Abraham Verghese: A doctor's touch

453,885 views ใƒป 2011-09-26

TED


ืื ื ืœื—ืฅ ืคืขืžื™ื™ื ืขืœ ื”ื›ืชื•ื‘ื™ื•ืช ื‘ืื ื’ืœื™ืช ืœืžื˜ื” ื›ื“ื™ ืœื”ืคืขื™ืœ ืืช ื”ืกืจื˜ื•ืŸ.

ืžืชืจื’ื: Yubal Masalker ืžื‘ืงืจ: Ido Dekkers
00:15
A few months ago,
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ืœืคื ื™ ืžืกืคืจ ื—ื•ื“ืฉื™ื,
00:17
a 40 year-old woman came to an emergency room
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ืื™ืฉื” ื‘ืช 40 ื”ื’ื™ืขื” ืœื—ื“ืจ ืžื™ื•ืŸ
00:20
in a hospital close to where I live,
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ื‘ื‘ื™ืช-ื—ื•ืœื™ื ื”ืงืจื•ื‘ ืœืžืงื•ื ืžื’ื•ืจื™ื™.
00:22
and she was brought in confused.
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ื”ื™ื ื”ื•ื‘ืื” ื‘ืžืฆื‘ ืฉืœ ืขื™ืจืคื•ืœ ื—ื•ืฉื™ื.
00:24
Her blood pressure was an alarming
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ืœื—ืฅ ื”ื“ื ืฉืœื” ื‘ื™ืฉืจ ืจืขื•ืช,
00:26
230 over 170.
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230 ืขืœ 170.
00:29
Within a few minutes, she went into cardiac collapse.
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ืชื•ืš ื›ืžื” ื“ืงื•ืช ืœื™ื‘ื” ื”ืคืกื™ืง ืœืคืขื•ื.
00:32
She was resuscitated, stabilized,
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ื”ื™ื ืงื™ื‘ืœื” ื”ื—ื™ื™ืื”, ืžืฆื‘ื” ื”ืชื™ื™ืฆื‘,
00:35
whisked over to a CAT scan suite
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ื”ื•ืขื‘ืจื” ื‘ื“ื—ื™ืคื•ืช ืœืžืชืงืŸ ืกืจื™ืงื” ืžืžื•ื—ืฉื‘
00:37
right next to the emergency room,
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ื‘ืฆืžื•ื“ ืœืžื™ื•ืŸ,
00:39
because they were concerned about blood clots in the lung.
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ื‘ื’ืœืœ ืฉื”ื™ื” ื—ืฉืฉ ืœื”ื™ื•ื•ืฆืจื•ืช ืงืจื™ืฉื™-ื“ื ื‘ืจื™ืื•ืชื™ื”.
00:42
And the CAT scan revealed
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ื”ืกืจื™ืงื” ื”ืขืœืชื”
00:44
no blood clots in the lung,
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ืฉืื™ืŸ ืงืจื™ืฉื™-ื“ื ื‘ืจื™ืื•ืช,
00:46
but it showed bilateral, visible, palpable breast masses,
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ืื‘ืœ ื”ืจืืชื” ื’ื•ืฉื™ื ื”ื™ื›ื•ืœื™ื ืœื”ืชื’ืœื•ืช ื‘ืžื™ืฉื•ืฉ ื•ื‘ืจืื™ื” ื‘ืฉื ื™ ืฉื“ื™ื”,
00:51
breast tumors,
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ื’ื™ื“ื•ืœื™ื ื‘ืฉื“ื™ื™ื,
00:53
that had metastasized widely
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ืฉืฉืœื—ื• ื’ืจื•ืจื•ืช ืจื‘ื•ืช
00:55
all over the body.
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ื‘ื›ืœ ื’ื•ืคื”.
00:57
And the real tragedy was, if you look through her records,
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ื•ื”ืขืฆื•ื‘ ืžื›ืœ ื”ื™ื”, ืฉืื ืขื•ื‘ืจื™ื ืขืœ ื”ื”ื™ืกื˜ื•ืจื™ื” ื”ืจืคื•ืื™ืช ืฉืœื”,
01:00
she had been seen
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ื”ื™ื ื ื‘ื“ืงื” ื‘ืืจื‘ืขื”
01:02
in four or five other health care institutions
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ืื• ื—ืžื™ืฉื” ืžื›ื•ื ื™ื ืจืคื•ืื™ื™ื
01:04
in the preceding two years.
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ื‘ืฉื ื™ื ืฉืงื“ืžื•.
01:06
Four or five opportunities
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ืืจื‘ืข ืื• ื—ืžืฉ ื”ื–ื“ืžื ื•ื™ื•ืช
01:08
to see the breast masses, touch the breast mass,
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ืœื”ื‘ื—ื™ืŸ ื‘ื’ื•ืฉื™ื ื‘ืฉื“ื™ื™ื, ืœื’ืขืช ื‘ื’ื™ื“ื•ืœื™ื,
01:10
intervene at a much earlier stage
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ืœื”ืชืขืจื‘ ื‘ืฉืœื‘ ื”ืจื‘ื” ื™ื•ืชืจ ืžื•ืงื“ื
01:13
than when we saw her.
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ืžืืฉืจ ื”ืžื•ืขื“ ื‘ื• ืื ื• ืจืื™ื ื• ืื•ืชื.
01:15
Ladies and gentlemen,
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ื’ื‘ื™ืจื•ืชื™ื™ ื•ืจื‘ื•ืชื™ื™,
01:17
that is not an unusual story.
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ื–ื” ืœื ืกื™ืคื•ืจ ื™ื•ืฆื-ื“ื•ืคืŸ.
01:19
Unfortunately, it happens all the time.
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ืœืฆืขืจื™, ื”ื•ื ืžืชืจื—ืฉ ื›ืœ ื”ื–ืžืŸ.
01:22
I joke, but I only half joke,
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ืื ื™ ืžืชื‘ื“ื—, ืื‘ืœ ื–ื• ืจืง ื—ืฆื™ ื‘ื“ื™ื—ื”,
01:24
that if you come to one of our hospitals missing a limb,
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ืฉืื ืชื‘ื•ืื• ืœื‘ื™ืช-ื—ื•ืœื™ื ืขื ืื™ื‘ืจ ื—ืกืจ,
01:27
no one will believe you till they get a CAT scan, MRI
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ืืฃ ืื—ื“ ืœื ื™ืืžื™ืŸ ืœื›ื ืขื“ ืฉืชืขื‘ืจื• ืกืจื™ืงื” ืžืžื•ื—ืฉื‘ืช, MRI
01:30
or orthopedic consult.
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ืื• ื‘ื“ื™ืงื” ืื•ืจืชื•ืคื“ื™ืช.
01:32
I am not a Luddite.
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ืื ื™ ืœื ื ื’ื“ ืงื™ื“ืžื”.
01:34
I teach at Stanford.
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ืื ื™ ืžืœืžื“ ื‘ืกื˜ื ืคื•ืจื“.
01:36
I'm a physician practicing with cutting-edge technology.
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ืื ื™ ืจื•ืคื ืฉืžืฉืชืžืฉ ื‘ื˜ื›ื ื•ืœื•ื’ื™ื” ืžืชืงื“ืžืช.
01:38
But I'd like to make the case to you
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ืื‘ืœ ื”ื™ื™ืชื™ ืจื•ืฆื” ืœื˜ืขื•ืŸ ื‘ืคื ื™ื›ื
01:40
in the next 17 minutes
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ื‘-17 ื”ื“ืงื•ืช ื”ื‘ืื•ืช
01:42
that when we shortcut the physical exam,
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ืฉื›ืืฉืจ ืื ื• ืขื•ืฉื™ื ืงื™ืฆื•ืจื™-ื“ืจืš ื‘ื‘ื“ื™ืงื” ื”ื’ื•ืคื ื™ืช,
01:46
when we lean towards ordering tests
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ื•ื ื•ื˜ื™ื ืืœ ืขื‘ืจ ื‘ื“ื™ืงื•ืช ืžื›ืฉื™ืจื™ื
01:48
instead of talking to and examining the patient,
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ื‘ืžืงื•ื ืœืฉื•ื—ื— ืขื ื”ื—ื•ืœื” ื•ืœื‘ื“ื•ืง ืื•ืชื•,
01:51
we not only overlook simple diagnoses
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ืœื ืจืง ืฉืื ื• ืคื•ืกื—ื™ื ืขืœ ืื‘ื—ื ื•ืช ืคืฉื•ื˜ื•ืช
01:54
that can be diagnosed at a treatable, early stage,
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ื”ื ื™ืชื ื•ืช ืœื’ื™ืœื•ื™ ื•ืœื˜ื™ืคื•ืœ ื‘ืฉืœื‘ ื”ืžื•ืงื“ื,
01:57
but we're losing much more than that.
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ืืœื ืื ื• ืืฃ ืžืื‘ื“ื™ื ื”ืจื‘ื” ื™ื•ืชืจ ืžื–ื”.
01:59
We're losing a ritual.
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ืื ื• ืžืื‘ื“ื™ื ื”ืœื™ืš ื˜ืงืกื™.
02:01
We're losing a ritual that I believe is transformative, transcendent,
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ืื ื• ืžืื‘ื“ื™ื ื”ืœื™ืš ืฉืื ื™ ืžืืžื™ืŸ ืฉื”ื•ื ืžืชืคืชื—, ื ืขืœื”
02:04
and is at the heart
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ื•ื”ื ืžืฆื ื‘ืœื‘ ื”ื™ื—ืกื™ื
02:06
of the patient-physician relationship.
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ื‘ื™ืŸ ื”ืžื˜ื•ืคืœ ื•ื”ืจื•ืคื.
02:08
This may actually be heresy to say this at TED,
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ื–ื• ืขืฉื•ื™ื” ืœื”ื™ื•ืช ื›ืคื™ืจื” ืœื•ืžืจ ื–ืืช ื‘-TED,
02:11
but I'd like to introduce you
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ืื‘ืœ ื”ื™ื™ืชื™ ืจื•ืฆื” ืœื—ืฉื•ืฃ ื‘ืคื ื™ื›ื
02:13
to the most important innovation,
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ืืช ื”ื”ืžืฆืื” ื”ื—ืฉื•ื‘ื” ื‘ื™ื•ืชืจ,
02:15
I think, in medicine
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ืœื“ืขืชื™, ืฉืชื”ื™ื” ื‘ืจืคื•ืื”
02:17
to come in the next 10 years,
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ื‘-10 ื”ืฉื ื™ื ื”ื‘ืื•ืช,
02:19
and that is the power of the human hand --
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ื•ื–ื• ื”ื™ื›ื•ืœืช ืฉืœ ื™ื“ ืื“ื --
02:21
to touch, to comfort, to diagnose
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ืœื’ืขืช, ืœื ื—ื, ืœืื‘ื—ืŸ
02:24
and to bring about treatment.
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ื•ืœื™ืฆื•ืจ ื˜ื™ืคื•ืœ.
