Bringing Bedside Back w/ Dr. Abraham Verghese

– You know who I have with me here Z-Pac, the legendary Dr. Abraham Verghese. He is a legend on so many levels and I’ll tell you why. Because I have been wanting to talk with you forever and ever and ever because you’re a physician of Indian origin who has done so much in the humanities in terms of being an author, trying to bring back the touch and the relationship and the this to medicine where it’s been lost and so to be able to have you on the show is such a huge honor. Dr. Abraham Verghese, thank you for coming.

– The honor is mine, pleasure.

– Now you are a professor of this or that or the other thing. Can you give us your full credentials?

– Sure. I’m a professor of medicine at Stanford University. I’m the vice chair of the Department of Medicine, and I hold a professorship called the Linda Meier and Joan Lane Provostial Professorship.

– That’s a lot of stuff.

– That’s a lot of words.

– That’s a lot of stuff. But you didn’t, what really attracted me to your story and we knew each other briefly at Stanford when I was practicing, you had come just as I was leaving. Is your path.

– It wasn’t me, I hope.

– It was totally you. I was like, there can only be one bald Indian man in this facility at once.

– I have to tell you a story though.

– Blab.

– I get confused with you. People stop me and say, are you that ZDogg guy, and I’ll say, you know he’s younger and he’s better looking, thinking that they’ll contradict me, and they’ll say, you’re right.

– Okay, dad, are you listening because this guy, very famous, truly Indian okay, not just pretending like me. And he said that he gets confused, okay, so I bet, you better. That’s amazing actually. So a lot of my fans actually are big fans of your books.

– Oh, that’s great.

– So I mean Cutting for Stone, My Own Country, The Tennis Partner, these books are really iconic in the sense, and especially in the medical world, especially, even though they’re widely known and you’ve won awards and there’s a picture of you with Obama there. You’re the real deal, but the thing about these books is that they bring a medical perspective from a practicing physician who was on the front lines and that’s so much missing in much of our literature and in the humanities because when we do medicine, we often let that stuff, the creative spark, and I’m here in your office at home in the Bay Area, and I’m seeing how you work and how you let the muse come through you and how you outline everything and for your next book you’re working on, and to see that and be a professor of medicine at Stanford, how did, I mean, this is what I want to bring to you guys, Z-Pac, is how we can learn to reconnect with our inner passion and the humanities and the humanity in what we do that makes it a calling. And so that’s what I wanted to talk just as a broad framework.

– No, I’d love to talk to you about that. I think we have to remind ourselves that this was always an art and a science, and the doctors that we admired and the names we trot out, William Osler, they had books at their bedside and they weren’t medical texts. They were reading the classics. They were well versed in what’s out there and I think the creative part of medicine is very much what makes us good doctors, but it also keeps us refreshed, keeps us alive and I worry about the whole, I’m all for evidence based medicine, but it can seem like the soulless passionless exercise of algorithmic thinking. And to me the fun part was always the human being at the end of this experience. Both the physician and the patient and their humanness is what makes this so very special.

– Also, I think that you kind of nailed what has sucked some of the joy out of medicine for people like myself. When it went from that sitting at the bedside, right. And always coming into the room and sitting down and making eye contact and talking to the patient, especially in the hospital where they really are at their most vulnerable and they’re scared and they’re waiting all day for you. And then you come and stand and make a U turn at the bedside, looking at an iPad, clicking the buttons with the fleet flock of geese following you as an academic, it’s devastating to why we went in. And like you said, Osler and these guys, they were classically humanities trained in addition to being medically and scientifically trained.

– Well, I think we have to be sensitive to the idea that the data set that we’re dealing with would just terrify Osler, I would imagine. And there’s just no way to sit and juggle that by keeping it all in your head or the intern presenting from a clipboard. We now have vast amounts of data. So in a sense, we do need the computer, we do need all these things that are taking up more and more of our time. The trick is to try and find a way to integrate them better so that we can still feel like we’re at the bedside sufficiently.

– Well, and I think that’s the trick. Like, you’re not a Luddite. Like I see your computer here, I see this fancy microphone. You are a communicator, you use technology. What you’re not saying, and some people, I’ve heard critics of yours actually say he wants to bring us back to the witchcraft days of medicine where we’re just about this intuition that fails us so often.

– Oh, far from it.

– Right, right.

– I mean, I’m learning to use an ultrasound and very much into–

– What?

– Well somebody you know, John Kugler, I hope you talk to him one day, has become this sort of pioneer of ultrasound in internal medicine and I think it’s the next stethoscope and why not. If it’s at the bedside rather than sending someone off to a suite, to me that’s all part of bedside medicine.

– That’s the secret. So we just did an episode about point of care ultrasound in the OR, in the perioperative setting. And the fact that the anesthesiologist normally sends the patient off to have a study, something like that. Now the anesthesiologist is looking at the patient, laying hands on the patient, putting the probe on the patient right there. It’s so different. It actually brings us closer.

– I’m all for that. I’m all for that. I think that you’re right, I get characterized as being a Luddite and anti-technology. I’m only anti to the things that don’t serve us well. When a technology doesn’t serve us well when it’s all cut and paste and repetitive and when you walk into the intern’s room, the resident’s room, and they’re all facing the computers and we’re having no dialogue, I think we have to figure out better ways to do this.

– The electronic silos have been devastating. It’s interesting as much as, and for people who don’t kind of understand what Dr. Verghese’s stance is in all this, he’s really made, you did a TED talk, you’ve done a lot of work around bringing bedside medicine back and that sort of the physical exam and the ritual aspects of it as well as the scientific, the technological aspects, integrating them, that’s your sort of, that’s the gift that you bring to us. Eric Topol, Dr. Topol down at Scripps, who is a friend of mine as well, he has been sort of pigeonholed into he wants to replace all of that with technology.

– That’s not true either, is it?

– It’s not true. He is very much a bedside clinician.

– Very much so.

– And so both, all of us agree that technology serves the human relationship, that there’s a deeper, almost spiritual calling to what we do. Meaning it’s bigger than us, right.

– Yes.

– And that if we can build our technology and our processes where we get to do this, and this stuff, the technology takes this stuff off our plate, then then we’ve done a service to the healing.

– Absolutely. And I think we have to be really careful not to imply that if we got a better electronic health record we’d all be at the bedside. Actually, studies have shown that in the era when we didn’t have the electronic medical record, we didn’t necessarily spend more time with the patients. We probably spent more time at the elevator waiting for it to take us down to radiology, pull up the films. I don’t know if that was before your time.

– Oh, no, I did that, yeah.

– All the time we wasted looking for the jacket.

– Yeah.

– But we also run into other colleagues in radiology where you’ve got to talk to the surgeons, you’ve got to talk to the radiologists, and now that I can pull up my images anywhere around here, we’re not getting those kinds of interactions, which we’re realizing are some of the unintended consequences of the advances in technology. So I’m all for technological advances. I celebrate them. We need to make a science of looking at the unanticipated human consequences every time we roll something out because it’ll come.

– That gets me thinking a lot about when I left Stanford to move to Las Vegas to build our clinic, Turntable Health, and this idea that it was replacing a transaction which is a copay, a visit, a this, with a relationship. That was our goal. Part of the drive for that was Tony Hsieh, who was the CEO of Zappos. His whole vision was we want to encourage return on collisions, ROC, getting humans to collide with each other and the unanticipated benefits that come with that. In medicine, it’s exactly what you said. If you go down to radiology because that’s where the physical film is and you’re forced to talk to my wife down there, that’s the only time she’ll talk to anybody because she’s a misanthrope, I’m telling you, no, I’m kidding. She’s working right now in fact, at Stanford. You could get an insight or a connection or a spark of wisdom and she actually, Margaret, my wife, told me stories about when you would come down with the team.

– I’m one of the few who still does that.

