Saturday, February 21, 2009

What grief is really like - Meghan O'Rourke - Slate Magazine

The other morning I looked at my BlackBerry and saw an e-mail from my mother. At last! I thought. I've missed her so much. Then I caught myself. The e-mail couldn't be from my mother. My mother died a month ago.

The e-mail was from a publicist with the same first name: Barbara. The name was all that had showed up on the screen.

My mother died of metastatic colorectal cancer sometime before 3 p.m. on Christmas Day. I can't say the exact time, because none of us thought to look at a clock for some time after she stopped breathing. She was in a hospital bed in the living room of my parents' house (now my father's house) in Connecticut with my father, my two younger brothers, and me. She had been unconscious for five days. She opened her eyes only when we moved her, which caused her extreme pain, and so we began to move her less and less, despite cautions from the hospice nurses about bedsores.

For several weeks before her death, my mother had been experiencing some confusion due to ammonia building up in her brain as her liver began to fail. And yet, irrationally, I am confident my mother knew what day it was when she died. I believe she knew we were around her. And I believe she chose to die when she did. Christmas was her favorite day of the year; she loved the morning ritual of walking the dogs, making coffee as we all waited impatiently for her to be ready, then slowly opening presents, drawing the gift-giving out for hours. This year, she couldn't walk the dogs or make coffee, but her bed was in the room where our tree was, and as we opened presents that morning, she made a madrigal of quiet sounds, as if to indicate that she was with us.

Since my mother's death, I have been in grief. I walk down the street; I answer my phone; I brush my hair; I manage, at times, to look like a normal person, but I don't feel normal. I am not surprised to find that it is a lonely life: After all, the person who brought me into the world is gone. But it is more than that. I feel not just that I am but that the world around me is deeply unprepared to deal with grief. Nearly every day I get e-mails from people who write: "I hope you're doing well." It's a kind sentiment, and yet sometimes it angers me. I am not OK. Nor do I find much relief in the well-meant refrain that at least my mother is "no longer suffering." Mainly, I feel one thing: My mother is dead, and I want her back. I really want her back—sometimes so intensely that I don't even want to heal. At least, not yet.

Nothing about the past losses I have experienced prepared me for the loss of my mother. Even knowing that she would die did not prepare me in the least. A mother, after all, is your entry into the world. She is the shell in which you divide and become a life. Waking up in a world without her is like waking up in a world without sky: unimaginable. What makes it worse is that my mother was young: 55. The loss I feel stems partly from feeling robbed of 20 more years with her I'd always imagined having.

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Friday, February 20, 2009

Costs for individual health plans soar -

At a time when more people are forced to buy their own health insurance because of job losses, costs for many individual policies are soaring.

Advocates say the 17 million Americans who buy their own coverage can't negotiate lower rates the way employers or other large group plans can.

"These folks have their back against the wall," says Jerry Flanagan, a health advocate with Consumer Watchdog, a California-based group.

More people are shopping for coverage: The Golden Rule Insurance Company, a part of UnitedHealth Group, says sales of individual policies are up 24% in the past two months. A website that links people with insurers, eHealthInsurance, says applications are up 18% in the fourth quarter, compared with a year ago.

Among this year's large rate increases on the individual market:

• Anthem Blue Cross in California has notified about 80% of its 800,000 individual policyholders of double-digit increases, many above 30%. Spokesman Ben Singer says rising medical costs are prompting the increases.

• Blue Cross of Michigan is seeking state approval for a 56% increase in individual premiums. Spokesman Andy Hetzel says the company needs to offset losses stemming from state rules making it the sole insurer required to take all applicants.

• Regence Blue Cross Blue Shield of Oregon will raise rates for approximately 10,000 Washington state customers by 27.1% on March 1.

Another Washington insurer, LifeWise, raised rates 17.6% on Jan. 1, according to the Office of the Insurance Commissioner in Washington state.

By comparison, group health insurance premiums paid by employers rose about 5% in 2008, says a survey by the Kaiser Family Foundation.

Some insurers say increases this year for individual policies aren't out of the ordinary. Aetna, for example, says individual policy increases nationwide range from 8% to 22%.

