed five.’” To critics who scoff that making overworked apprentice physicians read Kurt Vonnegut fiction and watch Frankenstein movies is a waste of resources and time, Verghese points to a course syllabus that addresses the alarming incidence of depression and addiction among physicians; the anger of doctors and the motives of whistle-blowers; and the concerns of a deaf couple who employ in vitro fertilization and genetic diagnosis to ensure that their baby will also be born deaf and grow up in the culture they know. Right or wrong? Or does that language even apply? “Through the humanities,” says Verghese, “we can keep the students’ imagination of the suffering of others alive.” So he insists that his students pay attention to stories, the ones right in front of them—the ones he’s been writing about all his life.

DOUBTING THOMAS IS THE APOSTLE WHO SAW CHRIST after the Resurrection but had to touch the wounds from the nails and spear before he could believe it was him. Tradition holds that Thomas went on to preach in Parthia, an ancient country in what is now Iran, and that he died a martyr in Macedonia. But a church in Malabar, a coastal region in southwest India, contains a tomb where his bones are alleged to lie. It is in Kerala, a state with a significant Christian population whose legends boast the mission and ministry of Thomas. Centuries of occupation by the Portuguese doubtless influenced the choice of faith by the people of Kerala, but however it came about, Kerala is the only part of India where boys are commonly given names like Abraham.

Verghese’s parents were physics teachers who did not meet until after they had left Kerala and immigrated to Ethiopia. In the forties, after Emperor Haile Selassie had spent World War II trying to rid his country of the Italian fascist invaders of Benito Mussolini and of the British liberators who came afterward, he committed himself to modernizing Ethiopia. A diminutive and stylish man, Selassie was enormously impressed on a trip abroad by schoolteachers in Kerala, so he recruited them en masse, which is how two Indians named George and Miriam came to meet in Africa and have a boy named Abraham in 1955.

Haile Selassie was an accessible emperor, roving the eucalyptus-lined streets of Addis Ababa in a fleet of glass-topped Rolls-Royces, pressing his palms together and bowing to Indian women who caught a glimpse of him. Jacqueline Kennedy, whom he entertained in an imperial mansion modeled on Buckingham Palace, befriended him during a trip abroad as America’s first lady. One of Verghese’s strongest early memories is of his parents taking him and his brothers to the public hanging of three men who had attempted a coup. Verghese was six. The dead men swayed from a scaffold above “a dancing horde,” he would later write, which leaped “into the air in unison, chanting and ululating.” The men had been executed in their be­ribboned uniforms, and their shoes had been stolen. “But where are their shoes?” he asked his parents. His far-flung Indian family included several doctors, and he spent a fascinating year of premed study in India, but Verghese grew up thinking he would always live in Ethiopia. He was accepted into a medical program there in the early seventies, but he soon found himself a student without a school in a country in chaos. A colonel named Mengistu Haile Mariam, whom Verghese describes as the Stalin of Africa, would turn a mass revolt into a leftist military dictatorship; in 1974 the emperor with all those special-ordered Rolls-Royces was arrested and hauled off in the backseat of a Volkswagen Beetle, to die imprisoned and senile. The medical school was shut down by the authorities; in an apartment, Verghese and other students “smoked too much and drank too much and played endless games of Monopoly.” Every dawn presented the sight of corpses in the street. Verghese’s parents fled to the United States, but he procrastinated. One night in the tense weeks before the revolt, he was in a bar and had dallied past the eleven o’clock curfew. The owner locked her customers inside, because curfew violators were routinely shot. Again there came a moment of stark focus on feet.

Verghese saw men whose brightly polished shoes did not match their cheap pants and sports coats. He was getting loon drunk, he realized, with soldiers who carried guns and had been sent to inform on people like him. Long after midnight, two boozers got in a fight. One lost his pistol in the fracas, then brandished a grenade. The other man slammed through the door to the street. “A figure,” Verghese would write, “coattails flying, sprints away. Suddenly the coattails vanish in an explosion that rattles the windows. Minutes later the jeeps arrive, like hyenas that have picked up the scent of blood. The man who threw the grenade chats happily with the soldiers. A vague, crumpled mass is visible in the distance. I think: I cannot get out of this country soon enough.”

When Verghese at last got a visa, he joined his parents in Westfield, New Jersey. He thought his hopes of being a doctor had been extinguished. In America he would have to enroll at a college and get a bach­­­elor’s degree before he could even attend medical school. Ver­ghese lived at home and worked as an orderly in a nursing home, then in a hospital. He described his social life as “third shift,” friendships with young people who also worked at night. One day at work he picked up a copy of Harrison’s Principles of Internal Medicine and found himself inspired by the idealism and elegance of its preface. He understood again that he wanted to be a doctor, but to do that, he would first have to spend a long sojourn in the country of his ancestors.

