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.
Prije nekoliko mjeseci, 40-godišnja žena je došla na hitni prijem bolnice, blizu koje živim. Dovezena je zbunjena. Njezin krvni tlak je bio zabrinjavajućih 230 sa 170. Za nekoliko minuta je doživjela srčani zastoj. Oživljavana je i stabilizirana, odvedena na CT odmah uz hitni prijem, jer su bili zabrinuti zbog ugrušaka u plućima. I CT nije pokazao krvne ugruške u plućima, već obostrane, vidljive, palpabilne tvorbe u dojkama, tumore dojke, koji su opsežno metastazirali po cijelom tijelu. A prava tragedija je bila to što, kada biste pogledali njezinu dokumentaciju, je bila pregledana u četiri ili pet drugih zdravstvenih ustanova u prethodne dvije godine. Četiri ili pet prilika da se uoče tvorbe u dojkama, da se opipaju te tvorbe, da se intervenira u puno ranijem stadiju od onoga u kojem smo je mi vidjeli.
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.
Dame i gospodo, ovo nije neuobičajena priča. Nažalost, stalno se događa. Obično se šalim, ali samo djelomice, da ako dođete u jednu od naših bolnica bez noge ili ruke, nitko vam neće vjerovati dok se ne napravi CT, MRI ili konzilijarni pregled ortopeda. Nisam Ludit. Predajem na Stanfordu. Liječnik sam koji koristi naprednu tehnologiju. Ali želim obraniti tezu u sljedećih 17 minuta da kada skratimo fizikalni pregled, kada težište stavljamo na laboratorijske pretrage umjesto na razgovor s pacijentom i na pregled, ne samo da previdimo jednostavne dijagnoze koje mogu biti dijagnosticirane u izlječivom, ranom stadiju, nego gubimo mnogo više. Gubimo ritual. Gubimo ritual za kojeg smatram da je preobražavajuć, transcendentalan, i čini suštinu odnosa između pacijenta i liječnika. Možda je hereza što ću ovo reći na TED-u, ali htio bih vas upoznati s najvažnijom inovacijom, po mom mišljenju, u medicini koja će doći u sljedećih 10 godina. To je moć ljudske ruke -- da dodirne, utješi, dijagnosticira i započne liječenje.
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.
Prvo bih vas želio upoznati s ovom osobom, čiju sliku možda prepoznajete. Ovo je Sir Arthur Conan Doyle. S obzirom da smo u Edinburgu, veliki sam obožavatelj Conana Doylea. Mozda ne znate da je Conan Doyle išao na medicinski fakultet ovdje u Edinburgu, i njegov lik, Sherlock Holmes, je bio nadahnut Sirom Josephom Bellom. Joseph Bell je bio izuzetan učitelj u svakom pogledu. I Conan Doyle, pišući o Bellu, je opisao sljedeći razgovor između Bella i njegovih studenata.
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."
Zamislite Bella kako sjedi u ambulanti, studenti oko njega, pacijenti se upisuju na hitni prijem registriraju se i uvode unutra. I ulazi jedna žena s djetetom, i Conan Doyle opisuje sljedeći razgovor. Žena kaže, „Dobro jutro.” Bell kaže, “Kakav vam je bio prijelaz trajektom od Burntislanda?” Ona odogovori, “Bio je dobar.” Potom on kaže, „Što ste napravili s drugim djetetom?” Ona kaže, „Ostavila sam ga kod svoje sestre u Leithu.” I on kaže, „Jeste li išli prečacem kroz Inverleith Row da dođete ovdje u ambulantu?” Ona kaže, „Jesmo.” I on kaže, „Da li možda još radite u tvornici linoleuma?” Ona kaže, „Radim.”
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.
