The Good Doctor
(Page 2 of 3)
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.