Still, such hikes can cause "sticker shock" for people used to smaller increases under employer plans, says Robert Laszewski, who heads Health Policy and Strategy Associates, a consulting firm.

Premium rates for individual policies vary widely, depending on state rules, the type of coverage and the applicant's age and health. Unlike group coverage, in which all applicants are accepted, insurers can reject applicants for individual coverage in most states if they have medical problems.

A sample of 227,000 individual policies sold by eHealthInsurance found average monthly premiums for single people ranged from $107 to $301 in 2007, the latest data available. The average deductible, the amount paid before coverage begins, was nearly $2,000.

Family coverage ranged from $219 to $494 a month with an average $2,600 deductible.

Insurers face shrinking enrollment in group plans because employers are shedding jobs. They also have deflated investment portfolios and higher costs as patients use more health services, says a report out last week from ratings agency A.M. Best.

Those problems could lead to "higher rate increases than in the past," says Sally Rosen, a managing senior financial analyst at Best.

Thursday, February 19, 2009

Doctor and Patient - Getting Off the Patient Treadmill

During medical school, I learned about randomized clinical trials. Every experimental drug went through three types of clinical trials before approval. There were Phase I clinical trials which tested for toxicity and dosing. Phase II trials then examined optimal dosing and efficacy. Finally, Phase III trials compared the efficacy of the new drug with the current "gold standard" treatment.

I'm now learning that health care policy doesn't always undergo the same kind of rigorous study.

I met up recently with a friend who is a primary care physician. His practice has just signed a contract with the state's largest insurer that reimburses not according to the traditional fee-for-service, which pays doctors a set price for each visit, test or procedure they do, but according to a newer standard known as "pay-for-performance." The insurance company will give his practice a budget for each patient; the doctors in the practice can earn more by cutting costs and by meeting certain quality goals, like controlling blood sugar or high blood pressure in patients.

I asked my friend if he was happy about the new contract.

"I guess so," he replied with some hesitation. "I'm not sure how else we are going to stop spiraling health care costs." But then he added, "I do worry about how this will affect my relationship with patients. If my patient comes in with a headache and wants a CAT scan, but I don't order it because I think it's not medically indicated, will that patient think I'm just trying to save money?"

I thought about his concerns, and at first could not see any downside to linking quality to financial incentives. When doctors are working on a fee-for-service plan, there's just not that much incentive for them to take time to promote healthy living or strong doctor-patient relationships; the payment system rewards for high turnover and pits doctors against the clock.

I knew that other industries, like business corporations and education, had successfully used pay-for-performance to improve quality. And health care quality, which is a secondary concern with fee-for-service incentives, could definitely use a boost. A 2003 New England Journal of Medicine study showed that only about half of patients received the standard, nationally recognized care for preventive health issues and acute and chronic conditions.

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Outsourcing of Drug Trials Is Faulted -

As many American companies in the last decade have sent tasks like customer service and computer support to other countries, drug makers have followed suit by outsourcing clinical trials — the human studies that determine the safety and efficacy of medicines.

Now, an article about the globalization of clinical trials, published Thursday in The New England Journal of Medicine raises questions about the ethics and the science of increasingly conducting studies outside the United States — when the studies are meant to gather evidence for new drugs to gain approval in this country.

The article, by several Duke University researchers, suggests an ethical quagmire when drugs intended for wealthy nations are tested on people in developing countries. The authors suggest that human volunteers in foreign countries may be unduly influenced with the promise of financial compensation or free medical care to participate in clinical trials.

The report, "Ethical and Scientific Implications of the Globalization of Clinical Research," also asks whether drug research conducted in developing countries is relevant to the treatment of American patients.

"We don't want to imagine that lower-income countries are the clinical trial mill for higher-income countries," Dr. Kevin A. Schulman, the lead author of the article, said in a phone interview last week. Dr. Schulman is a professor of medicine at the Fuqua School of Business at Duke, in Durham, N.C.

But some critics say the authors used overly simplistic data mining to raise an alarm, without presenting hard evidence of widespread ethical or scientific problems.