Bell je potom objasnio studentima. Kaže, „Vidite, kada je rekla ‘Dobro jutro.’ primjetio sam njezin naglasak iz Fifa. A najbliži trajekt koji dolazi iz Fifea kreće iz Burntislanda. Tako da je morala doći trajektom. Primjetite da je kaput kojeg drži premalen za dijete koje je s njom, stoga je počela put s dvoje djece, ali je ostavila jedno putem. Primjetite glinu na njenim tabanima. Tako crvenu glinu ne možete naći stotinama kilometara od Edinburga, osim u botaničkim vrtovima. Stoga je išla prečacem kroz Inverleith Row da bi stigla ovdje. I naposljetku, ima dermatitis na prstima desne ruke, dermatitis koji je jedinstven radnicima tvornice linoleuma u Burntislandu.” A kada Bell još i skine pacijenticu, počne pregledavati pacijenticu, možete i sami zamisliti koliko bi još zaključaka mogao donijeti. A kao učitelj medicine, i kao student, bio sam jako nadahnut ovom pričom.
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.
Ali možda ne shvaćate da je naša sposobnost da pogledamo u tijelo na ovaj jednostavan način, koristeći naša osjetila, počela tek nedavno. Slika koju vam pokazujem, prikazuje Leopolda Auenbruggera, koji je krajem 18. stoljeća otkrio perkusiju. A priča kaže da je Leopold Auenbrugger bio sin gostioničara. Njegov otac bi išao u podrum i kuckao bi po stijenkama vinskih bačvi da odredi koliko je vina ostalo i da li treba još naručiti. Kada je Auenbrugger postao liječnik počeo je raditi istu stvar. Počeo je lupkati po prsima pacijenata i po njihovim trbusima. I praktički sve što znamo o perkusiji, koju možete zamisliti kao ultrazvuk svog doba, povećanje organa, tekućina oko srca, tekućina u plućima, promjene u trbuhu, sve je to opisao u ovom predivnom rukopisu „Inventum Novum”, „Novi izum”, koji bi otišao u zaborav da ga ovaj liječnik, Corvisart, poznati francuski liječnik, poznat jedino zato što je bio liječnik ovog gospodina, Corvisart je ponovno popularizirao i predstavio ovaj rad.
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.
Godinu-dvije nakon toga je popraćen Laennecovim otkrićem stetoskopa. Priča se da je Laennec hodao ulicama Pariza i vidio dvoje djece kako se igraju sa štapom. Jedan je strugao jedan kraj štapa, dok je drugo dijete slušalo na drugom kraju. I Laennec je pomislio kako bi ovo bio divan način slušanja prsa ili trbuha koristeći „cilindar”, kako ga je nazvao. Kasnije ga je preimenovao u stetoskop. I tako su se rodili stetoskop i auskultacija. Tako da je unutar nekoliko godina, krajem 19. i početkom 20. stoljeća, iznenada brijač-kirurg bio zamijenjen liječnikom, koji je pokušavao postaviti dijagnozu.
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.
Ako se sjećate, prije toga bez obzira na vaše tegobe, išli ste brijaču-kirurgu, koji vam je na kraju puštao krv pomoću roga, pustio vam krv, pročistio vas. I da, ako ste htjeli, podšišao vas je, kratko sa strane, dugo odostraga, i izvadio vam zub, kad ste već tamo. Nije ni pokušavao postaviti dijagnozu. Štoviše, neki od vas možda i znaju da brijački stup, sa crvenim i bijelim prugama, predstavlja krvave zavoje brijača-kirurga, a posude na oba kraja predstavljaju vrčeve u kojima se skupljala krv. Ali dolazak perkusije i auskultacije je predstavljao postupnu promjenu, trenutak kada su liječnici počeli gledati u tijelo.
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?
