Abraham Verghese: A doctor's touch

Translator: Morten Kelder Skouboe Reviewer: Anders Finn Jørgensen

A few months ago,

For et par måneder siden

a 40 year-old woman came to an emergency room

kom en nogen og 40 år gammel kvinde på skadestuen

in a hospital close to where I live,

på et hospital tæt på, hvor jeg bor,

and she was brought in confused.

og hun blev bragt forvirret ind.

Her blood pressure was an alarming

Hendes blodtryk var en alarmerende

230 over 170.

230 over 170.

Within a few minutes, she went into cardiac collapse.

Inden for få minutter fik hun hjertestop.

She was resuscitated, stabilized,

Hun blev genoplivet, stabiliseret,

whisked over to a CAT scan suite

kom hurtigt til en CAT scanning

right next to the emergency room,

lige ved siden af skadestuen,

because they were concerned about blood clots in the lung.

fordi de frygtede blodpropper i lungen.

And the CAT scan revealed

Og CAT scanningen viste

no blood clots in the lung,

ingen blodpropper i lungen,

but it showed bilateral, visible, palpable breast masses,

men den viste bilaterale, synlige, følbare knuder i brystet,

breast tumors,

brysttumorer,

that had metastasized widely

der havde metastaseret stort set

all over the body.

til hele kroppen.

And the real tragedy was, if you look through her records,

Og den virkelige tragedie var, hvis man gennemgår hendes journaler,

she had been seen

var hun blevet tilset

in four or five other health care institutions

i fire eller fem andre sundhedsinstitutioner

in the preceding two years.

i de forgangne to år.

Four or five opportunities

Fire eller fem muligheder

to see the breast masses, touch the breast mass,

for at se knuderne i brystet, mærke brystmassen,

intervene at a much earlier stage

gribe ind på et tidligere stadie,

than when we saw her.

end da vi så hende.

Ladies and gentlemen,

Mine damer og herrer,

that is not an unusual story.

det er ikke en usædvanlig historie.

Unfortunately, it happens all the time.

Desværre sker det hele tiden.

I joke, but I only half joke,

Jeg spøger med, men kun halvt,

that if you come to one of our hospitals missing a limb,

at hvis man kommer til et af vores hospitaler uden et lem,

no one will believe you till they get a CAT scan, MRI

vil ingen tro dig, før de får en CAT eller MRI scanning

or orthopedic consult.

eller ortopædisk konsultation.

I am not a Luddite.

Jeg er ikke maskinstormer.

I teach at Stanford.

Jeg underviser på Stanford.

I'm a physician practicing with cutting-edge technology.

Jeg er en læge, der praktiserer med banebrydende teknologi.

But I'd like to make the case to you

Men jeg vil gerne argumentere for

in the next 17 minutes

i de næste 17 minutter,

that when we shortcut the physical exam,

at når vi skærer den fysiske undersøgelse væk,

when we lean towards ordering tests

når vi læner mod at bestille prøver

instead of talking to and examining the patient,

i stedet for at tale til og undersøge patienten,

we not only overlook simple diagnoses

vil vi ikke kun overse simple diagnoser,

that can be diagnosed at a treatable, early stage,

der kan diagnosticeres på et tidligt stadie, hvor det kan behandles,

but we're losing much more than that.

vi mister meget mere end det.

We're losing a ritual.

Vi mister et ritual.

We're losing a ritual that I believe is transformative, transcendent,

Vi mister et ritual, som jeg mener er omdannende, transcendent

and is at the heart

og i hjertet

of the patient-physician relationship.

af patient-læge-forholdet.

This may actually be heresy to say this at TED,

Det kan muligvis være kætteri at sige dette på TED,

but I'd like to introduce you

men jeg vil gerne introducere jer

to the most important innovation,

for den vigtigste opfindelse,

I think, in medicine

synes jeg, i medicin

to come in the next 10 years,

i de næste 10 år,

and that is the power of the human hand --

og det er den menneskelige hånds magt --

to touch, to comfort, to diagnose

at berøre, trøste, diagnosticere

and to bring about treatment.

og sørge for behandling.

I'd like to introduce you first to this person

Jeg vil gerne introducere jer for denne person,

whose image you may or may not recognize.

hvis billede I måske genkender.

