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Abraham Verghese Thinks Medicine Can Do Better (Update)

2025-05-03 - source - Read full transcript

Steve Levitt (host)Abraham Verghese

Key insights

The 'iPatient' - the data record - has displaced the real patient as the object of medical attention.

Verghese argues that electronic medical records have made doctors 'the highest paid clerical workers in the hospital,' with residents and interns spending so much time on the computer that the patient in the bed becomes a mere icon for the version of them that exists in the chart. He says the iPatient gets beautiful care while the actual patient wonders where everyone went.

bedside-medicine

The physical exam is a trust ritual, not just a diagnostic tool.

Verghese describes the exam as a socially unusual act - a stranger in a white coat is permitted touch that would be assault anywhere else - and argues that performing it with skill and presence builds a buy-in from patients that cannot be replicated by opining from images or lab results alone.

bedside-medicine

Curing and healing are different acts, and medicine has gotten much better at the former than the latter.

Verghese says he entered infectious disease medicine chasing the 'conceit of cure' - dramatic diagnoses that make patients 'rise like Lazarus' - but AIDS, an incurable disease in the 1980s, taught him that healing (presence, ritual, accompanying a patient and family through illness and death) is a separate, older function of medicine, once called the Ministry of Healing.

bedside-medicine

US healthcare functions as a self-interested industry that resists any reduction in its own revenue.

Verghese describes healthcare as a multi-trillion-dollar 'trough' that suppliers, hospitals, instrument makers, doctors, and specialty groups all feed from, where anyone trying to shrink a portion gets attacked. He notes he once believed the system would self-correct once healthcare spending hit 15-18% of GDP, but the US has passed that threshold with no correction in sight.

physician-burnout

Physician burnout is a systemic problem, not a character flaw, and the scale of the crisis is itself a reason for optimism.

Verghese rejects the idea that doctors' apparent hubris reflects arrogance, attributing it instead to people under sustained pressure in a dysfunctional system. He says he is 'optimistic for a perverse reason': the physician wellness crisis has grown so large that there is now widespread recognition the system is untenable and needs large systemic change.

physician-burnout

Rural AIDS in the 1980s South followed a specific migration pattern: young gay men left small towns for cities, then returned home to die once infected.

Practicing in Johnson City, Tennessee in a region where colleagues expected one HIV patient every other year, Verghese ended up following about 100 HIV patients out of a population of 50,000. He traces the pattern to men leaving small towns for anonymity and community in cities like San Francisco and New York, contracting HIV there, and returning home once sick, often to be received with more acceptance than the Deep South stereotype predicted.

hiv-aids-history

The stigma and metaphor surrounding HIV sometimes did more harm than the virus itself.

Verghese recounts a patient who, upon learning he was HIV-positive, engineered a shootout with police rather than face the disease's associated shame and secrecy - a death Verghese attributes to the metaphor of HIV, not the disease. He also describes overt hostility from colleagues, including a radiologist who asked why he bothered treating 'these fags.'

hiv-aids-history

Deep qualitative knowledge of patients can constitute real data, even without a formal dataset.

Verghese plotted his HIV patients' current and origin locations from memory and index cards rather than a formal study, and the resulting maps revealed the urban-infection, rural-return migration pattern. Levitt endorses this as genuine data analysis, pushing back on the idea that only large, systematically collected datasets count as data.

hiv-aids-history

Working the lowest-status job in a hospital gave Verghese his defining orientation toward patient care.

After Ethiopia's Derg regime shut down universities and forced Verghese to abandon his third year of medical school, he worked as a hospital orderly in New Jersey. He describes this period, including seeing the 'warehousing of the elderly' in a nursing home, as the best training he ever received and the source of a lasting solidarity with nursing.

immigration-and-reinvention

Verghese gave up financial and career security to pursue writing because his dying patients taught him not to postpone what he truly wanted to do.

After five years treating AIDS patients in Tennessee, Verghese cashed out his 401k, gave up a tenured academic position, and moved his family to attend the Iowa Writers' Workshop for an MFA, crediting the lesson directly to what his patients had shown him about the cost of deferring what matters.

immigration-and-reinvention

Fiction can change public policy and culture in ways nonfiction and data cannot.

Verghese cites Uncle Tom's Cabin as more responsible for shifting sentiment against slavery than any other single work, and The Citadel as credited with helping inspire the UK's National Health Service, arguing fiction is 'the great lie that tells the truth about how the world lives.'

fiction-writing-craft

Verghese's novel-writing process is organic and image-first rather than outlined, and resembles clinical diagnostic reasoning.

He says he typically starts with a single image (a nun giving birth to twins, for Cutting for Stone) rather than a full plot, and that disparate narrative threads only cohere later, in a moment he compares to Occam's razor resolving a diagnosis from scattered symptoms.

fiction-writing-craft

Books referenced

Cutting for Stone - Abraham Verghese - Verghese's first novel, two years on the NYT bestseller list and on Barack Obama's summer reading list; began with an image of a nun giving birth to twins in Africa.
The Covenant of Water - Abraham Verghese - Verghese's most recent novel, a huge bestseller that Oprah Winfrey named one of her three favorite books of all time.
My Own Country: A Doctor's Story - Abraham Verghese - Verghese's memoir of practicing infectious disease medicine during the early AIDS epidemic in rural Tennessee; named one of TIME's five best books of 1994.
Harrison's Textbook of Medicine - The textbook Verghese saw a medical student leave behind at the nursing home where he worked as an orderly, which reignited his desire to return to medicine.
Grey's Anatomy - Mentioned alongside Harrison's as the textbooks Verghese had memorized in medical school in Ethiopia before the civil war interrupted his training.
Uncle Tom's Cabin - Harriet Beecher Stowe - Cited by Verghese as an example of fiction that did more to end slavery than any other single thing, supporting his belief in the real-world power of novels.
The Citadel - A.J. Cronin - Cited by Verghese as the novel about a Welsh mining town's medical conditions credited with helping give rise to the UK's National Health Service.
The Body as Text - Abraham Verghese - Working title of the memoir Verghese is currently drafting, looking at his own life, including childhood, through a medical lens.

