For et par måneder siden kom en nogen og 40 år gammel kvinde på skadestuen på et hospital tæt på, hvor jeg bor, og hun blev bragt forvirret ind. Hendes blodtryk var en alarmerende 230 over 170. Inden for få minutter fik hun hjertestop. Hun blev genoplivet, stabiliseret, kom hurtigt til en CAT scanning lige ved siden af skadestuen, fordi de frygtede blodpropper i lungen. Og CAT scanningen viste ingen blodpropper i lungen, men den viste bilaterale, synlige, følbare knuder i brystet, brysttumorer, der havde metastaseret stort set til hele kroppen. Og den virkelige tragedie var, hvis man gennemgår hendes journaler, var hun blevet tilset i fire eller fem andre sundhedsinstitutioner i de forgangne to år. Fire eller fem muligheder for at se knuderne i brystet, mærke brystmassen, gribe ind på et tidligere stadie, end da vi så hende.
A few months ago, a 40 year-old woman came to an emergency room in a hospital close to where I live, and she was brought in confused. Her blood pressure was an alarming 230 over 170. Within a few minutes, she went into cardiac collapse. She was resuscitated, stabilized, whisked over to a CAT scan suite right next to the emergency room, because they were concerned about blood clots in the lung. And the CAT scan revealed no blood clots in the lung, but it showed bilateral, visible, palpable breast masses, breast tumors, that had metastasized widely all over the body. And the real tragedy was, if you look through her records, she had been seen in four or five other health care institutions in the preceding two years. Four or five opportunities to see the breast masses, touch the breast mass, intervene at a much earlier stage than when we saw her.
Mine damer og herrer, det er ikke en usædvanlig historie. Desværre sker det hele tiden. Jeg spøger med, men kun halvt, at hvis man kommer til et af vores hospitaler uden et lem, vil ingen tro dig, før de får en CAT eller MRI scanning eller ortopædisk konsultation. Jeg er ikke maskinstormer. Jeg underviser på Stanford. Jeg er en læge, der praktiserer med banebrydende teknologi. Men jeg vil gerne argumentere for i de næste 17 minutter, at når vi skærer den fysiske undersøgelse væk, når vi læner mod at bestille prøver i stedet for at tale til og undersøge patienten, vil vi ikke kun overse simple diagnoser, der kan diagnosticeres på et tidligt stadie, hvor det kan behandles, vi mister meget mere end det. Vi mister et ritual. Vi mister et ritual, som jeg mener er omdannende, transcendent og i hjertet af patient-læge-forholdet. Det kan muligvis være kætteri at sige dette på TED, men jeg vil gerne introducere jer for den vigtigste opfindelse, synes jeg, i medicin i de næste 10 år, og det er den menneskelige hånds magt -- at berøre, trøste, diagnosticere og sørge for behandling.
Ladies and gentlemen, that is not an unusual story. Unfortunately, it happens all the time. I joke, but I only half joke, that if you come to one of our hospitals missing a limb, no one will believe you till they get a CAT scan, MRI or orthopedic consult. I am not a Luddite. I teach at Stanford. I'm a physician practicing with cutting-edge technology. But I'd like to make the case to you in the next 17 minutes that when we shortcut the physical exam, when we lean towards ordering tests instead of talking to and examining the patient, we not only overlook simple diagnoses that can be diagnosed at a treatable, early stage, but we're losing much more than that. We're losing a ritual. We're losing a ritual that I believe is transformative, transcendent, and is at the heart of the patient-physician relationship. This may actually be heresy to say this at TED, but I'd like to introduce you to the most important innovation, I think, in medicine to come in the next 10 years, and that is the power of the human hand -- to touch, to comfort, to diagnose and to bring about treatment.