This is Sir Arthur Conan Doyle.

Dette er Sir Arthur Conan Doyle.

Since we're in Edinburgh, I'm a big fan of Conan Doyle.

Da vi er i Edinburg, er jeg en stor fan af Conan Doyle.

You might not know that Conan Doyle went to medical school

I ved måske ikke, at Conan Doyle studerede medicin

here in Edinburgh,

her i Edinburgh,

and his character, Sherlock Holmes,

og hans karakter, Sherlock Holmes,

was inspired by Sir Joseph Bell.

var inspireret af Sir Joseph Bell.

Joseph Bell was an extraordinary teacher by all accounts.

Joseph Bell var en usædvanlig lærer på alle måder.

And Conan Doyle, writing about Bell,

Og Conan Doyle, skrivende om Bell,

described the following exchange

beskrev den følgende udveksling

between Bell and his students.

mellem Bell og hans studerende.

So picture Bell sitting in the outpatient department,

Forestil jer Bell siddende i ambulatoriet,

students all around him,

studerende rundt om ham,

patients signing up in the emergency room

patienter, der skriver sig ind på skadestuen

and being registered and being brought in.

og bliver registrerede og bragt ind.

And a woman comes in with a child,

En kvinde kommer ind med et barn,

and Conan Doyle describes the following exchange.

og Conan Doyle beskriver den følgende udveksling.

The woman says, "Good Morning."

Kvinden siger, "Godmorgen."

Bell says, "What sort of crossing did you have

Bell siger, "Hvordan var turen

on the ferry from Burntisland?"

med færgen fra Burntisland?"

She says, "It was good."

Hun siger, "Den var god."

And he says, "What did you do with the other child?"

Og han siger, "Hvad gjorde du med det andet barn?"

She says, "I left him with my sister at Leith."

Hun siger, "Jeg gav ham til min søster på Leith."

And he says,

Og han siger,

"And did you take the shortcut down Inverleith Row

"Og tog du genvejen ned af Inverleith Row

to get here to the infirmary?"

for at komme til sygehuset?"

She says, "I did."

Hun siger, "Det gjorde jeg."

And he says, "Would you still be working at the linoleum factory?"

Og han siger, "Arbejder du stadig på linoleumsfabrikken?"

And she says, "I am."

Og hun siger, "Det gør jeg."

And Bell then goes on to explain to the students.

Og Bell starter med at forklare for sine studerende.

He says, "You see, when she said, 'Good morning,'

Han siger, "Ser I, da hun sagde, 'Godmorgen,'

I picked up her Fife accent.

anede jeg hendes Fife-accent.

And the nearest ferry crossing from Fife is from Burntisland.

Og den nærmeste færge fra Fife afgår fra Burnisland.

And so she must have taken the ferry over.

Og derfor måtte hun have taget færgen over.

You notice that the coat she's carrying

Læg mærke til, at jakken, hun bærer,

is too small for the child who is with her,

er for lille til barnet, der er med hende,

and therefore, she started out the journey with two children,

og derfor begyndte hun turen med to børn,

but dropped one off along the way.

men afleverede det ene på vejen.

You notice the clay on the soles of her feet.

Læg mærke til leret på hendes skosåler.

Such red clay is not found within a hundred miles of Edinburgh,

Den slags rødt ler findes ikke inden for hundrede mil fra Edinburgh,

except in the botanical gardens.

bortset fra i botanisk have.

And therefore, she took a short cut down Inverleith Row

Og derfor skød hun genvej ned ad Inverleith Row

to arrive here.

for at komme her.

And finally, she has a dermatitis

Og endelig har hun hudbetændelse

on the fingers of her right hand,

på hendes højre hånds fingre,

a dermatitis that is unique

en betændelse, der er unik

to the linoleum factory workers in Burntisland."

for linoleumfabriksarbejderne i Burnisland."

And when Bell actually strips the patient,

Og da Bell får afklædt patienten,

begins to examine the patient,

begynder at undersøge patienten,

you can only imagine how much more he would discern.

kan man kun forestille sig, hvor meget mere han ville udlede.