02:26
I'd like to introduce you first to this person
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ืชื—ื™ืœื” ื‘ืจืฆื•ื ื™ ืœื”ืฆื™ื’ ื‘ืคื ื™ื›ื ืื“ื ื–ื”
02:29
whose image you may or may not recognize.
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ืฉืืช ื“ืžื•ืชื• ืืชื ืขืฉื•ื™ื™ื, ืื• ืฉืœื, ืœื–ื”ื•ืช.
02:31
This is Sir Arthur Conan Doyle.
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ื–ื”ื• ืกืจ ืืจืชื•ืจ ืงื•ื ืŸ ื“ื•ื™ืœ.
02:33
Since we're in Edinburgh, I'm a big fan of Conan Doyle.
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ืžืื—ืจ ื•ืื ื• ื ืžืฆืื™ื ื‘ืื“ื™ื ื‘ื•ืจื•, ืื ื™ ื—ืกื™ื“ ื’ื“ื•ืœ ืฉืœื•.
02:36
You might not know that Conan Doyle went to medical school
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ืื•ืœื™ ืื™ื ื›ื ื™ื•ื“ืขื™ื ืฉืงื•ื ืŸ ื“ื•ื™ืœ ืœืžื“ ื‘ื‘ื™ืช-ืกืคืจ ืœืจืคื•ืื”
02:38
here in Edinburgh,
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ื›ืืŸ ื‘ืื“ื™ื ื‘ื•ืจื•,
02:40
and his character, Sherlock Holmes,
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ื•ืืช ื”ื”ืฉืจืื” ืœื“ืžื•ืชื• ืฉืœ
02:42
was inspired by Sir Joseph Bell.
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ืฉืจืœื•ืง ื”ื•ืœืžืก ื”ื•ื ืงื™ื‘ืœ ืžืกืจ ื’'ื•ื–ืฃ ื‘ืœ.
02:45
Joseph Bell was an extraordinary teacher by all accounts.
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ื’'ื•ื–ืฃ ื‘ืœ ื”ื™ื” ืžื•ืจื” ื™ื•ืฆื ื“ื•ืคืŸ ืžื›ืœ ื”ื‘ื—ื™ื ื•ืช.
02:48
And Conan Doyle, writing about Bell,
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ื•ืงื•ื ืŸ ื“ื•ื™ืœ, ื‘ื›ื•ืชื‘ื• ืื•ื“ื•ืช ื‘ืœ,
02:51
described the following exchange
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ืชื™ืืจ ืืช ื”ืฉื™ื—ื” ื”ื‘ืื”
02:53
between Bell and his students.
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ื‘ื™ืŸ ื‘ืœ ื•ื”ืชืœืžื™ื“ื™ื ืฉืœื•.
02:55
So picture Bell sitting in the outpatient department,
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ื“ืžื™ื™ื ื• ืืช ื‘ืœ ื™ื•ืฉื‘ ื‘ืžื—ืœืงืช ืžื™ื•ืŸ,
02:58
students all around him,
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ืชืœืžื™ื“ื™ื• ืกื‘ื™ื‘ื•,
03:00
patients signing up in the emergency room
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ื”ื—ื•ืœื™ื ื ื›ื ืกื™ื ืœืžื™ื•ืŸ,
03:02
and being registered and being brought in.
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ื ืจืฉืžื™ื ื•ื‘ืื™ื ืœืคื ื™ื•.
03:05
And a woman comes in with a child,
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ืื™ืฉื” ืื—ืช ื ื›ื ืกืช ืขื ื™ืœื“,
03:07
and Conan Doyle describes the following exchange.
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ื•ืงื•ื ืŸ ื“ื•ื™ืœ ืžืชืืจ ืืช ื”ืฉื™ื—ื” ื”ื‘ืื” ื‘ื™ื ื™ื”ื.
03:10
The woman says, "Good Morning."
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ื”ืื™ืฉื” ืื•ืžืจืช, "ื‘ื•ืงืจ ื˜ื•ื‘."
03:14
Bell says, "What sort of crossing did you have
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ื‘ืœ ืฉื•ืืœ, "ืื™ืš ื”ื™ื” ื”ืฉื™ื•ื˜
03:17
on the ferry from Burntisland?"
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ื‘ืžืขื‘ื•ืจืช ืžื‘ืจื ื˜ืื™ืœื ื“?"
03:20
She says, "It was good."
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ื”ื™ื ืขื•ื ื”, "ื”ื™ื” ื˜ื•ื‘."
03:22
And he says, "What did you do with the other child?"
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ื”ื•ื ืฉื•ืืœ, " ืžื” ืขืฉื™ืช ืขื ื™ืœื“ืš ื”ืฉื ื™?"
03:25
She says, "I left him with my sister at Leith."
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ื”ื™ื ืขื•ื ื”, "ื”ืฉืืจืชื™ ืื•ืชื• ืืฆืœ ืื—ื•ืชื™ ื‘-ืœื™ื™ืช'."
03:28
And he says,
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ื”ื•ื ืฉื•ืืœ,
03:30
"And did you take the shortcut down Inverleith Row
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"ื”ืื ืขืฉื™ืช ืงื™ืฆื•ืจ-ื“ืจืš ื“ืจืš ืื™ื ื•ื•ืจืœื™ื™ืช' ืจื•
03:32
to get here to the infirmary?"
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ื›ื“ื™ ืœื”ื’ื™ืข ืœื›ืืŸ?"
03:34
She says, "I did."
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ื”ื™ื ืขื•ื ื” ืฉื›ืŸ.
03:36
And he says, "Would you still be working at the linoleum factory?"
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ื”ื•ื ืฉื•ืืœ, "ื”ืื ืืช ืขื“ื™ื™ืŸ ืขื•ื‘ื“ืช ื‘ืžืคืขืœ ื”ืœื™ื ื•ืœื™ื•ื (ื—ื•ืžืจ ื”ืžื›ื™ืœ ืฉืขื)?"
03:40
And she says, "I am."
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ื”ื™ื ืขื•ื ื” ืฉื›ืŸ.
03:42
And Bell then goes on to explain to the students.
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ื•ืื– ื‘ืœ ืžืกื‘ื™ืจ ืœืชืœืžื™ื“ื™ื•:
03:44
He says, "You see, when she said, 'Good morning,'
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"ืืชื ืจื•ืื™ื, ื›ืืฉืจ ื”ื™ื ืืžืจื”, 'ื‘ื•ืงืจ ื˜ื•ื‘',
03:47
I picked up her Fife accent.
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ืงืœื˜ืชื™ ืืช ืžื‘ื˜ื ื”ืคื™ื™ืค ืฉืœื”.
03:49
And the nearest ferry crossing from Fife is from Burntisland.
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ื•ื”ืžืขื‘ื•ืจืช ื”ืงืจื•ื‘ื” ื‘ื™ื•ืชืจ ืž-ืคื™ื™ืค ื”ื™ื ื‘-ื‘ืจื ื˜ืื™ืœื ื“.
03:52
And so she must have taken the ferry over.
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ื•ืœื›ืŸ ื”ื™ื ื”ื™ืชื” ื—ื™ื™ื‘ืช ืœื ืกื•ืข ื‘ืžืขื‘ื•ืจืช ื–ื•.
03:55
You notice that the coat she's carrying
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ืฉืžืชื ืœื‘, ื”ืžืขื™ืœ ืฉื”ื™ื ื ื•ืฉืืช
03:57
is too small for the child who is with her,
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ืงื˜ืŸ ืžื“ื™ ืœื™ืœื“ ืฉืื™ืชื”,
04:00
and therefore, she started out the journey with two children,
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ื•ื–ื” ืื•ืžืจ ื”ื™ื ื”ื—ืœื” ืืช ื ืกื™ืขืชื” ืขื ืฉื ื™ ื™ืœื“ื™ื,
04:03
but dropped one off along the way.
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ืื‘ืœ ื”ืฉืื™ืจื” ืื—ื“ ืื™ืคื” ืฉื”ื•ื ื‘ื“ืจืš.
04:06
You notice the clay on the soles of her feet.
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ืฉืžืชื ืœื‘ ืœืื“ืžื” ื‘ื›ืคื•ืช ืจื’ืœื™ื”.
04:08
Such red clay is not found within a hundred miles of Edinburgh,
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ืื“ืžื” ืื“ื•ืžื” ื›ื–ื• ืื™ื ื” ื ืžืฆืืช ื‘ืจื“ื™ื•ืก ืฉืœ ื›-150 ืง"ืž ืžืื“ื™ื ื‘ื•ืจื•,
04:12
except in the botanical gardens.
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ืžืœื‘ื“ ื‘ื’ื ื™ื ื”ื‘ื•ื˜ื ื™ื™ื.
04:14
And therefore, she took a short cut down Inverleith Row
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ื•ืœื›ืŸ ื”ื™ื ืขืฉืชื” ืงื™ืฆื•ืจ-ื“ืจืš ื“ืจืš ืื™ื ื•ื•ืจืœื™ื™ืช' ืจื•
04:17
to arrive here.
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ื›ื“ื™ ืœื”ื’ื™ืข ืœื›ืืŸ.
04:19
And finally, she has a dermatitis
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ื•ืœื‘ืกื•ืฃ, ื™ืฉ ืœื” ื“ืœืงืช ืขื•ืจ
04:21
on the fingers of her right hand,
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ืขืœ ืืฆื‘ืขื•ืช ื™ื“ ื™ืžื™ื ื”,
04:23
a dermatitis that is unique
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ื“ืœืงืช ื”ื™ื™ื—ื•ื“ื™ืช
04:25
to the linoleum factory workers in Burntisland."
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ืœืขื•ื‘ื“ื™ื ื‘ืžืคืขืœ ื”ืœื™ื ืœื™ื•ื ื‘-ื‘ืจื ื˜ืื™ืœื ื“."
04:28
And when Bell actually strips the patient,
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ื›ืืฉืจ ื‘ืœ ืžืคืฉื™ื˜ ืืช ื”ืžื˜ื•ืคืœ,
04:30
begins to examine the patient,
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ืžืชื—ื™ืœ ืœื‘ื—ื•ืŸ ืื•ืชื•,
04:32
you can only imagine how much more he would discern.
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ื ื™ืชืŸ ืจืง ืœื“ืžื™ื™ืŸ ืขื“ ื›ืžื” ื”ืจื‘ื” ื™ื•ืชืจ ื”ื•ื ืžืื‘ื—ืŸ.
04:35
And as a teacher of medicine, as a student myself,
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ื•ื‘ืชื•ืจ ืžืจืฆื” ืœืจืคื•ืื”, ื‘ืชื•ืจ ืชืœืžื™ื“ ื‘ืขืฆืžื™,
04:38
I was so inspired by that story.
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ืžืื•ื“ ื”ืชืœื”ื‘ืชื™ ืžื”ืกื™ืคื•ืจ.