Jeg vil gerne introducere jer for denne person, hvis billede I måske genkender. Dette er Sir Arthur Conan Doyle. Da vi er i Edinburg, er jeg en stor fan af Conan Doyle. I ved måske ikke, at Conan Doyle studerede medicin her i Edinburgh, og hans karakter, Sherlock Holmes, var inspireret af Sir Joseph Bell. Joseph Bell var en usædvanlig lærer på alle måder. Og Conan Doyle, skrivende om Bell, beskrev den følgende udveksling mellem Bell og hans studerende.
I'd like to introduce you first to this person whose image you may or may not recognize. This is Sir Arthur Conan Doyle. Since we're in Edinburgh, I'm a big fan of Conan Doyle. You might not know that Conan Doyle went to medical school here in Edinburgh, and his character, Sherlock Holmes, was inspired by Sir Joseph Bell. Joseph Bell was an extraordinary teacher by all accounts. And Conan Doyle, writing about Bell, described the following exchange between Bell and his students.
Forestil jer Bell siddende i ambulatoriet, studerende rundt om ham, patienter, der skriver sig ind på skadestuen og bliver registrerede og bragt ind. En kvinde kommer ind med et barn, og Conan Doyle beskriver den følgende udveksling. Kvinden siger, "Godmorgen." Bell siger, "Hvordan var turen med færgen fra Burntisland?" Hun siger, "Den var god." Og han siger, "Hvad gjorde du med det andet barn?" Hun siger, "Jeg gav ham til min søster på Leith." Og han siger, "Og tog du genvejen ned af Inverleith Row for at komme til sygehuset?" Hun siger, "Det gjorde jeg." Og han siger, "Arbejder du stadig på linoleumsfabrikken?" Og hun siger, "Det gør jeg."
So picture Bell sitting in the outpatient department, students all around him, patients signing up in the emergency room and being registered and being brought in. And a woman comes in with a child, and Conan Doyle describes the following exchange. The woman says, "Good Morning." Bell says, "What sort of crossing did you have on the ferry from Burntisland?" She says, "It was good." And he says, "What did you do with the other child?" She says, "I left him with my sister at Leith." And he says, "And did you take the shortcut down Inverleith Row to get here to the infirmary?" She says, "I did." And he says, "Would you still be working at the linoleum factory?" And she says, "I am."
Og Bell starter med at forklare for sine studerende. Han siger, "Ser I, da hun sagde, 'Godmorgen,' anede jeg hendes Fife-accent. Og den nærmeste færge fra Fife afgår fra Burnisland. Og derfor måtte hun have taget færgen over. Læg mærke til, at jakken, hun bærer, er for lille til barnet, der er med hende, og derfor begyndte hun turen med to børn, men afleverede det ene på vejen. Læg mærke til leret på hendes skosåler. Den slags rødt ler findes ikke inden for hundrede mil fra Edinburgh, bortset fra i botanisk have. Og derfor skød hun genvej ned ad Inverleith Row for at komme her. Og endelig har hun hudbetændelse på hendes højre hånds fingre, en betændelse, der er unik for linoleumfabriksarbejderne i Burnisland." Og da Bell får afklædt patienten, begynder at undersøge patienten, kan man kun forestille sig, hvor meget mere han ville udlede. Og som lærer i medicin og studerende selv blev jeg inspireret af den historie.
And Bell then goes on to explain to the students. He says, "You see, when she said, 'Good morning,' I picked up her Fife accent. And the nearest ferry crossing from Fife is from Burntisland. And so she must have taken the ferry over. You notice that the coat she's carrying is too small for the child who is with her, and therefore, she started out the journey with two children, but dropped one off along the way. You notice the clay on the soles of her feet. Such red clay is not found within a hundred miles of Edinburgh, except in the botanical gardens. And therefore, she took a short cut down Inverleith Row to arrive here. And finally, she has a dermatitis on the fingers of her right hand, a dermatitis that is unique to the linoleum factory workers in Burntisland." And when Bell actually strips the patient, begins to examine the patient, you can only imagine how much more he would discern. And as a teacher of medicine, as a student myself, I was so inspired by that story.