– One of the few who still comes down with the team to the gaggle of students and residents and interns and Dr. Verghese and they would come down and they would ask her to go through the film, look at the different parts, clarify things, talk it out. And she loved that. That’s why she went into radiology. It wasn’t because she hated talking to people, quite the opposite. In fact, she board certified in medicine with me at Stanford. We met as interns. But then she was like, you know what I hate about medicine is you can’t know everything about the interaction. There’s a black box there. Whereas in radiology it’s all there. It’s up to you to know how…

– You know here, anecdotally, fewer students are going into radiology. I’m writing letters right now for the fourth year medical students.

– Oh wow.

– I haven’t met one yet who’s looking for a radiologist, but maybe there are more that I’m missing, but it used to be, we used to talk about the road to success. Do you remember that?

– Road, it was radiology, ophthalmology?

– Orthopedics.

– Orthopedics, derm, anesthesia, derm.

– So now it’s the ode to success. It’s O-A-D, you see?

– Oh, so what happened to radiology?

– Well, I think there’s a perception that you’re lonely down there. Not many people are coming to see you. They can get the image anywhere. They can get the interpretation done remotely. They may not need you one day and there are all these fears around that. I don’t know that they’re justified, but that’s certainly the perception. So my understanding is that, here’s the technology that’s actually put in jeopardy the very technology itself in the sense of the people who brought it us.

– It’s interesting because I have this argument with my wife because–

– You do? You sound smart.

– Believe me, it’s not smart to argue with Mrs. Harvard Stanford because I’m a child of public education, Berkeley and UCSF and I lose every time because of funding. It’s purely funding.

– That’s why.

– I’m just telling you, but the truth is the argument is around I told her there’s a fair chance that radiologists are gonna be replaced by AI within our working careers. And she disagrees. And I ask her why and she says, you don’t understand the human piece that actually goes into interpreting those shadows. That it is integrating a lot of information, yes, but there is an unspoken piece that often comes from this where Dr. Verghese comes down and gives this piece of information that the computer doesn’t have and will never have.

– And I agree with her. I agree with her totally. And I also think it’s sort of a specious argument to pit AI against humans.

– Okay, we had a little technical glitch because my iPhone went blalalalala because it doesn’t like AI. You know why? Because the robot overlords from the future are watching this, and they’re like, if he starts getting into AI, it’s gonna change the course of history. So we were talking about my wife and our disagreement over whether radiology will be replaced by AI. And you were saying it’s a specious argument. Yeah, I think it is because we don’t need to pit AI against the physician. Every tool we’ve picked up in the last 200 years from a stethoscope to an opthalmoscope, it’s never been there to replace us. It’s just made us better at saying what’s going on.

– Yeah.

– So I completely agree with her. I think AI will do a much better job of presenting to the radiologist cleaner options to look at. But ultimately it will be some human being to try and make sense of that because we can keep refining it and refining, but I think we still need someone at that end to put the story together and have a dialogue with the patient, which might be happening more in radiology then ever before, I suspect.

– There are radiologists who are talking about it.

– Yes, very much so.

– Yeah, who are bringing sexy back to the–

– Well, it’s so frustrating, you get an MRI on your knee or something, it’s there, you can see it, but you can’t be told what’s there. It has to go through the circuitous. And I would love for the radiologist to come out of that suite and come talk to me and say, hey, I was watching this and here’s what we’re seeing and you can talk to your orthopod. I mean, why not?

– Why not? And I was talking to Patrick Ha, who’s gonna be on the show tonight. He’s head of the ENT neck surgical oncology at UCSF. And as a friend of mine, we were gonna talk more about HPV cancer. Now, he was saying, and some others here at Stanford, I was talking to some other radiologist here, they have technology now where you can do an intra operative MRI.

– Wow.

– So they roll the thing on rails, the magnet on rails into the OR, and say you’re having a brain tumor removed, your skull is open, instead of closing the skull and sending you back, they can bring the MR to you and the radiologist is there reading and can talk to the surgeon in real time and say, you missed a spot right there. And it’s transformative. But it’s that relationship.

– Yeah.

– And I think what we’ve seen is we’ve seen this siloed off, but it’s not that we don’t want technologies, it’s that we don’t want bad technology.

– Exactly, yeah.

– Well, and speaking about technology, so this brings us to the EHR piece.

– About which you seem to have an opinion.

– I have a couple opinions. And here’s the thing, I love technology. I’m using, you saw the little device I’m using. I think it’s disruptive, everything, it’s brilliant. The EHR, I had such high hopes. I was there at Stanford in 2004 or whatever when Epic went live. I was on call that night and I went from paper to plastic very, very quick and you saw the promise. All the data was there. So many errors were removed, however, new errors were introduced, and they switch a radiology PACS system, new errors are introduced every time. And we forget about that stuff. We don’t acknowledge it and we incentivize the wrong things. Meaningful use. Everyone should have an EHR with this and this and this capability. Well, is there any evidence that what you’re asking for actually makes a difference? Maybe you should ask us because we kind of know what matters.

– I think that’s the missing link. The whole thing was designed, as you know, very much around billing.

– Yeah.

– And as useful as it is, I don’t think it’s fundamental purpose was to ease our life or that of the nurses or everybody else is using them or the patient, for that matter.

– Heaven forbid we care about the patient, right.

– And so I think that that’s where the clunkiness comes in and yet, I think, I badly would love to see the kind of computer technology that allows us to have a very complex patient and have them just laid out like this board here, where I can truly see the trajectory of their illness rather than having to sort of scroll through screens. And that’s what AI and that’s what a good EHR should be doing for us, is giving us a version that we can digest and understand and allow us to go to the patient and say, okay, I have a better sense of you.

– Oh, that’s so exciting to even think about it because I mean, look, I’m gonna give a flash of this. Can I flash your whiteboard?

– Please, yes.

– So he’s writing a new book. He’s sequestered here. He has his process. This is a storyboard, alright. That’s what it looks–

– Which I don’t follow, I keep running away from in other direction.

– Because he’s an actual artist. It’s like, you can’t really. But the thing is, what you just said actually is the first time I’ve heard it put in those terms, that an EHR could actually storyboard a patient’s, not just their illness, but who they are.

– I go to some of these presentations, or you go to Hollywood Disney production and the graphics that they are using, the things that they’re doing, bring us some of the stuff. Why are you holding back?

– Right.

– Right, give it to us.

– Here’s how we do audio. Right. It’s not complicated, it’s simple, it’s elegant. With an iPad I can capture your voice, I can augment it, I can do things. With an EHR, it’s just a cash register that’s clunky based on old technology that had to fulfill a certain mission that’s now outdated, or should be outdated.

– Yeah. I think perhaps we underestimate the complexity of what it takes. Epic was at the forefront of having a system that worked for everybody in every setting, but it’s hard for us to appreciate that because we’re left with just what we perceive as the terrible clunkiness, the time suck.

– Yeah, and the Epic people have reached out as well to me and they want to talk about, let’s about this.

– At least they’re talking to you. I’m on their hit list, okay.

– I tell you, when we put out our video sometimes I wonder, they disappear. And I’m like, these guys are professional hackers. But the thing is, it’s not about Epic. It’s not me hating on Epic, although I use them because they’re the 800 pound gorilla. It’s that we want to be at the table. We want to be in the room where it happens, to quote Hamilton. And I feel like we haven’t been. I think it’s our fault. I think we haven’t owned this as our problem. We complain about it really well, and we meaning The Royal Group of physicians and nurses and frontline clinicians because we’re busy and we have other things that really take our time and to have to think about the technology, to think about the water the fish is swimming in is very hard for the fish.

– Also, I think it’s happened so incrementally. It’s not like overnight someone said, okay, for every one hour you spend with a patient, you’ll spend two hours on the record. It was one key stroke added at a time, quality measure there, a little bit of this there, another billing click. And pretty soon you’re like 10,000 clicks a day, and suddenly physicians were like, I can’t do this. And this whole physician wellness is the first moment I think that administration picked up on this. We at Stanford and big medical centers simply cannot afford the recruiting costs of bringing someone here and then having them after a few years get unhappy and leave. This is just not a viable thing for any big medical industrial complex, so by God, you’ve got our attention. I’m really proud that Stanford took the lead in starting a physician wellness program, recruiting a physician wellness officer.