"More places outside the United States are participating in research — is that a bad thing?" said Dr. Ezekiel J. Emanuel, the chairman of bioethics at the Clinical Center of the National Institutes of Health in Bethesda, Md., after reading an abstract of the article sent to him by a reporter.

Dr. Emanuel cited a clinical trial of the Merck drug Gardasil, a vaccine against the human papilloma virus, that was conducted in Costa Rica, where there is a high incidence of the disease. "This is the kind of case where it is a good thing."

Whatever the interpretations, the use of offshore clinical trials is growing. In the last 10 years, the proportion of United States-based researchers who direct clinical trials registered with the federal Food and Drug Administration has declined significantly, while the percentage of F.D.A.-registered researchers outside the United States has significantly increased, according to a report in January by the Tufts Center for the Study of Drug Development in Boston.

In 1997, about 86 percent of F.D.A.-registered principal investigators were based in the United States, the Tufts study said. By 2007, only about 54 percent of about 26,000 F.D.A.-regulated chief scientists who conducted clinical trials that year were based in the United States.

Kenneth A. Getz, a senior research fellow at the Tufts center, said drug companies were looking abroad because it was often less expensive to conduct clinical trials outside the United States, and it was easier to find a large group of study subjects who had never been treated with medications.

Critics of the Duke article take issue with its methodology. The authors, for example, compare the locations of 300 clinical trials published in three leading medical journals in 1995 and 2005, concluding that the number of countries participating in studies more than doubled over that decade.

But critics question that comparison, because about 40 percent of the published clinical trials from 1995 did not indicate where the studies were conducted.

One of the authors, Dr. Seth W. Glickman, a senior scholar at the Fuqua School of Business at Duke, said he did not know how omitting those studies might have skewed the analysis.

And although the article uses the country statistics to raise concerns about the increased globalization of clinical research, the Tufts study shows that the majority of F.D.A.-regulated drug researchers are still in the United States. Offshore researchers, moreover, are represented largely by Western Europe and middle-income countries in Eastern Europe and Latin America, according to the Tufts data.

The Duke authors also write that drug research in developing countries — where certain populations may metabolize medications differently because of environmental factors or genetic mutations — might not be relevant for American patients. "There are issues with the interpretability of the findings," Dr. Glickman said.

Dr. Emanuel of the N.I.H. agreed that it was possible that some offshore drug research might not be applicable to American patients. But he faulted the report for seeming to treat all foreign countries alike. Research conducted in some places outside the United States — like Canada and Sweden — might be perfectly relevant to American patients, he said.

"It's not a sufficiently nuanced concern to give it credibility," said Dr. Emanuel.

Wednesday, February 18, 2009

Conflicting studies about health risks and benefits can drive you crazy. Here's how to sort through the science.

Coffee, elixir of the gods.

Studies say drinking it can lower your risk of developing Type 2 diabetes, Parkinson's disease, Alzheimer's disease and mouth cancer. It can prevent cavities. It can make you happier. It can kill a headache. It can make asthmatics breathe a little easier. It can ease the effects on the heart and liver of hard, heavy drinking.

And yet, we are a nation of coffee drinkers and still we have mouth cancer, Parkinson's, Alzheimer's, rotten teeth, unhappiness, headaches, asthma attacks, heart attacks and liver disease. When we go to the doctor, dentist or personal trainer, they almost never write a prescription for a daily trip to Starbucks.

Every day, we sip a steady stream of health news about something we could eat or drink and how it will help save us from Health Nightmare X—or help cause it. Avoid refined sugar. Take fish oil pills. Drink coffee. Don't.

So here's the good news, according to experts who study disease and risk: You can pretty much ignore almost all of these health bulletins, with a few exceptions:

Exercise, eat a balanced diet, don't be fat, drink only in moderation and, whatever you do, don't smoke.

"There are some risk factors that have a major impact. Like, there is no doubt smoking kills millions of people," said epidemiologist John Ioannidis of Tufts University School of Medicine in Boston. "But for most lifestyle and diet choices—I'm not claiming none have an impact, but their impact is likely to be very small, if anything."

This is not to say science is pointless. After all, it was the painstaking work of scientists that conclusively proved that smoking is a health disaster.