And as a teacher of medicine, as a student myself,

Og som lærer i medicin og studerende selv

I was so inspired by that story.

blev jeg inspireret af den historie.

But you might not realize

Men I ved måske ikke,

that our ability to look into the body

at vores evne til at se ind i kroppen

in this simple way, using our senses,

på denne simple måde med vores sanser

is quite recent.

er ret ny.

The picture I'm showing you is of Leopold Auenbrugger

Billedet, jeg viser jer, er af Leopold Auenbrugger,

who, in the late 1700s,

der sidst i 1800-tallet

discovered percussion.

opdagede percussion.

And the story is that Leopold Auenbrugger

Historien går, at Leopold Auenbrugger

was the son of an innkeeper.

var søn af en krofatter.

And his father used to go down into the basement

Hans far plejede at gå ned i kælderen

to tap on the sides of casks of wine

for at banke på vintøndernes sider

to determine how much wine was left

og bestemme, hvor meget vin, der var tilbage,

and whether to reorder.

og om der skulle bestilles mere.

And so when Auenbrugger became a physician,

Så da Auenbrugger blev læge,

he began to do the same thing.

begyndte han at gøre det samme.

He began to tap on the chests of his patients,

Han begyndte at banke på sine patienters bryst,

on their abdomens.

på deres maver.

And basically everything we know about percussion,

Stort set alt vi kender til percussion,

which you can think of as an ultrasound of its day --

som man kan kalde den tids ultralyd --

organ enlargement, fluid around the heart, fluid in the lungs,

organforstørrelse, væske om hjertet, væske i lungerne,

abdominal changes --

forandringer i maven --

all of this he described in this wonderful manuscript

alt dette beskriver han i dette manuskript

"Inventum Novum," "New Invention,"

"Inventum Novum," "Ny Opfindelse,"

which would have disappeared into obscurity,

som ville være gået i glemmebogen,

except for the fact that this physician, Corvisart,

hvis ikke for denne læge, Corvisart,

a famous French physician --

en kendt fransk læge --

famous only because he was physician to this gentleman --

kun kendt, fordi han var læge for denne herre --

Corvisart repopularized and reintroduced the work.

Corvisart genpopulariserede og genintroducerede værket.

And it was followed a year or two later

Det blev fulgt op et år eller to senere

by Laennec discovering the stethoscope.

af Laennecs opdagelse af stetoskopet.

Laennec, it is said, was walking in the streets of Paris

Laennec, siges det, spadserede i Paris' gader

and saw two children playing with a stick.

og så to børn lege med en pind.

One was scratching at the end of the stick,

Det ene kradsede på pindens ende,

another child listened at the other end.

et andet barn lyttede i den anden ende.

And Laennec thought this would be a wonderful way

Og Laennec tænkte, dette ville være en skøn måde

to listen to the chest or listen to the abdomen

at lytte til brystet eller bugen

using what he called "the cylinder."

ved at bruge, hvad han kaldte "cylinderen."

Later he renamed it the stethoscope.

Senere omdøbte han det stetoskopet.

And that is how stethoscope and auscultation was born.

Sådan blev stetoskopet og auskultation født.

So within a few years,

Så i løbet af få år

in the late 1800s, early 1900s,

i slutningen af 1800-, starten af 1900-tallet,

all of a sudden,

lige pludselig,

the barber surgeon had given way

var barberkirurgen blevet skubbet til side

to the physician who was trying to make a diagnosis.

af lægen, der forsøgte at stille en diagnose.

If you'll recall, prior to that time,

Husk på, at før den tid,

no matter what ailed you, you went to see the barber surgeon

uanset hvad man fejlede, gik man til barberkirurgen,

who wound up cupping you,

der endte med at tappe en,

bleeding you, purging you.

bløde en, rense en.

And, oh yes, if you wanted,

Og, åh ja, hvis man ønskede det,

he would give you a haircut -- short on the sides, long in the back --

ville han klippe en -- kort i siderne, lang i nakken --

and pull your tooth while he was at it.

og trække en tand ud, nu han var i gang.

He made no attempt at diagnosis.

Han forsøgte ikke at diagnosticere.

