Touch humanizes the doctor patient relationship

I’ve written previously that many doctors are finding the physical exam obsolete, and are favoring more technologically advanced, and expensive, tests.

In fact, I alluded to traditional physical exam advocates as “arguing for staying with a horse and buggy when cars are rapidly becoming available.”

In a recent piece from the New York Times, internist Danielle Ofri says we need to look past the lack of evidence supporting the physical exam. The benefits of touching the patient, and listening to his heart and lungs, cannot be quantitatively measured:

Does the physical exam serve any other purpose? The doctor-patient relationship is fundamentally different from, say, the accountant-client relationship. The laying on of hands sets medical practitioners apart from their counterparts in the business world. Despite the inroads of evidence-based medicine, M.R.I.s, angiograms and PET scanners, there is clearly something special, perhaps even healing, about touch. There is a warmth of connection that supersedes anything intellectual, and that connection goes both ways in the doctor-patient relationship.

Great point.  She continues, saying that,

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. As has been proved in newborn nurseries, and intuited by most doctors, nurses and patients, one of the most basic ways to establish trust is to touch.

Although some doctors — myself included, at times — may dismiss the much of the physical exam as data-bereft relics of the past, listening to a patient’s heart and lungs, palpating the abdomen, and looking into the eyes and ears, is in part what separates physicians from being test-ordering, guideline-following automatons.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • HJ

    “The laying on of hands sets medical practitioners apart from their counterparts in the business world. ”

    I am frequently reminded that I am a health care consumer and the free market will solve all our problems. So how much are you going to charge for this laying on of hands? Since it there is no evidence it improves my health, why would I want to pay for it?

  • http://secondbasedispatch.com Jackie Fox

    I think you summed it up perfectly with “the laying on of hands.” I’m always in wonderment at how you can “read” us that way. And I’d like to expand on how important “non-exam” touching is too. I never had surgery in my life until I found myself having five breast cancer surgeries in eight months. My general surgeon always rubbed my arm or took my hand when he came in to visit while I was being prepped. The day of the big “M,” he came over and put his arm around me. I wish I could convey just how powerful and comforting that simple gesture was.

    Thank you for the great post.

  • anonymous

    There is so much information about a person’s health that can be gleaned by a doctor who is acutely aware and takes the time to touch, listen, smell, and observe—but only if they are thoroughly trained to do so or learn through their own practice. I’ve heard that doctors of traditional Chinese medicine can discriminate between dozens of different patterns in patients’ pulses. (Regardless of what you may think of TCM, this is an impressive hands-on skill.) Dogs can apparently detect early-stage lung, breast, and ovarian cancers by a patient’s scent alone.

    Okay, so humans will never have as good a sense of smell as dogs, but the point is that important information about a patient IS potentially available via the senses. If you’re not taught these hands-on evaluation techniques and if you don’t value them enough to take the time to do them well, I imagine they will increasingly strike you as useless. High-tech tests may be just as good as a doctor’s keen touch and observation, even better in some instances, but these tests are often expensive, time consuming (from the patient’s point of view), and risky for the patient, so the more a doctor can learn by directly interacting with a patient, the better.

    I’m only arguing for the technical value of a hands-on exam. I don’t necessarily value it as a marker of the medical profession or a way to build a relationship. A doctor can touch a patient in a comforting way without disguising it as a lung or heart exam.

  • http://www.lovelessdo.com Brian Loveless, DO

    As an osteopath I spend my day with my hands on patients, in diagnosis and in treatment. Two things that continue to amaze me are how healing a trained, purposeful touch can be; and how often my peers fail to put their hands on a patient and make a diagnosis. A sad commentary, indeed.

  • Annie Stith (@Gr8fulAnnie)

    Hey, Kevin!

    E-Patient Annie, here. (Just letting you know from which perspective this comment comes.)

    I believe both types of doctor’s touch are important: the competent touch of examination, and the human touch of caring.

    My PCP does something I’ve never had another doctor do: when he walks in the exam room, he sets down my file then comes over and gives me a hug. (The initial visit, this was only at the end rather than also at the beginning, and he asked permission.)

    He regularly has students and Interns from the local medical schools and hospitals in for training and I’ve heard him explain why he hugs his patients. He’s said that, beyond the human connection, there are many things he can glean from a hug, among them: the state of relaxation or nervousness; whether (in general) muscles are tight with strain or pain; any odors about the patient; etc. He is also one who continues to use a physical exam.

    Between his hugs, physical exams, bedside manner and competence, he is one of the most popular PCP’s for those of us who may not get much physical contact, such as FM and other chronic pain patients, HIV/AIDS patients and their partners, and the lesbian/gay/bi/trans communities. He’s often not taking on new patients because his practice is thriving.