– What’s her name?

– His name, Tait Shanafelt, the most well published physician in this area, from Mayo Clinic. And I think because we’re really seeing this as big a problem as anything else that’s on the horizon that we have to grapple with it.

– You kind of nailed it, the costs of recruiting and retention are so high because we’ve gotten something wrong in the system and the fact that it’s been death by a thousand clicks, so click one, click two, click three, it adds up and the next thing you know, like you said, for every hour you’re spending two on the documentation. Nobody intended this, right. It’s not where, we’re not victim of some evil genius who wants to destroy us.

– True. I also think that we’re at fault in the sense that all our individual lobbying organizations that represent hospitalists or you or me, I think we’ve spent too much time in Congress fighting for our reimbursement, our financial interests. So when we start to get behind a good cause, whether it’s anything from this sort of thing to wellness, to gun control, people are ready to tune us out because we, I think when we had the voice at the table and to some degree even now, it was all about don’t cut my money, which is understandable, but it makes it hard for us to then take on the big moral issues and say, well, we have a stance on this.

– Are you a member of the AMA?

– No, I’m not.

– Neither am I, and the thing is, the reason is, is I felt that that was the focus is it’s really lobbying for these little bits and grabbing little bits and not seeing the big picture. Now again, and I’m not picking on AMA–

– My reason was different if I may tell you.

– Well, yeah, tell me.

– I was a foreign physician. I think for the longest time the AMA acted as though we were invisible, that we simply weren’t there, and they kept denying that there was a physician shortage when every year there was this influx of people like your parents and myself who have to come in to staff the inner city hospitals and places that relied on foreign medical graduates. And I must say to the AMA’s credit that in the last 10, 20 years they’ve really embraced the international medical graduates. We have our own lobby and forum, but it wasn’t that long ago that we simply didn’t exist.

– Wow. And I never heard that from my dad. My dad was never a member of AMA, but he would get frustrated about how IMGs were treated and so on, and my mother as well being a psychiatrist. Yeah.

– That’s one of the great things about this country, is that whatever this country lacks, it imports. Basketball players or–

– Oil.

– Baseball players or physicians to fill the needs of inner city hospitals that were not producing enough medical students to graduate and go fill. And I think that, acknowledging that is a good thing. I think a lot of the motivation for writing My Own Country was also to not just describe this disease, HIV in the heartland of America, but also the anachronism, the strangeness of all these salt of the earth folks being taken care of, for the most part, in the small mining towns by the foreign medical graduates who were willing to go out there and work and provide yeoman’s service.

– So you guys should definitely check out that book because again, I think it does capture exactly that ethos and it’s a paradox. This country has a lot of innate paradox, but that’s one of them, is that we do import these very smart, these are top of their class folks from their countries. And we just did a parody video. I might’ve sent it to you, you may not have had a chance to check it out.

– You did, yeah.

– The One Sikh, so it’s really a tribute to some of the stereotypes, but really some of the way that we don’t acknowledge that these guys are doing the heavy lifting, guys and girls are doing the heavy lifting. My parents, for example, this was a tribute to them and how they had to work so hard, they had to work triply hard for the same thing. And so that’s why your story was so compelling too, because born in Addis Ababa, Ethiopia, to expat Indian parents and then going and training in India for med school, then doing residency at Boston, and then again in, what, in Tennessee, was it?

– My residency in Tennessee and then fellowship in Boston.

– Oh, got it, yeah, yeah. And what was your fellowship in?

– Infectious diseases.

– In ID. And then you’re seeing GRID, right? Gay Related Immune Disorder.

– It was an exciting, scary time and just as I was finishing my fellowship, the virus was established to be, it was established that it was a virus. I don’t know if you remember that period when we didn’t know what it was and the blood test was established and it showed that for every one person we took care of in the hospital, there were probably thousands out there carrying the same virus and everything we knew suggested that it would have the same downhill progression as the folks who saw it in the hospital. But I was moving to Tennessee, a small town population, 50,000, and everyone expected that they would see one patient maybe every other year because AIDS was this urban problem. Instead of which, in a very short time, I was seeing about 100 people with HIV infection. And it was basically a story of migration. It was young gay men growing up in a small town, leaving for all the reasons that you and I leave small towns and decades later, the virus finding them and they were now coming back because their partners had died, they were sick, and there I was at the tail end of this quiet migration. And I wrote the book, I became a writer essentially because that story, even though I wrote a scientific paper describing it, the compelling nature of that story, the heartache of the family and the individuals and my own grief at seeing that again and again just made me feel that the language of medicine didn’t quite capture. Maybe that’s what you do comedy also.

– I’m like getting vaguely emotional hearing your tale of this because that is why I do what I do too. Although mine is not, to see that, and that idea of coming home with this illness. You were from a small town.

– Yes.

– I’m from a small town, and this idea of coming home and then being with this disease that people associated with urban excess and immorality and all this other prejudicial things. And by the way, we talk about this now on the day. I just released a clip with my brother-in-law who’s an infectious disease professor at University of Michigan. He talks about the new HIV treatment guidelines. The fact that we treat it as a chronic disease instead of a death sentence is a testament to medicine as a science. But what you wrote in that book is a testament to medicine as a human endeavor.

– And it was also a tribute to those little towns because people are ready to characterize that little corner of Tennessee, Virginia, and imagine that these patients would have been received prejudicially and treated poorly. But the amazing thing was that family trumped all these prejudices.

– Trumps everything.

– To see families rally around their children, rally around gayness when it’s something that they would never have thought they could ever come to terms to. That’s the reason I wrote the book. It was a tribute in many ways to that small town, something to admire about America greatly.

– It really is. And it’s a distinctly American thing. We were talking a little earlier about how politics has become so polarizing and this is a great example of how this idea of family and loyalty is a moral pallet in certain parts of the country. And it’s less established in other parts of the country where diversity, inclusion, justice is more valued. In certain parts of the country, it’s almost evolutionarily necessary to value a sort of our solidarity as a family or as a tribe or as a town. And so the acceptance of this otherness of being gay, it doesn’t surprise me actually.

– Doesn’t? Good, yeah.

– In a setting of family trumping that.

– It’s in a setting of good values that are inherently going to come through.

– That are shared, exactly. And that’s a wonderful kind of twist on that story because it is, it is a stereotype that there’s so much prejudice and so much in small towns. And I’ve not, I grew up in that small town environment. Yes, there was prejudice and bias and that, but it wasn’t something that you couldn’t overcome by being part of the community.

– Exactly. Indeed, I feel the same way. I feel very proud to be an American. I became a citizen in that corner of Tennessee.

– Yeah.

– And it was a very warm feeling having lived in Africa, having my education there interrupted by civil war, now coming here, working as an orderly for a year before I could finish in India a year and a half later. I just felt like this was the one country where everything that you aspire to be, you could. Becoming a citizen was a way to sort of embrace that. And you don’t have to worry about someone knocking on your door with a gun or taking away your rights, and I think in funny ways, I think us immigrants perhaps appreciate and celebrate the richness of America in a way that others can stop seeing because they take it for granted.

– As a first, as a born in, American born Desi, I often miss that. I went through a phase actually in, probably sometime in the last 10 years where I was very much like, what is going on in this country and I don’t feel part of it and I could live anywhere and do it. And that has totally gone away. Having traveled the country, having done the show that I do, having talked to people from everywhere, having seen the bright spots and the stories and the humanity, this is still the most amazing, most inclusive, warm place, in my feeling.

– Absolutely.

– And it took me going through that little valley of despair to recognize it.

– Well see, I remember growing up and recalling the moment that John F. Kennedy got shot and then seeing the despair in the streets Addis Ababa.

– Wow.

– So far away from where this was actually happening, and the emperor of Ethiopia flying to walk in the funeral procession.

– Haile Selassie, yeah.