Some of his relatives persuaded the Indian government that he was indeed a native son and that he had been unjustly deprived of a promising medical education. The government granted him educational status as a refugee and arranged for his admission to a medical school in Madras. After a whirlwind courtship, Verghese married a young woman of upper-middle-class background who was an account executive in an advertising agency (he knew he had to move fast to get around his penurious circumstances and the Indian tradition of marriages arranged by families). In an infectious-diseases ward he gained clinical experience treating typhoid fever, scrofula, and measles; once he was even called out to give a shot of Demerol to an elderly Brahmin priest who was dying of rabies in a padlocked “dog-bite room.” He admired the personal, hands-on approach that Indian medicine had adapted from the British. But at the same time he grew frustrated. The medical professions were rapturous because of the technological breakthroughs in America. But he soon learned that he was not going to have the advantage of MRIs or CAT scans in the hospitals of India. “One learns that the American dream,” he says today, “can only be lived in America.”

So in 1980 he followed what he calls “the cow path” of foreign medical graduates to inner-city and small-town hospitals in the United States. For him it led to Boston and Johnson City, Tennessee. In 1981 he took curious note of an article in the New England Journal of Medicine with a rambling title that read, in part, “Previously healthy homosexual men—evidence of a new acquired cellular immuno­deficiency.” AIDS was already wreaking havoc in Los Angeles, New York, and San Francisco, but no one had yet written about its arrival in Appalachian Tennessee when Verghese and his wife and young son moved there. Homosexual men were hardly the only ones afflicted, of course, but when Verghese was first seeing the virus and the resulting all-systems breakdowns, even its victims were expressing fears of a “gay cancer.” Cases multiplied during his five years in Johnson City. He treated everyone who wanted to be treated, wrote prescriptions for infections for those who otherwise did not, and watched his patients weaken and die, sometimes in horrible distress and pain. Verghese won wide recognition and praise for his work there, but his all-consuming and controversial work was less appreciated in Tennessee.

“The last straw,” he says, “was when an administrator called me in and asked me if I thought we were going to see an increase in these cases at our hospital. ‘Absolutely,’ I said, and began to tell him what I knew and believed. He cut me off and said, ‘I wonder how many more we’d see if you weren’t here.’”

Trying to regain his equilibrium, Verghese  left Johnson City with his family for Iowa City, Iowa, on New Year’s Eve, 1989.

In San Antonio, Verghese divides his clinical practice between the university hospital and the nearby Audie L. Murphy Veterans Hospital, where I joined him this summer to go “rounding” with some of his third-year students. For an hour or two they gathered at the bedsides of patients and talked about physical diagnoses. We met three students at a nurses’ station, and as we approached a room, one of them started to tell Verghese about the patient’s leukemia. The teacher politely but firmly cut the student off. He wanted them to come in with no preconceptions and study the clues.

Patients in a VA ward can be a cranky and irascible lot. This is all the medical care most can afford, many know the hospital may be their last stop on earth, and some believe it’s run with the efficiency and compassion of a bus station. But the old-timer with leukemia was perfectly amiable. Ed, I’ll call him, had a fine-boned, long-jawed face and iron-gray hair that was neatly combed. He sat propped up in the bed, hands clasped over his belly, which was veiled by the sheet but was swol­len the size of a peach bushel basket. If Ed made it out of there, it would be to die at home. His leukemia was far advanced.

Verghese asked him how he came to live in Texas. “Oh, my daddy brought us here during the Depression,” Ed replied. “He liked the weather, and it was a cheaper place to live. I’ve lived in Texas all my life, except during World War II.”

“Where were you in the war?” Verghese went on.

“In the Pacific, with the Navy,” Ed said proudly. “Running landing crafts at Saipan and Guadalcanal.” He beamed at our murmured compliments of that intense combat service, and his smile broadened at our exclamations when he revealed that he was 92. He looked about a decade younger. “I believe I’m here because the good Lord has a purpose for me,” he said. “When he’s done with me, I’ll be ready to go.”

While this conversation proceeded, Ver­ghese briskly tapped around on Ed’s chest, sternum, and abdomen with his middle finger. I had never seen a doctor percuss with quite the same air of enjoyment. Verghese has written about his personal discovery of the art of percussing, which is not used by many American doctors. A professor in Addis Ababa, Ethiopia, once drilled students in his third-year class: “Which is the least important instrument in our armamentarium?”

“The stethoscope, sir!” they cried.

“And why is that, pray?”

“Because, sir,” they chanted, “by the time you have looked, felt, and percussed, you should know what you will hear!”