A posebice ova slika, po mom mišljenju, predstavlja vrh, vrhunac tog kritičnog razdoblja. Ovo je vrlo poznata slika: „Liječnik” Luka Fildesa. Tate je naručio sliku od Luka Fildesa, i potom je osnovao Tate galeriju. Tate je zamolio Fildesa da naslika sliku od društvenog značaja. Zanimljivo je da je Fildes izabrao ovu temu. Fildesov najstariji sin Philip je umro u dobi od devet godina na Badnjak nakon kratke bolesti. Fildes je bio toliko zadivljen liječnikom koji je probdio dvije-tri noći uz krevet djeteta, da je odlučio pokušati prikazati liječnika našeg vremena, skoro poput odavanja počasti tom liječniku. I tako je nastala slika „Liječnik”, vrlo poznata slika. Bila je na kalendarima, poštanskim markama mnogih zemalja. Često sam se zapitao, što bi Fildes napravio da su ga zatražili da naslika ovu sliku u modernom dobu, u 2011. godini. Bi li računalni zaslon stavio umjesto pacijenta?
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.
Malo sam upao u nevolje u Silikonskoj dolini zato što sam rekao da je pacijent u krevetu praktički postao ikona pravog pacijenta, koji je u računalu. Čak sam osmislio i naziv za to stvorenje u računalu. Zovem ga iPacijent. iPacijent dobiva predivnu skrb diljem Amerike. Pravi pacijent se često pita gdje su svi. Kada će netko doći i objasniti mi stvari? Tko je glavni? Postoji pravi nesrazmjer između pacijentove predodžbe i naše vlastite, kao liječnika, u tome što znači najbolja medicinska skrb.
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.
Želim vam pokazati sliku kako su vizite izgledale dok sam se ja školovao. Težište je bilo oko pacijenta. Išli smo od kreveta do kreveta. Vodeći liječnik je bio glavni. Danas prečesto vizite izgledaju ovako, raspravlja se u sobi daleko od pacijenta. Rasprava se svede na slike na računalu, na podatke. I nedostaje jedan ključan dio, a to je pacijent.
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.
Na ovo moje razmišljanje su utjecale dvije anegdote, koje želim podijeliti s vama. Jedna je o mojoj prijateljici, koja je imala tumor dojke, otkrili su joj mali tumor dojke. Obavljena je lumpektomija u gradu u kojem sam živio. To je bilo dok sam živio u Teksasu. Nakon toga je provela puno vremena u traženju najboljeg centra za tumore u svijetu za nastavak njege. Našla je mjesto i odlučila je otići tamo. Otišla je tamo. I zato sam bio iznenađen nekoliko mjeseci nakon toga kada sam je vidio u našem gradu, kako prima daljnju njegu kod svog privatnog onkologa.
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.
I inzistirao sam, i pitao sam je. „Zašto si se vratila i dobivaš medicinsku njegu ovdje?“ Nećkala se. Rekla je, „Znaš, centar za tumore je bio predivan. Imali su predivne prostore, golemo predvorje, privatno parkiranje, klavir koji je sam svirao, djelatnik centra koji vas je vodio uokolo. Ali, “ rekla je, „ali, nitko nije dodirnuo moje grudi.” Vi i ja bismo mogli braniti stajalište da vjerojatno nisu ni trebali dodirnuti njene grudi. Pregledali su je iznutra i izvana. Shvaćali su njezin tumor na molekularnoj razini. Nije bilo potrebe dirati njezine grudi.
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.
Ali njoj je to bilo od izrazite važnosti. To joj je bilo dovoljno da donese odluku da daljnju njegu prima kod svog privatnog onkologa, koji je svaki put kada je došla pregledao obje dojke, uključujući i aksilarni rep, pažljivo pregledao obje aksile, pregledao vrat, preponsku regiju, napravio je opsežni pregled. Njoj je to govorilo u prilog pažnji, koju je trebala. Ova anegdota je imala veliki utjecaj na mene.
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.