– It was because what America represents and represented, especially embodied by Kennedy, was this beautiful embrace of all things noble, these values that were never gonna change.

– Yeah.

– And I think that we perhaps go through phases, but I don’t think we’ve ever lost the kind of things that are in the Constitution that very few other countries can point to so proudly.

– Yeah, yeah. No, you nailed it. Tom and Logan an I really got into Hamilton, the musical. And part of the reason I think, it doesn’t matter what your political bent is because we span the spectrum, right. It’s about the really magical thing that happened to create this beacon in the world, and that these founding fathers and their wives who are an important part of it, and all this group of people that built this country, built something that lasts as a beacon and a legacy to the world, and has set the bar for how we should treat other people and how we should, even you go through slavery and you go through, like you said, there’s a way forward and a little bit of a recession and a way forward. And we’ve been through the horrors of those things. Interment of the Japanese, we’ve been through that. And I think when you come out the other end, bigger for it, more transcendent, then that’s what makes the country even stronger. It doesn’t weaken us. Yeah.

– Yeah, I think the thing that’s polarizing as I suspect is less around politics than it is about the polarizing effect of poverty and the increasing gap between the haves and the have nots. It’s a huge problem, and I think that’s at the root of a lot of the things that superficially appear to be political problems, but they really are, I think, problems with equity, access, income, good healthcare. They come back to just fundamental things that the government should, I think, work hard to provide.

– And I think we can talk about social determinants of health as a major problem. All of the problems in terms of poverty, bad education, violence, crime, et cetera, are laid at the steps, many of them are laid at the steps of the healthcare system. And I’ve talked about this, that on our shoulders is the weight of all these social issues that we have failed to address. And then we wonder why a $3 trillion expense is not buying us better health.

– Right.

– And I think we really have to look at those issues, and it’s not necessarily, look, you can span a political spectrum and still figure out ways to reduce wealth inequality, to open up opportunities for people to participate in the bounty that is America without giving it away or creating entitlement and all that. There’s plenty of ways to do this, and there’s plenty of ways to use science and data, and that’s where I think the technology too. The EHR has given us an opportunity to gather data and once we get enough data points, we might be able to come up with solutions that actually don’t make intuitive sense.

– Yeah, no, I love that. I love the promise of big data.

– Right.

– The promise of AI. And again, I love the fact that we’re now not as naive as we were when we first opened our Facebook account or embraced the EHR. We recognize that with any of these things comes an opportunity to crash big time if you’re not paying attention.

– When you were writing your books, and this is a little tangential, but it just popped in my head. When you were writing your books, you were working at institutions as a physician. Did you ever worry that you were gonna lose your job because of something you said in the book?

– No, not because of something I said in the book. My books were very self revealing in that sense. I would talk candidly about my marriage and so on, but they weren’t fundamentally untrue.

– But doctors don’t do that, typically.

– But it’s not as though I got up on Oprah and dropped my pants or something.

– I’ve been wanting to do that.

– I’m writing this in a book, and if you do me the honor of buying the book, preferably buying it, not borrowing it, and reading it, then you’re entitled to know this thing about me. I’m must say, it wasn’t easy for me to write that way. I think it took my editors, two different editors in two different books, the first two are memoirs, to say, you know what Abraham, you’ve become a character in this book and you can’t, every time the lens swings over to you, you can’t just shut the screen. You’ve got to really be willing to, since you’re being a character becoming transformed by these individuals with HIV or in The Tennis Partner, you’re the best friend of this young medical student physician who is going through the throes of drug addiction, you’re actually enabling him without even realizing it. So you’ve got to be willing to turn the lens onto yourself. And so, it was hard to do, but once it was done, I was happy with it.

– I’ve noticed that about authenticity. ‘Cause on my show, a lot of times something, especially when we do it live, but even when we don’t, I’ll say things that I never meant to reveal. Like it’ll just come out and it’s because I feel it at that time and I need to tell people about it. And then if I sat and cogitated on it, if I really thought about it before I did it, I would never do that.

– Probably wouldn’t do it.

– I’d never do it. But once it’s done and it’s out in the world, I feel the sense of this relief, no matter how embarrassing or how personal, it feels like I’ve done a service to myself by saying this. And I wonder if that was a similar process for you or if it was something different. Did your editor’s really have to pound on you to get this?

– They did to a degree, yeah. And in my naive notion was that I’m writing a story about HIV, I’m writing a story about doctors and doctors–

– That was your thought going in?

– It was my thought going in. I didn’t recognize to what degree it would almost become a device for me that I was the character being acted on even as I’m observing what’s happening. So I would say that some parallels with what we’re doing here.

– What we’re doing now, because every now and again I’ll adjust the camera and make sure that, and it’s kind of like this third wall or fourth wall? I forget what wall it is in film. So using yourself as the device versus using yourself as yourself, how did that transition?

– You are using yourself as yourself. You’re actually willing to turn the lens in and show how, for example, when I came to this country in that HIV era, I was not homophobic, but I was homo-ignorant. I don’t think I knew an openly gay person. My only knowledge about gayness were these stereotype jokes and behaviors that I’d seen, sort of bad behaviors by heterosexuals towards gay people.

– Right.

– And to come all the way around to where I would think that gay men taught me more about manhood than anybody else I ever met, that they showed me how one could be, when you take away the male posturing for women, gay men sort of teach you the possibilities of malehood.

– Wow.

– You could have a healthy interest in the arts, you can be talented in the kitchen and you can do all these things, it was sort of a revelation to me. I think that by my best friends then and now remained a gay man who sort of brought a lightness to my being that I wasn’t aware of before.

– You know what? You kind of nailed the Queer Eye for the Straight Guy phenomenon.

– Is that what it’s called?

– That’s what it’s called. So there’s a show.

– Who knew?

– Yeah, there’s a show called Queer Eye for the Straight Guy and it became very big early on and then it disappeared and then it came back in a new iteration. And it was like three or four gay men teaching a straight man how to improve his life. Whether it’s decoration in the house, whether it’s wardrobe, whether it’s how to cook, whether it’s those kind of things so that he could be better in relationships with women. And it was such a cultural hit because I think it was exactly that. People stripped away, you stripped away all the posturing and now here’s how to be a better person.

– And with them, it was even more poignant because they’re the ones that I remember best who I mentioned in my book, My Own Country, they were giving up their lives far too young. They never lived to reach your age or mine and they were dying of this disease, and in that death they were generous, continue to be generous, and they continue to support each other and their partners continued to volunteer in clinic and they were teaching us, don’t postpone your dreams. The things that are important to you, don’t wait too long because life is fragile, it’s transient. Celebrate your relationships. All the things that are, sound like cliches, but seeing it happen to someone who’s your age and dying, it was profound. It was the moment that I decided that I would take a little break from medicine and go the Iowa Writers’ workshop if they took me and become a writer because I heard from them, don’t postpone your dream. And my dream was to tell that story and I couldn’t see how I would do it without getting off the treadmill.

– Yeah, but off the treadmill. So you took what, like a year or two years, how long did you take off to really train to be a writer?

– So I went to the Iowa Writers’ Workshop, which is a unique place where you meet once a week. We discuss two stories from the students that are submitted the previous week. When it’s your story, you sit there and you don’t say a word and you have the privilege of people who care deeply about writing, respond to that and tell you, this is great till this moment where the story clumped. It just, fictional dream crashed because of this thing you did, and it was very humbling. That sort of stuff your parents think is cute and your wife thinks is precious just doesn’t fly there.

– Then they destroy it, yeah.

– In fact, when your spouse becomes deeply disturbed by what’s you’ve written, you’ve found your voice.

– Oh, that makes sense actually. My wife, so there’s certain episodes she cannot watch.

– I can understand that.

– Because I get angry, I get emotional and she feels it as a presence that she, it makes her uncomfortable. Because I’m not, I actually don’t let those things out so much in our relationship. So that’s fascinating.