04:40
But you might not realize
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ืื‘ืœ ืื•ืœื™ ืœื ื”ื‘ื—ื ืชื
04:42
that our ability to look into the body
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ืฉื™ื›ื•ืœืชื ื• ืœื”ืกืชื›ืœ ืขืœ ื”ื’ื•ืฃ
04:44
in this simple way, using our senses,
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ื‘ืื•ืคืŸ ืคืฉื•ื˜ ื›ืœ-ื›ืš, ื‘ืขื–ืจืช ื—ื•ืฉื™ื ื•,
04:46
is quite recent.
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ื”ื™ื ื“ื™ ืžืื•ื—ืจืช.
04:48
The picture I'm showing you is of Leopold Auenbrugger
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ื”ืชืžื•ื ื” ืฉืžื•ืคื™ืขื” ื›ืืŸ ื”ื™ื ืฉืœ ืœื™ืื•ืคื•ืœื“ ืื™ื•ืื ื‘ืจื•ื’ืจ
04:51
who, in the late 1700s,
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ืฉืœืงืจืืช ืกื•ืฃ ื”ืžืื” ื”-18,
04:53
discovered percussion.
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ื’ื™ืœื” ืืช ืฉื™ื˜ืช ื”ื ืงื™ืฉื”.
04:55
And the story is that Leopold Auenbrugger
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ื”ืกื™ืคื•ืจ ื”ื•ื ืฉืœื™ืื•ืคื•ืœื“ ืื™ื•ืื ื‘ืจื•ื’ืจ
04:58
was the son of an innkeeper.
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ื”ื™ื” ื”ื‘ืŸ ืฉืœ ื‘ืขืœ ืคื•ื ื“ืง.
05:01
And his father used to go down into the basement
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ืื‘ื™ื• ื ื”ื’ ืœืจื“ืช ืœืžืจืชืฃ
05:04
to tap on the sides of casks of wine
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ื•ืœื”ืงื™ืฉ ืขืœ ืฆื™ื“ื™ ื—ื‘ื™ื•ืช ื™ื™ืŸ
05:06
to determine how much wine was left
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ื›ื“ื™ ืœื“ืขืช ื›ืžื” ื™ื™ืŸ ื ืฉืืจ
05:08
and whether to reorder.
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ื•ืื ืฆืจื™ืš ืœื”ื–ืžื™ืŸ ืขื•ื“.
05:10
And so when Auenbrugger became a physician,
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ื•ื›ืš ื›ืืฉืจ ืื™ื•ืื ื‘ืจื•ื’ืจ ื”ืคืš ืœืจื•ืคื,
05:12
he began to do the same thing.
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ื”ื•ื ื”ื—ืœ ืœืขืฉื•ืช ืื•ืชื• ื”ื“ื‘ืจ.
05:14
He began to tap on the chests of his patients,
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ื”ื•ื ื”ื—ืœ ืœื”ืงื™ืฉ ืขืœ ื—ื–ื™ื”ื ืฉืœ ื—ื•ืœื™ื•,
05:17
on their abdomens.
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ืขืœ ื‘ื˜ื ื™ื”ื.
05:19
And basically everything we know about percussion,
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ื•ื‘ืขื™ืงืจื•ืŸ, ื›ืœ ืžื” ืฉืื ื• ื™ื•ื“ืขื™ื ืขืœ ื”ืงืฉื”,
05:21
which you can think of as an ultrasound of its day --
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ืฉื ื™ืชืŸ ืœื—ืฉื•ื‘ ืขืœื™ื” ื‘ืชื•ืจ ืื•ืœื˜ืจืืกืื•ื ื“ ืฉืœ ืื– --
05:25
organ enlargement, fluid around the heart, fluid in the lungs,
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ื”ืชื ืคื—ื•ืช ืื™ื‘ืจ, ื ื•ื–ืœ ืกื‘ื™ื‘ ื”ืœื‘, ื ื•ื–ืœ ื‘ืจื™ืื•ืช,
05:28
abdominal changes --
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ืฉื™ื ื•ื™ื™ื ื‘ืงื™ื‘ื” --
05:30
all of this he described in this wonderful manuscript
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ื›ืœ ื–ื” ืžืชื•ืืจ ื‘ื›ืชื‘-ื™ื“ ืžืงืกื™ื ื–ื”
05:32
"Inventum Novum," "New Invention,"
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"Inventum Novum," "ื”ืžืฆืื” ื—ื“ืฉื”",
05:35
which would have disappeared into obscurity,
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ืฉื”ื™ื” ื ืขืœื ื‘ืชื”ื•ืžื•ืช ื”ื ืฉื™ื”,
05:37
except for the fact that this physician, Corvisart,
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ืœื•ืœื ื”ืขื•ื‘ื“ื” ืฉืจื•ืคื ื–ื”, ื›ื•ืจื•ื•ื™ืกืืจื˜,
05:40
a famous French physician --
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ืจื•ืคื ืฆืจืคืชื™ ืžืคื•ืจืกื --
05:42
famous only because he was physician to this gentleman --
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ืžืคื•ืจืกื ืจืง ื‘ื’ืœืœ ืฉื”ื•ื ื”ื™ื” ืจื•ืคื ืฉืœ ืื“ื•ืŸ ื–ื” --
05:45
Corvisart repopularized and reintroduced the work.
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ื›ื•ืจื•ื•ื™ืกืืจื˜ ืคื™ืฉื˜ ื•ื”ืฆื™ื’ ืžื—ื“ืฉ ืืช ื”ืžื—ืงืจ.
05:49
And it was followed a year or two later
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ื•ืฉื ื” ืื• ืฉื ืชื™ื™ื ืื—ืจ-ื›ืš,
05:51
by Laennec discovering the stethoscope.
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ืœืื™ื ืง ืฉื”ืžืฆื™ื ืืช ื”ืกื˜ื˜ื•ืกืงื•ืค ื”ืžืฉื™ืš ืื•ืชื•.
05:54
Laennec, it is said, was walking in the streets of Paris
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ืžืกืคืจื™ื ืฉืœืื™ื ืง ื”ื™ื” ืžืชื”ืœืš ื‘ืจื—ื•ื‘ื•ืช ืคืจื™ื–
05:57
and saw two children playing with a stick.
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ื•ื”ื•ื ืจืื” ืฉื ื™ ื™ืœื“ื™ื ืžืฉื—ืงื™ื ื‘ืžืงืœ.
05:59
One was scratching at the end of the stick,
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ืื—ื“ ื’ื™ืจื“ ืืช ืงืฆื” ื”ืžืงืœ
06:02
another child listened at the other end.
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ื•ื”ืื—ืจ ื”ืื–ื™ืŸ ื‘ืงืฆื” ื”ืฉื ื™.
06:04
And Laennec thought this would be a wonderful way
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ืœืื™ื ืง ื—ืฉื‘ ืฉื–ื• ื“ืจืš ื ืคืœืื”
06:06
to listen to the chest or listen to the abdomen
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ืœื”ืื–ื™ืŸ ืœื—ื–ื” ืื• ืœืงื™ื‘ื”
06:08
using what he called "the cylinder."
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ื‘ืขื–ืจืช ืžื” ืฉื”ื•ื ื›ื™ื ื” "ื”ืฆื™ืœื™ื ื“ืจ".
06:10
Later he renamed it the stethoscope.
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ื™ื•ืชืจ ืžืื•ื—ืจ ื”ื•ื ืฉื™ื ื” ืืช ื”ืฉื ืœืกื˜ื˜ื•ืกืงื•ืค.
06:12
And that is how stethoscope and auscultation was born.
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ื‘ื“ืจืš ื–ื• ื ื•ืœื“ื• ื”ืกื˜ื˜ื•ืกืงื•ืค ื•ื”ื”ืื–ื ื” ื‘ืืžืฆืขื•ืชื•.
06:16
So within a few years,
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ื›ืš ืฉื‘ืชื•ืš ืฉื ื™ื ืžืขื˜ื•ืช,
06:18
in the late 1800s, early 1900s,
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ื‘ืฉืœื”ื™ ื”ืžืื” ื”-19
06:20
all of a sudden,
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ื•ืชื—ื™ืœืช ื”ืžืื” ื”-20, ืคืชืื•ื,
06:22
the barber surgeon had given way
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ื”ืžื ืชื— ื”ืžื’ืœื— ืคื™ื ื” ืืช ืžืงื•ืžื•
06:25
to the physician who was trying to make a diagnosis.
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ืœืจื•ืคื ื”ืžื ืกื” ืœืื‘ื—ืŸ.
06:28
If you'll recall, prior to that time,
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ืื ืืชื ื–ื•ื›ืจื™ื, ืœืคื ื™ ื–ื”,
06:30
no matter what ailed you, you went to see the barber surgeon
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ืœื ืžืฉื ื” ืžื” ื›ืื‘ ืœื›ื, ื”ืœื›ืชื ืœื‘ืงืจ ืืช ื”ืžื ืชื— ื”ืžื’ืœื—
06:33
who wound up cupping you,
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ืฉื”ื™ื” ืžื›ืกื” ืืชื›ื ื‘ื›ื•ืกื•ืช ืจื•ื—,
06:35
bleeding you, purging you.
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ืžืงื™ื– ืืช ื“ืžื›ื, ืžื˜ื”ืจ ืืชื›ื.
06:37
And, oh yes, if you wanted,
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ืื” ื›ืŸ, ืื ืจืฆื™ืชื,
06:39
he would give you a haircut -- short on the sides, long in the back --
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ื’ื ื”ื™ื” ืžืกืคืจ ืืชื›ื -- ืงืฆืจ ื‘ืฆื“ื“ื™ื, ืืจื•ืš ืžืื—ื•ืจ --
06:42
and pull your tooth while he was at it.
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ื•ืื ื›ื‘ืจ, ื’ื ืขื•ืงืจ ืœื›ื ืฉืŸ.
06:44
He made no attempt at diagnosis.
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ื”ื•ื ืœื ื”ืชืืžืฅ ืœืื‘ื—ืŸ.
06:46
In fact, some of you might well know
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ืœืžืขืฉื”, ื—ืœืงื™ื›ื ืื•ืœื™ ืžื›ื™ืจื™ื ื”ื™ื˜ื‘
06:48
that the barber pole, the red and white stripes,
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ืฉื”ืชื•ืจืŸ ืฉืœ ืื•ืชื• ืžื ืชื—, ื”ืจืฆื•ืขื•ืช ื”ืื“ื•ืžื•ืช ื•ื”ืœื‘ื ื•ืช,
06:51
represents the blood bandages of the barber surgeon,
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ืžื™ื™ืฆื’ื•ืช ืืช ื”ืชื—ื‘ื•ืฉื•ืช ืกืคื•ื’ื•ืช ื”ื“ื ืืฆืœ ืื•ืชื• ืžื ืชื—-ืžื’ืœื—,
06:54
and the receptacles on either end
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ื•ื”ืงืขืจื™ื•ืช ื‘ืฉื ื™ ืงืฆื•ื•ืชื™ื•
06:56
represent the pots in which the blood was collected.
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ืžื™ื™ืฆื’ื•ืช ืืช ื›ืœื™-ื”ืงื™ื‘ื•ืœ ืฉื‘ื”ื ื ืืกืฃ ื”ื“ื.