Men I ved måske ikke, at vores evne til at se ind i kroppen på denne simple måde med vores sanser er ret ny. Billedet, jeg viser jer, er af Leopold Auenbrugger, der sidst i 1800-tallet opdagede percussion. Historien går, at Leopold Auenbrugger var søn af en krofatter. Hans far plejede at gå ned i kælderen for at banke på vintøndernes sider og bestemme, hvor meget vin, der var tilbage, og om der skulle bestilles mere. Så da Auenbrugger blev læge, begyndte han at gøre det samme. Han begyndte at banke på sine patienters bryst, på deres maver. Stort set alt vi kender til percussion, som man kan kalde den tids ultralyd -- organforstørrelse, væske om hjertet, væske i lungerne, forandringer i maven -- alt dette beskriver han i dette manuskript "Inventum Novum," "Ny Opfindelse," som ville være gået i glemmebogen, hvis ikke for denne læge, Corvisart, en kendt fransk læge -- kun kendt, fordi han var læge for denne herre -- Corvisart genpopulariserede og genintroducerede værket.
But you might not realize that our ability to look into the body in this simple way, using our senses, is quite recent. The picture I'm showing you is of Leopold Auenbrugger who, in the late 1700s, discovered percussion. And the story is that Leopold Auenbrugger was the son of an innkeeper. And his father used to go down into the basement to tap on the sides of casks of wine to determine how much wine was left and whether to reorder. And so when Auenbrugger became a physician, he began to do the same thing. He began to tap on the chests of his patients, on their abdomens. And basically everything we know about percussion, which you can think of as an ultrasound of its day -- organ enlargement, fluid around the heart, fluid in the lungs, abdominal changes -- all of this he described in this wonderful manuscript "Inventum Novum," "New Invention," which would have disappeared into obscurity, except for the fact that this physician, Corvisart, a famous French physician -- famous only because he was physician to this gentleman -- Corvisart repopularized and reintroduced the work.
Det blev fulgt op et år eller to senere af Laennecs opdagelse af stetoskopet. Laennec, siges det, spadserede i Paris' gader og så to børn lege med en pind. Det ene kradsede på pindens ende, et andet barn lyttede i den anden ende. Og Laennec tænkte, dette ville være en skøn måde at lytte til brystet eller bugen ved at bruge, hvad han kaldte "cylinderen." Senere omdøbte han det stetoskopet. Sådan blev stetoskopet og auskultation født. Så i løbet af få år i slutningen af 1800-, starten af 1900-tallet, lige pludselig, var barberkirurgen blevet skubbet til side af lægen, der forsøgte at stille en diagnose.
And it was followed a year or two later by Laennec discovering the stethoscope. Laennec, it is said, was walking in the streets of Paris and saw two children playing with a stick. One was scratching at the end of the stick, another child listened at the other end. And Laennec thought this would be a wonderful way to listen to the chest or listen to the abdomen using what he called "the cylinder." Later he renamed it the stethoscope. And that is how stethoscope and auscultation was born. So within a few years, in the late 1800s, early 1900s, all of a sudden, the barber surgeon had given way to the physician who was trying to make a diagnosis.
Husk på, at før den tid, uanset hvad man fejlede, gik man til barberkirurgen, der endte med at tappe en, bløde en, rense en. Og, åh ja, hvis man ønskede det, ville han klippe en -- kort i siderne, lang i nakken -- og trække en tand ud, nu han var i gang. Han forsøgte ikke at diagnosticere. Nogle af jer ved måske endda, at barberpælen, de røde og hvide striber, repræsenterer barberkirurgens blodige bandager, og beholderne i hver ende repræsenterer potterne, hvori blodet blev opsamlet. Men auskultations og percussions ankomst repræsenterede et skift, et øjeblik, hvor læger begyndte at se ind i kroppen.
