If you're seeing this message, it means we're having trouble loading external resources on our website.

If you're behind a web filter, please make sure that the domains *.kastatic.org and *.kasandbox.org are unblocked.

Main content
Current time:0:00Total duration:8:48

Video transcript

this is Sal again I'm here at Stanford Medical School with dr. Abraham Verghese and what we're going to talk about we're going to talk about the ritual of the physical exam the bedside exam the physical exam the Richer why do you call it a ritual that's interesting that you you call it a ritual yeah I think the the lesson I've learned from hanging around with my hands apology colleagues here at Stanford is that rituals are all about transformation a ritual signals the crossing of a threshold hmm you know we baptize to signal the crossing of a threshold we marry to signal our departure from a life of solitude loneliness and misery to one of eternal bliss yes so our lives are full of you shouldn't be laughing some no this is it resonates so strongly with it so crossing a threshold is why we have a ritual and I would say that the act of one individual coming to another and telling them things they wouldn't tell their rabbi or their preacher yeah and then incredibly disrobing and allowing touch yeah I would say that that's signals a ritual of incredible importance yeah and the fact that we in the postmodern sort of medical world have stopped seeing it that way yeah and just see the sort of yes another data gathering tool may work for us but I don't think it works for the patient and I think that a major disconnect between us and our patients is our failure to see what they see which is a profound ritual and which they're highly invested and when we then come and just stick our stethoscope on top of them yeah shirt or don't examine them thoroughly we are sort of short changing ourselves of an important ritual yeah I now feel short-changed yeah that's like but I'd love to enlist for you if I may those aspects of what make this a ritual yeah so if you if you look at it first of all there's always a specialized space you don't examine a patient out in the corridor as always yeah special rule a ceremonial room if you will yeah mysterious looking objects on the walls yeah a very specialized bed that you sit on so that's another those are all signals that this is a ritual then when they when the physician walks the physician often is wearing the ceremonial garb which happens to be a white coat fascinating yeah no this is this is interesting just from an anthropological point of view I never you know you just yeah the physicians are wearing ceremonial garb and the patient is also instructed to disrobe and you know gets a patient gown so yes both participants clearly have it which seems specially designed to put patients in a position of weakness I know it is we should be rethinking because I think there's a major yeah and then the physician then begins a systematic exam which at some level is mysterious to the patient it's not always clear to the patient why the physician is thumping on their chest or why the physician is saying take a deep breath right cross your arms or stand on tiptoe or take your hand and touch your nose rapid you know so there's there mysterious and ritualistic aspects to it and very often the physician is using terms that are somewhat Latinate right and arcane and utterly mysterious to the patient such as fremitus and percussion and what is fremitus me from addis means el you ask the patient is a ninety nine and you listen you said put your hand on their chest and you pick up the vibration and if they have consolidation or collapse the the fremitus is not what it should be compared to the other side different remedies so with the sound or the it's more like a vibration or the vibration i see sound being transmitted through and being picked up by your hand interesting interesting so and then we you know the thing that's most interesting to me about the ritual is that the person coming in might be a policeman a teacher you know an entrepreneur but in the process of putting on that gown and sitting on that ceremonial chair they have sort of been stripped of all that identity yeah and they are taking on the identity of being the patient yeah but conversely I think there's something very important that happens which is that just before this the patient has been vocalizing all their symptoms and their complaints and you know at that point the physician could order ten tests and you know go and look at the images but there's something about physician then laying hands on the patient right that sort of gives weight to what the patient just talked about right you talk about your belly hurting and then this individual carefully examines your belly it's sort of right it's it's sort of validating your soma you're right your body is being validated in this ritual right and then you know when you finally have the tests all sent off they become sort of what follows intuitively on the ritual first having it validated on your body yeah one of the things that I I the Mon sometimes is that at times the patient in the bed I feel in hospitals around America has almost become an icon for the real patient who's in the computer okay you know the entity in the kitchen sorry interface with to get to that data structure they come here that's interesting I've going to term for that entity in the computers the eye patient yeah be here and the eye patient is getting fabulous care the real patient I think has a need to feel their complaints validated to feel it validated on their soma right and to engage in a ritual for which there's a transformation and you might well ask me what is the transformation that takes place in this ritual and I think the transformation is the sense of the patient has delivered the story here the physician in the process of the ritual has validated that they've heard the story and try to locate it on the soma and the transformation is really the ceiling of the patient-physician relationship Wow and so you know I think what has happened Sal unfortunate is that because we have so much technology what become very sloppy and the way we examine patients you know I think that we could we should be a hundredfold better at examining people given that we have real-time feedback with echocardiograms angiograms and all that instead of which I think people have never been less certain of their bedside skills what about this phenomenon just talking to physicians I know in my own family that you know there's so much time pressure that there's young have to see so many patients one every 15 minutes and all of this and they wish they could do this but they'll say that you know I have so many other things to worry about in the paperwork and all of that I mean is it realistic to - I think that's a very real but I think if you can do this well and our goal at Stanford is to teach our students to do it very well you actually save time right because if you do a quick examine you find that they're tender in certain spot you can or order the test that sorts just that out rather than which I think is much more common which is I don't really know what's going on I'll take off every box maybe something will fall out of the sky right so I think a directed exam not only fulfills the ritual but if you're any good at it it'll actually allows you to ask better questions in the tests you order yeah and minimize the patient's exposure to radiation and you know I think the trouble is we get all these tests and we get back results we don't know what to do with we stumble onto what we call incidentalomas if you hear that term incidental well I have heard that VIPs often get worst medical care because they do everything for the other day and they wind up with finding things they don't know what to do exactly these two were over diagnosing things but to come back to a ritual I think we at Stanford are very proud to feel that as much as we represent you know this great bastion of Technology and advancement we also celebrate the fundamental ritual aspects of the patient-physician relationship which is best symbolized in the physical exam that I think this is why a lot of physicians originally want to enter the field it sometimes gets lost but this is why they wanted to do it and you're right I think they often get disappointed when they learn to do this and arrive on the wards and find that no one's carrying a stethoscope and no one's carrying right me they cameras telescope I think it's like a meeting a cymbal run no you got it you got to carry one of those yeah but they don't carry the nyhammer and they don't carry all the other tools which I once visited my wife of the doctor and I wore her coat I felt very good yeah did you drape your stethoscope on the neck too oh I did yeah I look very authoritative that's that's a great signal that's your yeah so I think that we have so much to learn from our anthropology colleagues about the importance of ritual I think sometimes we operate as though medicine is all about reason but you know it's really reason ritual emotion they all tie in together this is the art and science no this is fascinating I'm gonna reflect on some of the rituals I do now to see if they are anyway very cool well thank you for this thank you so much