06:59
But the arrival of auscultation and percussion
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ืื‘ืœ ื›ื ื™ืกืช ื”ืกื˜ื˜ื•ืกืงื•ืค ื•ื”ื ืงื™ืฉื•ืช
07:02
represented a sea change,
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ืžื™ื™ืฆื’ืช ืฉื™ื ื•ื™ ืžื”ื•ืชื™,
07:04
a moment when physicians were beginning to look inside the body.
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ื ืงื•ื“ืช ื–ืžืŸ ื‘ื” ื”ืจื•ืคืื™ื ื”ื—ืœื• ืœื”ื‘ื™ื˜ ืืœ ืชื•ืš ื”ื’ื•ืฃ.
07:07
And this particular painting, I think,
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ื•ืฆื™ื•ืจ ืžืกื•ื™ื™ื ื–ื”, ืœื“ืขืชื™, ืžื™ื™ืฆื’ ืืช ื”ืฉื™ื,
07:10
represents the pinnacle, the peak, of that clinical era.
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ืืช ื”ืคื™ืกื’ื”, ืฉืœ ืื•ืชื” ืชืงื•ืคื” ื‘ืจืคื•ืื”.
07:13
This is a very famous painting:
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ื–ื”ื• ืฆื™ื•ืจ ืžืื•ื“ ืžืคื•ืจืกื:
07:15
"The Doctor" by Luke Fildes.
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"ื”ืจื•ืคื" ืžืืช ืœื•ืง ืคื™ืœื“ืก.
07:18
Luke Fildes was commissioned to paint this by Tate,
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ืœื•ืง ืคื™ืœื“ืก ืžื•ื ื” ืœืฆื™ื™ืจ ืื•ืชื• ืขืœ-ื™ื“ื™ ื˜ื™ื™ื˜,
07:21
who then established the Tate Gallery.
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ืืฉืจ ื™ื™ืกื“ ืื– ืืช ื’ืœืจื™ื™ืช ื˜ื™ื™ื˜.
07:23
And Tate asked Fildes to paint a painting
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ื˜ื™ื™ื˜ ื‘ื™ืงืฉ ืžืคื™ืœื“ืก ืœืฆื™ื™ืจ ืฆื™ื•ืจ
07:25
of social importance.
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ืฉื™ืฉ ืœื• ื—ืฉื™ื‘ื•ืช ื—ื‘ืจืชื™ืช.
07:27
And it's interesting that Fildes picked this topic.
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ื•ื–ื” ืžืขื ื™ื™ืŸ ืฉืคื™ืœื“ืก ื‘ื—ืจ ื ื•ืฉื ื–ื”.
07:30
Fildes' oldest son, Philip,
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ื‘ื ื• ื”ื‘ื›ื•ืจ ืฉืœ ืคื™ืœื“ืก, ืคื™ืœื™ืค,
07:33
died at the age of nine on Christmas Eve
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ืžืช ื‘ื’ื™ืœ 9, ื‘ืขืจื‘ ื—ื’-ืžื•ืœื“
07:36
after a brief illness.
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ืœืื—ืจ ืžื—ืœื” ืงืฆืจื”.
07:38
And Fildes was so taken by the physician
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ืคื™ืœื“ืก ื›ื” ื”ืชืจืฉื ืžื”ืจื•ืคื
07:41
who held vigil at the bedside for two, three nights,
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ืฉื ืฉืืจ ืขืจ ืœืฆื™ื“ื• ื‘ืžืฉืš 2, 3 ืœื™ืœื•ืช,
07:45
that he decided that he would try and depict
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ืฉื”ื•ื ื”ื—ืœื™ื˜ ืœื ืกื•ืช ืœืชืืจ
07:47
the physician in our time --
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ืืช ื”ืจื•ืคื ื‘ืŸ-ื–ืžื ื• --
07:49
almost a tribute to this physician.
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ืžืขื™ืŸ ืžื—ื•ื•ื” ืœืจื•ืคื ื–ื”.
07:51
And hence the painting "The Doctor," a very famous painting.
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ืœื›ืŸ ื”ืฆื™ื•ืจ ื”ื–ื”, "ื”ืจื•ืคื", ื”ื•ื ืฆื™ื•ืจ ื›ื” ืžืคื•ืจืกื.
07:54
It's been on calendars, postage stamps in many different countries.
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ื”ื•ื ืžื•ืคื™ืข ื‘ืœื•ื—ื•ืช-ืฉื ื”, ื‘ื•ืœื™ ื“ื•ืืจ ื‘ืžื“ื™ื ื•ืช ืฉื•ื ื•ืช ื•ื›ื•'.
07:57
I've often wondered, what would Fildes have done
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ืœืขื™ืชื™ื ืชื”ื™ืชื™, ืžื” ืคื™ืœื“ืก ื”ื™ื” ืขื•ืฉื”
08:00
had he been asked to paint this painting
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ืื ื”ื™ื” ืžืชื‘ืงืฉ ืœืฆื™ื™ืจ ืฆื™ื•ืจ ื–ื”
08:02
in the modern era,
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ื‘ืชืงื•ืคื” ื”ืžื•ื“ืจื ื™ืช ืฉืœื ื•,
08:04
in the year 2011?
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ื‘ืฉื ืช 2011?
08:07
Would he have substituted a computer screen
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ื”ืื ื”ื•ื ื”ื™ื” ืฉื ืžืกืš ืžื—ืฉื‘ ื‘ืžืงื•ืžื•
08:11
for where he had the patient?
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ืฉืœ ื”ื—ื•ืœื”?
08:13
I've gotten into some trouble in Silicon Valley
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ื”ื™ื• ืœื™ ืฆืจื•ืช ื‘ืขืžืง ื”ืกื™ืœื™ืงื•ืŸ
08:15
for saying that the patient in the bed
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ื›ืืฉืจ ืืžืจืชื™ ืฉื”ื—ื•ืœื” ื‘ืžื™ื˜ื”
08:17
has almost become an icon
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ื”ืคืš ื›ืžืขื˜ ืœืฆืœื
08:20
for the real patient who's in the computer.
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ืฉืœ ื”ื—ื•ืœื” ื”ืืžื™ืชื™ ืฉืฉื•ื›ืŸ ื‘ืžื—ืฉื‘.
08:23
I've actually coined a term for that entity in the computer.
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ื‘ืขืฆื ื˜ื‘ืขืชื™ ืžื•ื ื— ืœืื•ืชื” ื™ืฉื•ืช ื‘ืžื—ืฉื‘.
08:26
I call it the iPatient.
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ืื ื™ ืžื›ื ื” ืื•ืชื• ื—ื•ืœื” ื”-iP.
08:28
The iPatient is getting wonderful care all across America.
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ื—ื•ืœื” ื”-iP ื–ื•ื›ื” ืœื˜ื™ืคื•ืœ ื ื”ื“ืจ ื‘ื›ืœ ืืจื”"ื‘.
08:31
The real patient often wonders,
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ื”ื—ื•ืœื” ื”ืืžื™ืชื™ ืชื•ื”ื” ืœืขื™ืชื™ื,
08:33
where is everyone?
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ืื™ืคื” ื›ื•ืœื?
08:35
When are they going to come by and explain things to me?
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ืžืชื™ ื”ื ื™ื—ื–ืจื• ืืœื™ื™ ื›ื“ื™ ืœื”ืกื‘ื™ืจ ืœื™ ืžืฉื”ื•?
08:38
Who's in charge?
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ืžื™ ืื—ืจืื™?
08:40
There's a real disjunction between the patient's perception
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ืื™ืŸ ืงืฉืจ ื‘ื™ืŸ ืื™ืš ืฉื”ื—ื•ืœื” ืชื•ืคืก ืœื‘ื™ืŸ ืื™ืš ืฉืื ื—ื ื•
08:43
and our own perceptions as physicians of the best medical care.
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ืชื•ืคืกื™ื ื‘ืชื•ืจ ืจื•ืคืื™ื ืžื”ื• ื”ื˜ื™ืคื•ืœ ื”ื˜ื•ื‘ ื‘ื™ื•ืชืจ.
08:46
I want to show you a picture
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ืืจืื” ืœื›ื ืชืžื•ื ื”
08:48
of what rounds looked like
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ืฉืœ ืื™ืš ื ืจืื• ื‘ื™ืงื•ืจื™-ืจื•ืคื
08:50
when I was in training.
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ื›ืืฉืจ ืื ื™ ืœืžื“ืชื™.
08:52
The focus was around the patient.
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ื”ื”ืชืžืงื“ื•ืช ื”ื™ืชื” ื‘ื—ื•ืœื”.
08:54
We went from bed to bed. The attending physician was in charge.
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ื”ืœื›ื ื• ืžืžื™ื˜ื” ืœืžื™ื˜ื”. ื”ืจื•ืคื ื”ืชื•ืจืŸ ื”ื™ื” ื”ืื—ืจืื™.
08:57
Too often these days,
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ื‘ื™ื•ืชืจ ืžื“ื™ ืžืงืจื™ื ื‘ื™ืžื™ื ื•,
08:59
rounds look very much like this,
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ื‘ื™ืงื•ืจื™-ืจื•ืคื ื ืจืื™ื ื›ืš,
09:01
where the discussion is taking place
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ื›ืืฉืจ ื”ื“ื™ื•ืŸ ืžืชืจื—ืฉ
09:03
in a room far away from the patient.
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ื‘ื—ื“ืจ ื”ืจื—ื•ืง ืžื”ื—ื•ืœื”.
09:06
The discussion is all about images on the computer, data.
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ื›ืœ ื”ื“ื™ื•ืŸ ื”ื•ื ืื•ื“ื•ืช ืชืžื•ื ื•ืช ื‘ืžื—ืฉื‘ ื•ื ืชื•ื ื™ื.
09:09
And the one critical piece missing
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ืื‘ืœ ื”ื—ืœืง ื”ืงืจื™ื˜ื™ ืฉื—ืกืจ
09:11
is that of the patient.
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ื”ื•ื ื”ื—ื•ืœื”.
09:13
Now I've been influenced in this thinking
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ื‘ื—ืฉื™ื‘ื” ืฉืœื™ ื–ื• ื”ื•ืฉืคืขืชื™
09:16
by two anecdotes that I want to share with you.
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ืžืฉืชื™ ืื ืงื“ื•ื˜ื•ืช ืฉื‘ืจืฆื•ื ื™ ืœื—ืœื•ืง ืื™ืชื›ื.
09:19
One had to do with a friend of mine who had a breast cancer,
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ืื—ืช ื ื•ื’ืขืช ืœื™ื“ื™ื“ื” ืฉืœื™ ืฉื”ื™ื” ืœื” ืกืจื˜ืŸ ืฉื“,
09:22
had a small breast cancer detected --
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ืกืจื˜ืŸ ืงืœ ืฉืื•ืชืจ --
09:25
had her lumpectomy in the town in which I lived.
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ืฉืขื‘ืจื” ื ื™ืชื•ื— ืœื”ืกืจืช ื’ื™ื“ื•ืœ ื‘ืขื™ืจ ืžื’ื•ืจื™ื™.
09:27
This is when I was in Texas.