In fact, some of you might well know

Nogle af jer ved måske endda,

that the barber pole, the red and white stripes,

at barberpælen, de røde og hvide striber,

represents the blood bandages of the barber surgeon,

repræsenterer barberkirurgens blodige bandager,

and the receptacles on either end

og beholderne i hver ende

represent the pots in which the blood was collected.

repræsenterer potterne, hvori blodet blev opsamlet.

But the arrival of auscultation and percussion

Men auskultations og percussions ankomst

represented a sea change,

repræsenterede et skift,

a moment when physicians were beginning to look inside the body.

et øjeblik, hvor læger begyndte at se ind i kroppen.

And this particular painting, I think,

Og lige præcis dette maleri, synes jer,

represents the pinnacle, the peak, of that clinical era.

repræsenterer toppen af den kliniske æra.

This is a very famous painting:

Dette er et meget kendt maleri:

"The Doctor" by Luke Fildes.

"Doktoren" af Luke Fildes.

Luke Fildes was commissioned to paint this by Tate,

Luke Fildes blev bestilt til at male dette af Tate,

who then established the Tate Gallery.

som etablerede Tate Gallery.

And Tate asked Fildes to paint a painting

Tate bad Fildes male et maleri

of social importance.

med social vigtighed.

And it's interesting that Fildes picked this topic.

Og det er interessant, at Fildes valgte dette emne.

Fildes' oldest son, Philip,

Fildes' ældste søn, Philip,

died at the age of nine on Christmas Eve

døde i en alder af ni juleaften

after a brief illness.

efter en kort sygdom.

And Fildes was so taken by the physician

Og Fildes blev så rørt over lægen,

who held vigil at the bedside for two, three nights,

der holdt vagt ved sengen i to, tre nætter,

that he decided that he would try and depict

at han besluttede, at han ville forsøge at afbilde

the physician in our time --

vor tids læge --

almost a tribute to this physician.

næsten en hyldest til denne læge.

And hence the painting "The Doctor," a very famous painting.

Og derfor maleriet "Doktoren," et meget kendt maleri.

It's been on calendars, postage stamps in many different countries.

Det har været på kalendere, frimærker i mange lande.

I've often wondered, what would Fildes have done

Jeg har ofte tænkt, hvad ville Fildes havde gjort,

had he been asked to paint this painting

var han blevet bedt male dette maleri

in the modern era,

i den moderne æra,

in the year 2011?

i år 2011?

Would he have substituted a computer screen

Ville han have indsat en computerskærm,

for where he had the patient?

hvor patienten havde været?

I've gotten into some trouble in Silicon Valley

Jeg er kommet i problemer i Silicon Valley

for saying that the patient in the bed

for at sige, at patienten i sengen

has almost become an icon

næsten er blevet et ikon

for the real patient who's in the computer.

for den virkelige patient, der er i computeren.

I've actually coined a term for that entity in the computer.

Jeg har faktisk fundet på et ord for det væsen i computeren.

I call it the iPatient.

Jeg kalder det iPatienten.

The iPatient is getting wonderful care all across America.

iPatienten bliver sørget godt for over hele Amerika.

The real patient often wonders,

Den virkelige patient tænker tit,

where is everyone?

hvor er alle?

When are they going to come by and explain things to me?

Hvornår kommer de og forklarer mig tingenes tilstand?

Who's in charge?

Hvem fører an?

There's a real disjunction between the patient's perception

Der er stor forskel på patientens opfattelse

and our own perceptions as physicians of the best medical care.

og vores egen opfattelse som læger af den bedste medicinske behandling.

I want to show you a picture

Jeg vil gerne vise jer et billede af,

of what rounds looked like

hvordan stuegang så ud,

when I was in training.

da jeg var under uddannelse.

The focus was around the patient.

Fokus var på patienten.

We went from bed to bed. The attending physician was in charge.

Vi gik fra seng til seng. Den ledende overlæge førte an.

Too often these days,

Alt for ofte nu om dage

rounds look very much like this,

ser stuegang meget ud som dette,

where the discussion is taking place

hvor diskussionen finder sted

in a room far away from the patient.

i et rum langt fra patienten.

The discussion is all about images on the computer, data.

Diskussionen handler om billeder på en computer, data.