But being a good consumer of science news means understanding how scientific studies work. Sometimes, findings that sound spectacular may be completely useless to you—though important to other scientists working on the bigger picture.

For example: A recent study published in the American Journal of Epidemiology followed 39,000 middle-age Japanese people for 13 years and found that the people who reported drinking one or more cups of coffee a day were about half as likely to get oral, pharyngeal or esophageal cancer as the others.

That sounds like a great excuse to order another cappuccino because these are some of the deadlier cancers—only 16 in 100 people diagnosed with esophageal cancer live five years after diagnosis, according to the American Cancer Society.

But before you do, consider that the study's findings tell us only about relative risk—the cancer risk for coffee drinkers in relation to non-coffee drinkers. Half as much risk sounds like a lot, but the bottom line is that very few people in either group got cancer.

In other words, the absolute risk is low, coffee or no coffee.

So you decide. Is it worth taking up daily coffee drinking to turn your already small risk of oral, pharyngeal or esophageal cancer into an even smaller risk? Keep in mind that buying one small Dunkin' Donuts coffee a day adds up to almost $600 a year in Chicago. With cream and sugar, it also means absorbing an extra 43,800 calories a year.

Ask yourself also: Could some other factor be responsible for the decreased cancer risk? Maybe something else that Japanese coffee drinkers tend to do or experience is what's protecting them against cancer. Researchers try to take into account such confounding factors—such as income levels or health issues—but they don't always think of everything.

"Ask yourself, who are the coffee-drinking people? Did these people smoke less? Have these questions in the back of your mind," said Sherry Seethaler, author of "Lies, Damned Lies, and Science: How to Sort Through the Noise Around Global Warming, the Latest Health Claims, and Other Scientific Controversies.",0,1420238,print.story

Tuesday, February 17, 2009

Booster Shots - Los Angeles Times

Oddities, musings and some news from the world of health.

Deadly bacteria defy drugs, alarming doctors

When Ruth Burns had surgery to relieve a pinched nerve in her back, the operation was supposed to be an "in-and-out thing," recalled her daughter, Kacia Warren. 

But Burns developed pneumonia and was put on a ventilator. Five days later, she was discharged -- only to be rushed by her daughter to the hospital hours later, disoriented and in alarming pain.

Seventeen days after the surgery, the 67-year-old nurse was dead.

Burns had developed meningitis -- an infection of the fluid that surrounds the spinal cord and brain. The culprit wasAcinetobacter baumannii, a bug that preys on the weak in hospitals. Worse, it was a multi-drug-resistant strain. 

Acinetobacter doesn't garner as many headlines as methicillin-resistant Staphylococcus aureus, the dangerous superbug better known as MRSA. But a January report by the Infectious Diseases Society of America warned that drug-resistant strains of Acinetobacter baumannii and two other microbes -- Pseudomonas aeruginosa and Klebsiella pneumoniae -- could soon produce a toll to rival MRSA's.

The three bugs belong to a large category of bacteria called "gram-negative" that are especially hard to fight because they are wrapped in a double membrane and harbor enzymes that chew up many antibiotics. As dangerous as MRSA is, some antibiotics can still treat it, and more are in development, experts say. 

But the drugs once used to treat gram-negative bacteria are becoming ineffective, and finding effective new ones is especially challenging. 

"We're literally running out of drugs to treat gram-negatives," said Dr. Brad Spellberg, an infectious disease specialist at Harbor-UCLA Medical Center. "And there is nothing in the pipeline right now."

Exact numbers are hard to come by, because infections by these three bacteria are not reportable by law. But using 2002 data voluntarily reported to the Centers for Disease Control and Prevention from about 300 large, mostly urban hospitals, the Infectious Diseases Society of America identified about 104,000 gram-negative infections that were resistant to at least some antibiotics, roughly the same as the 102,000 MRSA infections found that year. 

A class of broad-spectrum antibiotics known as carbapenems have been the drug of last resort for gram-negative bugs.

"The carbapenems are . . . the best gram-negative drugs we have," said Dr. Helen Boucher of Tufts University, an infectious disease specialist. "These bugs have found a way to make an enzyme that dissolves these drugs. That means our best gun is ineffective."