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ื–ื” ืงืจื” ื›ืืฉืจ ื—ื™ื™ืชื™ ื‘ื˜ืงืกืก.
09:29
And she then spent a lot of time researching
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ื”ื™ื ื—ื™ืคืฉื” ืื– ื”ืจื‘ื” ื–ืžืŸ ืืช ื”ืžืจื›ื–
09:32
to find the best cancer center in the world
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ื”ื˜ื•ื‘ ื‘ื™ื•ืชืจ ื‘ืขื•ืœื ืœื˜ื™ืคื•ืœ ื‘ืกืจื˜ืŸ
09:35
to get her subsequent care.
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ื›ื“ื™ ืœืงื‘ืœ ืฉื ืืช ื”ื˜ื™ืคื•ืœ.
09:37
And she found the place and decided to go there, went there.
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ื”ื™ื ืžืฆืื” ืื—ื“ ื›ื–ื” ื•ื”ื—ืœื™ื˜ื” ืœืœื›ืช ืœืฉื.
09:40
Which is why I was surprised a few months later
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ื–ื• ื”ืกื™ื‘ื” ืœืžื” ืžืกืคืจ ื—ื•ื“ืฉื™ื ื™ื•ืชืจ ืžืื•ื—ืจ ื”ื•ืคืชืขืชื™
09:43
to see her back in our own town,
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ื›ืืฉืจ ืจืื™ืชื™ ืื•ืชื” ืฉื•ื‘ ื‘ืขื™ืจ ืžื’ื•ืจื™ื™,
09:46
getting her subsequent care with her private oncologist.
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ืžืงื‘ืœืช ืืช ื”ื˜ื™ืคื•ืœ ืืฆืœ ื”ืื•ื ืงื•ืœื•ื’ ื”ืคืจื˜ื™ ืฉืœื”.
09:49
And I pressed her, and I asked her,
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ืฉืืœืชื™ ืื•ืชื”,
09:51
"Why did you come back and get your care here?"
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"ืžื“ื•ืข ื—ื–ืจืช ื›ื“ื™ ืœืงื‘ืœ ืืช ื”ื˜ื™ืคื•ืœ ื›ืืŸ?"
09:54
And she was reluctant to tell me.
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ื”ื™ื ืœื ื”ืชืœื”ื‘ื” ืœืกืคืจ ืœื™.
09:56
She said, "The cancer center was wonderful.
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ื”ื™ื ืืžืจื”, "ื”ืžืจื›ื– ืœืกืจื˜ืŸ ื”ื™ื” ื ื”ื“ืจ.
09:59
It had a beautiful facility,
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ื™ืฉ ืฉื ืžืชืงื ื™ื ื ื”ื“ืจื™ื,
10:01
giant atrium, valet parking,
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ืจื—ื‘ื” ืžืจื›ื–ื™ืช ื’ื“ื•ืœื”, ืžื—ื ื™ื ืœืš ืืช ื”ืื•ื˜ื•,
10:03
a piano that played itself,
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ืคืกื ืชืจ ืฉืžื ื’ืŸ ืœื‘ื“,
10:05
a concierge that took you around from here to there.
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ืขื•ื‘ื“ ืฉืœื”ื ืฉืœื•ืงื— ืื•ืชืš ืœื›ืœ ืžืงื•ื.
10:08
But," she said,
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ืื‘ืœ, ื”ื™ื ืืžืจื”,
10:10
"but they did not touch my breasts."
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"ื”ื ืœื ื ื’ืขื• ื‘ืฉื“ื™ื™."
10:14
Now you and I could argue
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ื•ืื›ืŸ ืืคืฉืจ ืœื˜ืขื•ืŸ
10:16
that they probably did not need to touch her breasts.
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ืฉื”ื ื›ื ืจืื” ืœื ื”ื™ื• ื–ืงื•ืงื™ื ืœื’ืขืช.
10:18
They had her scanned inside out.
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ื”ื ืขืฉื• ืœื” ืกืจื™ืงื” ืžื›ืœ ื”ื›ื™ื•ื•ื ื™ื.
10:20
They understood her breast cancer at the molecular level;
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ื”ื ื”ื‘ื™ื ื• ืืช ื”ืกืจื˜ืŸ ืฉื”ื™ื” ืœื” ื‘ืจืžื” ื”ืžื•ืœืงื•ืœืจื™ืช;
10:23
they had no need to touch her breasts.
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ืœื ื”ื™ื” ืœื”ื ืฆื•ืจืš ืœื’ืขืช ื‘ืฉื“ื™ื”.
10:25
But to her, it mattered deeply.
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ืื‘ืœ ืขื‘ื•ืจื” ื–ื” ื”ื™ื” ืžืื•ื“ ื—ืฉื•ื‘.
10:28
It was enough for her to make the decision
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ื–ื” ื”ืกืคื™ืง ืœื” ืœื”ื—ืœื™ื˜ ืœืขื‘ื•ืจ ืืช ื”ื˜ื™ืคื•ืœ ื”ืžืžืฉื™ืš
10:32
to get her subsequent care with her private oncologist
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ืืฆืœ ื”ืื•ื ืงื•ืœื•ื’ ื”ืคืจื˜ื™ ืฉืœื”
10:35
who, every time she went,
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ืืฉืจ, ื‘ื›ืœ ืคืขื ืฉื”ื™ื ื”ืœื›ื” ืืœื™ื•,
10:37
examined both breasts including the axillary tail,
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ื‘ื“ืง ืืช ืฉื ื™ ืฉื“ื™ื” ื›ื•ืœืœ ื‘ื™ืช-ื”ืฉื—ื™,
10:40
examined her axilla carefully,
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ื‘ื“ืง ืืช ื‘ื™ืช-ื”ืฉื—ื™ ื‘ืงืคื“ื ื•ืช,
10:42
examined her cervical region, her inguinal region,
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ื‘ื“ืง ืืช ืื–ื•ืจ ื”ืฆื•ื•ืืจ, ืืช ืื–ื•ืจ ื”ืžืคืฉืขื”,
10:44
did a thorough exam.
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ื‘ื—ืŸ ืืช ื›ื•ืœื ื‘ื™ืกื•ื“ื™ื•ืช.
10:46
And to her, that spoke of a kind of attentiveness that she needed.
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ื•ืขื‘ื•ืจื”, ื–ื” ื”ื™ื” ืžื™ืŸ ื‘ื™ื˜ื•ื™ ืœืชืฉื•ืžืช ืœื‘ ืฉื”ื™ื ื ื–ืงืงื” ืœื”.
10:50
I was very influenced by that anecdote.
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ืื ืงื“ื•ื˜ื” ื–ื• ื”ืฉืคื™ืขื” ืขืœื™ื™ ืžืื•ื“.
10:52
I was also influenced by another experience that I had,
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ื›ืžื•-ื›ืŸ ื”ื•ืฉืคืขืชื™ ื’ื ืžื ื™ืกื™ื•ืŸ ืื—ืจ ืฉื”ื™ื” ืœื™,
10:55
again, when I was in Texas, before I moved to Stanford.
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ืฉื•ื‘, ื‘ื”ื™ื•ืชื™ ื‘ื˜ืงืกืก, ืœืคื ื™ ืฉืขื‘ืจืชื™ ืœืกื˜ื ืคื•ืจื“.
10:58
I had a reputation
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ื™ืฆื ืœื™ ืžื•ื ื™ื˜ื™ืŸ
11:00
as being interested in patients
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ื‘ืชื•ืจ ื›ื–ื” ืฉืžืชืขื ื™ื™ืŸ
11:02
with chronic fatigue.
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ื‘ื—ื•ืœื™ื ืฉื™ืฉ ืœื”ื ืขื™ื™ืคื•ืช ื›ืจื•ื ื™ืช.
11:05
This is not a reputation you would wish on your worst enemy.
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ืžื•ื ื™ื˜ื™ืŸ ื›ื–ื” ืืชื” ืœื ืžืื—ืœ ืืคื™ืœื• ืœืื•ื™ื‘ื™ืš ื”ื’ืจื•ืขื™ื ื‘ื™ื•ืชืจ.
11:09
I say that because these are difficult patients.
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ืื ื™ ืื•ืžืจ ื–ืืช ื›ื™ ื—ื•ืœื™ื ื”ืœืœื• ื”ื ืื ืฉื™ื ืงืฉื™ื.
11:12
They have often been rejected by their families,
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ืœืขื™ืชื™ื ืงืจื•ื‘ื•ืช ื”ื ื“ื—ื•ื™ื™ื ืขืœ-ื™ื“ื™ ืžืฉืคื—ื•ืชื™ื”ื,
11:15
have had bad experiences with medical care
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ื™ืฉ ืœื”ื ื ื™ืกื™ื•ืŸ ืจืข ืขื ืžืขืจื›ืช ื”ื‘ืจื™ืื•ืช
11:17
and they come to you fully prepared
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ื•ื”ื ื‘ืื™ื ืœืจื•ืคื ืžื•ื›ื ื™ื ืžืจืืฉ ื›ื“ื™ ืœื”ื›ื ื™ืก
11:20
for you to join the long list of people
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ื’ื ืื•ืชื• ืœืจืฉื™ืžื” ื”ืืจื•ื›ื” ืฉืœ ืื ืฉื™ื
11:22
who's about to disappoint them.
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ืฉื›ื‘ืจ ืื™ื›ื–ื‘ื• ืื•ืชื.
11:24
And I learned very early on with my first patient
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ืœืžื“ืชื™ ืžื”ืจ ืžืื•ื“ ื›ื‘ืจ ืขื ื”ืžื˜ื•ืคืœ ื”ืจืืฉื•ืŸ ืฉืœื™
11:27
that I could not do justice
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ืฉืื ื™ ืœื ื™ื›ื•ืœ ืœื˜ืคืœ ื›ืจืื•ื™
11:29
to this very complicated patient
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ื‘ืžื˜ื•ืคืœ ืขื ืชืกื‘ื•ื›ืช ื›ื–ื•,
11:31
with all the records they were bringing
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ืขื ื›ืœ ื”ื ื™ื™ืจืช ืฉื”ื•ื ื”ื‘ื™ื,
11:33
in a new patient visit of 45 minutes.
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ื‘ืžื™ืคื’ืฉ ื”ืจืืฉื•ืŸ ืื™ืชื• ื‘ืŸ 45 ื“ืงื•ืช.
11:35
There was just no way.
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ืื™ืŸ ืฉื•ื ืกื™ื›ื•ื™ ืฉื–ื” ื™ืฆืœื™ื—.
11:37
And if I tried, I'd disappoint them.
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ื•ืื ืื ืกื”, ื‘ืกื•ืš ื”ื•ื ื™ืชืื›ื–ื‘.
11:40
And so I hit on this method
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ืœื›ืŸ ื”ืžืฆืืชื™ ืฉื™ื˜ื”
11:42
where I invited the patient
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ืฉื‘ื” ื‘ื™ืงืฉืชื™ ืžืžื ื•
11:44
to tell me the story for their entire first visit,
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ืœืกืคืจ ืœื™ ืืช ืกื™ืคื•ืจื• ื‘ืžืฉืš ื›ืœ ื”ืžืคื’ืฉ ื”ืจืืฉื•ืŸ,
11:47
and I tried not to interrupt them.