Verghese’s breakthrough came one night in 1972 when he lay awake tapping on himself. Thoom, thoom! went the lungs. Thunk, thunk! the liver. Tup, tup! the sacs of air trapped in the large intestine. Up and down, back and forth, playing himself like an instrument: Only a doctor who thinks in the metaphors of a writer would liken this diagnostic procedure to letting his “fingertips fall like piano hammers.”

One might say that Verghese was just going through the motions with an examination of this patient, whom he’d probably never see again, but for him the ritual was an article of faith. Verghese adjusted the angle of Ed’s bed to make him more comfortable. Even this worked into his free-form lecture. People suffering from congestive heart failure, Verghese told the students, cannot lie flat, because they doze and then wake to the sensation that they’re drowning. “I’ve heard about them kicking out windows,” he said. Ed tilted his head and smiled. Soon the teacher and the students would come back around to the bloated abdomen, a symptom of this man’s leukemia, but Verghese quizzed them on the meaning of all sorts of things they saw in his hands, his lips. The students thought back to classroom lectures and their voluminous reading and usually came up with an answer, but often he stumped them.

Finally, Verghese told his students about a case that came to him when he was practicing in Tennessee. “An elderly man is hospitalized, suffering from a severe stroke,” he said. “His right side is completely paralyzed, but we don’t know if it happened yesterday, last week, or a month ago, and that’s essential knowledge if we’re going to help him. If the stroke is acute—ongoing—we really have to know that. But he can’t tell us. Then we notice the fingernail. Now what could that mean?”

Verghese has a photograph of this fingernail on a wall in his office. The lower half of the nail is flesh-colored, but, as if it had been slammed in a door, the upper half is marked by an abrupt line straight across, where the nail’s color changes to an unsightly orange hue. The effect is not the common hemorrhage and bruising symptomatic of a smashed finger. To Verghese, this is one of the best examples of a diagnostic clue.

The students offered various conjectures that sounded unsatisfactory once they gave the riddle more thought. Finally, Verghese said, “It’s the yellowing of nails distinctive of someone who has been a heavy cigarette smoker.” The students murmured thoughtfully. “But why would the color just change?” he asked.

“Because he quit smoking,” said one.

Verghese nodded and coaxed more with motions of his hands. “Sure seems sudden, though. Why?”

“Where he was,” theorized another, “he wasn’t allowed to smoke.”

Verghese was nodding. “Or he couldn’t smoke,” realized the third student. “He had lost the ability.”

Just like that, the apprentice clinicians had begun to unravel the poor man’s mystery. Verghese reminded them that fingernails grow out at a rate of about one millimeter a week. If they measured how many millimeters of normal nail had grown from the line of demarcation, they could calculate with certainty when the man had suffered his stroke, and with that knowledge, they could begin to know how to help him.

Later, when we were back in his office, I look at the bookshelves and walls and found myself staring at the photograph of the man’s fingernail. The puzzle had a missing piece. I asked Verghese, “But why would you know nothing about the man who had the stroke?”

The doctor smiled sadly. The fleeting moments of transcendence always come paired with tragedy. “Members of his family brought the man to an emergency room,” he said, remembering that evening in Tennessee. “They said they were going out to park the car, and they never came back.”

WHEN HE AND HIS FAMILY arrived in Iowa City, Verghese worked part-time in an AIDS clinic, but the real reason for his move was to enroll in the prestigious University of Iowa Writers’ Workshop. Verghese dressed for class in doctor’s corduroys and tweeds and worried that he hadn’t read enough to write well; other students sauntered into class in jeans and T-shirts, spouting their knowledge of postmodernism and other critical theories. Ver­ghese’s good friend at the University of Iowa, Tom Grimes, is a novelist and playwright who has since helped launch the thriving writing program at Texas State University. “Abe was a little tentative at first,” he tells me, “but he had such tremendous subject matter in his grasp that he soon lost his anxiety. He always said, ‘I can’t just be a doctor, and I can’t just be a writer. I want to do both.’”

One night there was a big reading in Iowa City by John Irving, the author of The Cider House Rules and The World According to Garp. The famous novelist’s real purpose in town was to watch an NCAA wrestling tournament. But Irving went to a student party, where the apprentice writers put out some chips and beer in a dirty apartment and, out of intimidation, were slow to approach him. Verghese introduced himself to the author, who, as it happened, was researching a novel called A Son of the Circus, a story about a doctor trying to find his way in India. Verghese had found a mentor, and a friendship took root.

Verghese wrote some dark and self-conscious stories about junkies in that period, but the story that struck a match to his talent and career was “Lilacs.” An agent who had passed through Iowa City discovered the manuscript and sold it, to Verghese’s amazement, to the New Yorker. The story portrays an AIDS victim in Boston who tries to prepare and counsel another with a personalized shock treatment: “It’s not illegal to hold hands—is it, Clovis? O.K., I’m going to let go of your hand. I want you to answer a series of questions for me. I’ll write down your answers on paper, and then you put that paper in your pocket and carry it with you. Then—trust me—you will have conquered death. It worked for me. O.K.? First of all, where do you want to die?’”

