Tazria: The Patient’s Examination

The Lord spoke to Moses and Aaron, saying: When a person has on the skin of his body a swelling, a rash, or a discoloration, and it develops into a scaly affection on the skin of his body, it shall be reported to Aaron the priest or to one of his sons, the priests. The priest shall examine the affection on the skin of his body…(Vayikra 13:1-3)

Who will disregard his lofty status
to roll up pristine sleeves
and look the patient fully in the eye?

Who will meet the anxious gaze
and smile a friendly smile
that owes nothing to pretension

but bridges the divide
between the dauntless healer
and the would-be healed?

Who will lay his hands on blemished skin,
will gently touch the oozing sores
and probe the scaly scourge

and not recoil from fearsome wounds
reflected in the desperation etched
upon a stricken face?

Who will yield professional aloofness
for some kindly human comfort
and tend the desolation of disease?

Who will air the painful unasked questions
and pay attention to the softly voiced response
and listen to the feelings left unspoken

and know that both are wounded, bound together
and balanced at the edge of the ravine?

The two parashot Tazria and Metsora, focus intensely on the intricacies of the diagnosis and treatment of the disease “tsara’at – leprosy” (but not Hansen’s disease as we know it today). The Rabbis detected a similarity between the word metsora meaning leper, and the expression motsi shem ra meaning slanderer, and thus derived that leprosy was the punishment for slander. They liken gossip to leprosy as both are highly contagious. The Etz Hayim commentary on this issue notes, “Today we recognize that it is medically inaccurate and psychologically cruel to tell someone that he or she has been afflicted with illness as a punishment for behavior not organically related to the illness, or that failure to heal is to be blamed on a lack of will. It should be noted that the Torah itself presents tsara’at as an affliction to be cured, not as a punishment to be explained. We might ask: What actions or conditions cause an individual to be isolated from the community today? And what can religious institutions do to restore that person to the community?”

We find in this parasha, in Chapter 13 alone, mention of the priest examining the sufferer no less than twenty times, and part of the priest’s mandate was to tell what he’d found (mentioned nineteen times), and ideally to re-integrate the afflicted person back into the community.

In the Midrash in Vayikra Rabbah 15:8, we read an interesting story: Rabbi Levi said in the name of Rabbi Chama ben Rabbi Chanina: “Moses was extremely pained by this matter, saying, ‘Is this the honor of Aaron, my brother, that he should be the one who has to see the lesions [of the sick]?'” Moses, the most humble of men, seems distressed that his older brother, who is the spiritual leader – the first High Priest – is expected to soil his hands and besmirch his sacred status by palpating the sores of lepers!
It seems though, that in this exclamation, the spiritual connection between the healer and sufferer eluded Moses. However, in ancient times, the role of the spiritual leader – the priest – was also that of the healer. Before healing became transformed into the scientific discipline of medicine, the priest, shaman or witch-doctor represented the address for all ills.
In the last century, the practice of medicine has been totally transfigured by new drugs and new procedures. Life expectancy has climbed steadily from under fifty in 1900, more than sixty by the 1930s, and has reached over 80 (in 2013) in quite a number of developed countries. However, with this incredible transformation, aided by undreamed-of technological advances, has come a distancing between the patient and the physician.

In a TED Talk from 2011 by Dr Abraham Verghese, who is a physician and an author (Professor for the Theory and Practice of Medicine at Stanford University Medical School and Senior Associate Chair of the Department of Internal Medicine), he addresses this loss of contact which is so emphasized in our parasha.
Dr Verghese bemoans the replacement of physically examining and talking to the patient, with batteries of tests. He says, “I am not a Luddite. I teach at Stanford. I’m a physician practicing with cutting-edge technology. But I’d like to make the case …that when we shortcut the physical exam, when we lean towards ordering tests instead of talking to and examining the patient, we not only overlook simple diagnoses that can be diagnosed at a treatable, early stage, but we’re losing much more than that. We’re losing a ritual. We’re losing a ritual that I believe is transformative, transcendent, and is at the heart of the patient-physician relationship.” Dr Verghese suggests that “the most important innovation, I think, in medicine to come in the next 10 years… is the power of the human hand — to touch, to comfort, to diagnose and to bring about treatment.” In his novel, Cutting for Stone, one character asks, “Tell us please, what treatment in an emergency is administered by ear?” and the response is “Words of comfort.”
Dr Verghese compares the ward rounds during which he and other students accompanied the senior physician and went from bed to bed examining and talking to the patients, with the situation so common today, where the patient is discussed in a separate room, reduced to data and images on a computer screen. He says, “…the patient in the bed has almost become an icon for the real patient who’s in the computer. I’ve actually coined a term for that entity in the computer. I call it the iPatient. The iPatient is getting wonderful care all across America. The real patient often wonders, Where is everyone? When are they going to come by and explain things to me? Who’s in charge? There’s a real disjunction between the patient’s perception and our own perceptions as physicians of the best medical care.”
Dr Verghese was influenced by his experience with patients with chronic fatigue. He notes that these are difficult patients: in addition to their symptoms, they have often suffered rejection by their families and have not been helped by the medical profession and thus have low expectations of this next physician. He says, “…I learned very early on with my first patient that I could not do justice to this very complicated patient with all the records they were bringing in a new patient visit of 45 minutes. There was just no way. And if I tried, I’d disappoint them.
“And so I hit on this method where I invited the patient to tell me the story for their entire first visit, and I tried not to interrupt them. We know the average American physician interrupts their patient in 14 seconds. And if I ever get to heaven, it will be because I held my peace for 45 minutes and did not interrupt my patient. I then scheduled the physical exam for two weeks hence, and when the patient came for the physical, I was able to do a thorough physical, because I had nothing else to do. I like to think that I do a thorough physical exam, but because the whole visit was now about the physical, I could do an extraordinarily thorough exam.”
He recalls that his very first patient continued to tell more of his history in the second session, but as Dr Verghese slipped into his “ritual” examination, the patient gradually became quiet. He continuues, “And I remember having a very eerie sense that the patient and I had slipped back into a primitive ritual in which I had a role and the patient had a role. And when I was done, the patient said to me with some awe, “I have never been examined like this before.” He recognized that something important had occurred in the exchange, so he consulted with his colleagues in the Anthropology Department at Stanford. “…they immediately said to me, “Well you are describing a classic ritual.” And they helped me understand that rituals are all about transformation.”
Dr Verghese concludes by relating that in the early days of HIV, before the advent of drugs that transformed the treatment of the disease, he would attend his patients in the last days of their lives. He reads a passage that he wrote, describing such a scene, in which the skeletal patient, unable to talk, weakly points at his chest, inviting Dr Verghese to examine him one more time. “It was an offering, an invitation. I did not decline.
“I percussed. I palpated. I listened to the chest. I think he surely must have known by then that it was vital for me just as it was necessary for him. Neither of us could skip this ritual, which had nothing to do with detecting rales in the lung, or finding the gallop rhythm of heart failure. No, this ritual was about the one message that physicians have needed to convey to their patients. Although, God knows, of late, in our hubris, we seem to have drifted away. We seem to have forgotten – as though, with the explosion of knowledge, the whole human genome mapped out at our feet, we are lulled into inattention, forgetting that the ritual is cathartic to the physician, necessary for the patient – forgetting that the ritual has meaning and a singular message to convey to the patient.
“And the message, which I didn’t fully understand then, even as I delivered it, and which I understand better now is this: I will always, always, always be there. I will see you through this. I will never abandon you. I will be with you through the end.”


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