– So I left a tenure track job, cashed in my retirement and headed off to Iowa and the only people in the medical world who understood, and I was by then an associate professor, I was doing work in pneumonia, had friends everywhere. The only people who understood were the people at Iowa because they had the Iowa Writers’ Workshop in their backyard. They had seen people like John Irving and others come through. They knew what that was about. So they embraced me, gave me a visiting appointment and when it was all done, I was ready to get back on the treadmill.

– On the treadmill.

– On the academic treadmill. I was interviewing, and I interviewed in Reno and Las Vegas. But then I thought, what am I doing? Because all those jobs were at that stage where I was gonna be like a chair of medicine at the VA in Reno or things like that, and they were gonna be very administrative.

– Yeah.

– And I just backed out of that whole interview process and I took a job in El Paso, Texas, where I was gonna be on the faculty teaching students, seeing patients in the county hospital and that was it. My nights and weekends were mine, no grants, no NIH stuff.

– Minimal administrative.

– Minimal, yeah. I was attending an ID 12 months a year and I was doing general medicine four months a year. But it seemed to me a relief.

– That’s my brother-in-law, same thing, yeah.

– And I tell my students all the time that life is ironic. Had I come to Stanford in the first place then, not that they would have ever taken me, let’s say I–

– Oh, tell me about it, they are real butt heads about that.

– Just about now I would probably be losing my tenure and heading to Texas. Because I made the choice to go to Texas and I loved it, I think I learned more medicine in that county hospital than anywhere else, because I went there I wound up writing these two books that brought me here. So life is ironic. It’s not always linear and you just embrace the things that come your way and you never know how they take you to the next place.

– That’s an amazing story.

– Look at your story. Look at where you are.

– Well, it’s interesting because–

– I’m impressed.

– No, don’t. By the way, I emailed him.

– That’s why I like imitating you, I pretend that I am you.

– I emailed Dr. V and I was like, please, I wrote this big long email trying to explain why it’d be cool if he was on the show and what the show is and so on. And I just get the response, it’s like, yeah, I’m a fan, I’ll do it. And I was like, huh! I was so ecstatic. You should’ve seen, my wife, she was like, he said yes to you? Yeah he did. So you know the story of like life taking you and I tell the Z-pack this all the time, that you have to be open to these possibilities. You need to allow for ROL, return on luck. So if you’re not in a place of openness when luck hits, you’re not gonna capitalize on it. When I left Stanford, it was the hardest thing I ever did in my life.

– I can imagine.

– Here I am, it’s the same thing. I had this gig. It paid really well, I had a 401K, I had the house in Belmont on the hill. I was living this Bay Area dream, but deep down I’m like, why am I making videos and putting them on YouTube? Because I’m unhappy with how things are, because there’s something wrong. And so leaving, going to Vegas was a huge risk. Now six years later, having run a clinic, closed a clinic, grown this thing with these guys and having this now opportunity to bring people’s voice out to the world, I’m back in the Bay Area.

– It’s wonderful.

– And it feels like, it’s a strange and wonderful feeling to be able to be with someone like yourself who’s at my institution, who, when I was a medical student, a resident here, I would have just been like, oh my Gosh, Dr. V.

– I don’t see myself that way, but thank you.

– We never do. But it’s a real honor. So El Paso, Texas, for 10 years?

– 11 years.

– 11 years.

– Yeah, and I loved it there. There was something about those wide open spaces that, many writers gravitated over there. Cormac McCarthy was there, Rick DeMarinis, and I think it’s like the endless horizon just gave you this license. I still miss it. I know I love the place.

– The tax rate is nice too. No state income tax, so I like that. That’s a wide open horizon as far as I’m concerned.

– But coming to Stanford has been a dream. I don’t think I could have found a medical school more willing to do what they did, which is embrace my writing as being my research equivalent. I mean everywhere else I was hiding the writing, I was doing it on the side, I was doing it after hours. But Stanford, the department of medicine really just sort of, I’m sure I tried their patience at times. The seven year book project is not quite the same as a RO1 grant coming in.

– Right, right, right. But you’re a national treasure, and honestly they chose their wisdom and I’m actually very proud of that institution for doing something like that.

– I am too, I’m in awe of being here. But I don’t know if you have this feeling, you probably don’t, but I keep having this feeling that someone’s gonna tap me on the shoulder and say, okay, we’re onto you, you’re out of here.

– [Zdogg] You know what?

– He’s gone.

– Now you’ve touched on something that’s a real pain point of mine because this is what we call imposter syndrome.

– Yeah, but the only moment I don’t have it, two weeks ago, I was attending on the wards and I was in the midst of all kinds of crap going on in my life, attention. Everything was fun. It’s the one moment that I’m not–

– Flows day.

– I’m not an imposter.

– You’re in your element.

– Isn’t that something? That’s our calling, that’s what we do.

– You know you’re in your calling. The thing is the imposter syndrome, guys, where you feel like at any moment they’re gonna tap you on the shoulder and go, you’re not supposed to be here, we screwed up, we put in, it was Abraham Vergoosy and it wasn’t you and now we’re gonna have to rewind it.

– We thought you were Zdogg.

– But that’s very common among creatives, amongst successful people.

– Is it really?

– It is. And it’s actually been studied to some extent that it is almost a requirement for people who attain certain levels of accomplishments. Because if you don’t have that innate fear or feeling that you’re not doing what, you’re not good enough, if you don’t necessarily have the drive and also the self insight because you and I both know when we look inwards, we see something there, we see us. It’s not what the world sees. And our, at least for me, I’m speaking for myself, my inner feeling is always, if the world saw me the way I see me, they would just see this shriveled, insecure, mass of goo and they’re not gonna like that. And that’s the nature of my imposter syndrome.

– But you do something very different in your art than what I do. I mean I’m at this desk 12, 16 hours a day in a private dialogue with myself, dreaming my way through the story.

– Wow.

– One day readers will see it, but it’s happening in solitude, it’s happening so quietly. And I see you and your videos and it’s a very, I mean, I can’t believe that you’re saying that you feel this imposter syndrome because seems to me you really own your space, your body, your voice.

– See to me, you even telling me that, you, who I hold on such a pedestal, it doesn’t make sense. It doesn’t compute to me. But again, each of us does our thing in our own way. Actually, what you just said about sitting here in solitude for hours communing with yourself and dreaming your way through the story, what a beautiful description of the creative process of what you’re doing.

– That’s how I think of it. And you know, you’re often wrong. You can only see as far as your headlights show you. I don’t ever see it all the way to the end. I try with these whiteboards and all that, but the magical thing is sitting there and realizing that you’ve spent eight hours and it’s absolute crap, but then there’s a moment where you step away and suddenly as you are trying to step away, suddenly it all breaks through. That’s why you do it. It’s like a fix.

– I’ve had that experience. You’re banging your head against the wall and then as you write it all coalesces and there’s some magic.

– It’s a muse. I think that you have to be receptive to the muse, the right brain, whatever. You have to have your ass in the chair. At least for me, I do. I can’t do it while I’m walking past pastures in the stream. To me, I have to be trying, my fingers bleeding. And if it’s gonna come, it can only come when I’m trying.

– You know what, I would not expect anything less from a physician. That is our approach. To some extent, it’s sweat equity for us. That’s how we were conditioned.

– Right.

– And that makes sense. For me, if I’m writing lyrics or I’m thinking of ideas for a video or something funny, I have to get into a state where my thinking mind turns off and it’s just unconscious stuff and it bubbles up. And then the thinking mind has to be present enough to recognize the bits that are funny. A lot of times if you don’t do that right, you’ll get a bunch of bits, you’ll write ’em down, you look at them later and you go, what was I high when I did that? Like this is not–

– I think the art is in revision. The art is revision.

– Have you ever heard the rough tapes, the demos for Sergeant Pepper’s Lonely Hearts Club Band?

– No, no.

