[dropcap]T[/dropcap]ouch is an essential part of the doctor-patient relationship. On a very basic level, it is assumed that the doctor will touch the patient during the physical exam, in an effort to discover the source of the patient’s symptoms. But there are also other forms of touch that can be healing and comforting when the patient receives them from the doctor in an appropriate, well-intentioned, and meaningful way. Touch in medicine can foster communication, connection, and support for the patient. In today’s world of modern medicine, touch is often neglected, ignored, or purposely avoided, all to the detriment of the patient and the doctor. There are many who feel that touch should be reintroduced into the medical encounter because of its potential to make a difference in both the patient’s and the doctor’s experience.
The physical exam itself is an essential part of the patient’s visit and does involve touching the patient. Because of the phenomenal advances in medical technology that can visualize, probe, and elucidate abnormalities, the physical exam can frequently take a backseat in the patient’s workup and evaluation. But a lot can still be learned and discovered during a good and focused physical exam. This fact is emphasized by Abraham Verghese, M.D. in article that appeared in the NY Times on October 11, 2010 entitled Physician Revives a Dying Art:The Physical. Dr. Verghese, who is Professor for the Theory and Practice of Medicine at Stanford University Medical School and Senior Associate Chair of the Department of Internal Medicine, feels that the physical exam is a lost art and that medical schools have “let the exam slide,” resulting in less development of examination skills in medical education and training. He is on a mission to “save the physical exam because it seems to be wasting away….in an era of CT, ultrasound, MRI, countless lab tests, and doctor visits that whip by like speed dates.” Dr. Verghese emphasizes that a good physical exam can give helpful information about possible diagnoses and a sense of direction as to how a patient workup should proceed and which studies to order.
Some radiologists have told me that X-rays and other radiographic studies, such as CT and MRI, are ordered in the hospital today without a physical exam even being done first. This practice does not help the radiologist evaluate the test results; it is also an example of keeping the patient at a distance and not incorporating physical findings into decision making. Years and generations ago, when there was not the technology we have today, doctors relied on a skillful exam with lots of nuances to help determine the cause of the patient’s physical problem. And those physical exams involved extensive and thorough touching of the patient.
I heard Dr. Verghese speak at the 5th Annual Medical Spirituality Conference at the Boonshoft School of Medicine at Wright State University in Dayton, Ohio in 2013. One of his most cogent statements was, “The most powerful instrument in our armamentarium is the hand… Not only does the hand explore the patient’s body looking for signs and findings, but by doing that, the patient perceives that the doctor is looking for answers and trying to help. This in itself is therapeutic and creates a bond between the physician and the patient. This cannot happen without touching the patient.” During that talk, Dr. Verghese made another observation that I thought was very insightful – “The ritual of the physical exam preserves the embodied identity of the patient. It validates the patient’s complaint…” Technology, for all its advances and amazing capabilities, cannot give the patient the same sense that he/she really matters as an individual, as perceived by the doctor doing the exam.
All of the above certainly emphasizes the necessity of touching the patient, when the patient has physical symptoms and complaints. But what about touching the patient during a physical exam when the patient is in for a wellness visit and has no symptoms or complaints?
Dr. Danielle Ofri, Associate Professor of Medicine at the New York University School of Medicine and a physician at New York’s Bellevue Hospital, wrote an interesting article in the NY Times (August 2, 2010) entitled Not on the Doctor’s Checklist, but Touch Matters. She relates a clinical encounter with a healthy middle aged female who was a new patient. Dr. Ofri asked all the required questions: patient’s lifestyle, work history, exercise pattern, flu shots, colonoscopy history, family history, domestic violence screen, and mental health status. Blood pressure was taken as well, and so all that scientific medical guidelines suggest as being important for a healthy person was done. The patient, however, responded with a “quizzical look” and appeared dissatisfied. Dr. Ofri then realized “A doctor’s visit is not a doctor’s visit until the stethoscope has probed the inner rhythms of the heart, and a set of medical hands has palpated the belly. Research has shown that patients expect a physical exam.”
While there is little evidence that a physical exam can pick up abnormalities in a patient with no symptoms, although there are many anecdotes where that has actually happened, and, as Dr. Ofri points out, there is no guarantee that a normal physical exam rules out any underlying disease, Dr. Ofri’s healthy patient would not have felt that her visit was complete without a physical exam. Dr. Ofri comments, “There clearly is something special, even healing, about touch.” She goes on to notice that by doing a physical exam, the tone of the interaction moves from businesslike to more intimate. Dr. Ofri concludes, “Touch is inherently humanizing, and for a doctor-patient relationship to have meaning beyond that of a business interaction, there needs to be trust – on both ends…One of the most basic ways to establish trust is to touch.” In an era where, to many, medicine seems to have become a business, this is an important observation. Touch and the physical exam are an integral part of the doctor-patient relationship.
There is another aspect of touch besides the information it might gain and the trust it might establish through the physical exam. Touch also provides a way for a doctor to communicate with a patient. In a Letter to the Editor in response to an article on teaching the core physical exam to medical students, Drs. Martina Kelly and Wendy Fink, from the Department of Family Medicine at the University of Calgary, wrote about “the interpersonal nature of physical examination.” (Academic Medicine, October, 2014, Volume 89, Issue 10, p.1314) They suggest that instead of a physical exam being done “on” a patient, the physical exam should be done “with” a patient. They go on to say, “Physical examination is not only a process of information gathering, technique, or hypothesis testing; it is an important form of communication and a key element in the delivery of patient-centered care.” The authors also emphasize that human touch is a key element of the physical exam. And, “Touch is a dominant form of nonverbal communication used in clinical care.”