Verghese left Iowa City in 1991 with a master’s degree in fine arts and a desperate need to earn a living again. He moved his family to El Paso, where he taught medical students and residents of its Texas Tech Health Sciences Center and worked in a county hospital. He fell in love with the isolation, scruffiness, and spunk of El Paso, though it was during those years that his first marriage failed. The AIDS epidemic had become a permanent part of his life. At the El Paso clinic, he treated a Hispanic man who later died from the disease; the man’s lover also became Verghese’s patient and one of his closest friends—years later, he died as well. A woman named Sylvia, a cousin of the first AIDS victim and a friend of the other, worked as a volunteer at the clinic. She and the doctor of her loved ones married in 1996 and now have a small son.

Editors at the New Yorker, meanwhile, urged Verghese to write a long nonfiction piece about the coming of HIV and AIDS to rural Tennessee. He submitted a proposal, but the magazine rejected it—actually a piece of luck, for he salvaged it and made it the proposal for My Own Country. He worked on the memoir for four years, and it came out to extraordinary acclaim. Showtime made a fine movie of it. During the time between marriages, Verghese had first lived in a barely furnished apartment and, when he wasn’t working or trying to entertain his two children, he had played obsessive tennis with a young medical student named David Smith, an Australian who had come to America on a tennis scholarship and had played briefly as a pro. But the friendship was not enough to save the young man from an addiction to cocaine. In The Tennis Partner, which Verghese wrote several years afterward, he last sees David snarling in an alley, like a cornered rottweiler. “Leave me alone,” the best friend shouts, then crashes between garbage cans and runs off to his doom.

“I sometimes think I don’t learn anything from an experience until I write about it,” Ver­ghese tells me. “From My Own Country I learned that relationship and family almost always win out. I don’t care how bigoted and rednecked people might seem; when AIDS happens to their families, the overwhelming response is to show courage and caring. Gay men also taught me a great deal about maleness. They’re free of so much posturing that heterosexual men think they have to do to impress women. The Tennis Partner delivered me from the guilt of a terrible experience in my life. People who were close to others who’ve committed suicide are always thinking, ‘What could I have done? How could I have stopped it?’ Writing that book, telling that story, enabled me to learn that the addiction was David’s illness. It was his responsibility.”

With the books have come numerous requests from editors to write pieces for magazines: British Esquire, the Atlantic, Granta. Verghese smiles and says that despite the time constraints and the urge to finish his novel, he seldom turns the magazine editors down—he doesn’t want to take their calls for granted. His experience is so broad that he can draw a convincing personal essay from life on three continents. A year behind Verghese at the medical school in Addis Ababa was a brilliant young student named Meles Zenawi. He took to the harsh countryside in a guerilla army, and they fought the dictatorship’s troops in running battles for seventeen years. The victorious rebels wore long hair, khaki shorts, and sandals when they took the capital, in 1991. Zenawi is now Ethiopia’s prime minister. Amazed that he could have known such a man, Verghese returned to Addis Ababa to interview Zenawi for Talk in 1999. The leader of the country greeted his onetime colleague: “Welcome back.”

THOUGH HE’S STILL hard at work on his novel, Verghese spends much time these days making speeches, raising money, and building support for the new center in San Antonio. And since his curriculum is only two years old, he is constantly tweaking it, trying to find new ways to shake up his students’ perspectives.

In one of the school’s first sessions, a lecture he gives to the incoming class, Verghese describes the course objectives in broad terms and talks again about the importance of story—not just patients’ stories but the students’ stories as well. Then he introduces Patti Wetzel. She is a polished, attractive, self-assured physician—everything the medical students hope to become. “I tell them that as they learn about disease, they’ll start thinking they have every one,” she tells me. “If the subject is breast cancer, and you’re a woman, you will start feeling lumps. That can’t continue, of course, because if you’re constantly frightened, you can’t treat your patients. So you construct this wall that protects you, but the problem is that it divides you from your patients.”

Then, as Verghese observes, Wetzel will tell the students her story. She was a practitioner in Fort Worth who had dedicated herself to the care of HIV and AIDS patients. In 1991 she had an accident that happens all the time in hospitals and doctor’s offices. “I was drawing blood from a patient and pricked myself with the needle. For thirteen years, I’ve been living with the HIV virus. Dr. Ver­ghese is my physician.” Verghese will watch his students as a total hush grips the room. Divisions of rank between doctor and patient are eliminated. Any psychological and judgmental barriers that his students may have constructed against AIDS and its victims will have just come crashing down.

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