– So apparently, and I’ve heard some of them. It was their early demo takes. It sounds terrible. It’s the same song, it’s just 80% there, but it’s that 20% where Ringo was like, it’s not the right beat or John Lennon was just got an extra tab of acid and figured it had the enlightenment where it just made it magical. And I tell the boys all the time on my team when we’re editing video, I’m like, the reason, and they know this, the reason, the difference between you doing a project for Moen Faucets as a commercial, as a video production team, and me, is that we’re gonna sit here with a fine tooth comb going through every frame, every transition, every click point until it’s just as perfect as we can make it. Because in that cohesive perfection emerges the art.

– Yeah.

– And so it’s painful. But you’re right, it’s in the revisions.

– It’s funny, I heard the phrase God is in the details, both in medicine and in writing school.

– It makes sense.

– And the actual phrase is that the devil is in the details.

– The devil is in the details.

– And now we’ve changed it to God is in the details.

– God is in the details. There was a TEDMED talk or TED talk by the woman who wrote Eat, Love, Pray, and she talks about the muse and she talks about making herself sensitive to it. And the idea that this term, ole, that the Spanish say came from, in African tribal villages, they would sit around the fire chanting and dancing and every now and again, someone’s muse would hit and the dance would be transcended, and through this dancer they would see God. And being Islamic, they would say Allah, Allah, Allah, Allah.

– Became ole.

– And it came to Spain, it became ole. And so this idea that somehow you channel this greater thing through your art means you have to be receptive and sometimes receptiveness means revision.

– Right.

– So God is in the details.

– That’s right.

– That’s amazing. Okay, I’m gonna derail you with something related to that that I don’t know if you’re gonna like. Recent research on psychedelics, resurgent research on psychedelics, has creating a mystical experience.

– Yeah, actually I saw that in the New York Times Magazine because Michael Pollan’s piece is right next to mine about the EHR and all that.

– You get a piece in New York Times Magazine.

– And you didn’t read it?

– Next to, actually I saw it online. It is about the EHR, and I was like this guy, this guy. But the fact that you get to like, oh, I just, me and Michael Pollan are just like. I hate you so much. No.

– It’s just where our page is next to each other. It’s not like I was–

– Amazing. I’m reading his book right now.

– I think it’s a great, I think it’s a breakthrough. I think the sort of backlash against the ’60s psychedelic use probably has kept us from really understanding some of these drugs and their great potential.

– The idea that Timothy Leary did tremendous harm to the movement by being Timothy Leary and the idea that now they’re under controlled circumstances with guided experiences, people can have mystical experiences. Now, you had said a few things in the course of our interview and I’m gonna adjust this. There we go. And a couple of them, you said it sounds like cliche. It sounds like platitude. God is in the details. The family trumps everything. What Michael Pollan says in the book, and I feel as having experimented with psychedelics in college and nothing since, is there’s a, what they describe people who have these mystical experiences, whether it’s meditation, whether it’s prayer, whether it’s psychedelics, is that these platitudes are experienced by them in a way that it transcends the ability to describe that the platitude that they’ve known all their life–

– Is a shorthand for–

– Is a shorthand for this deep, spiritual truth about the nature of everything. And so we say things like, God is love. Well, when they experienced this, that everything is love, they come to you and they say God is love, and you look at them like they’ve been doing drugs. And the truth is they have experienced it. And that’s why I think people who have had a religious conversion experience, scientists who sit in awe of the Milky Way, they have this ineffable experience that defies words. And so these platitudes, they’re not really platitudes. They’re just our monkey mind’s way of talking about the divine.

– I didn’t realize that, that’s wonderful.

– We can thank Michael Pollan for turning me onto that idea. Yeah.

– But I must say, I think the great privilege of being in medicine is that if you’re not reminded any other times of your life in the care of someone who’s really sick, you’re just reminded how precious this moment is. And you don’t need to smoke a joint to appreciate the way the light is hitting the leaves and the richness of this moment. You just need to decide to slow down enough to enjoy this moment and be present. So in fact, that word present means a lot to me. We’ve started a center at Stanford called Presence and we’re really interested in every aspect of the human experience of medicine, both patient and physician and all the things that impact on that. We have all the signs are on everything going on in your body, but if you come to us at best, you’ll be described as a 33-year-old male. Two days prior to admission, maybe developed acute onset of. I mean, we don’t begin to capture the richness of who you are, even though we can tell you all about your sodium and how it trends in time. And so I think that our interest is in that aspect of human beings, but to come back to that word present. Presence is the word we chose because I think it’s the one thing patients want more of. It’s what we want to be allowed to do. We want to be allowed to be more present. And we’re trying to develop these presence five rituals. I don’t know what they will be, we’re in the process of this funded by the Moore Foundation, but one of them for me has always been the idea that you wash your hands and I learnt this from a rabbi colleague at Stanford, Bruce Feldman.

– Oh Bruce is great. He was a doctor and he became–

– He wrote a beautiful paper. He talks about how you wash your hands, but it’s a reminder because in every religion it’s the same washing. It’s a reminder that you’re now leaving the secular space to enter the sacred space.

– Oh wow.

– And it’s a reminder to be intentional. It’s a reminder to be present and if you can bring that to your day, not just to your moments with patients, but to your everyday, to your every conversation, to your interactions with every human being, it’s a struggle. Don’t–

– Oh yeah, not easy, yeah.

– But when you do, I think you’ve sort of hit on the edge of what perhaps psychedelics might–

– One gateway to.

– One day show you you need to do, but it’s there. It’s at the end of your meditation, it’s there, that sense of, this is what I need more of.

– Oh, man. See this is the thing and the fact that you. Okay, listen, JCAHO, he just combined something that’s divine and bigger than all of us with a simple act that you would like to mandate, which is washing our hands before we enter the room. I think the most beautiful things are that where this act helps protect our patients, but it also prepares us for the sacredness of the interaction we’re about to have.

– You know second thing I do? I always like to look at people’s shoes.

– Oh, tell me about this now.

– First couple of reasons.

– Now I’m embarrassed because I wore slippers in here.

– Well, I don’t know about your slippers too. But because it tells you a lot about them. For example, if you look under the curtain of a county hospital and you see shackles and an orange jumpsuit, prison issue slippers, you know–

– You know what’s up.

– But in a clinic you also get to see what choice did they make in shoes, how is it worn and all that, but even more importantly, it’s that moment to put yourself in their shoes and how does this feel for them? And then it’s not about the EHR and others. It’s about, how does this feel for them at that moment?

– So again, we get to the platitude of walking in another’s shoes.

– But I mean literally.

– But if you really unpack that, what does that mean. It’s a beautiful, difficult, complex thing. And this gets me to one other thing I wanted to talk about, which is this idea of empathy, which whenever you Google Abraham Verghese, it says, he is bringing empathy back to the bedside and this and that. And again, this is crucial, something that I advocate, but I’m curious what your thoughts are on empathy, affective empathy, feeling another’s discomfort or feelings versus a more cognitive empathy where you can walk in their shoes and understand but you don’t take their pain as your pain. And I’m curious if you think about that as a distinction at all.

– Well, I mean I think there is a distinction, but I think that we have done a disservice to our young physicians by suggesting that they need to maintain distance. I know what people are talking about, I think Osler began that. But frankly, I’m always just in awe when I see a medical student cry. I know they’re gonna be a great doctor. If you’re moved enough by the suffering of this patient to cry, I don’t have to worry about you. You’re gonna be a great doctor.

– Yeah.

– And so, where does this come from, this unwillingness to, and I think the flip side of this is if you don’t react to what you’re seeing, if you put up that wall, which admittedly you have to do in many situations, if somebody’s bleeding on the street, you need to be thinking about airway, breathing, circulation, and not worrying about the widow and the four kids. But I think that what happens in medicine is that the repetitive putting up that wall, slamming shut the emotional content of what you’re seeing from the medical content, we begin to do that to ourselves. And the sort of a method of addiction that I discovered, the mechanism behind many addictions in physicians was that they’d done this for so long that they no longer could register their own emotional distress.

– Yeah.