If you'll recall, prior to that time, no matter what ailed you, you went to see the barber surgeon who wound up cupping you, bleeding you, purging you. And, oh yes, if you wanted, he would give you a haircut -- short on the sides, long in the back -- and pull your tooth while he was at it. He made no attempt at diagnosis. In fact, some of you might well know that the barber pole, the red and white stripes, represents the blood bandages of the barber surgeon, and the receptacles on either end represent the pots in which the blood was collected. But the arrival of auscultation and percussion represented a sea change, a moment when physicians were beginning to look inside the body.
Og lige præcis dette maleri, synes jer, repræsenterer toppen af den kliniske æra. Dette er et meget kendt maleri: "Doktoren" af Luke Fildes. Luke Fildes blev bestilt til at male dette af Tate, som etablerede Tate Gallery. Tate bad Fildes male et maleri med social vigtighed. Og det er interessant, at Fildes valgte dette emne. Fildes' ældste søn, Philip, døde i en alder af ni juleaften efter en kort sygdom. Og Fildes blev så rørt over lægen, der holdt vagt ved sengen i to, tre nætter, at han besluttede, at han ville forsøge at afbilde vor tids læge -- næsten en hyldest til denne læge. Og derfor maleriet "Doktoren," et meget kendt maleri. Det har været på kalendere, frimærker i mange lande. Jeg har ofte tænkt, hvad ville Fildes havde gjort, var han blevet bedt male dette maleri i den moderne æra, i år 2011? Ville han have indsat en computerskærm, hvor patienten havde været?
And this particular painting, I think, represents the pinnacle, the peak, of that clinical era. This is a very famous painting: "The Doctor" by Luke Fildes. Luke Fildes was commissioned to paint this by Tate, who then established the Tate Gallery. And Tate asked Fildes to paint a painting of social importance. And it's interesting that Fildes picked this topic. Fildes' oldest son, Philip, died at the age of nine on Christmas Eve after a brief illness. And Fildes was so taken by the physician who held vigil at the bedside for two, three nights, that he decided that he would try and depict the physician in our time -- almost a tribute to this physician. And hence the painting "The Doctor," a very famous painting. It's been on calendars, postage stamps in many different countries. I've often wondered, what would Fildes have done had he been asked to paint this painting in the modern era, in the year 2011? Would he have substituted a computer screen for where he had the patient?
Jeg er kommet i problemer i Silicon Valley for at sige, at patienten i sengen næsten er blevet et ikon for den virkelige patient, der er i computeren. Jeg har faktisk fundet på et ord for det væsen i computeren. Jeg kalder det iPatienten. iPatienten bliver sørget godt for over hele Amerika. Den virkelige patient tænker tit, hvor er alle? Hvornår kommer de og forklarer mig tingenes tilstand? Hvem fører an? Der er stor forskel på patientens opfattelse og vores egen opfattelse som læger af den bedste medicinske behandling.
I've gotten into some trouble in Silicon Valley for saying that the patient in the bed has almost become an icon for the real patient who's in the computer. I've actually coined a term for that entity in the computer. I call it the iPatient. The iPatient is getting wonderful care all across America. The real patient often wonders, where is everyone? When are they going to come by and explain things to me? Who's in charge? There's a real disjunction between the patient's perception and our own perceptions as physicians of the best medical care.
Jeg vil gerne vise jer et billede af, hvordan stuegang så ud, da jeg var under uddannelse. Fokus var på patienten. Vi gik fra seng til seng. Den ledende overlæge førte an. Alt for ofte nu om dage ser stuegang meget ud som dette, hvor diskussionen finder sted i et rum langt fra patienten. Diskussionen handler om billeder på en computer, data. Og det ene vigtige element, der mangler, er patienten.
I want to show you a picture of what rounds looked like when I was in training. The focus was around the patient. We went from bed to bed. The attending physician was in charge. Too often these days, rounds look very much like this, where the discussion is taking place in a room far away from the patient. The discussion is all about images on the computer, data. And the one critical piece missing is that of the patient.
