Abraham Verghese’s Cutting for Stone

Dr. Abraham Verghese

chisels away with his fictional scalpel and writer’s pen to discover the meaning of life, living and medicine…

It’s a frenetic juxtaposition of ever-changing airports, taxis, hotels, new places, unknown streets and lots and lots of nameless faces. Indeed, in recent days Dr. Abraham Verghese has been boarding jets at breakneck speed, shuttling between countless cities and towns in North America, not for medical conferences or research but for that quintessential ritual of an author’s life – the book tour.

‘Cutting for Stone’, his monumental first novel has just been published and the accolades are pouring in. A decade in the making, this intriguing tale is keeping readers hooked. Yet on a deeper level, the book is an exploration of medicine, ethics, the relationship of patient and physician and all the dichotomies of the healing profession. It is, in fact, for Verghese, a distillation of all these dilemmas seen through the lens of his own experiences and imagination.

“Fiction is a higher form of truth telling than nonfiction, in the sense that if a novel is compelling it’s usually because it has managed to penetrate some truth about the human condition that is well illustrated by that novel,” says Verghese, who has also written two acclaimed works of nonfiction. “Novels are instruction for living.”

Indeed right from the start the stethoscope and the writer’s pen have been deeply entwined for Verghese, making him who he is today. Currently he is Professor for the Theory and Practice of Medicine at the Stanford University School of Medicine and Senior Associate Chair of the Department of Internal Medicine in California. He also has two acclaimed nonfiction books and scores of articles in major publications under his belt.

His journey started many years ago in Addis Ababa in Ethiopia where he was born to Indian parents. “I am very much of Indian origin, that’s my culture,” he says. “My parents were part of a large and interesting community in Ethiopia – all teachers – so we grew up very much steeped in that tradition.”

Political turmoil in Ethiopia terminated his medical training and Verghese returned to India to complete his studies at Madras Medical College, and he has many happy memories of deep friendships and family ties there. He says, “I think now I’m coming full circle to my roots in California where frankly there is a huge Indian Diaspora so that it feels almost like I’m reconnecting and re-circling back to the beginning.”

After completing his medical studies in India, he went on to the US for his residency as a foreign medical graduate, and spent three years in Johnson City, Tennessee before doing his fellowship at Boston University School of Medicine and working at Boston City Hospital for two years.

These were the days of the start of the horrific AIDS epidemic and as an assistant professor of medicine he saw first hand the tragedy of AIDS in rural communities and how it impacted so many lives. His hands-on work with dying patients and the relationships he formed affected him deeply. Writing became an emotional outlet and he also enrolled at the Iowa Writers Workshop at the University of Iowa, earning a Master of Fine Arts degree there.

His work next took him to El Paso, Texas where he was professor of medicine and chief of the Division of Infectious Diseases at Texas Tech Health Sciences Center. He lived here for eleven years and this was also where his writing became a serious commitment.

His debut book, ‘My Own Country: A Doctor’s Story’ was a powerful memoir about working with AIDS patients in rural Tennessee, and in the process, finding himself. It was a finalist for the National Book Critics Circle Award and selected by Time magazine as one of the five best books of the year, and was also made into a film by Mira Nair.
His second book, “The Tennis Partner,” about the drug addiction and death of his friend, a young medical student, was a New York Times notable book and a national bestseller. His articles have also appeared in many publications including including Granta, The New York Times and Wall Street Journal.

Ask him how he managed to juggle his work, his writing and his young family in those early years and he says: “I’m not the best example of this – I really think not being able to balance those things well cost me my first marriage; that and an inherent restlessness and the whole HIV experience. So I’m not sure I’m the poster child for balance but I think I’m smarter about it now and I try a lot harder to say no to things.”

“When you’re starting out, it’s much more difficult to do. So the answer to how do I do it all is, frankly I don’t know. I have one motto that I think has been very helpful – You just try and do this day’s work well. Pay attention to that which is in front of you – so if it’s my son, then nothing else exists for me at that moment in my life. I’m not good at this but this is what I try to do.”

Abraham Verghese: Writing and Medicine

For Verghese, writing and medicine are closely knit. He says that in medical school you are taught to observe, pick up on details and bring it all into a diagnosis, and these are factors fundamental to the process of writing too.

“I often feel I write in order to understand what I’m thinking – when I start to write, then it starts to emerge, a sort of secondary, tertiary understanding that I wouldn’t have had if I hadn’t tried to write it – so that’s the part of writing that I think is utterly mysterious and enjoyable,” he says.

Verghese has served as the founding director of the Center for Medical Humanities and Ethics at the University of Texas Health Sciences Center in San Antonio, a novel program for medical students. Here he emphasized bedside medicine, inviting medical students to accompany him on rounds, highlighting the value of detailed physical examinations and empathy towards patients and families.

“The humanities are vital in helping students maintain empathy with their patients,” he says. “Students come to medicine with a great capacity to imagine the suffering of others. In their clinical years, however, they are taught to take the patient’s unique story of illness and translate it into the depersonalized language of the chart. We want to keep alive their innate humanity, integrity and empathy.”

Abraham Verghese:  Time to Write

And that brings us full circle to Stanford, where he and wife Sylvia moved from Palo Alto with their 10 year old son Tristan. His two older boys, Steven and Jacob, are away at college. His current position at Stanford offers him a rare chance to officially merge his two loves – writing and medicine.

“One of the beautiful things about this position is that for the first time in my life I have a forty percent protected time to write.” he says, “So I’m bringing about the separation of the two roles – something that I never did before. It’s delightful – I feel I’ve finally earned the ability to do that.”