Na mene je utjecalo i jedno iskustvo koje sam imao, opet, kada sam bio u Teksasu, prije no što sam se preselio na Stanford. Pratio me glas da me zanimaju pacijenti koji boluju od kroničnog umora. To ne biste poželjeli svojem najgorem neprijatelju. To kažem zato što su to zahtjevni pacijenti. Često su ih se njihove obitelji odrekle, imali su loša iskustva s medicinskom njegom i dolaze vam potpuno spremni da ćete se i vi pridružiti dugom popisu ljudi koji će ih razočarati. Vrlo sam rano naučio sa svojim prvim pacijentom da ne mogu dati dovoljno pažnje ovom kompliciranom pacijentu sa svom dokumentacijom koju donosi i s trajanjem posjeta od 45 minuta. Jednostavno nije bilo šanse. A da sam pokušao, razočarao bi ih.
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.
I tako sam počeo s metodom kojom bih zatražio od pacijenta da mi priča tijekom cijelog prvog posjeta, i pokušao sam ih ne prekidati. Znamo da prosječni američki liječnik prekine svojeg pacijenta za 14 sekundi. I ako ikad odem u raj to će biti zato što sam 45 minuta mirno slušao svojeg pacijenta bez prekidanja. Potom sam naručio pacijenta za fizikalni pregled za dva tjedna, i kada je pacijent došao na pregled mogao sam napraviti detaljni fizikalni pregled, zato što nisam imao ništa drugo za raditi. Smatram da radim detaljan fizikalni pregled, ali zbog toga što je cijeli dolazak sada bio zbog pregleda, mogao sam obaviti iznimno detaljan fizikalan pregled.
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.
I sjećam se da mi je prvi pacijent iz te grupe nastavio pričati svoju anamnezu tijekom posjete koja je trebala biti samo fizikalni pregled. I počeo sam svoj ritual. Uvijek počinjem s pulsom, potom pregledam ruke, pogledam ležište nokta, onda prođem rukom do epitrohlearnog limfnog čvora, i bio sam u svom ritualu. A kada je moj ritual počeo, ovaj vrlo govorljiv pacijent je postajao sve tiši. I sjećam se da sam imao jezovit osjećaj da smo pacijent i ja ušli u primitivni ritual u kojem sam ja imao ulogu i pacijent je imao ulogu. I kada sam bio gotov, pacijent mi je rekao s blagim strahopoštovanjem, „Nikad me nitko nije ovako pregledao.“ Ako je to istina, to bi bila prava osuda našeg zdravstvenog sustava, zato što su bili pregledani na drugim mjestima.
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.
Onda sam nastavio govoriti pacijentu, kada je bio obučen, standardne stvari koje je sigurno čuo u ostalim institucijama, a to su, „Ovo nije u vašoj glavi. Ovo je stvarno. Dobra je vijest da se ne radi o tumoru ili o tuberkulozi, niti o kokcidioidomikozi ili nekoj drugoj bizarnoj gljivičnoj infekciji. Loša vijest je da ne znamo točno uzrok vašim tegobama, ali trebali biste napraviti sljedeće, trebali bismo napraviti sljedeće.“ I iznio bih sve standardne mogučnosti liječenja, koje je pacijent čuo i prije.
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.
I uvijek sam mislio da ako moj pacijent odustane od potrage za čarobnim liječnikom, čarobnim liječenjem, i krene sa mnom na put prema dobrostanju, to znači da sam zavrijedio pravo da im kažem takve stvari na temelju pregleda. Nešto važno se odvilo tijekom te razmjene. Iznio sam to svojim kolegama na Stanfordu na antropologiji i ispričao sam im istu priču. I odmah su mi rekli, „Opisuješ klasični ritual.“ Pomogli su mi da shvatim da je bit rituala u preobrazbi.
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.