Jeg er blevet påvirket til denne tankegang af to anekdoter, som jeg gerne vil dele med jer. En handler om en ven, der havde brystkræft, fik opdaget en lille brystkræft -- fik lumpektomi i byen, hvor jeg boede. Dette er, da jeg var i Texas. Hun brugte så en masse tid på at undersøge, hvilket der var det bedste kræftcenter i verden at få hendes efterbehandling. Hun fandt stedet og valgte at tage derhen. Hvilket er derfor, jeg blev overrasket få måneder efter over at se hende tilbage i byen og modtage hendes efterbehandling hos hendes private onkolog.
Now I've been influenced in this thinking by two anecdotes that I want to share with you. One had to do with a friend of mine who had a breast cancer, had a small breast cancer detected -- had her lumpectomy in the town in which I lived. This is when I was in Texas. And she then spent a lot of time researching to find the best cancer center in the world to get her subsequent care. And she found the place and decided to go there, went there. Which is why I was surprised a few months later to see her back in our own town, getting her subsequent care with her private oncologist.
Jeg pressede og spurgte hende, "Hvorfor kom du tilbage og får din behandling her?" Hun ville helst ikke fortælle mig det. Hun sagde, "Kræftcenteret var skønt. Det havde et smukt anlæg, kæmpe atrium, parkeringsservice, et piano, der selv spillede, en concierge, der tog dig rundt fra her til der. Men," sagde hun, "men de rørte ikke mine bryster." Nu kan vi argumentere for, at de nok ikke behøvede at røre hendes bryster. De fik hende scannet på alle ledder. De forstod hendes brystkræft på det molekylære niveau; de havde intet behov for at røre hendes bryster.
And I pressed her, and I asked her, "Why did you come back and get your care here?" And she was reluctant to tell me. She said, "The cancer center was wonderful. It had a beautiful facility, giant atrium, valet parking, a piano that played itself, a concierge that took you around from here to there. But," she said, "but they did not touch my breasts." Now you and I could argue that they probably did not need to touch her breasts. They had her scanned inside out. They understood her breast cancer at the molecular level; they had no need to touch her breasts.
Men for hende betød det meget. Det var nok for hende til at foretage beslutningen at få sin efterbehandling hos hendes egen onkolog, der, hver gang hun kom, undersøgte begge bryster og armhuler, undersøgte hendes lymfeknuder grundigt, undersøgte hendes livmoderhals- og lyskeregioner, foretog en grundig undersøgelse. Og for hende, var det en slags opmærksomhed, som hun behøvede. Jeg blev meget påvirket af den anekdote.
But to her, it mattered deeply. It was enough for her to make the decision to get her subsequent care with her private oncologist who, every time she went, examined both breasts including the axillary tail, examined her axilla carefully, examined her cervical region, her inguinal region, did a thorough exam. And to her, that spoke of a kind of attentiveness that she needed. I was very influenced by that anecdote.
Jeg blev også påvirket af en anden oplevelse, jeg havde, igen, da jeg var i Texas, før jeg flyttede til Stanford. Jeg havde et ry for at være interesseret i patienter med kronisk træthed. Dette er ikke et ry man ville ønske for sin værste fjende. Det siger jeg, fordi disse er svære patienter. De er ofte blevet afvist af deres familier, har haft dårlige erfaringer med sundhedsvæsnet, og de kommer til en fuldt forberedt på, at man kan komme på listen over folk, der snart vil skuffe dem. Jeg lærte allerede fra min første patient, at jeg ikke kunne yde retfærdighed for denne meget komplicerede patient med alle de journaler, de bragte ved et nyt patientbesøg på 45 minutter. På ingen måde. Hvis jeg forsøgte, ville jeg skuffe dem.