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ื•ื ื™ืกื™ืชื™ ืœื ืœืงื˜ื•ืข ืื•ืชื• ื‘ืืžืฆืข.
11:50
We know the average American physician
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ืื ื• ืžื›ื™ืจื™ื ืืช ื”ืจื•ืคื ื”ืืžืจื™ืงืื™ ื”ืžืžื•ืฆืข
11:52
interrupts their patient in 14 seconds.
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ืฉืงื•ื˜ืข ืืช ื”ืžื˜ื•ืคืœ ืชื•ืš 14 ืฉื ื™ื•ืช.
11:55
And if I ever get to heaven,
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ื•ืื ืื’ื™ืข ืื™-ืคืขื ืœื’ืŸ-ืขื“ืŸ,
11:57
it will be because I held my piece for 45 minutes
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ื–ื” ื™ืงืจื” ื‘ื’ืœืœ ืฉื”ืชืืคืงืชื™ ื‘ืžืฉืš 45 ื“ืงื•ืช
12:00
and did not interrupt my patient.
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ื•ืœื ืงื˜ืขืชื™ ืืช ื”ืžื˜ื•ืคืœ.
12:02
I then scheduled the physical exam for two weeks hence,
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ืื—ืจ-ื›ืš ืงื‘ืขืชื™ ื‘ื“ื™ืงื” ื’ื•ืคื ื™ืช ืœืขื•ื“ ืฉื‘ื•ืขื™ื™ื,
12:05
and when the patient came for the physical,
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ื•ื›ืืฉืจ ื”ืžื˜ื•ืคืœ ื”ื’ื™ืข ืœื‘ื“ื™ืงื” ื–ื•,
12:07
I was able to do a thorough physical,
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ื™ื›ื•ืœืชื™ ืœื‘ื“ื•ืง ืื•ืชื• ื‘ื™ืกื•ื“ื™ื•ืช,
12:09
because I had nothing else to do.
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ืžื›ื™ื•ื•ืŸ ืฉื–ื” ื›ืœ ืžื” ืฉื”ื™ื™ืชื™ ืฆืจื™ืš ืœืขืฉื•ืช.
12:11
I like to think that I do a thorough physical exam,
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ืื ื™ ืื•ื”ื‘ ืœื—ืฉื•ื‘ ืฉืื ื™ ืขื•ืฉื” ื‘ื“ื™ืงื” ื’ื•ืคื ื™ืช ื™ืกื•ื“ื™ืช
12:14
but because the whole visit was now about the physical,
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ืื‘ืœ ืžืื—ืจ ื•ื›ืœ ื”ืžืคื’ืฉ ื”ื™ื” ืžื›ื•ื•ืŸ ืจืง ืœื‘ื“ื™ืงื” ื›ื–ื•,
12:17
I could do an extraordinarily thorough exam.
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ื™ื›ื•ืœืชื™ ืœื‘ืฆืขื” ื‘ื™ืกื•ื“ื™ื•ืช ื‘ืฆื•ืจื” ื™ื•ืฆืืช-ื“ื•ืคืŸ.
12:20
And I remember my very first patient in that series
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ืื ื™ ื–ื•ื›ืจ ืฉื”ืžื˜ื•ืคืœ ื”ืจืืฉื•ืŸ ืฉืœื™ ื‘ืื•ืชื” ืกื™ื“ืจื”
12:24
continued to tell me more history
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ื”ืžืฉื™ืš ืœืกืคืจ ืœื™ ื™ื•ืชืจ ืขืœ ืขื‘ืจื•
12:26
during what was meant to be the physical exam visit.
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ื‘ืžื”ืœืš ืžื” ืฉื”ื™ื” ืืžื•ืจ ืœื”ื™ื•ืช ืžืคื’ืฉ ืœืฆื•ืจื›ื™ ื‘ื“ื™ืงื” ื’ื•ืคื ื™ืช.
12:29
And I began my ritual.
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ื”ืชื—ืœืชื™ ืืช ื”ืœื™ืš ื”ื‘ื“ื™ืงื” ื”ืฉื™ื’ืจืชื™.
12:31
I always begin with the pulse,
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ืื ื™ ืชืžื™ื“ ืžืชื—ื™ืœ ืขื ื”ื“ื•ืคืง,
12:33
then I examine the hands, then I look at the nail beds,
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ืื—ืจ-ื›ืš ื‘ื•ื“ืง ืืช ื”ื™ื“ื™ื™ื, ืื—ืจ-ื›ืš ืืช ืžืฆืขื™ ื”ืฆื™ืคื•ืจื ื™ื™ื,
12:36
then I slide my hand up to the epitrochlear node,
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ืœืื—ืจ-ืžื›ืŸ ืื ื™ ืžื—ืœื™ืง ืืช ื™ื“ื™ ืžืขืœื” ืืœ ื‘ืœื™ื˜ืช ื”ืžื™ืคืจืง,
12:38
and I was into my ritual.
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ื•ื›ืš ื”ืชื ื”ืœ ืžื”ืœืš ื”ื‘ื“ื™ืงื” ื”ืฉื™ื’ืจืชื™.
12:40
And when my ritual began,
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ื›ืืฉืจ ื”ื‘ื“ื™ืงื” ื”ื—ืœื”,
12:42
this very voluble patient
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ืžื˜ื•ืคืœ ืงื•ืœื ื™ ื–ื”
12:44
began to quiet down.
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ื”ื—ืœ ืœื”ื™ื•ืช ื™ื•ืชืจ ื‘ืฉืงื˜.
12:46
And I remember having a very eerie sense
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ืื ื™ ื–ื•ื›ืจ ืืช ื”ืชื—ื•ืฉื” ื”ืžืื•ื“ ืžื•ื–ืจื”
12:49
that the patient and I
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ืฉื”ืžื˜ื•ืคืœ ื•ืื ื™ ื’ื•ืœืฉื™ื ื‘ื—ื–ืจื”
12:52
had slipped back into a primitive ritual
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ืืœ ื”ืžื”ืœืš ื”ืฉื™ื’ืจืชื™ ื”ืžื™ื•ืฉืŸ
12:54
in which I had a role
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ืฉื‘ื• ืœื™ ื™ืฉ ืชืคืงื™ื“
12:56
and the patient had a role.
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ื•ืœืžื˜ื•ืคืœ ื™ืฉ ืชืคืงื™ื“.
12:58
And when I was done,
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ื›ืืฉืจ ืกื™ื™ืžืชื™,
13:00
the patient said to me with some awe,
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ื”ืžื˜ื•ืคืœ ืืžืจ ืœื™ ื‘ื™ืจืืช-ื›ื‘ื•ื“ ืžืกื•ื™ื™ืžืช,
13:02
"I have never been examined like this before."
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"ืžืขื•ืœื ืœื ื‘ื“ืงื• ืื•ืชื™ ื‘ืฆื•ืจื” ื–ื•."
13:05
Now if that were true,
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ืื ื–ื” ื ื›ื•ืŸ,
13:07
it's a true condemnation of our health care system,
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ื–ื”ื• ืฆื™ื•ืŸ ืœื’ื ืื™ ืœืžืขืจื›ืช ื”ื‘ืจื™ืื•ืช ืฉืœื ื•,
13:09
because they had been seen in other places.
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ืžื›ื™ื•ื•ืŸ ืฉื”ื•ื ื ื‘ื“ืง ื’ื ื‘ืžืงื•ืžื•ืช ืื—ืจื™ื.
13:12
I then proceeded to tell the patient,
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ื”ืžืฉื›ืชื™ ื•ืกื™ืคืจืชื™ ืœืžื˜ื•ืคืœ,
13:14
once the patient was dressed,
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ืœืื—ืจ ืฉื”ื•ื ื”ืชืœื‘ืฉ,
13:16
the standard things that the person must have heard in other institutions,
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ืืช ื”ื“ื‘ืจื™ื ื”ืจื’ื™ืœื™ื ืฉื”ื•ื ื•ื•ื“ืื™ ื›ื‘ืจ ืฉืžืข ื‘ืžื›ื•ื ื™ ื‘ื“ื™ืงื” ืื—ืจื™ื,
13:19
which is, "This is not in your head.
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ืฉื–ื”, "ื–ื” ืœื ืกืชื ื‘ืจืืฉ ืฉืœืš.
13:21
This is real.
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ื–ื” ืืžื™ืชื™.
13:23
The good news, it's not cancer, it's not tuberculosis,
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ื”ื—ื“ืฉื•ืช ื”ื˜ื•ื‘ื•ืช ื”ืŸ ืฉื–ื” ืœื ืกืจื˜ืŸ, ื–ื• ืœื ืฉื—ืคืช,
13:26
it's not coccidioidomycosis or some obscure fungal infection.
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ื–ื• ืœื ืคื˜ืจืช ืงื•ืงื™ื“ื™ื•ืื™ื“ื™ืก ืื• ื–ื™ื”ื•ื ืคื˜ืจื™ื™ืชื™ ืื—ืจ ืœื ื™ื“ื•ืข.
13:29
The bad news is we don't know exactly what's causing this,
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ื”ื—ื“ืฉื•ืช ื”ืจืขื•ืช ื”ืŸ ืฉืื™ื ื ื• ื™ื•ื“ืขื™ื ืžื” ื‘ื“ื™ื•ืง ื”ื’ื•ืจื ืฉืœ ื–ื”,
13:32
but here's what you should do, here's what we should do."
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ืื‘ืœ ื”ื ื” ืžื” ืฉืขืœื™ืš ืœืขืฉื•ืช, ื”ื ื” ืžื” ืฉืขืœื™ื ื• ืœืขืฉื•ืช."
13:35
And I would lay out all the standard treatment options
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ื•ืื– ื”ื™ื™ืชื™ ืžืคืจื˜ ืืช ื›ืœ ืืคืฉืจื•ื™ื•ืช ื”ื˜ื™ืคื•ืœ ื”ืจื’ื™ืœื•ืช
13:38
that the patient had heard elsewhere.
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ืฉื”ืžื˜ื•ืคืœ ื›ื‘ืจ ืฉืžืข ืขืœื™ื”ืŸ ื‘ืžืงื•ืžื•ืช ืื—ืจื™ื.
13:41
And I always felt
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ืชืžื™ื“ ื—ืฉืชื™ ืฉืื
13:43
that if my patient gave up the quest
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ื”ืžื˜ื•ืคืœ ืฉืœื™ ื•ื™ืชืจ ืขืœ ื”ื—ื™ืคื•ืฉ
13:45
for the magic doctor, the magic treatment
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ืื—ืจ ื”ืจื•ืคื ื”ืงื•ืกื, ื”ื˜ื™ืคื•ืœ ื”ืงืกื•ื
13:48
and began with me on a course towards wellness,
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ื•ื”ืชื—ื™ืœ ืืฆืœื™ ืืช ื”ื—ืœืžืชื•, ื–ื” ื”ื™ื” ื‘ื’ืœืœ
13:51
it was because I had earned the right
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ืฉื”ืจื•ื•ื—ืชื™ ื‘ื™ื•ืฉืจ ืืช ื”ื–ื›ื•ืช
13:53
to tell them these things
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ืœืกืคืจ ืœื• ืขืœ ื”ื“ื‘ืจื™ื ื”ืœืœื•
13:55
by virtue of the examination.