Primjerice, vjenčamo se u velikoj raskoši, ceremoniji i o velikom trošku da označimo naš odlazak iz života samoće, jada i usamljenosti u život vječnog blagostanja. Ne znam zašto se smijete. To je bila izvorna zamisao, zar ne? Označavamo prijelaze moći ritualima. Označavamo prolaznost života ritualima. Rituali su iznimno važni. Njihova bit je u preobrazbi. Pa, predložio bih vam da je ritual dolaska jednog pojedinca drugome i pričanje o stvarima, koje ne bi rekli svojem svećeniku ili rabinu, i onda, začuđujuće, povrh toga skidanje odjeće i dopuštanje dodira. Predložio bih da je taj ritual od iznimne važnosti. I ako loše obavite ovaj ritual tako da ne skinete pacijenta, ili slušate stetoskopom preko ogrtača, ili ne obavite cjeloviti pregled, propustili ste priliku učvrstiti odnos između pacijenta i liječnika.
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.
Ja sam spisatelj, i želio bih završiti izlaganje s čitanjem kratkog odlomka kojeg sam napisao, koji ima veze s ovom situacijom. Ja sam infektolog, i u počecima HIV-a, prije nego smo imali naše lijekove, prisustvovao sam mnogim situacijama poput ove. Sjećam se da svaki put kada bih išao do pacijenta na smrtnoj postelji, bilo u bolnici ili kod kuće, sjećam se svog osjećaja poraza, osjećaja da ne znam što moram reći; ne znam što mogu reći, ne znam što bih trebao napraviti. I iz tog osjećaja neuspjeha, sjećam se, uvijek bih pregledao pacijenta. Pogledao bih njihove kapke. Pogledao bih im jezik. Perkutirao bih prsa. Poslušao bih srce. Opipao bih trbuh. Sjećam se mnogih pacijenata, njihova imena još uvijek prisutna na mojim usnama, njihova lica još uvijek jasna. Sjećam se toliko velikih, upalih, ukletih očiju kako me gledaju, dok obavljam ovaj ritual. I onda bih došao sljedeći dan i ponovio ga.
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.
Htio sam vam pročitati i ovaj završni odlomak o jednom pacijentu. „Sjećam se jednog pacijenta koji u tom stadiju nije bio ništa više od kostura u oklopu skupljajuće kože, nije mogao govoriti njegova usta obložena kandidom koja je bila otporna na uobičajene lijekove. Kada me vidio u svojim zadnjim satima na Zemlji, njegove ruke su se pomakle kao u usporenom filmu. I dok sam se pitao što to radi, njegovi su se štapićasti prsti pomakli do košulje njegove piđame petljajući s gumbima. Shvatio sam da je htio otkriti svoja prsa, koja su izgledala poput pletene košare. Bila je to ponuda, poziv. Nisam odbio.
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.
Perkutirao sam. Palpirao sam. Poslušao sam pluća. Mislim da je do tada morao znati kako je ovo bilo toliko vitalno za mene koliko je bilo nužno za njega. Nijedan od nas dvojice nije mogao preskočiti ovaj ritual, koji nije imao nikakve veze s otkrivanjem hropaca na plućima, ili traženjem galopnog ritma srčanog zastoja. Ne, ovaj ritual je bio o poruci koju su liječnici trebali prenijeti svojim pacijentima. Iako sam Bog zna da se čini da smo u zadnje vrijeme, odlutali u našoj oholosti. Kao da smo zaboravili, kao da s eksplozijom znanja, cijeli ljudski genom stoji mapiran pred nama, uljuljkani smo u nepažnju, zaboravljajući da ritual pruža katarzu liječniku, da je nužan za pacijenta, zaboravljajući da ritual ima značenje i jednu jedinu poruku koju treba prenijeti pacijentu.
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."
A poruka, koju nisam u potpunosti tada shvatio, čak i kad sam je prenosio, a koju shvaćam sada bolje je ova: Uvijek, uvijek, uvijek ću biti uz tebe. Pratit ću te kroz ovo. Nikad te neću napustiti. Bit ću s tobom do kraja.“
Thank you very much.
Puno vam hvala.
(Applause)
(Pljesak)