I was also influenced by another experience that I had, again, when I was in Texas, before I moved to Stanford. I had a reputation as being interested in patients with chronic fatigue. This is not a reputation you would wish on your worst enemy. I say that because these are difficult patients. They have often been rejected by their families, have had bad experiences with medical care and they come to you fully prepared for you to join the long list of people who's about to disappoint them. And I learned very early on with my first patient that I could not do justice to this very complicated patient with all the records they were bringing in a new patient visit of 45 minutes. There was just no way. And if I tried, I'd disappoint them.
Så jeg prøvede denne metode, hvor jeg bad patienten fortælle mig historien i hele deres første besøg, og jeg prøvede ikke at afbryde dem. Vi ved, den gennemsnitlige amerikanske læge afbryder deres patient inden 14 sekunder. Hvis jeg skulle komme i Himlen, bliver det, fordi jeg holdt min mund i 45 minutter og ikke afbrød min patient. Så planlagde jeg den fysiske undersøgelse to uger senere, og da patienten kom for undersøgelsen, kunne jeg foretage en grundig fysisk undersøgelse, fordi jeg intet andet havde at gøre. Jeg synes selv, jeg foretager grundige undersøgelser, men fordi hele besøget nu handlede om den fysiske, kunne jeg foretage en usædvanlig grundig undersøgelse.
And so I hit on this method where I invited the patient to tell me the story for their entire first visit, and I tried not to interrupt them. We know the average American physician interrupts their patient in 14 seconds. And if I ever get to heaven, it will be because I held my piece for 45 minutes and did not interrupt my patient. I then scheduled the physical exam for two weeks hence, and when the patient came for the physical, I was able to do a thorough physical, because I had nothing else to do. I like to think that I do a thorough physical exam, but because the whole visit was now about the physical, I could do an extraordinarily thorough exam.
Jeg husker min allerførste patient i den serie, blev ved med at fortælle mig mere historie under, hvad skulle have været besøget for den fysiske undersøgelse. Jeg begyndte mit ritual. Jeg begynder altid med pulsen, så undersøger jeg hænderne, så på neglelejerne, så fører jeg hånden op til epitroklærkirtlen, og jeg var i gang med mit ritual. Og da mit ritual begyndte, begyndte denne meget talende patient at tie stille. Jeg mindes at have en sælsom fornemmelse, at patienten og jeg var gledet tilbage i et primitivt ritual, i hvilket jeg havde en rolle og patienten havde en rolle. Da jeg var færdig, sagde patienten til mig med ærefrygt, "Jeg er aldrig blevet undersøgt sådan før." Hvis det var sandt, er det en sand fordømmelse af vores sundhedssystem, fordi de var blevet tilset andre steder.
And I remember my very first patient in that series continued to tell me more history during what was meant to be the physical exam visit. And I began my ritual. I always begin with the pulse, then I examine the hands, then I look at the nail beds, then I slide my hand up to the epitrochlear node, and I was into my ritual. And when my ritual began, this very voluble patient began to quiet down. And I remember having a very eerie sense that the patient and I had slipped back into a primitive ritual in which I had a role and the patient had a role. And when I was done, the patient said to me with some awe, "I have never been examined like this before." Now if that were true, it's a true condemnation of our health care system, because they had been seen in other places.
Jeg gik da videre til at fortælle patienten, da patienten var blevet påklædt, standardtingene, som personen må have hørt i andre institutioner, hvilket er, "Dette er ikke i dit hoved. Det er virkeligt. Det gode er, det er ikke kræft, det er ikke tuberkulose, det er ikke coccidioidomycosis eller en underlig svampeinfektion. Det dårlige er, vi ved ikke præcis, hvad forårsager dette, men nu skal du høre, hvad du skal gøre, hvad vi skal gøre." Jeg ville lægge alle standard- behandlingsmulighederne ud, som patienten havde hørt andre steder.
I then proceeded to tell the patient, once the patient was dressed, the standard things that the person must have heard in other institutions, which is, "This is not in your head. This is real. The good news, it's not cancer, it's not tuberculosis, it's not coccidioidomycosis or some obscure fungal infection. The bad news is we don't know exactly what's causing this, but here's what you should do, here's what we should do." And I would lay out all the standard treatment options that the patient had heard elsewhere.