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ืขืœ ืกืžืš ื”ื‘ื“ื™ืงื”.
13:57
Something of importance had transpired in the exchange.
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ืžืฉื”ื• ื—ืฉื•ื‘ ื”ืชื‘ืจืจ ื‘ืชืžื•ืจื”.
14:01
I took this to my colleagues
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ืœืงื—ืชื™ ืืช ื–ื” ืœืขืžื™ืชื™ื™
14:03
at Stanford in anthropology
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ื”ืื ืชืจื•ืคื•ืœื•ื’ื™ื ื‘ืกื˜ื ืคื•ืจื“
14:05
and told them the same story.
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ื•ืกื™ืคืจืชื™ ืœื”ื ืืช ื”ืกื™ืคื•ืจ ื›ื•ืœื•.
14:07
And they immediately said to me,
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ื•ื”ื ืžื™ื™ื“ ืืžืจื•
14:09
"Well you are describing a classic ritual."
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ืฉืื ื™ ืžืชืืจ ื”ืœื™ืš ื˜ืงืกื™ ืงืœืืกื™.
14:11
And they helped me understand
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ื”ื ืขื–ืจื• ืœื™ ืœื”ื‘ื™ืŸ
14:13
that rituals are all about transformation.
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ืฉื”ืœื™ื›ื™ื ื˜ืงืกื™ื™ื ืงืฉื•ืจื™ื ื‘ืฉื™ื ื•ื™.
14:16
We marry, for example,
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ืœื“ื•ื’ืžื, ืื ื• ืžืชื—ืชื ื™ื,
14:18
with great pomp and ceremony and expense
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ื‘ืจื•ื‘ ืคืืจ, ื˜ืงืกื™ื ื•ื”ื•ืฆืื•ืช
14:21
to signal our departure
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ื›ื“ื™ ืœืกืžืœ ืืช ืคืจื™ื“ืชื™ื ื•
14:23
from a life of solitude and misery and loneliness
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ืžื—ื™ื™ ื‘ื“ื™ื“ื•ืช ื•ืฆืขืจ
14:25
to one of eternal bliss.
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ื•ืžืขื‘ืจ ืืœ ืื•ืฉืจ ื ืฆื—ื™.
14:28
I'm not sure why you're laughing.
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ืื™ื ื™ ื‘ื˜ื•ื— ืžื“ื•ืข ืืชื ืฆื•ื—ืงื™ื.
14:30
That was the original intent, was it not?
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ื–ื• ื”ื™ืชื” ื”ื›ื•ื•ื ื” ื”ืžืงื•ืจื™ืช, ืœื?
14:32
We signal transitions of power
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ืื ื• ืžืฆื™ื™ื ื™ื ื”ืขื‘ืจืช ื›ื•ื‘ื“ ืžืฉืงืœ
14:34
with rituals.
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ื‘ืืžืฆืขื•ืช ื˜ืงืกื™ื.
14:36
We signal the passage of a life with rituals.
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ืื ื• ืžืฆื™ื™ื ื™ื ืฉืœื‘ื™ื ื‘ื—ื™ื™ื ื‘ืืžืฆืขื•ืช ื˜ืงืกื™ื.
14:38
Rituals are terribly important.
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ืœื˜ืงืกื™ื ื™ืฉ ื—ืฉื™ื‘ื•ืช ืขืฆื•ืžื”.
14:40
They're all about transformation.
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ื”ื ื›ื•ืœื ืงืฉื•ืจื™ื ื‘ืฉื™ื ื•ื™.
14:42
Well I would submit to you
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ืื’ืœื” ืœื›ื
14:44
that the ritual
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ืฉื”ื˜ืงืก ืฉืœ
14:46
of one individual coming to another
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ืื“ื ืื—ื“ ื”ื ื™ื’ืฉ ืœืื—ืจ
14:48
and telling them things
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ื•ืžืกืคืจ ืœื• ื“ื‘ืจื™ื
14:50
that they would not tell their preacher or rabbi,
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ืฉืœื ื™ืกืคืจ ืœืžื˜ื™ืฃ ื”ื“ืช ืื• ื”ืจื‘ื™ ืฉืœื•,
14:53
and then, incredibly on top of that,
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ื•ืื—ืจ-ื›ืš, ื‘ื ื•ืกืฃ ืœื–ื”,
14:55
disrobing and allowing touch --
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ื™ืชืคืฉื˜ ื•ื™ืืคืฉืจ ืžื’ืข --
14:58
I would submit to you that that is a ritual of exceeding importance.
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ืื’ืœื” ืœื›ื ืฉื˜ืงืก ื–ื” ื”ื•ื ื‘ืขืœ ื—ืฉื™ื‘ื•ืช ืขืฆื•ืžื”.
15:02
And if you shortchange that ritual
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ื•ืื ืžื—ืคืคื™ื ื‘ื˜ืงืก ื–ื”
15:04
by not undressing the patient,
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ื‘ื›ืš ืฉืœื ืžื‘ืงืฉื™ื ืžื”ืžื˜ื•ืคืœ ืœื”ืชืคืฉื˜,
15:06
by listening with your stethoscope on top of the nightgown,
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ื‘ื›ืš ืฉืžืื–ื™ื ื™ื ื‘ืืžืฆืขื•ืช ื”ืกื˜ื˜ื•ืกืงื•ืค ื“ืจืš ื›ื•ืชื•ื ืช ื”ืœื™ืœื”,
15:09
by not doing a complete exam,
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ื‘ื›ืš ืฉืœื ืžื‘ืฆืขื™ื ื‘ื“ื™ืงื” ืฉืœืžื”,
15:11
you have bypassed on the opportunity
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ืื– ืคื•ืกื—ื™ื ืขืœ ื”ื”ื–ื“ืžื ื•ืช
15:13
to seal the patient-physician relationship.
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ืœื—ื–ืง ื•ืœืชืช ื’ื•ืฉืคื ืงื ืœื™ื—ืกื™ ืจื•ืคื-ืžื˜ื•ืคืœ.
15:17
I am a writer,
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ืื ื™ ืกื•ืคืจ,
15:19
and I want to close by reading you a short passage that I wrote
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ื•ื‘ืจืฆื•ื ื™ ืœืกื™ื™ื ื‘ืงืจื™ืืชื• ืฉืœ ืงื˜ืข ืงืฆืจ ืฉื›ืชื‘ืชื™
15:23
that has to do very much with this scene.
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ืฉื™ืฉ ืœื• ืงืฉืจ ื”ื“ื•ืง ืขื ืžืจืื” ื–ื”.
15:25
I'm an infectious disease physician,
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ืื ื™ ืจื•ืคื ื”ืžืชืžื—ื” ื‘ืžื—ืœื•ืช ืžื™ื“ื‘ืงื•ืช,
15:27
and in the early days of HIV, before we had our medications,
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ื•ื‘ื™ืžื™ ืื™ื™ื“ืก ื”ืจืืฉื•ื ื™ื, ืœืคื ื™ ืฉื”ื™ื• ืœื ื• ื”ืชืจื•ืคื•ืช ืœื–ื”,
15:30
I presided over so many scenes like this.
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ื”ื™ื™ืชื™ ืขื“ ืœื”ืจื‘ื” ืžืจืื•ืช ื›ืืœื”.
15:34
I remember, every time I went to a patient's deathbed,
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ืื ื™ ื–ื•ื›ืจ ืฉื‘ื›ืœ ืคืขื ืฉื ื™ื’ืฉืชื™ ืœืขืจืฉ-ื“ื•ื•ื™ ืฉืœ ื—ื•ืœื”,
15:37
whether in the hospital or at home,
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ื‘ื™ืŸ ืื ื‘ื‘ื™ืช-ื—ื•ืœื™ื ื•ื‘ื™ืŸ ืื ื‘ื‘ื™ืชื•,
15:39
I remember my sense of failure --
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ืื ื™ ื ื–ื›ืจ ื‘ืชื—ื•ืฉืช ื”ื›ื™ืฉืœื•ืŸ ืฉื”ื™ืชื” ืœื™ --
15:43
the feeling of I don't know what I have to say;
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ื”ื”ืจื’ืฉื” ืฉืื™ื ื™ ื™ื•ื“ืข ืžื” ืขืœื™ื™ ืœื•ืžืจ;
15:45
I don't know what I can say;
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ืื™ื ื™ ื™ื•ื“ืข ืžื” ืื ื™ ื™ื›ื•ืœ ืœื•ืžืจ;
15:47
I don't know what I'm supposed to do.
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ืื™ื ื™ ื™ื•ื“ืข ืžื” ืื ื™ ืืžื•ืจ ืœืขืฉื•ืช.
15:49
And out of that sense of failure,
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ื•ืžืชื•ืš ืื•ืชื” ืชื—ื•ืฉืช ื›ื™ืฉืœื•ืŸ,
15:51
I remember, I would always examine the patient.
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ื›ืš ืื ื™ ื–ื•ื›ืจ, ื”ื™ื™ืชื™ ื‘ื•ื“ืง ืืช ื”ื—ื•ืœื”.
15:54
I would pull down the eyelids.
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ื”ื™ื™ืชื™ ืžื•ืฉืš ืžื˜ื” ืืช ื”ืขืคืขืคื™ื™ื.
15:56
I would look at the tongue.
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ื”ื™ื™ืชื™ ืžืกืชื›ืœ ืขืœ ื”ืœืฉื•ืŸ.
15:58
I would percuss the chest. I would listen to the heart.
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ื”ื™ื™ืชื™ ื ื•ืงืฉ ืขืœ ื”ื—ื–ื”. ื”ื™ื™ืชื™ ืžืื–ื™ืŸ ืœืœื‘.
16:01
I would feel the abdomen.
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ื”ื™ื™ืชื™ ื ื•ื’ืข ื•ื—ืฉ ืืช ื”ื‘ื˜ืŸ.
16:03
I remember so many patients,
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ืื ื™ ื–ื•ื›ืจ ื›ืœ-ื›ืš ื”ืจื‘ื” ืžื˜ื•ืคืœื™ื,
16:06
their names still vivid on my tongue,
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ืฉืžื•ืชื™ื”ื ืขื“ื™ื™ืŸ ืžืชืจื•ืฆืฆื™ื ืขืœ ืœืฉื•ื ื™,
16:08
their faces still so clear.
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ืคื ื™ื”ื ืขื“ื™ื™ืŸ ื›ื” ื‘ืจื•ืจื™ื.
16:10
I remember so many huge, hollowed out, haunted eyes
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ืื ื™ ื–ื•ื›ืจ ื›ืœ-ื›ืš ื”ืจื‘ื” ืขื™ื ื™ื™ื ืคืขื•ืจื•ืช, ืžื‘ื•ืขืชื•ืช,
16:14
staring up at me as I performed this ritual.
