The sensitive topic of physical contact during exams

Touch is a sensitive thing. No pun is intended here, but whether and how we touch our patients deserves our careful thought and deliberation.

So much interpersonal contact these days is virtual, with emojis, abbreviations and whole words thrown around as substitutes for human contact. Think XOXO and, “hugs and kisses.” And when people do touch in our health care environment, it is often with gloves, even for simple fingerstick blood sugars, immunizations or routine ambulance transports.

Shaking hands when you meet a patient for the first time is not standard procedure by any means. I wonder if it shouldn’t be in this country. There’s a lot of cultural history behind such a simple gesture.

When I examine a patient, I often start by listening to their heart. I do this sitting, and I almost always do this through their shirt or blouse. For my purposes, I’m able to hear what I need to hear through one thin layer of clothing; these days we tend to get an echocardiogram anyway if we hear or suspect that a murmur is present.

Listening to the heart is something so expected that almost no one is surprised, intimidated, or offended by it. As I do this, I often put my left hand on the patient’s back as I press my stethoscope a little firmer against the patient’s chest with my right hand. This does give me a better chance to hear, and it prevents the patient from moving away subconsciously from my stethoscope. It also creates a sort of clinical embrace as I, still fairly lightly and very clinically and professionally put their body between my two hands.

Listening to someone’s lungs, whether I do it through a thin layer of clothing, which I sometimes do, or after asking permission to pull a shirt or blouse up on the back, I don’t also touch the back with my hands while I listen to the lungs.

If, in doing a review of systems, the topic of leg swelling comes up, I often start my exam checking thereby first lightly touching and then pressing with my finger for pitting edema. This is a non-threatening place to start touching a patient, and it feels natural as part of the history taking.

After either of those two initial exam points, I do what everyone does, although I will point out that I don’t wear gloves unless I am doing a genital or rectal exam or perhaps examining an Ebola suspect or something else that might be dreadfully contagious. I have known doctors who wear gloves for every patient visit, and I think that does not help in gaining anybody’s trust or confidence in you.

Social touching I don’t do much of. I often shake hands at the end of a visit, and I only occasionally put my hand on somebody’s leg, arm, or shoulder. The reason is that I’m not a very gregarious person, and I wouldn’t feel that being socially touched by me would seem natural in most cases. I do make a point of “touching” people in spirit, by talking about their personal concerns and sometimes sharing my interests, joys, or experiences.

The more I feel that we have a personal connection, the more likely I would be to place my hand on an arm or shoulder, and the less we connect in words or “energy,” the less likely I am to touch someone in a social way.

I find that by being “open” as a person, patients are likely to initiate social physical contact with me, and that’s easier to navigate.

But I do feel awkward if during a visit with a patient there isn’t even a brief clinical physical contact, and I have heard so many patients speak of other doctors with the words “he didn’t even touch me.” I feel strongly that even a small amount of physical contact can cement the therapeutic alliance between doctor and patient.

As I renewed my Maine medical license the other day, I had to answer questions about what is proper and improper physical contact between doctor and patient. I answered correctly the multiple-choice questions about kissing and about having affairs when the patient initiates them.

It’s sad to think that someone would have to formulate questions like that for licensing adults who are supposed to be among the most trusted professionals in our society.

Hans Duvefelt, also known as “A Country Doctor,” is a family physician who blogs at A Country Doctor Writes:.

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