Og jeg følte altid, at hvis min patient opgav søgningen efter den magiske læge eller behandling og begyndte med mig på en kurs mod velvære, var det, fordi jeg havde fortjent retten til at fortælle dem disse ting i kraft af undersøgelse. Noget vigtigt var kommet frem i udvekslingen. Jeg tog dette til mine kolleger på Stanford i antropologi og fortalte dem den samme historie. De fortalte mig straks, "Jamen, du beskriver et klassisk ritual." De hjalp mig med at forstå, at ritualer handler om forvandling.
And I always felt that if my patient gave up the quest for the magic doctor, the magic treatment and began with me on a course towards wellness, it was because I had earned the right to tell them these things by virtue of the examination. Something of importance had transpired in the exchange. I took this to my colleagues at Stanford in anthropology and told them the same story. And they immediately said to me, "Well you are describing a classic ritual." And they helped me understand that rituals are all about transformation.
Vi gifter os, for eksempel, med pomp og ceremoni og udgifter for at markere vores udtræden af et liv i ensomhed og ulykkelighed til et af evig lyksalighed. Jeg ved ikke, hvorfor I ler. Det var det oprindelige formål, ikke sandt? Vi markerer overgivelse af magt med ritualer. Vi markerer, at et liv er forbi, med ritualer. Ritualer er frygteligt vigtige. De handler alle om forvandlinger. Jeg vil sige jer, at ritualet, hvor en person kommer til en anden og fortæller dem ting, som de ikke ville fortælle deres præst eller rabbi, og så, utroligt nok derudover, afklæder og tillader berøring -- jeg vil sige jer, at det er et ritual af stor vigtighed. Og forkorter man det ritual ved ikke at afklæde patienten, ved at lytte med sit stetoskop uden på natkjolen, ved ikke at foretage en fuld undersøgelse, har man forspildt muligheden til at forsegle patient-læge-forholdet.
We marry, for example, with great pomp and ceremony and expense to signal our departure from a life of solitude and misery and loneliness to one of eternal bliss. I'm not sure why you're laughing. That was the original intent, was it not? We signal transitions of power with rituals. We signal the passage of a life with rituals. Rituals are terribly important. They're all about transformation. Well I would submit to you that the ritual of one individual coming to another and telling them things that they would not tell their preacher or rabbi, and then, incredibly on top of that, disrobing and allowing touch -- I would submit to you that that is a ritual of exceeding importance. And if you shortchange that ritual by not undressing the patient, by listening with your stethoscope on top of the nightgown, by not doing a complete exam, you have bypassed on the opportunity to seal the patient-physician relationship.
Jeg er forfatter, og jeg vil afslutte med at læse en kort tekst, jeg skrev, som omhandler dette scenarie. Jeg er infektionsspeciallæge, og i HIVens tidlige dage, før vi havde vores medikamenter, overværede jeg så mange lignende forløb. Jeg husker, hver gang jeg gik til en patients dødsleje på hospitalet eller i hjemmet, husker jeg følelsen af fiasko -- følelsen af, jeg ved ikke, hvad jeg skal sige; Jeg ved ikke, hvad jeg kan sige; jeg ved ikke, hvad jeg bør gøre. Ud af den følelse af fiasko, husker jeg, jeg altid ville undersøge patienten. Jeg ville trække øjenlågene ned. Jeg ville se på tungen. Jeg ville banke på brystet, lytte til hjertet. Jeg ville føle maven. Jeg husker så mange patienter, deres navne stadig levende på min tunge, deres ansigter stadig tydelige. Jeg husker så mange enorme, udhulede, hjemsøgte øjne, der stirrede på mig, mens jeg udførte dette ritual. Den næste dag ville jeg komme og gøre det igen.
