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  • 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.

  • 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.

  • 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.

  • 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."

  • 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.

  • 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.

  • 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.

  • 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.

  • 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?

  • 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.

  • 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.

  • 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.

  • 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.

  • But to her, it mattered deeply.

  • It was enough for her to make the decision

  • to get her subsequent care with her private oncologist