– And when they became sick, they focused on the physical symptoms, their back pain or whatever. And oftentimes they got a Tylenol number three from a colleague, and anybody else, that colleague would say, wait a minute, how much alcohol are you drinking, how’s your marriage. But in a colleague, we just–

– Give them the drug.

– And I remember one neurosurgeon telling me that he took a Tylenol number three in this very situation and he said he felt this weight that he’d been carrying on his chest for 32 years just slide off. And he knew he was gonna be addicted.

– Wow.

– ‘Cause he had never, and physicians don’t take drugs to produce euphoria.

– No, no, no.

– They take it to relieve the dysphoria of their existence.

– I have talked about this. I’ve actually gotten yelled at by patients, by chronic pain advocates when I say things like many times, we are medicating emotional and existential distress with narcotics. It’s not so much the physical pain, although it can manifest like that. It’s a different thing. Tylenol can medicate psychic pain to some distress.

– In this case I think I was, I’m not quite linking it to that kind of, I understand what you’re saying. What I’m saying is that they weren’t taking it to get high.

– No, no, no, no, no.

– They stumbled onto it and discovered that it had erased this emotional thing. Maybe we are saying the same thing.

– We are, same thing, I’m just saying it less eloquently because I am not good at that. You said it perfectly, which is they’re medicating this emotional pain or you said it slid to the side. It just, it was gone for a minute.

– It was just gone for a minute.

– And that is something that we desperately crave. And so of course you then want more of that.

– Yeah, because we all carry a weight that we don’t even know we’re carrying.

– Oh yeah.

– And the moment that weight’s released, it becomes very tempting to, how can I do that again?

– This is why, and again, not to bring it back to Michael Pollan, but psychedelics for addiction, you confront the weight in the experience of ego dissolution from high dose psychedelic and you see it there, you encounter it and you understand what it is and you’re liberated, in some patients, from it. So this is an interesting story he tells in the book. The founder, one of the co-founders of Alcoholics Anonymous–

– Was a doctor.

– Was a doctor, and I don’t know if that was the one who had this experience, but he had an experience with psychedelics and LSD and felt that it gave him this glimpse, this spiritual glimpse that was the higher power to which he referred when he said, you must connect with a higher power. Now since then, it’s evolved into religion or God, but it started with a psychedelic experience.

– This higher power, whatever you conceive it to be.

– Whatever you conceive it to be.

– It could be your cat, but it’s just–

– My cat is a higher power.

– Conceding that it’s not you.

– Right. Conceding that it’s not you, and that you–

– Are powerless.

– Are powerless, and that you may even be a bit of an illusion in this kind of neuronal storm. What’s bigger than you is what stays, yeah.

– Right.

– So it’s funny, we speak the same, I think we’re getting at the same truth with different language, which is how it has to be.

– See, I should do you. I should just go up there on stage and just pretend to be you and shave the beard and–

– He’s a better version of me. More empathic, more… So this distinction, I make the distinction between empathy and compassion. I say empathy is kind of taking another’s pain as your own, and the reason I’m less fond of that specific nomenclature is that Paul Bloom and others have talked about empathy being a narrow spotlight. You can only feel a narrow bit of pain and that you tend to react in short term to try to relieve the feeling. Compassion is a bigger love in the face of suffering but you have to have an empathic eye to feel that. So you recognize your patient, you walk in their shoes, you sit at the bedside, you cry, that’s okay, but then in response, you feel this tremendous love that doesn’t tire, that doesn’t burn you out, that grows with practice. The Buddhists have been doing this Metta Meditation.

– Yeah.

– So that I think, if we can teach that to our students, and I’m gonna charge you with that because you round a lot more than I do–

– I would push back and say our students don’t need to be taught this. We just need to allow it to stay alive in them. They come in full of all the right qualities and we just beat it out of them. We take their curiosity about you as an individual and we’ve teach them this language which is necessary for diagnosis about taking the unique story and making it two- to three-year-old male comes in with acute onset, you know.

– The shorthand, yeah.

– So they are not lacking anything. It’s the experience of medicine that just beats it out of them, and the good news is that it comes back.

– Yes, it does.

– Some version of it comes back, they find themselves, but I wish they didn’t have to depart in the first place.

– You nailed it because I remember at the end of second year of residency, I was a robot. I had everything filtered through, and you know what triggered it ultimately was rotating on F Ground at Stanford Oncology and seeing young people were dying, and it was probably similar to the experience you had with those HIV Aids patients where you see this person in their humanity and their suffering and you feel it and you’re in the, I was in the stairwell crying and just… But then immediately having to see the 20 other patients and take the call and do all of that. So bottle it up and go on with your day and the more you build the wall, eventually you forget the wall is there. So it took me years for that wall to come back down. And when it did, it was such a relief, even though it was harder. But I thought like my patients now understand how much I care instead of me having to hide it around this wall.

– Yeah. I think we’ve gotten better and our medical students come in better prepared to take care of themselves. More concerned about their own emotional state and physical state. That just wasn’t true of our generation where the great intern was the one who never left the hospital.

– Right, right, right. You’re strong. Don’t go pee. But let me ask you a question now and again, I’ll play devil’s advocate a little bit. A lot of our generation, and I feel like the new interns, residents, et cetera, I was just talking to somebody at Stanford, and I’m not gonna say what department it was, but they felt like they’ve never seen the level of lack of responsibility, of ownership of the patient, a shift work mentality, do the minimal necessary without curiosity, without drive that they’ve seen in this incoming batch. And they said that it’s been progressively eroding. That was their take.

– Oh, I completely disagree.

– So tell me about that.

– I think that they’re not the ones who chose to be in that room with their backs to each other on the computer all the time. We did that to them. That’s not their choice. In fact, I had a poignant email from a resident who read something I wrote years ago and wrote saying, I’m writing to you this message from a computer from which I will not move for the next two hours. I want to do all the things you’ve preached, but how am I gonna do it? It’s our fault. You know the shift group, that’s our doing. We allowed, and I think by the way, I think that work hour regulation was really necessary.

– Yeah, I agree. So as brutal as it was an era, I’m not one who thinks that oh, we should go back.

– No, no, no, I agree.

– So I think that’s really quite unfair.

– Yeah.

– Anything that our current generation of interns are experiencing is our doing, and frankly we couldn’t fix it. $3 trillion GDP. I think that I see them and I’m just inspired. About two years ago we had our best go to the Brigham, but they went there on the primary care track. Three of them were MBAs. They were going there to change the world. They weren’t going there to do their own individual thing. So I mean they have vision that I think we lacked perhaps.

– Yeah.

– So I would completely disagree. I think that they are polite and not telling us you screwed up, what did you do that I came through medical school with all this passion and I’m stuck in this room eight hours a day because everything I order, every exchange I have has to happen through here. I can’t be with my patient. That’s not their doing, that’s ours.

– That’s funny because my team, Tom and Logan, they’re 29 and 26 or so respectively, and they’re my co-producers, co-writers, so I spend most of my day within Las Vegas. They’re millennials, technically, right. And it’s funny, I often try to impose my sort of way of thinking or work ethic or whatever it is on them. Whereas they’re like, well, you work that hard because you think that’s the right thing to do. Does it actually accomplish more? Does it make you happy? Is it making a better product? Or should we maybe do it this way?

– Love it.

– Yeah. And I was like, screw you guys, you lazy millennials. And then I thought about it and I’m like, you know what, there’s arguments both ways because I’m still entrenched, but then I’m like, maybe there’s something here. And I think that’s exactly how we ought to look at. And the thing is, it’s because our systems haven’t caught up too with their way of doing things. We’re still built kind of for our way of doing things, our meaning our old you gotta work way too much.

– There are some things that we worked very hard to bring them back to them. For example, the joy of being at the bedside. 100 years ago, Osler could pick up all these things going on with the human body. If anything, we should be 100 times better because of all this feedback. But the joy of showing them how much their eyes can tell them, the joy of showing them that their examination is still required for neurological condition. The CT scan might show you what it is or where it is, but only you know what the functional deficit is as a result of that lesion. Only you can do that on your exam. And I think introducing them to the joy of that, which has been a big part of my charge at Stanford through what we call the Stanford Medicine 25 and Bedside Medicine Program.