As the drugs fail, doctors find themselves as a last resort turning to older, more toxic ones such as colistin, largely abandoned because of the severe side effects: kidney damage and deafness. At one East Coast hospital, the number of orders doctors made for colistin went from one in 2001 to 68 in 2007, Boucher said.

"This is a drug that's like poison," she said.

For the most part, gram-negative bacteria are hospital scourges -- harmless to healthy people but ready to infect already-damaged tissue. The bacteria steal into the body via ventilator tubes, catheters, open wounds and burns, causing pneumonia, urinary tract infections, and bone, joint and bloodstream infections. 

Pseudomonas is widely found in soil and water, and rarely causes problems except in hospitals. 

Klebsiella causes a sudden, severe pneumonia, mostly in people already suffering from ailments such as diabetes or chronic lung disease. Its telltale sign is a blood-tinged sputum dubbed "currant jelly." It can also cause urinary tract and abdominal infections. 

Acinetobacter generally causes wound and bloodstream infections. It has become notorious among veterans of the wars in Iraq and Afghanistan. They are believed to have contracted it in field hospitals and carried it to veterans hospitals in the U.S.

The first U.S. outbreak of Klebsiella resistant to all known antibiotics occurred at a Brooklyn hospital in 2000. The so-called pan-resistant strain has since been found along the Eastern Seaboard and throughout the Midwest. 

A December report of Israeli hospitals found mortality rates from pan-resistant Klebsiella to be 44%. 

Doctors have no doubt that pan-resistant Klebsiella will show up in California and other states. California hospitals are already encountering strains that, although not resistant to all known antibiotics, are resistant to many. Harbor-UCLA had two cases of highly-drug-resistant Klebsiella last year, Spellberg said.

Similarly resistant strains of Pseudomonas and Acinetobacter also are on the rise, as are resistant strains of Escherichia coli, another gram-negative bacterium. 

These four microbes are among the six leading causes of infections in hospitals, nursing homes and other healthcare settings, the Infectious Diseases Society of America reported. 

The bacteria have remained largely off the public's radar, Boucher said, because they affect mostly the elderly or ill. But they do not always limit themselves that way. Drug-resistant Pseudomonas was behind the widely publicized Jan. 24 death of Brazilian beauty queen Mariana Bridi, 20, of sepsis -- a bloodstream infection. 

The health department in Espirito Santo, Brazil, said what began as a urinary tract infection spread rapidly. 

Bridi died after doctors had tried to contain the rampaging infection by amputating her feet and hands and removing her kidneys.,0,5079716.story

Baby's gestures reflect family's wealth

A baby throws up his arms asking to be picked up, points at an object to answer a question or quiets himself when his mother puts her index finger to her lips to make the universal "shh" sign.

Using and understanding hand gestures is one way babies start to flex their communication muscles before they can speak.

New evidence suggests that the better a baby is at grasping the meanings of these hand gestures, the better his or her vocabulary will be by preschool age - which is itself a known predictor of future academic success.

The new study out of the University of Chicago, which appears today in the journal Science, also found that children from higher socio-economic backgrounds have a distinct advantage over those from lower-income backgrounds. They gesture more as babies and have larger vocabularies at age 4½.

Study co-author and developmental psychologist Meredith Rowe said more research is needed to determine whether it's possible to manipulate how frequently parents and babies are inclined to gesture, but the potential implications are intriguing.

"Can you get parents and young children to gesture more when they're communicating? And if you can, will it lead to an increase in children's vocabulary?" said Dr. Rowe, a postdoctoral scholar at the university.

To measure the use of gesture, Dr. Rowe and her colleagues filmed 50 14-month-olds and their primary caregivers for 90-minute sessions, then transcribed the use of words and gestures by both caregivers and babies.

About 70 per cent of the moves involved pointing at objects. Conventional gestures such as waving, shaking the head and the two-armed "up" gesture accounted for about 20 per cent of the moves recorded.