He’s come to Stanford as a professor with tenure and that’s generally something reserved for those with research grants and scientific breakthroughs under their belt. He says, “It’s just very humbling to see how over time the effect of my writing has been that it’s taken to be the equivalent of scientific research. I think it’s looked at as seriously a contribution as research – and that’s really gratifying to me.”

Besides his writing, Verghese is responsible for third year medical students on rotation in internal medicine, something typically delegated to junior faculty: “To me, it’s a great privilege and honor, because it’s precisely the thing that I consider terribly important, a moment to shape them.”

Now that he has a small office of his own and the time to write, Verghese wants to explore with the pen how medicine is evolving and how his own thinking is evolving. “We have never had more ability to bring patients a cure or better their medical conditions, yet I think there has never been a time when patients have been more dissatisfied with medicine.”

“It’s a very strange paradox – science is at this brilliant phase where we are curing some cancers with a single pill but the public, I think, feels quite the opposite, that medicine is getting further and further away from the patient, from one human being interacting with another. It’s more like you’re getting swallowed up by a system when you have an illness and being farmed out to all these tests and specialists.”

He feels the real issue of the day is to balance this almost mathematical, scientific model of disease with our need as human beings to have someone to give us comfort, reassurance and be with us through the course of a long illness. He says, “That’s what intrigues me the most right now.”

Verghese, who has always stayed close to his Indian roots, gratefully recalls his student days at Madras Medical College and his Indian training has a lot to do with his convictions about interactions between physician and patient.

“Even though I knew I was getting very good training, I didn’t realize how precious the kind of training I got in India would be,” he says, recalling the days of in-depth teaching at the bedside with wonderful clinicians – one teacher and 10-15 students, would learn really everything about this one patient, spending an hour or even two, absorbing every detail.

“That has become so rare in America, that when I think back about how I had that happen every single day for three years, in medicine and surgery and obstetrics, I feel very, very blessed,” he says. “I think I had superb medical training – I’m very, very privileged. These clinicians demonstrated that the body is text and showed us how the body can be read. I took it for granted that that’s how everyone is trained everywhere and didn’t realize how rare that was till I got here.”

Indeed, the case of the invisible patient, the I-patient who exists just on the physician’s computer monitor as so much data, while the real live patient in the bed is ignored, has become an important issue for Verghese. His recent article in the New England Journal of Medicine, Culture Shock – ‘Patient as Icon, Icon as Patient,’ addresses this conundrum, as does his novel.

“I think technology – and this is true even in India as well because it’s happening in India very much as well – technology has created the illusion that we don’t need to examine the patient. The argument I make is that if you subscribe to that it’s very, very inefficient and inexpensive; it means that you’re going to not believe someone has lost a finger until you get a Cat scan, an MRI, and an orthopedic consult. It dismisses the ability of the senses to tell you what is going on.”

 

Verghese has a deep belief in this sacrosanct relationship: “I think that there’s a very special transaction that takes place between physician and the patient during the course of a careful examination,” he says. “It’s during that exam when the physician touches you and pulls your eyelid down and looks into your eyes and thumps on your chest – that’s when a very ritualistic bond is formed and if you shortchange that by just sitting behind your desk and saying ‘Let’s send you for this test, let’s send you for that test,’ you have essentially shortchanged yourself from an important transaction.”

“Rituals like that I think are about transformation and if you do it well, the patient is transformed and you are transformed. You have a bond that can only be established by that act. I’m a big believer that that time honored tradition of examining the patient can never become redundant; it can never be something that we just stop doing.”

So this must be a crucial part of what he teaches his students? “It is, and the funny thing is they love it. In this era of technology, it’s almost like being a kind of artisan and preserving an older art form or something! The students uniformly came to medicine imagining that it would be something like this, the sense of being a detective at the bedside. I think that they thrill to someone who can show this to them – they love it and it’s very relevant to them.”

In this age of medical treatment by remote control where the patient is just a faceless number, Dr. Abraham Verghese is attempting to bring the human bond back into the patient-physician pact, and underscoring it with the power of his pen.

 

TEACHERS WHO TAUGHT THE TEACHER

Abraham Verghese

recalls two professors who were his mentors at Madras Medical College.

“K.V. Thirudengadan, everyone called him KVT – was really my great hero – he showed me how colorful medicine could be and was a wonderful, dedicated teacher. I find myself saying things, sentence for sentence, because he had said them to me in just that way and it was just the right way to say it, just something to make medicine memorable. He would say something to us and we’d be hearing it for the first time and there was such excitement. Teaching is about repetition and he would teach the same thing year after year, making it a little bit better every time, keeping it brand new, keeping it fresh. He was a master at that.

I had a tremendous surgical experience in India as a student with Professor M. Rangabashyan. He was a very charismatic figure, a decisive man, dedicated teacher and a skilled surgeon, very much on the international scene. He was very tough, he had very high standards and I felt that I met his standards and got his approval. I was really quite thrilled to have him interested in me.

When I came to America, I had choice to go to surgery or medicine but decided to go into medicine instead because the prospects seemed better. I was sorry I never got to meet him and tell him why I didn’t take surgery. I was probably sheepish about it – but his example was a wonderful one for me to follow – it just so happened that I headed in another direction. This book in many ways was my tribute to surgery – almost doing it vicariously – doing surgery without having done surgery! A tribute to how much I had enjoyed it.”

© Lavina Melwani

(This article first appeared in Housecalls)

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