And the one critical piece missing

Og det ene vigtige element, der mangler,

is that of the patient.

er patienten.

Now I've been influenced in this thinking

Jeg er blevet påvirket til denne tankegang

by two anecdotes that I want to share with you.

af to anekdoter, som jeg gerne vil dele med jer.

One had to do with a friend of mine who had a breast cancer,

En handler om en ven, der havde brystkræft,

had a small breast cancer detected --

fik opdaget en lille brystkræft --

had her lumpectomy in the town in which I lived.

fik lumpektomi i byen, hvor jeg boede.

This is when I was in Texas.

Dette er, da jeg var i Texas.

And she then spent a lot of time researching

Hun brugte så en masse tid på at undersøge,

to find the best cancer center in the world

hvilket der var det bedste kræftcenter i verden

to get her subsequent care.

at få hendes efterbehandling.

And she found the place and decided to go there, went there.

Hun fandt stedet og valgte at tage derhen.

Which is why I was surprised a few months later

Hvilket er derfor, jeg blev overrasket få måneder efter

to see her back in our own town,

over at se hende tilbage i byen

getting her subsequent care with her private oncologist.

og modtage hendes efterbehandling hos hendes private onkolog.

And I pressed her, and I asked her,

Jeg pressede og spurgte hende,

"Why did you come back and get your care here?"

"Hvorfor kom du tilbage og får din behandling her?"

And she was reluctant to tell me.

Hun ville helst ikke fortælle mig det.

She said, "The cancer center was wonderful.

Hun sagde, "Kræftcenteret var skønt.

It had a beautiful facility,

Det havde et smukt anlæg,

giant atrium, valet parking,

kæmpe atrium, parkeringsservice,

a piano that played itself,

et piano, der selv spillede,

a concierge that took you around from here to there.

en concierge, der tog dig rundt fra her til der.

But," she said,

Men," sagde hun,

"but they did not touch my breasts."

"men de rørte ikke mine bryster."

Now you and I could argue

Nu kan vi argumentere for,

that they probably did not need to touch her breasts.

at de nok ikke behøvede at røre hendes bryster.

They had her scanned inside out.

De fik hende scannet på alle ledder.

They understood her breast cancer at the molecular level;

De forstod hendes brystkræft på det molekylære niveau;

they had no need to touch her breasts.

de havde intet behov for at røre hendes bryster.

But to her, it mattered deeply.

Men for hende betød det meget.

It was enough for her to make the decision

Det var nok for hende til at foretage beslutningen

to get her subsequent care with her private oncologist

at få sin efterbehandling hos hendes egen onkolog,

who, every time she went,

der, hver gang hun kom,

examined both breasts including the axillary tail,

undersøgte begge bryster og armhuler,

examined her axilla carefully,

undersøgte hendes lymfeknuder grundigt,

examined her cervical region, her inguinal region,

undersøgte hendes livmoderhals- og lyskeregioner,

did a thorough exam.

foretog en grundig undersøgelse.

And to her, that spoke of a kind of attentiveness that she needed.

Og for hende, var det en slags opmærksomhed, som hun behøvede.

I was very influenced by that anecdote.

Jeg blev meget påvirket af den anekdote.

I was also influenced by another experience that I had,

Jeg blev også påvirket af en anden oplevelse, jeg havde,

again, when I was in Texas, before I moved to Stanford.

igen, da jeg var i Texas, før jeg flyttede til Stanford.

I had a reputation

Jeg havde et ry

as being interested in patients

for at være interesseret i patienter

with chronic fatigue.

med kronisk træthed.

This is not a reputation you would wish on your worst enemy.

Dette er ikke et ry man ville ønske for sin værste fjende.

I say that because these are difficult patients.

Det siger jeg, fordi disse er svære patienter.

They have often been rejected by their families,

De er ofte blevet afvist af deres familier,

have had bad experiences with medical care

har haft dårlige erfaringer med sundhedsvæsnet,

and they come to you fully prepared

og de kommer til en fuldt forberedt på,

for you to join the long list of people

at man kan komme på listen over folk,

who's about to disappoint them.

der snart vil skuffe dem.