    Namasté

    Annie

  • J.T. Wenting

    As a patient, if a doctor seems to come to a diagnosis of my physical problems just by talking to me and browsing through files, I’m sceptical about his procedures.
    How the heck can he know I’ve a collapsed lung if he’s not used that stereoscope?
    Or that I’ve a hernia if he’s not even felt the lump in my back?

    Maybe he can, but the patient has learned over time to distrust his doctors because of the massive amount of malpractice coverage in the media (most of it indeed serious errors, if sometimes exagerrated) and personal experience.
    If the man (or woman) then seems to come to conclusions leading to serious consequences (including surgery and long term treatment) based on a casual talk and an internet search, why should I trust him?

    The physical exam is a way for the physician to show he knows his profession, even if he could do the job without by means the patient doesn’t understand.
    It puts the patient at ease, establishes that relation of trust and understanding.

  • http://drgrumpyinthehouse.blogspot.com/ Dr. Grumpy

    I routinely shake hands. And, more importantly, do exams. The neurological exam is often what guides me to where I need to be looking. Otherwise might as well just order MRI’s of the whole body.

  • Ana

    From the experiences I’ve had on both sides of the bed rail, as a nurse and also as a patient, I can assure you that caring touch is of the most profound importance. As a nurse, touch allows me to assess my patient on a number of levels – most esp. physical, emotional. AND they appreciate it, esp. when in pain that is prolonged and hard to control. Touch can calm a patient and, as noted, build trust between caregiver and patient. It conveys warmth and compassion on the part of the provider and gives some valuable info about the patient’s state. I’ve had patients, too many to enumerate, who have told me that they have felt love and kindness coming through my hands; some have even especially asked for me to be assigned to care for them in the ICU and CCU when I was on duty because for some reason, my touch during my ministrations to them, calmed and quieted them, esp during bouts of pain, anxiety and misery. I’ve always considered this a real gift and have treasured my patients’ trust in me. It made all the other crap in health care nowadays (read bureaucracy!) worth it somehow. That was why I became a nurse in the first place : to heal, to soothe suffering, to help people cope when suffering couldn’t be completely mitigated or an ailment couldn’t be cured.

    As for myself, I can also absolutely insist that the compassionate, caring touch of health care providers is vital to a patients well-being. I’ve been to both types of doctors. . .the kind who take the time and care to touch, whether by a greeting hug or a farewell hug, or both, as well as using the stethescope to listen to heart and lungs, or rubbing a shoulder or arm, taking a hand in theirs, and also the impersonal type who sit across the room from you, never approach you or touch you in any way other than the business-like handshake when entering the room. I really hate the second type!! And so many patients I know do as well. I’ve even considered leaving my primary care physician because he’s one of the latter. Despite the fact that he has given me good care technically, he has managed to do so without ever touching me in the 4 years I’ve been seeing him. I am very discontent with this situation. In the past, every doctor I’ve had in my life has always touched me in a kind and caring manner, held my hand on occasion, inquired about my family, wanted to know if there was anything worrying me at the time, or if there was anything really good that may have occurred in my life recently. In general, others of my physicians do still perform the chest exam and pat my arm on occasion and I don’t mind seeing them on F/U visits because I appreciate the gesture. Please take note, physicians, allow your humanity to show through, not just in your occasional crabbiness, but in your compassion and caring as well.
    Thanks

  • Hexanchus

    Ana,

    Guess we’re polar opposites. I am extremely uncomfortable with any physical contact from strangers that goes beyond a formal handshake. Anyone that feels the need to touch me had better both tell me ahead of time and ask my permission. Sans my permission, I consider it a serious violation of my personal space and will not tolerate it.

    It can also be a cultural issue – in some cultures being touched by strangers is a grievous insult. It’s always better to ask first.

  • Emotionalintelligence

    As the child of a parent with early onset Alzheimer’s I can only say that a physician’s capacity for true empathy is a life-saver. Our family went from a “cold fish” of an expert to a gerontologist in her mid-50′s. Caring, patient, she listened, even winced. At the end of our initial appointment she apologized for the crappy hand life had dealt us, gave us a hug and made a promise to us to be there for us and our mother until the end. We have been ecstatic with the level of care ever since.

  • Dave Mittman, PA

    I have been a PA forever 35 years. Touch matters. It may be a hand on the shoulder or it may be a hug, put it is a primal way people know you care for them. I may be a bit grey but a good history and physical with a look in the eye and a nod that says I care means more than anything else we can do.
    Dave

  • http://www.talktoyourunconscious.wordpress.com BobBapaso

    If we had stuck with the horse and buggy, and other technology of the time, we would not have global warming and pollution. If we don’t do a good history and physical today’s technology has no guidance, and is wasted.

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