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ื”ื ื ืขืฆื•ืช ื‘ื™ ื‘ืขื•ื“ื™ ืžื‘ืฆืข ืืช ื”ื‘ื“ื™ืงื”.
16:17
And then the next day,
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ื•ืื– ืœืžื—ืจืช,
16:19
I would come, and I would do it again.
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ื”ื™ื™ืชื™ ืžื’ื™ืข ื•ื—ื•ื–ืจ ืขืœ ื›ืœ ื–ื”.
16:21
And I wanted to read you this one closing passage
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ืจืฆื™ืชื™ ืœืงืจื•ื ื‘ืคื ื™ื›ื ืงื˜ืข ืกื™ื•ื ื–ื”
16:24
about one patient.
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ืขืœ ืžื˜ื•ืคืœ ืื—ื“.
16:26
"I recall one patient
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"ืื ื™ ื ื–ื›ืจ ื‘ืžื˜ื•ืคืœ ืื—ื“
16:28
who was at that point
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ืฉื”ื™ื” ืื–
16:30
no more than a skeleton
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ืœื ื™ื•ืชืจ ืžืืฉืจ ืฉืœื“ ื”ืืจื•ื–
16:32
encased in shrinking skin,
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ื‘ืขื•ืจ ืฉื”ื•ืœืš ื•ืžืชื›ื•ื•ืฅ,
16:34
unable to speak,
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ืื™ื ื• ืžืกื•ื’ืœ ืœื“ื‘ืจ,
16:36
his mouth crusted with candida
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ืคื™ื• ืขื˜ื•ื™ ืงืœื™ืคืช ืงื ื“ื™ื“ื” (ืกื•ื’ ืคื˜ืจื™ื”)
16:38
that was resistant to the usual medications.
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ืฉื”ื™ืชื” ืขืžื™ื“ื” ื‘ืคื ื™ ื”ืชืจื•ืคื•ืช ื”ืจื’ื™ืœื•ืช.
16:41
When he saw me
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ื›ืืฉืจ ื”ื•ื ืจืื” ืื•ืชื™
16:43
on what turned out to be his last hours on this earth,
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ื‘ืฉืขื•ืช ื—ื™ื™ื• ื”ืื—ืจื•ื ื•ืช,
16:45
his hands moved as if in slow motion.
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ื™ื“ื™ื• ื ืขื• ื›ืื™ืœื• ื‘ื”ื™ืœื•ืš ืื™ื˜ื™.
16:48
And as I wondered what he was up to,
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ื•ื‘ืขื•ื“ื™ ืชื•ื”ื” ืขืœ ื›ื•ื•ื ื•ืชื™ื•,
16:50
his stick fingers made their way
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ืืฆื‘ืขื•ืชื™ื• ื”ื“ื‘ื™ืงื•ืช ืขืฉื• ืืช ื“ืจื›ืŸ
16:52
up to his pajama shirt,
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ื‘ืžืขืœื” ื—ื•ืœืฆืช ื”ืคื™ื’'ืžื” ืฉืœื•,
16:54
fumbling with his buttons.
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ืžืžืฉืฉื•ืช ืืช ื”ื›ืคืชื•ืจื™ื.
16:57
I realized that he was wanting
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ื”ื‘ื ืชื™ ืฉื”ื•ื ืจื•ืฆื”
16:59
to expose his wicker-basket chest to me.
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ืœื—ืฉื•ืฃ ืืช ื—ื–ื”ื• ื”ืฉื“ื•ืฃ.
17:02
It was an offering, an invitation.
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ื–ื• ื”ื™ืชื” ื”ื–ืžื ื”.
17:05
I did not decline.
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ืœื ื“ื—ื™ืชื™ ืื•ืชื”.
17:07
I percussed. I palpated. I listened to the chest.
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ื ืงืฉืชื™. ืžื™ืฉืฉืชื™. ื”ืื–ื ืชื™ ืœื—ื–ื”ื•.
17:10
I think he surely must have known by then
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ืื ื™ ื—ื•ืฉื‘ ืฉื”ื•ื ืœื‘ื˜ื— ื™ื“ืข ืื–
17:12
that it was vital for me
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ืฉื–ื” ื”ื™ื” ื—ื™ื•ื ื™ ืขื‘ื•ืจื™ ื‘ืื•ืชื” ืžื™ื“ื”
17:14
just as it was necessary for him.
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ืฉื–ื” ื”ื™ื” ื ื—ื•ืฅ ื‘ืฉื‘ื™ืœื•.
17:16
Neither of us could skip this ritual,
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ืืฃ ืœื ืื—ื“ ืžืื™ืชื ื• ื”ื™ื” ืžืกื•ื’ืœ ืœืคืกื•ื— ืขืœ ื˜ืงืก ื–ื”,
17:19
which had nothing to do with detecting rales in the lung,
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ืฉืื™ืŸ ืœื• ืฉื•ื ืงืฉืจ ืœืื™ืชื•ืจ ื—ื™ืจื—ื•ืจื™ื ื‘ืจื™ืื•ืช,
17:22
or finding the gallop rhythm of heart failure.
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ืื• ืœืื™ืชื•ืจ ืžื™ืงืฆื‘ ื”ื“ื”ื™ืจื” ื”ืงืฉื•ืจ ื‘ืื™-ืกืคื™ืงืช ืœื‘.
17:25
No, this ritual was about the one message
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ืœื, ื”ื˜ืงืก ื”ื™ื” ืื•ื“ื•ืช ืžืกืจ ืื—ื“
17:28
that physicians have needed to convey to their patients.
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ืฉื ื“ืจืฉ ืžืจื•ืคืื™ื ืœื”ืขื‘ื™ืจ ืœืžื˜ื•ืคืœื™ื”ื.
17:31
Although, God knows, of late, in our hubris,
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ืืฃ ืขืœ-ืคื™ ืฉืœืื—ืจื•ื ื” ื ืจืื” ื›ืื™ืœื•
17:33
we seem to have drifted away.
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ื ืกื—ืคื ื• ื”ืจื—ืง ืžืžื ื• ื‘ื‘ื™ื˜ื—ื•ื ื ื• ื”ืžื•ืคืจื–.
17:35
We seem to have forgotten --
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ื ืจืื” ื›ืื™ืœื• ืฉื›ื—ื ื• --
17:37
as though, with the explosion of knowledge,
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ื‘ื™ื—ื“ ืขื ื”ืชืคื•ืฆืฆื•ืช ื”ื™ื“ืข,
17:39
the whole human genome mapped out at our feet,
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ื›ืืฉืจ ืžืœื•ื ื”ื’ื ื•ื ื”ืื ื•ืฉื™ ืคืจื•ืก ืœืจื’ืœื ื•,
17:42
we are lulled into inattention,
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ืื ื• ืฉืงื•ืขื™ื ื‘ืชื•ืš ื—ื•ืกืจ-ืงืฉื‘,
17:44
forgetting that the ritual is cathartic to the physician,
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ืฉื•ื›ื—ื™ื ืฉื”ื”ืœื™ืš ื”ื˜ืงืกื™ ื”ื•ื ืžืฉื—ืจืจ ื•ืžื–ื›ืš ืขื‘ื•ืจ ื”ืจื•ืคื,
17:47
necessary for the patient --
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ื—ื™ื•ื ื™ ืขื‘ื•ืจ ื”ื—ื•ืœื” --
17:49
forgetting that the ritual has meaning
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ืฉื•ื›ื—ื™ื ืฉืœื”ืœื™ืš ื”ื˜ืงืกื™ ื™ืฉ ืžืฉืžืขื•ืช
17:51
and a singular message to convey to the patient.
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ื•ืžืกืจ ื‘ืจื•ืจ ื›ื“ื™ ืœื”ืขื‘ื™ืจ ืœืžื˜ื•ืคืœ.
17:55
And the message, which I didn't fully understand then,
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ื•ื”ืžืกืจ, ืฉื‘ื–ืžื ื• ืœื ื”ื‘ื ืชื™ ื‘ืžืœื•ืื•,
17:58
even as I delivered it,
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ืืคื™ืœื• ื›ืฉื”ืขื‘ืจืชื™ ืื•ืชื•,
18:00
and which I understand better now is this:
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ื•ืฉืื•ืชื• ืื ื™ ืžื‘ื™ืŸ ื”ื™ื•ื ื™ื•ืชืจ ื˜ื•ื‘ ื”ื•ื ื–ื”:
18:03
I will always, always, always be there.
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ืื ื™ ืชืžื™ื“, ืชืžื™ื“ ืื”ื™ื” ืฉื.
18:06
I will see you through this.
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ืื ื™ ืืœื•ื•ื” ืื•ืชื›ื.
18:08
I will never abandon you.
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ืœื ืื ื˜ื•ืฉ ืืชื›ื ืœืขื•ืœื.
18:10
I will be with you through the end."
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ืื”ื™ื” ืื™ืชื›ื ืขื“ ื”ืกื•ืฃ."
18:12
Thank you very much.
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ืชื•ื“ื” ืจื‘ื” ืœื›ื.
18:14
(Applause)
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(ืžื—ื™ืื•ืช ื›ืคื™ื™ื)
ืขืœ ืืชืจ ื–ื”

ืืชืจ ื–ื” ื™ืฆื™ื’ ื‘ืคื ื™ื›ื ืกืจื˜ื•ื ื™ YouTube ื”ืžื•ืขื™ืœื™ื ืœืœื™ืžื•ื“ ืื ื’ืœื™ืช. ืชื•ื›ืœื• ืœืจืื•ืช ืฉื™ืขื•ืจื™ ืื ื’ืœื™ืช ื”ืžื•ืขื‘ืจื™ื ืขืœ ื™ื“ื™ ืžื•ืจื™ื ืžื”ืฉื•ืจื” ื”ืจืืฉื•ื ื” ืžืจื—ื‘ื™ ื”ืขื•ืœื. ืœื—ืฅ ืคืขืžื™ื™ื ืขืœ ื”ื›ืชื•ื‘ื™ื•ืช ื‘ืื ื’ืœื™ืช ื”ืžื•ืฆื’ื•ืช ื‘ื›ืœ ื“ืฃ ื•ื™ื“ืื• ื›ื“ื™ ืœื”ืคืขื™ืœ ืืช ื”ืกืจื˜ื•ืŸ ืžืฉื. ื”ื›ืชื•ื‘ื™ื•ืช ื’ื•ืœืœื•ืช ื‘ืกื ื›ืจื•ืŸ ืขื ื”ืคืขืœืช ื”ื•ื•ื™ื“ืื•. ืื ื™ืฉ ืœืš ื”ืขืจื•ืช ืื• ื‘ืงืฉื•ืช, ืื ื ืฆื•ืจ ืื™ืชื ื• ืงืฉืจ ื‘ืืžืฆืขื•ืช ื˜ื•ืคืก ื™ืฆื™ืจืช ืงืฉืจ ื–ื”.

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