– Tell me about that.

– Friends of yours, John Kugler.

– John Kugler, great, great hospitalist, yeah.

– Errol Ozdalga, just great guys, Jeff Chi.

– Jeff Chi’s fantastic.

– So we’re basically trying to bring back the excitement and the joy of being great diagnosticians at the bedside in addition to all the stuff you do. Why not have a headstart on the lab work and everything else because you nailed the exam. You just think it’s gonna probably be this and that. Maybe you pulled out your ultrasound and you, and then you get the test. You’re asking a better level of question of your test than well, let’s see what comes back.

– Right, right.

– It keeps us young. It keeps us engaged, it’s interesting.

– I’m gonna give a pitch for this because the Stanford 25 is a course you’re teaching. What month is it?

– So we teach it continuously to our house staff, but we have this big national symposium. This one’s happening in September in the first week.

– 2018.

– We’ll put it on your–

– Yeah, I’ll put it up on the link and everything, yeah.

– And we have people coming from all over the world and we’ve actually now formed our Society of Bedside Medicine. John Kugler is leading that.

– I’m so glad John’s doing that. He’s such a wonderful human being.

– He’s wonderful. Talk to him about ultrasound one day.

– I will, I will, I’m excited. Yeah, yeah, yeah. My wife is still, it’s funny because my wife being a radiologist, she’s like, these guys are just gonna make mistakes.

– Oh, we don’t pretend to do much more than two or three simple things. We’re not trying to do what they do.

– Yeah, yeah, yeah, yeah.

– It’s just some basic things. Your fluid status, fluid before we stick a needle in, I think it’s safe.

– Tremendously helpful, yeah. When I used to do thoracentesis, paracentesis, I was going blind. I would have to, dook, dook, dook, dook, ding.

– Or send them down to ultrasound to mark it.

– Yeah, that’s if you’re really concerned. But a lot of it was using the force, which we got good at doing. The thing is, if there’s a better way, why wouldn’t you do it?

– That’s where I absolutely would want to be doing ultrasounds, as much as I… People would mistake me for being someone who doesn’t want that and I want a PercuSense, stick a needle, far from it.

– Yeah, yeah.

– Why?

– Well, and the thing about, so I think we’re gonna, Obviously we’ll put links to the course and to where you can get your books as well because I think you said something earlier which is preferably buy, don’t borrow the books. And the thing is–

– I was being facetious.

– No, I know, I know, but the truth is I think artists should be able to be rewarded and make a living and get some sustenance from their work. And I think of it as, in myself, people will sometimes complain that there are ads on the video, there may be ads on this video. The idea that somehow this is a horrible thing, but it’s how we are able to continue to do our art.

– Right.

– And so, that’s important. I think the course is a tremendous gift and people who are interested in bedside medicine and bringing this–

– Please come.

– Yes. And again, these guys are great–

– This is for young hospitalists, chief residents, anybody who teaches people at the bedside and is a bit intimidated by that, please come and we’ll show you lots of good tips.

– How about nurses and stuff?

– Nurses, nurse practitioners. We were trying to train teachers. So if you’re coming there to perfect your own skills, that’s fine.

– Yeah.

– But the course is shaped her on the pedagogy of how do you take this ancient skill and get good at it and convey it to someone else.

– It makes perfect sense. And any other pitches you want to throw in for Stanford as a residency program, because I can vouch for it. It’s dope.

– I think it’s only gotten better under Ronald Witteles’ leadership. We’re just a great program, we rock.

– Ron was like my intern back in the day.

– Oh, was he really?

– Yeah. He was one or two years behind me and it’s great to see what he’s done.

– We look for brilliant people, but they have to be nice people too.

– Heaven forbid, why’d you take me? I don’t meet either of those criteria.

– I guess you slipped through somehow.

– Did I ever tell you the story of how I got into Stanford?

– No, tell me.

– I’ve never told this story publicly. Well, can I tell it?

– I don’t know, I don’t know what the story is.

– So here’s the story. It’s 1999, I graduate UCSF. I’m debating do I rank and UCSF number one or Stanford number one?

– Well that was easy.

– It was easy. It was because I was so–

– My friend Bob Wachter’s gonna be really–

– Bob! Bob’s my friend too. So the thing about UCSF is again, I’d had four years of it and some, I have a little seasonal affective disorder. So if it’s cloudy, if it’s foggy, I become unhappy and I was just unhappy a lot in medical school. More than residency. And so I saw Stanford, I loved Kelley Skeff, program director, and he’s just a wonderful teacher, wonderful human being. And so I applied. I got interviews at UCF, I got interviews at other top programs, I did not even get an interview at Stanford. And I was beside myself. I couldn’t believe, I could believe it because I had imposter syndrome and I was like, these are the only people who understand what a total loser I am and everybody else is fooled. But the thing was emotionally, I was so connected to this program because I kind of heard so much about it and I’d known who Kelley was and I said, okay, I’m gonna do something I would never do. I got on the phone and I called the front office and it was Fran Brumbaugh who was–

– The friend of mine.

– She’s a good friend of mine to this day. And I said, hi, you don’t know me, I applied to your thing. I didn’t even get an interview and I’m just want to know why because I can’t sleep. I just feel like that was my place.

– That’ll get to Fran.

– It got to Fran so Fran was like, well sweetie, let me just pull up your file. And she pulled out the file and opened it up and looked through it. And she’s like, well, you seem pretty smart to me. You know what, just come by for an interview and somehow I got tossed in the pile. The next thing you know, because apparently it was some glitch in I didn’t get honors in pediatrics.

– You didn’t get honors in pediatrics?

– And I’ll tell you why. Well, it’s political. I ended up calling in sick because I had gastroenteritis the night before one of these tests and they thought that I was calling in sick just to study for the test. But I was actually sick so I missed a day of clinic, the one crucial day and I think they wrote this in my evaluation and I was like, I actually was nearly dying. So in any event, it didn’t matter, I didn’t feel like I deserved it anyways, but the thing was that was enough for an algorithm, a computer to screen me from the first batch, whereas the other programs didn’t use that algorithm, so she was the human.

– She was the algorithm.

– That step behind the algorithm and said, I see the human in this application, I hear him on the phone and I got the interview, I got in. It was the best decision of my life. I met my wife first year. We were both interns at Stanford. We have two beautiful daughters. To this day, I owe Fran and Kelley and everybody there like everything that I have. And it was because a human being connected with another human being.

– That’s wonderful, great story.

– So I don’t know. That was a tough–

– We need to get you back to the department of medicine. You know our chair, Bob Harrington?

– I don’t know Bob.

– Well, you should come meet Bob. He’s just amazing and really bridges that world of cutting edge science and clinical judgment clinicians, big trials, that’s his area is clinical trials.

– Oh, that’s awesome.

– So come by.

– I will, I will definitely do that.

– He has his own show called At Heart Bob. It’s a radio show and–

– What?

– Yeah, I hate to burst your bubble, but there’s more than one doctor out there with a show.

– I told you about my imposter syndrome and you can take advantage of me. Like, well he’s also the chair of department at Stanford. Abraham Verghese, what a pleasure.

– Pleasure of mine.

– Thank you for talking with me.

– Well thank you.

– And I think everybody’s gonna get, please guys, check out the links to what Dr. Verghese is doing in the Stanford 25, in the Presence. Is it the Presence Institute or is it–

– It’s the Presence Center. They art and science of human connection.

– I love that. And also hit share, send this to a medical student or a pre-med or a nurse to be, or a nursing student who is feeling like all my mentors are telling me that medicine is going to suck and that I’m not gonna be able to do what I really love, which is connect with others and we’re telling you no, that we take it back and we re-humanize it in a way that incorporates technology and that you can all be a part of this. And we call it Health 3.0. I think you just call it medicine. But thanks guys, Dr. V. We out. Peace.