And I learned very early on with my first patient

Jeg lærte allerede fra min første patient,

that I could not do justice

at jeg ikke kunne yde retfærdighed

to this very complicated patient

for denne meget komplicerede patient

with all the records they were bringing

med alle de journaler, de bragte

in a new patient visit of 45 minutes.

ved et nyt patientbesøg på 45 minutter.

There was just no way.

På ingen måde.

And if I tried, I'd disappoint them.

Hvis jeg forsøgte, ville jeg skuffe dem.

And so I hit on this method

Så jeg prøvede denne metode,

where I invited the patient

hvor jeg bad patienten

to tell me the story for their entire first visit,

fortælle mig historien i hele deres første besøg,

and I tried not to interrupt them.

og jeg prøvede ikke at afbryde dem.

We know the average American physician

Vi ved, den gennemsnitlige amerikanske læge

interrupts their patient in 14 seconds.

afbryder deres patient inden 14 sekunder.

And if I ever get to heaven,

Hvis jeg skulle komme i Himlen,

it will be because I held my piece for 45 minutes

bliver det, fordi jeg holdt min mund i 45 minutter

and did not interrupt my patient.

og ikke afbrød min patient.

I then scheduled the physical exam for two weeks hence,

Så planlagde jeg den fysiske undersøgelse to uger senere,

and when the patient came for the physical,

og da patienten kom for undersøgelsen,

I was able to do a thorough physical,

kunne jeg foretage en grundig fysisk undersøgelse,

because I had nothing else to do.

fordi jeg intet andet havde at gøre.

I like to think that I do a thorough physical exam,

Jeg synes selv, jeg foretager grundige undersøgelser,

but because the whole visit was now about the physical,

men fordi hele besøget nu handlede om den fysiske,

I could do an extraordinarily thorough exam.

kunne jeg foretage en usædvanlig grundig undersøgelse.

And I remember my very first patient in that series

Jeg husker min allerførste patient i den serie,

continued to tell me more history

blev ved med at fortælle mig mere historie

during what was meant to be the physical exam visit.

under, hvad skulle have været besøget for den fysiske undersøgelse.

And I began my ritual.

Jeg begyndte mit ritual.

I always begin with the pulse,

Jeg begynder altid med pulsen,

then I examine the hands, then I look at the nail beds,

så undersøger jeg hænderne, så på neglelejerne,

then I slide my hand up to the epitrochlear node,

så fører jeg hånden op til epitroklærkirtlen,

and I was into my ritual.

og jeg var i gang med mit ritual.

And when my ritual began,

Og da mit ritual begyndte,

this very voluble patient

begyndte denne meget talende patient

began to quiet down.

at tie stille.

And I remember having a very eerie sense

Jeg mindes at have en sælsom fornemmelse,

that the patient and I

at patienten og jeg

had slipped back into a primitive ritual

var gledet tilbage i et primitivt ritual,

in which I had a role

i hvilket jeg havde en rolle

and the patient had a role.

og patienten havde en rolle.

And when I was done,

Da jeg var færdig,

the patient said to me with some awe,

sagde patienten til mig med ærefrygt,

"I have never been examined like this before."

"Jeg er aldrig blevet undersøgt sådan før."

Now if that were true,

Hvis det var sandt,

it's a true condemnation of our health care system,

er det en sand fordømmelse af vores sundhedssystem,

because they had been seen in other places.

fordi de var blevet tilset andre steder.

I then proceeded to tell the patient,

Jeg gik da videre til at fortælle patienten,

once the patient was dressed,

da patienten var blevet påklædt,

the standard things that the person must have heard in other institutions,

standardtingene, som personen må have hørt i andre institutioner,

which is, "This is not in your head.

hvilket er, "Dette er ikke i dit hoved.

This is real.

Det er virkeligt.

The good news, it's not cancer, it's not tuberculosis,

Det gode er, det er ikke kræft, det er ikke tuberkulose,

it's not coccidioidomycosis or some obscure fungal infection.

det er ikke coccidioidomycosis eller en underlig svampeinfektion.

The bad news is we don't know exactly what's causing this,

Det dårlige er, vi ved ikke præcis, hvad forårsager dette,

but here's what you should do, here's what we should do."

men nu skal du høre, hvad du skal gøre, hvad vi skal gøre."