To further explore the idea of the physical exam as part of a communication process, Drs. Kelly and Fink comment on how the doctor not only looks for physical findings, but also can notice “the patient’s comfort and emotional state.” In turn, the authors comment on how the patient can respond to the physical exam by looking at the doctor’s facial expressions or noticing the pressure exerted by the examiner’s hand and whether there is “gentleness” or not. They conclude by proposing a “…wider consideration of physical exam teaching that moves beyond the technical to include the human experience.”
Research in the field of touch has shown that touch can communicate a wide range of human emotions. In particular, Dr. Matt Hertenstein in a study at the University of California, Berkeley, has shown that human subjects can communicate compassion purely through touch. What a doctor communicates by the way that he/she touches a patient can play a significant role in establishing a good doctor-patient relationship that involves caring on the physician’s part and trust on the patient’s part.
Touch is also a means of connection between a doctor and a patient. As Dr Abraham Verghese so simply and elegantly states, “Touch is so much more than touch.” (Health Affairs, July/August 2009, Volume 28, Number 4, pgs 1177-82) To allow a doctor to touch his/her body during the physical exam, the patient must give permission. This involves trust on the patient’s part, but it also grants the doctor a real privilege. This process allows for a connection based on the fact that the doctor is trying to help answer questions and relieve suffering, when possible. When a patient is ill and in need of help and support, the attentiveness of the doctor, when fully focused, can thus create a very strong bond with the patient because of this understanding. Dr Verghese actually mentions in the above article that “When we are sick, we become infantilized; we seek the reassuring touch of the surrogate father and mother.”
The connection through touch can be transformative for the doctor as well as for the patient. Dr Verghese mentions a “sacred space” that can be entered by both patient and doctor by virtue of the physical exam and the touch that is part of it. As an example, he relates how as an infectious disease specialist taking care of AIDS patients during the early epidemic before there were good suppressive medications, there was little he could do for many patients other than doing a physical exam, even as they were close to death. And yet this act was reassuring to the patients and gave them comfort, because Dr. Verghese was conveying that he was there for the patients and would still be there no matter what. That can, indeed, be a very transforming experience for both sides, even in the face of medical powerlessness. Connection through touch can overcome isolation, even under desperate circumstances.
Touch can provide comfort and even healing for a patient. The holding of a patient’s hand, the gentle touch of a healthcare professional on a patient’s shoulder, a hug, when permitted, if things are going badly or there has been a loss: these actions can be so comforting during an illness. We are such a touch-phobic society, and also a litigious one, and so often touch in medicine is held back, when it can actually be so meaningful. The caring, compassion, and support that could be conveyed by simple touch can be very healing. Studies have shown the positive effects of touch on bolstering the immune system, lowering blood pressure, reducing stress, and easing depression. Beyond those physical effects, the positive emotional effects of touch can give the patient a sense that the healthcare professional is there for the patient, as evidenced by Dr. Verghese’s interaction with his dying AIDS patients, mentioned above. Healing is much more than taking care of the physical problems a patient may have. The emotional wounds of an illness and the anxiety and spiritual distress an illness can provoke also need attention. In a good doctor-patient relationship, the bond between the two participants can contribute to the emotional and spiritual healing as well, and touch, when respectful and allowed, can foster that healing.
Norman Cousins, the well known writer and editor, summarized the potential of touch when he said, “The physician celebrates computerized tomography. The patient celebrates the outstretched hand.” Whether through the touch of the physical exam or the reassuring touch of the physician when lending support or showing caring and concern, the power of human touch is a crucial part of the doctor-patient relationship and medical practice itself.
Finally, I think a very moving and meaningful example of the power of human touch is medicine can be found in an article, entitled In the Hands of Another, written by Daniel Webb Markwalter in The Journal of the American Medical Association (JAMA, Volume 313, Number 9, pgs. 899-900, March 3, 2015). Mr. Markwalter, currently a medical student, had a cardiac arrest while in the hospital for septic shock less than a year before he started medical school. He clearly describes the searing pain and burning he felt and the terrifying shortness of breath he experienced, all related to this traumatic event. As he put it, “I am engulfed in pain and consumed by fear.” And then he feels a hand firmly gripping his left hand and hears words of comfort and encouragement. He describes the hand as “a lifeline, tossed into my ocean of terror…It replaces all that I lack – oxygen, strength, peace. It gives me hope. I am not alone.” The owner of the hands lets go and then soon grabs Mr. Markwalter’s other hand while telling him to keep breathing. The author/patient then comments, “I need that hand. It tells me that I am not alone in this. I do not have to remain adrift and unaccompanied.” He then decides to fight for his survival, knowing that “with the firm grasp of that hand and the deliberate tone of that voice, I will not be left to die.” In looking back on his terrifying experience, one of his most vivid memories is “the soothing hand that led me to safety.”
Mr. Markwalter doesn’t find out until later that the person who held his hand was a respiratory therapist and not a doctor or nurse, as he had imagined. In one of the most telling statements of the article, he comments, regarding the therapist, that after the code was over, “…she sifted through the medicine to find the person.” Mr. Markwalter goes on to discuss how empathy and compassion can be conveyed to a patient and concludes that it does not have to be by grand gestures or calculated words. Sometimes, he comments, “All you need to do is extend a hand.” This is certainly a testimony to the power of respectful touch in medical practice and the possibility of connection and healing that it generates.
Donald M. Friedman, M.D.
Spirituality and Healthcare