Friday, October 15, 2010

Abraham Verghese - The Top Gun of American Medicine

The first year medical students I precept were too young to see Tom Cruise's alter ego Lieutenant Pete "Maverick" Mitchell grace the big screen in the 1986 blockbuster film Top Gun.  Yet, the story has a relevant analogy to medicine. 

According to the film, during the Vietnam war American pilots were relying too much on technology to bring enemy fighters down.  They weren't as skilled in taking out the opposition.  They fired their technologically advanced missiles to try and get the job done.  They didn't think.  It didn't work.  They forgot the art of dogfighting.

The military discovered that technology alone wasn't going to get the job done. The best fighter pilots needed the skills, insight, and wisdom on when to use technology and when not to. As a result, the Navy Fighter Weapons School, known simply as Top Gun, was created to retrain the military pilots on this vital lost skill. 

The goal of the program was specifically to make the best of the best even better.

Like the military, the country is discovering that the healthcare system enabled with dazzling technology isn't getting the job done either.  One study suggests that Americans don't live as long as citizens from other industrialized countries not due to our obesity or smoking habits but because of the failings of the healthcare system even though we pay more per capita on healthcare.  Since the recent and current generation of doctors, residents, and medical students are trained to rely heavily on technology, the situation is only going to get worse.  These doctors do not know how to do a thoughtful history or thorough physical examination.  Individual patients as well as the nation will pay a price for more unnecessary testing as well as wasted time and money which could have been avoided if doctors focused on the art of medicine. 

To slow healthcare costs, the next generation of doctors will need the skills, insight, and wisdom on how to take an accurate history, perform a thoughtful clinical examination, and use technology judiciously.  They must be experts in the art of medicine.  Like the art of dogfighting, the art of medicine was a skill that should have been embraced as technology proliferated instead of being marginalized in training.

So who are medicine's Top Guns?  Who are the best of the best?  Where is medicine's Navy Fighter Weapons School?

If medical students want to be the best of the best, then they should look no further than Dr. Abraham Verghese of Stanford Medical School.  Dr. Verghese, already an accomplished author who is also board certified in internal medicine and infectious disease, engages them with the virtuoso performances on the fine art of medicine.  For doctors to become expert diagnosticians, he and his colleagues outlined 25 skills doctors should know simply as a beginning to more learning.

If students want to be in the specialty where the best and brightest work, then they should look no further than primary care, family medicine or internal medicine.  Besides dermatology, primary care is a specialty where doctors often start evaluating patients by talking, observing and examining.  Primary care doctors often see patients for the first time without any test results as these visits are usually the first time someone has sought medical care.  As a result, they need to skills to figure out which patient needs more extensive work-up and which one can safely care for the problem at home.  Though primary care isn't as attractive to medical students and proposals are underway to make the field more appealing, there is no question that it is the most cognitive specialty - a doctor's doctor specialty.

If the US healthcare system is to provide Americans better care it will need a generation of Top Guns in primary care to lead the change.  What Dr. Verghese offers his medical students and residents in his training is what all of us want in our doctor - someone who listens, observes, and examines thoughtfully to get the right diagnosis.

In other words, a doctor who is the best of the best.  As a practicing doctor, I would jump at the opportunity to learn from him.

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