And I would lay out all the standard treatment options

Jeg ville lægge alle standard- behandlingsmulighederne ud,

that the patient had heard elsewhere.

som patienten havde hørt andre steder.

And I always felt

Og jeg følte altid,

that if my patient gave up the quest

at hvis min patient opgav søgningen

for the magic doctor, the magic treatment

efter den magiske læge eller behandling

and began with me on a course towards wellness,

og begyndte med mig på en kurs mod velvære,

it was because I had earned the right

var det, fordi jeg havde fortjent retten

to tell them these things

til at fortælle dem disse ting

by virtue of the examination.

i kraft af undersøgelse.

Something of importance had transpired in the exchange.

Noget vigtigt var kommet frem i udvekslingen.

I took this to my colleagues

Jeg tog dette til mine kolleger

at Stanford in anthropology

på Stanford i antropologi

and told them the same story.

og fortalte dem den samme historie.

And they immediately said to me,

De fortalte mig straks,

"Well you are describing a classic ritual."

"Jamen, du beskriver et klassisk ritual."

And they helped me understand

De hjalp mig med at forstå,

that rituals are all about transformation.

at ritualer handler om forvandling.

We marry, for example,

Vi gifter os, for eksempel,

with great pomp and ceremony and expense

med pomp og ceremoni og udgifter

to signal our departure

for at markere vores udtræden

from a life of solitude and misery and loneliness

af et liv i ensomhed og ulykkelighed

to one of eternal bliss.

til et af evig lyksalighed.

I'm not sure why you're laughing.

Jeg ved ikke, hvorfor I ler.

That was the original intent, was it not?

Det var det oprindelige formål, ikke sandt?

We signal transitions of power

Vi markerer overgivelse af magt

with rituals.

med ritualer.

We signal the passage of a life with rituals.

Vi markerer, at et liv er forbi, med ritualer.

Rituals are terribly important.

Ritualer er frygteligt vigtige.

They're all about transformation.

De handler alle om forvandlinger.

Well I would submit to you

Jeg vil sige jer,

that the ritual

at ritualet,

of one individual coming to another

hvor en person kommer til en anden

and telling them things

og fortæller dem ting,

that they would not tell their preacher or rabbi,

som de ikke ville fortælle deres præst eller rabbi,

and then, incredibly on top of that,

og så, utroligt nok derudover,

disrobing and allowing touch --

afklæder og tillader berøring --

I would submit to you that that is a ritual of exceeding importance.

jeg vil sige jer, at det er et ritual af stor vigtighed.

And if you shortchange that ritual

Og forkorter man det ritual

by not undressing the patient,

ved ikke at afklæde patienten,

by listening with your stethoscope on top of the nightgown,

ved at lytte med sit stetoskop uden på natkjolen,

by not doing a complete exam,

ved ikke at foretage en fuld undersøgelse,

you have bypassed on the opportunity

har man forspildt muligheden

to seal the patient-physician relationship.

til at forsegle patient-læge-forholdet.

I am a writer,

Jeg er forfatter,

and I want to close by reading you a short passage that I wrote

og jeg vil afslutte med at læse en kort tekst, jeg skrev,

that has to do very much with this scene.

som omhandler dette scenarie.

I'm an infectious disease physician,

Jeg er infektionsspeciallæge,

and in the early days of HIV, before we had our medications,

og i HIVens tidlige dage, før vi havde vores medikamenter,

I presided over so many scenes like this.

overværede jeg så mange lignende forløb.

I remember, every time I went to a patient's deathbed,

Jeg husker, hver gang jeg gik til en patients dødsleje

whether in the hospital or at home,

på hospitalet eller i hjemmet,

I remember my sense of failure --

husker jeg følelsen af fiasko --

the feeling of I don't know what I have to say;

følelsen af, jeg ved ikke, hvad jeg skal sige;

I don't know what I can say;

Jeg ved ikke, hvad jeg kan sige;

I don't know what I'm supposed to do.

jeg ved ikke, hvad jeg bør gøre.

And out of that sense of failure,

Ud af den følelse af fiasko,

I remember, I would always examine the patient.

husker jeg, jeg altid ville undersøge patienten.

