I once knew an emergency physician who would do anything he could to avoid touching his patients. In today’s environment of contagious disease he might be considered ahead of his time. But it wasn’t that he was afraid of getting or giving an infectious disease or even being afraid of touching a patient so much as he was afraid of being touched.
Emergency medicine just wasn’t a good fit for him. Real emergency physicians can’t be afraid to touch their patients, head to toe, inside and out, clean or dirty. This is not a specialty for the squeamish. Nor do I mean to say that I ignore universal precautions. I wear a mask, gloves and gowns any and every time that they are indicated. No, what I’m getting at is the tendency to stand off and examine the patient from afar. Not literally from afar, though I did know a physician once who would shine his flashlight from across the room to look into his patient’s throats. I’m talking about examining a patient from the standpoint of detachment.
While I hold in high regard the respect that shows for the vulnerability of the patient, there can also be barriers. Yes, the patient could be totally disrobed, but we may never really “see” them. There is a very efficient systems triage patients according to a standard form, with standard questions. “Score your pain from one to ten,” we ask.
According to the patient’s answers we get a standard set of labs and x-rays. The doctor will confirm the information on the forms, perform a cursory exam, look at the labs and x-rays, and dispose of the patient using either a standard set of admission orders or a pre-printed set of home-going instructions. The end result is a well documented chart than can withstand the assault of the most tenacious tort lawyer while also pleasing the administration with a chart that captures all the possible charges. But the system can also cause the physician to miss seeing the whole patient much less really touching them.
‘Of course, I touch the patient,’ my colleagues will say when challenged on the point. ‘I look into their throats; I feel their necks, listen to the chests.’ And I’m sure that’s true. We all have to touch, and probe, and cut, and sew our patients. And that touching is sometimes not very pleasant — for us or for them. So we even train ourselves to be somewhat detached. When I was a young physician with sweaty palms and a racing heart I used to tell myself ‘If I care too much about hurting the patient, I won’t be able to do what I need to do or I might miss something important.’ And the truth is that there may have been an element of truth in it. But that sort of detachment may also lead to missing a fundamental aspect of the doctor/patient relationship.
I once knew a doctor who, when he spoke to a patient, particularly the very sick and dying, he would hold their hand. Not just a long handshake. He would stand at the bedside and hold their hand. Today such behavior might rightly be considered an infection risk to the patient.
Consider the fact that many patients today will never see the covered face of their caregiver, unless he or she is wearing a clear shield, and can never see a look of caring or concern on that face. And if it’s not the mask hiding my face from the patient, it is the bedside computer that hides the human side of me. I’m not advocating for breaking rules on infection control in the interest of human connection. I’m simply noting that we must overcome the barriers, shields and gowns to really see our patients.
And his physical exam went the same way. He had developed a fine touch by closely observing the details of every exam. His exam was slow and gentle, analyzing the patient’s slightest reaction to his probing while relying on fewer lab tests and x-rays. He could diagnose appendicitis with similar accuracy to CT, without all the radiation. He had such a relationship with the patient that they seldom considered blaming him if things went badly, much less suing. They seemed to see him as human, even a friend, not just a technician.
Even more than getting a better diagnosis, touching goes a long way toward starting the healing process. When a patient would tell my mentor about something that was painful or worrisome, if he wasn’t already touching them, he would reach out and take a hand or shoulder and say something like “I’m really sorry. That sounds like it really hurts.” I know that sounds hokey, but he really meant it and patients knew he meant it. Social distancing doesn’t have to be emotional distancing.
I can just see all my colleagues rolling their eyes as they assume that this guy was an easy mark for every whiney patient looking for a little sympathy and a lot of narcotics. But he wasn’t. He seldom wrote for big time analgesics. When it was appropriate, of course, he would. But he didn’t have to prove he cared by giving inappropriate doses of opiates. If he thought narcotics addiction was a potential problem, he would say so, and explain that he couldn’t do that to the patient. It wasn’t that he was disgusted with the junkies, like so many providers often are, but more that he really cared for them and didn’t want to hurt them further. And believe it or not, they usually bought it.
Some people have tried to make touching patients into a science itself. It’s called ‘touch therapy.’ Practitioners of this ‘science’ believe that the body gives off some kind of energy that the ‘therapists’ hands can line up, like an MRI, by passing the hands over an injured area. It is an attempt to touch the patient without actually touching them. And believe it or not, until recently some hospitals, mostly in California, are actually providing this as a therapeutic modality.
But science has a way of taking the humanity out of everything. If listening is nothing more than interpreting the sounds that a patient makes, care givers will eventually be replaced by speech recognition programs. And if touching is no more than coordinating energy waves that are interpreted by our electro-neural pathways, we will be replaced by some sort of supersensitive scanner. But this will only happen if we allow it; if we lose the very skills that make us indispensable.
It’s true that when my next patient comes in with cardiac arrest, I’ll need to know the chemistry and physics, the anatomy and physiology, to get that heart started again. And if there is a risk of infectious disease this will all be done wearing the latest barrier suits and respirators. But that is not all there is to being an emergency physician.
I’ll need to find a way to hold the hands, dry the eyes, or hold up his wife as she walks to his room. I’ll need to touch and care for the hearts of my own team, who put everything on the line to save a life. Barriers to infection, efficient and complete electronic records, and other improvements to care should not remove us from the patient and their suffering. As painful and messy as it might be, for the patient and for myself, that touch is important. We must find a way of accomplishing the task without undue risk to our patients or ourselves.
1 Comment
Thank you, Mark, for emphasizing the importance of touch, which to so many of us intimacy-averse ER docs feels like that place “where angels fear to tred.” What saddens me about your article is that there is any need to apologize for touching patients. We never call discussions of keeping a critical patient’s MAP above 65 “hokey,” for example, nor the use of tPA for strokes. Yet… when it comes to simple human touch, the clinical importance of which has been studied so thoroughly… the biases raise their ugly noggins. Oy. What fools we muggles be.
Thank you for a wonderful article.