A third category covered more representational gestures, such as flapping the arms to represent flying. (Babies at 14 months haven't mastered this style of gesture, but their parents use it. Children start to mimic them at about 26 months of age, Dr. Rowe said.)

Researchers counted the number of meanings connected with the hand gestures, rather than the total number of gestures. For instance, Dr. Rowe said, a baby pointing at a dog 10 times would be scored as a single gesture meaning.

"We were looking for the diversity of objects being portrayed."

The children were assessed again at 54 months with a standard vocabulary test.

The study also took into account the socio-economic status of the parent or primary caregiver, on a scale of 10 to 18 education years, with 12 years being equivalent to a high-school degree. The average family income of the participants ranged from $15,000 to $100,000 (U.S.) per year.

The most striking finding, Dr. Rowe said, was just how connected the early use of gesture was with socio-economic status.

At 14 months, children of families with higher socio-economic status are producing an average of 24 different gesture meanings during 90 minutes, compared with about 13 meanings from those with less affluent backgrounds.

At age 4½, children from higher-income families understood about 117 words, whereas children from lower-income families scored about 93.

"We can explain some of that gap by looking at how a child and his or her parents are gesturing several years earlier," Dr. Rowe said. "When children are 14 months old, before they're even saying much and before we see socio-economic differences in their speech, we're seeing socio-economic differences in their gestures," Dr. Rowe said.

The study also found that a baby's gesture vocabulary mirrors that of the parent or primary caregiver, which could explain the relationship to the parents' income and level of education, Dr. Rowe said.

The findings are "an indication that we really need to look at what's going on at home or during the early childhood period to try and figure out how that gap's getting created," Dr. Rowe said.

It's not that higher-paid, more educated parents are magically producing more gestures, she said, but that they are instilling more meanings with gesture.

Gesturing could play a role in learning words by eliciting and reinforcing vocabulary from parents. In response to a child pointing at a doll, the parent might say, "Yes, that's a doll," for instance.

The connection may also be more direct, the study suggests. Gestures may allow children to use their hands to convey meaning if they have difficulty uttering words.

Previous research has found that lower-paid and less-educated parents tend to talk less to their children, she said. Gesturing may follow the same pattern - but show up much earlier than speech.

"The key here is that it's the gesture in the children at 14 months that helps explain that socio-economic gap in their vocabulary later on."

Sunday, February 15, 2009

Lessons From the Bedside Exam -

Over the last year, in articles and interviews, Dr. Abraham Verghese, the critically acclaimed author of two nonfiction books and a professor of medicine at Stanford University, has been reminding doctors, medical educators and medical students about the importance of the physical exam, or what he refers to as "bedside skills," in modern medical practice. But the most eloquent and moving argument to date has come in his newest book, a novel.

"Cutting for Stone" is the story of Dr. Marion Stone, a conjoined twin who is separated from his brother shortly after birth. Born of an Indian nun and raised in Ethiopia, he searches across continents for his English father and his own identity. It is an epic tale, populated by a series of unforgettable characters. I was drawn in from the very first page.

But Dr. Verghese's book is more than an engrossing read. It is a tribute to great doctoring, a novel that sent me searching frantically for my old medical school physical exam textbook.

Take, for example, one character's description of typhoid fever. "'Coma vigil,' he said....'See how her eyes keep roving as if she's waiting for something? A grave sign. And look at the way she picks at the bedclothes — that's called carphology, and those little muscle twitches are subsultus tendinum.'"

Or another character's lecture on the descriptive names for different physical signs: "'Yes! A treasure trove of words! That's what you find in medicine. Take the food metaphors we use to describe disease: the nutmeg liver, the sago spleen, the anchovy sauce sputum, or currant jelly stools. Why, if you consider just fruits alone you have the strawberry tongue of scarlet fever, which the next day becomes the raspberry tongue. Or how about the strawberry angioma, the watermelon stomach, the apple core lesion of cancer, the peau d'orange appearance of breast cancer...and that's just the fruits! Don't get me started on the nonvegetarian stuff!"