I would pull down the eyelids.

Jeg ville trække øjenlågene ned.

I would look at the tongue.

Jeg ville se på tungen.

I would percuss the chest. I would listen to the heart.

Jeg ville banke på brystet, lytte til hjertet.

I would feel the abdomen.

Jeg ville føle maven.

I remember so many patients,

Jeg husker så mange patienter,

their names still vivid on my tongue,

deres navne stadig levende på min tunge,

their faces still so clear.

deres ansigter stadig tydelige.

I remember so many huge, hollowed out, haunted eyes

Jeg husker så mange enorme, udhulede, hjemsøgte øjne,

staring up at me as I performed this ritual.

der stirrede på mig, mens jeg udførte dette ritual.

And then the next day,

Den næste dag

I would come, and I would do it again.

ville jeg komme og gøre det igen.

And I wanted to read you this one closing passage

Jeg vil gerne læse denne afsluttende passage

about one patient.

om en patient.

"I recall one patient

"Jeg husker en patient,

who was at that point

som på det tidspunkt

no more than a skeleton

blot var et skelet

encased in shrinking skin,

omsluttet af skrumpende hud,

unable to speak,

ude af stand til at tale,

his mouth crusted with candida

hans mund skorpet af trøske,

that was resistant to the usual medications.

der var resistent over for normal medicin.

When he saw me

Da han så mig,

on what turned out to be his last hours on this earth,

i hvad der skulle blive hans sidste timer på denne jord,

his hands moved as if in slow motion.

bevægede hans hænder sig som i slowmotion.

And as I wondered what he was up to,

Og som jeg funderede over, hvad han ville,

his stick fingers made their way

nåede hans tændstikfingre

up to his pajama shirt,

op til hans pyjamasskjorte,

fumbling with his buttons.

fumlende med knapperne.

I realized that he was wanting

Jeg indså, at han ville

to expose his wicker-basket chest to me.

vise sit pilekurvsbryst til mig.

It was an offering, an invitation.

Det var et tilbud, en invitation.

I did not decline.

Jeg afslog ikke.

I percussed. I palpated. I listened to the chest.

Jeg bankede, palperede, lyttede til brystet.

I think he surely must have known by then

Jeg tænker, han vel må have vidst dengang,

that it was vital for me

at det var vigtigt for mig,

just as it was necessary for him.

som det var nødvendigt for ham.

Neither of us could skip this ritual,

Ingen af os kunne undvære dette ritual,

which had nothing to do with detecting rales in the lung,

som intet havde at gøre med at finde rallen i lungen

or finding the gallop rhythm of heart failure.

eller finde galloprytmen ved hjertesvigt.

No, this ritual was about the one message

Nej, dette ritual handlede om den ene besked,

that physicians have needed to convey to their patients.

som læger behøver at viderebringe til deres patienter.

Although, God knows, of late, in our hubris,

Selvom, ved Gud, på det seneste i vores hybris,

we seem to have drifted away.

lader vi til at være drevet væk.

We seem to have forgotten --

Vi lader til at have glemt --

as though, with the explosion of knowledge,

som med videnseksplosionen,

the whole human genome mapped out at our feet,

hele menneskegenomet kortlagt for vores fødder,

we are lulled into inattention,

bliver vi lullet ind i uopmærksomhed,

forgetting that the ritual is cathartic to the physician,

glemmer, at ritualet er rensende for lægen,

necessary for the patient --

nødvendig for patienten --

forgetting that the ritual has meaning

glemmer, at ritualet har betydning

and a singular message to convey to the patient.

og en enestående besked at bringe til patienten.

And the message, which I didn't fully understand then,

Og beskeden, som jeg ikke fuldt forstod dengang,

even as I delivered it,

selv mens jeg leverede den,

and which I understand better now is this:

og som jeg forstår bedre nu, er denne:

I will always, always, always be there.

Jeg vil altid, altid, altid være der.

I will see you through this.

Jeg vil hjælpe dig gennem dette.

I will never abandon you.

Jeg vil aldrig forlade dig.

I will be with you through the end."

Jeg er hos dig til det sidste."

Thank you very much.

Mange tak.

(Applause)

(Bifald)