Healing Metaphors – A Q&A with Abraham Verghese

At TEDMED 2014, physician and author Abraham Verghese shared a compelling and original perspective on the impact of language on medicine. In the Q&A below, he reveals more about how embracing our creative selves can help preserve the humanity in healthcare.

Abraham shares why it's important to breathe life back into medical language. [Photo: Kevork Djansezian, for TEDMED]

Abraham shares why it’s important to breathe life back into medical language. [Photo: Kevork Djansezian, for TEDMED] 

Why does this talk matter now? What impact do you hope the talk will have?

I was struck by the colorful metaphors that peppered medical descriptions in years past – the “strawberry” tongue, the “Mulberry” molar, the “Apple core” lesion of the colon, and so many more. I’ve found it so hard to believe that – with the avalanche of new diseases, new science and new technology – we simply haven’t developed new metaphors quite as colorful as the “saber-shinned tibia” or the “crackpot’s skull” of years past. It’s a peculiar atrophy of the imagination at a time when our scientific imagination knows no bounds. I think our right brains are churning, wanting to label and make colorful and to connect, but the imagined constraints of science and data have introduced a peculiar self-consciousness. I’m hoping that my talk encourages us to create more eponyms, more metaphors, and more colorful ways of capturing this incredible time we live in.

What is the legacy you want to leave?

I’d like to think that, in the era of tremendous advances in science and in medicine, I tried to keep us from losing sight of the patient, that vulnerable human being who gave us the great privilege of being with them at their time of need. What that human being needs in addition to our robotic technology, our beautiful diagnostic tools, is a caring relationship with another human being. I’d like to think that I spoke strongly for that and that I introduced a generation or more of students to the bedside and to that special privilege.

William Osler is quoted as saying that he desired no other epitaph “…than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.” I don’t know that he actually used that on his tombstone, but I understand the sentiment. Every single student I work with at the bedside (even though the process might seem inefficient to be working with just one or two students) has the potential to go out and, in a lifetime, care for hundreds and thousands of patients. So, if you influence them well, you truly have leveraged something in the best sense of that word. I’d like my legacy to be about that work, both at the physical bedside but also metaphorically, and having brought readers and listeners to that sacred space and having perhaps conveyed in every manner that I could, the romance and passion and privilege of being in medicine. It’s not a business and never will be. Even though it enriches a lot of people, and even though it seems to be very much a business, medicine will always be a calling.

What’s next for you?

I have in mind the shaping of something I am calling “The Center for the Patient and Physician,” which I think of as a place to explore every aspect of the patient-physician relationship. At one level it will be pedagogy, teaching at the bedside and refining methods for teachers. But it will also be bringing in folks from a multitude of disciplines. For example from anthropology and ethnography to look at the patient-physician interaction, or tapping into bioengineering and design schools to look at the spaces where we interact. Perhaps, using population health sciences to look at influences on large populations of certain styles of physician-patient relationship. Or serving as a locale where postdocs and scholars who are interested in any aspect of this, can develop their craft – from studying empathy, compassion and caring to developing the next generation of pocket tools.

Are there any action items that you want your viewers to take?

Invent a metaphor that captures the work you do! If something could be named after you, what would it be? Go ahead, don’t feel shy!

How risky is it, anyway?

These days, science can tell us in incredible detail the ways our decisions are impacting our health – it’s easier than ever to discover what is going on in our bodies. We know that a poor diet or lack of exercise can have negative impacts on our heart health. We know that too much sun exposure can lead to skin cancer. We even know how diseases spread – and how they don’t. But, in the face of all of this information, we still continue to make decisions that may not be the best for our health.

In other words, many medical professionals are dismayed by the large gap between risk as perceived by scientists, and risk as perceived by the population as a whole.

As an example of this gap, some doctors and scientists point to the country’s reaction to Ebola. Though the average American is more at risk for flu, a car accident, obesity, diabetes, or heart disease than Ebola, the entry of the disease into the U.S. has brought a high level of fear. This prompts the question: How can the medical community accurately and responsibly communicate risk in a way that encourages healthy choices?

Last week, as part of the Great Challenges program, we convened a group of experts on the topic. They discussed the psychology behind risk perception and talked about strategies and tools that the medical community can use to ensure that patients receive an accurate understanding of their risks and are encouraged to act accordingly. The event was moderated by James Maskell, CEO and Founder of Revive Primary Care.

The participants all agreed that our reactions to risk are often driven by feelings before facts – and that the low level of health literacy in this country doesn’t help. Brian Zikmund-Fisher, PhD, an Associate Professor of Health Behavior & Health Education at the University of Michigan School of Public Health, noted that other elements of human risk perception include our experience (or those of others), our knowledge, our level of control, and our level of dread. He stressed the importance of understanding risk as a population-level construct.

Glyn Elwyn, MBBCH, MSC, FRCGP, PhD, a physician-researcher, Professor and Senior Scientist at the Dartmouth Health Care Delivery Science Center and the Dartmouth Institute for Health Policy and Clinical Practice, posed a key question: “How do we frame information so that it’s easy to understand?” The group agreed that risk perception is largely about context; they stressed the importance of using language and tools to create this context – which is not always statistics. Brian shared his thoughts on the subject: “how can we give people the tools so that they can understand under what circumstances they would be at risk, and when they’re not at risk? We need to use stories to represent examples and also provide quantitative information.”

Thomas Workman, PhD, MA, the Principal Communication Researcher and Evaluator for the Health and Social Development Program at the American Institutes for Research (AIR), had one suggestion: asking patients to think about how they would feel if the health condition for which the patient is at risk occurred. He called for patient involvement in the development of these tools, asking, “How can we incorporate patients into the development of some of these tools and technologies?”

Participants emphasized the importance of the clinical encounter in creating this context. At the same time, the short time for each office visit was a concern. Thomas noted that “The conversation with the physician is just as important as the conversation with the community.” He suggested that risk and prevention discussions can take place with organizations within the community – or even within small family units. David Bell, MD, MPH, an Assistant Professor of Population and Family Health at the Columbia University Medical Center, echoed this sentiment. He stressed the need for risk information to come from a trusted source.

The participants also recognized that the media plays an important role in framing the public’s risk perception. We live in a world where we are confronted with sensationalized news daily. Glyn pointed to the low trust in public information plus dread as a “toxic mix that the media are ventilating,” while Thomas asked: “How can we create more balanced messages?” Brian noted that while individual stories may make interesting news stories, they “will never be representative of the broader range of what could possibly occur.”

On the whole, the participants concurred that, as David put it, “Every step of the way patients get different messages about their risk and we all need to be on the same page.” A tall order, of course, but one which may lead to more realistic understandings of risk – and consequently, it is hoped, the adoption of healthier behaviors.

If you missed the live event, catch the recast here: www.tedmed.com/greatchallenges/liveevent/494673, and stay tuned for our next Great Challenges hangout on Achieving Medical Innovation later this month!