Media referenced

Everything Is Tuberculosis (forthcoming episode with John Green) - podcast - Teased as next week's episode; a short clip of author John Green discussing his new book on tuberculosis and injustice closes this episode.

Companies

Stanford University - Verghese is a professor of medicine there; where he practices and teaches bedside medicine.
Iowa Writers' Workshop - Verghese quit his tenured academic position and cashed out his 401k to attend, spending two years earning his MFA while working part-time in an HIV clinic.
Freakonomics Radio Network - Parent network for the show; also includes Freakonomics Radio and The Economics of Everyday Things, produced by Stitcher and Renbud Radio.

Techniques and frameworks

The iPatient - Verghese's term, coined in a New England Journal of Medicine article, for how electronic medical records turn the patient into a data icon while the real patient in the bed becomes an afterthought.
Curing vs. healing - Verghese's distinction between eliminating disease (cure) and being present with a patient through illness and death (healing) - a distinction he says he learned from AIDS patients he could not cure.
Bedside ritual of the physical exam - Verghese's framing of the physical exam as a trust-building ritual - a stranger permits touch that would be assault in any other context - that gives patients a sense their illness has been localized and taken seriously, independent of its diagnostic yield.
Geographic mapping of qualitative patient data - Verghese plotted his HIV patients' hometowns against where they likely contracted the virus using index cards and memory rather than a formal dataset, revealing the migration-and-return pattern that defined rural AIDS in the 1980s.

Summary

This is an encore of Steve Levitt's 2023 conversation with Abraham Verghese, a Stanford professor of medicine and bestselling novelist (Cutting for Stone, The Covenant of Water), updated with a brief coda on what Verghese is writing now. The conversation opens with Verghese's early life: born in Ethiopia to Indian Christian parents descended from a community tracing back to Saint Thomas the Apostle, he was in his third year of medical school when Ethiopia's Derg regime seized power, closed the universities, and forced him to flee. Arriving in the US without a completed degree, he worked as a hospital orderly and nursing assistant in New Jersey for nine months - an experience he calls the best training he ever received, giving him a lasting solidarity with nursing and a firsthand view of what happens to patients in the hours doctors are absent. Finding a discarded medical textbook on a ward counter reignited his drive to finish medical school, which he completed in India before returning to the US to specialize in infectious disease.

That specialty put Verghese on the front lines of the AIDS epidemic in rural Johnson City, Tennessee, where he ended up treating roughly 100 HIV patients in a town where colleagues expected one every other year. He describes a migration pattern he uncovered not through formal research but by plotting his patients' current homes and likely infection sites, drawn from memory and index cards, onto two maps: young gay men had left small towns for cities like San Francisco and New York, found community there, contracted HIV, and returned home once sick. Levitt seizes on this as a model of real data analysis that doesn't require a large formal dataset. Verghese also recounts the acute stigma of the era - a colleague openly asking why he treated "these fags," and a patient who died by suicide-by-cop rather than face the shame associated with his diagnosis - arguing that the metaphor surrounding HIV sometimes did more damage than the virus itself.

From there, the conversation turns to Verghese's broader critique of modern medicine. He coined the term "the iPatient" to describe how electronic medical records have displaced the actual patient in the bed with a data proxy that receives excellent care while the real person is left wondering where everyone went. He distinguishes curing (eliminating disease) from healing (staying present through illness, even without a cure) and frames the physical exam as an underrated ritual of trust, not merely a diagnostic tool. He describes the US healthcare system as an unsustainable, self-interested "trough" that resists any reduction in its own revenue, and reframes physician burnout as a systemic failure rather than individual hubris - though he says the scale of that crisis is itself grounds for optimism, since it has forced overdue recognition that change is needed.

The second half of the episode covers Verghese's parallel career as a novelist. He resists the idea that he wears two hats, saying writing is simply another expression of how he sees the world as a physician. He argues fiction has real power to shift culture and policy, citing Uncle Tom's Cabin's role in turning sentiment against slavery and The Citadel's influence on the creation of the UK's National Health Service. His own writing process is non-linear: he starts from a single image rather than an outline (Cutting for Stone began with a nun giving birth to twins), and compares the way disparate narrative threads eventually cohere to the clinical process of Occam's razor resolving a diagnosis from scattered symptoms. He quit his tenured position and used his retirement savings to attend the Iowa Writers' Workshop, crediting his dying patients with teaching him not to defer what he truly wanted to do.

The episode closes with a short update: Verghese is drafting a memoir tentatively titled The Body as Text, looking at his own life (including childhood) through a medical lens, and is also making notes for his first novel set in America after previous novels set in India and Ethiopia. The episode ends with a brief teaser clip of author John Green discussing his forthcoming book on tuberculosis, framed as next week's guest.

Notable Quotes

"Most physicians I know share these same sentiments, but we are trapped. We are actually prisoners in what has become the healthcare business." - Abraham Verghese

"I said that the patient in the bed has become a mere icon for the real patient in the computer." - Abraham Verghese

"I always thought that if we get to 15 to 18 percent of the G.D.P. going to healthcare, then the system has to self-destruct and we'll correct. Well, we've gone past that. It's only getting more." - Abraham Verghese

"Fiction is the great lie that tells the truth about how the world lives." - Abraham Verghese

"Life is a terminal condition. All our days are going to end and some people are facing much sooner than others and they just want to know that you're there." - Abraham Verghese