He challenged them to diagnose it. Hemiplegia? Sensory ataxia? Chorea? Spastic diplegia?
"It would be a shame to have someone with a gait that's diagnostic, and yet we can't recognize it," he said.
It was their introduction to a rollicking workshop on abnormal gaits that soon had them shuffling, staggering and thrashing about, challenging one another. Parkinson's? Neuropathy? Stroke?
Dr. Verghese (ver-GEESE) is the senior associate chairman for the theory and practice of medicine at Stanford University. He is also the author of two highly acclaimed memoirs, "My Own Country" and "The Tennis Partner," and a novel, "Cutting for Stone," which is now a best seller.
At Stanford, he is on a mission to bring back something he considers a lost art: the physical exam. The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope.
Art and medicine may seem disparate worlds, but Dr. Verghese insists that for him they are one. Doctors and writers are both collectors of stories, and he says his two careers have the same joy and the same prerequisite: "infinite curiosity about other people." He cannot help secretly diagnosing ailments in strangers, or wondering about the lives his patients lead outside the hospital.
"People are endlessly mysterious," he said in an interview in his office at the medical school, where volumes of poetry share the bookshelves with medical texts, family photos and a collection of reflex hammers.
His sources of inspiration include W. Somerset Maugham and Harrison's Principles of Internal Medicine. In addition to his medical degree, he has one from the writing workshop at the University of Iowa.
He is out to save the physical exam because it seems to be wasting away, he says, in an era of CT, ultrasound, M.R.I., countless lab tests and doctor visits that whip by like speed dates. Who has not felt slighted by a stethoscope applied through the shirt, or a millisecond peek into the throat?
Some doctors would gladly let the exam go, claiming that much of it has been rendered obsolete by technology and that there are better ways to spend their time with patients. Some admit they do the exam almost as a token gesture, only because patients expect it.
Medical schools in the United States have let the exam slide, Dr. Verghese says, noting that over time he has encountered more and more interns and residents who do not know how to test a patient's reflexes or palpate a spleen. He likes to joke that a person could show up at the hospital with a finger missing, and doctors would insist on an M.R.I., a CT scan and an orthopedic consult to confirm it.
Dr. Verghese trained before M.R.I. or CT existed, in Ethiopia and India, where fancy equipment was scarce and good examination skills were a matter of necessity and pride. He still believes a thorough exam can yield vital information and help doctors figure out which tests to order and which to skip — surely a worthwhile goal as the United States struggles to control health care costs, he said.
A proper exam also earns trust, he said, and serves as a ritual that transforms two strangers into doctor and patient.
"Patients know in a heartbeat if they're getting a clumsy exam," he said.
He has lectured and written about the erosion of examination skills, and his ideas have resonated with many doctors.
Stanford recruited him in 2007, in large part because of his enthusiasm for teaching the exam. He seized the bully pulpit.
"Coming from here, it's taken more seriously," he said.
With colleagues, he developed the Stanford 25, a list of techniques that every doctor should know, like how to listen to the heart or look at blood vessels at the back of the eye. The 25 are not the only exams or even the most important ones, he emphasizes — just a place to start.
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http://www.nytimes.com/2010/10/12/health/12profile.html?ref=homepage&src=me&pagewanted=all