After reading through several of these passages about doctoring, I could not help but feel about Dr. Verghese as the young Marion Stone did about his first doctor-teacher. "He invited me to a world that wasn't secret, but it was well hidden. You needed a guide. You had to know what to look for, but also how to look. You had to exert yourself to see this world. But if you did, if you had that kind of curiosity, if you had an innate interest in the welfare of your fellow human beings, and if you went through that door, a strange thing happened: you left your petty troubles on the threshold."

The magical power of Marion Stone's first doctor-teacher reminded me of my own early awkward attempts to teach young doctors. I strived to convey the importance of looking, touching, listening and even smelling, but inspiring the kind of excitement Dr. Verghese's novel does is difficult for clinical teachers. The cards — and the glittering allure of technology — are stacked against us.

I recall one day, after finishing rounds with the residents in the I.C.U., when the head nurse pulled me aside. "The residents barely touch the patients," she whispered, her eyes darting back and forth to make sure no one else was listening. "What they are reciting during rounds is what is charted or what they see on the monitors and radiology reports."

When I confidentially mentioned the nurse's concern the next morning, none of the residents — three smart and hard-working young doctors — denied the charge. And as I lectured them about the importance of human touch in relationships, even for individuals who were sedated and unconscious in the I.C.U., they smiled politely, gamely even, the effort accentuating the dark bags under their eyes.

But I could not get too upset. I understood what drove them to shortchange their patients' bedside exams. I knew, as well as they did, that there was probably more information to be gleaned from radiologic studies, blood tests and monitors than from a rubber tube connected to a metal bell, fingers tapping against the chest, and a palm laid on the belly. And when time was short or when you were uncertain, it seemed far more efficient — and exact — to go by an objective radiologic study than by your subjective physical exam.

In fact, compared to the screens that beeped, the consoles that displayed the latest radiographs, and the machines that whistled and whirred before coughing out test results to the 10th decimal point, my sermon about the laying on of hands seemed, well, quaintly retro, a leftover from the days of the traveling doctor who carried a black bag of tricks.

I spoke to Dr. Verghese recently and asked him about his novel and the ascent of technology at the cost of bedside skills in modern medicine.

"I actually love bedside skills," he said to me over the phone. "And that is probably the most autobiographical part of the novel. It harkens back to when I was a student. My teachers were magically seeing things we students could not see; I wanted so much to be part of that magic society."

I asked Dr. Verghese what inspired him to become an outspoken advocate of these skills in modern practice. He recounted several incidents that occurred early in his practice and described the experience of a close friend with breast cancer. She had initially traveled to a famous cancer center for treatment but returned to her hometown to finish her chemotherapy.

"I pressed her on why she came back," he recalled. "And she said, 'They did everything just right — efficiency, caring, even valet parking — but they didn't really examine my breasts too well.'"

Dr. Verghese reflected on his friend's reaction. "You and I might argue that the cancer center doctors did examine her well, that they could see her better with scans and markers than they could with their hands. But to my friend, it was a sign of inattentiveness."

But how, I asked him, could overworked clinicians squeeze more detailed exams into their already overbooked schedules?

"The busy practitioner struggles with time pressures," Dr. Verghese responded. "But hurrying through makes us just hurry through. We order a lot of tests because we think we are saving time or because we are uncertain. If you spend more time listening to a patient or being more thoughtful, you end up saving time."

"I have no illusions about the limitations of the physical exam," he added. "But I increasingly feel that the exam is an important ritual whose importance has diminished for doctors because we have other ways of getting information."

"But it is still just as important for the patients," he continued. "The importance of the ritual of one patient baring his or her soul and body cannot be underestimated. Rituals are terribly important to human beings because they signify transformation. This is how you earn your right to say, 'I am your doctor.' If as a doctor you shortchange the ritual, you end up making patients feel you aren't interested. They lose trust."

He then remarked wryly, "We could inaugurate the president by an e-mail from the Chief Justice, but there's a reason we have an inauguration."

Dr. Verghese described the bedside clinical teaching rounds he holds every Wednesday with medical students. "I renew my faith in medicine when I see these students get excited. I want them to feel the awe and privilege of being at a patient's bedside."

"It's so easy for the doctor to just slide into a room and not think," he said. "But for the patient it is high drama and hugely symbolic. I want us to remember that all the time."