I am a writer, and I want to close by reading you a short passage that I wrote that has to do very much with this scene. I'm an infectious disease physician, and in the early days of HIV, before we had our medications, I presided over so many scenes like this. I remember, every time I went to a patient's deathbed, whether in the hospital or at home, I remember my sense of failure -- the feeling of I don't know what I have to say; I don't know what I can say; I don't know what I'm supposed to do. And out of that sense of failure, I remember, I would always examine the patient. I would pull down the eyelids. I would look at the tongue. I would percuss the chest. I would listen to the heart. I would feel the abdomen. I remember so many patients, their names still vivid on my tongue, their faces still so clear. I remember so many huge, hollowed out, haunted eyes staring up at me as I performed this ritual. And then the next day, I would come, and I would do it again.
Jeg vil gerne læse denne afsluttende passage om en patient. "Jeg husker en patient, som på det tidspunkt blot var et skelet omsluttet af skrumpende hud, ude af stand til at tale, hans mund skorpet af trøske, der var resistent over for normal medicin. Da han så mig, i hvad der skulle blive hans sidste timer på denne jord, bevægede hans hænder sig som i slowmotion. Og som jeg funderede over, hvad han ville, nåede hans tændstikfingre op til hans pyjamasskjorte, fumlende med knapperne. Jeg indså, at han ville vise sit pilekurvsbryst til mig. Det var et tilbud, en invitation. Jeg afslog ikke.
And I wanted to read you this one closing passage about one patient. "I recall one patient who was at that point no more than a skeleton encased in shrinking skin, unable to speak, his mouth crusted with candida that was resistant to the usual medications. When he saw me on what turned out to be his last hours on this earth, his hands moved as if in slow motion. And as I wondered what he was up to, his stick fingers made their way up to his pajama shirt, fumbling with his buttons. I realized that he was wanting to expose his wicker-basket chest to me. It was an offering, an invitation. I did not decline.
Jeg bankede, palperede, lyttede til brystet. Jeg tænker, han vel må have vidst dengang, at det var vigtigt for mig, som det var nødvendigt for ham. Ingen af os kunne undvære dette ritual, som intet havde at gøre med at finde rallen i lungen eller finde galloprytmen ved hjertesvigt. Nej, dette ritual handlede om den ene besked, som læger behøver at viderebringe til deres patienter. Selvom, ved Gud, på det seneste i vores hybris, lader vi til at være drevet væk. Vi lader til at have glemt -- som med videnseksplosionen, hele menneskegenomet kortlagt for vores fødder, bliver vi lullet ind i uopmærksomhed, glemmer, at ritualet er rensende for lægen, nødvendig for patienten -- glemmer, at ritualet har betydning og en enestående besked at bringe til patienten.
I percussed. I palpated. I listened to the chest. I think he surely must have known by then that it was vital for me just as it was necessary for him. Neither of us could skip this ritual, which had nothing to do with detecting rales in the lung, or finding the gallop rhythm of heart failure. No, this ritual was about the one message that physicians have needed to convey to their patients. Although, God knows, of late, in our hubris, we seem to have drifted away. We seem to have forgotten -- as though, with the explosion of knowledge, the whole human genome mapped out at our feet, we are lulled into inattention, forgetting that the ritual is cathartic to the physician, necessary for the patient -- forgetting that the ritual has meaning and a singular message to convey to the patient.
Og beskeden, som jeg ikke fuldt forstod dengang, selv mens jeg leverede den, og som jeg forstår bedre nu, er denne: Jeg vil altid, altid, altid være der. Jeg vil hjælpe dig gennem dette. Jeg vil aldrig forlade dig. Jeg er hos dig til det sidste."
And the message, which I didn't fully understand then, even as I delivered it, and which I understand better now is this: I will always, always, always be there. I will see you through this. I will never abandon you. I will be with you through the end."
Mange tak.
Thank you very much.
(Bifald)
(Applause)