Night Shift

I once knew an emergency physician who would do anything he could to avoid touching his patients. It wasn’t that he was afraid of getting or giving an infectious disease. At least I don’t think so. It seemed to go much deeper than that. Even when infection was not at issue, such as when he palpated the patient’s anterior abdomen, he would carefully cover the patient’s skin with a Kleenex tissue so that no part of his skin would contact the patient’s. I don’t think he is practicing emergency medicine anymore. I think he went on to a radiology residency where he could sit alone in a quiet dark room, never seeing, let alone touching, a real human being.

I don’t say this in criticism. 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 gown 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.

In certain areas of the Middle East, there is such a premium on modesty that a physician is not allowed to see his patients, except through a small hole in a blanket that is hung between them. He never sees the whole patient and is barely able to touch the patient at all.

In America we have a very similar problem, but it is expressed in a very different manner. The patient is totally disrobed, yet we may never really see them. In today’s environment of rapid triage, order sets, rapid referrals, and pre-printed discharge instructions, it is tempting to let the triage nurse or doctor take the history and order the labs. Then all you have to do is interpret the labs, X-rays, formulate a treatment plan, and write the discharge instructions or make the referral. This can be done, for the most part, from the quiet, sterile environment of the central station. In a world where having a medico-legally tight chart that captures all the possible charges is the priority, it is easy to miss seeing the whole patient much less really touching them.

‘Of course I touch the patient’, you might say. ‘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. ‘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,’ I used to tell myself. There may be an element of truth in it. But it may also miss a fundamental aspect of the doctor/patient relationship.

Let me give you an example. I used to know 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. I’ve even seen him stroke a patient’s hair. That may seem way too intimate for some, but it beats what I do many times, which is to sit across the room with my head buried in the chart asking questions and scribbling notes. I’ll bet at the end of the patient encounter, my friend knew a lot more about his patient than I did mine.

And his physical exam went the same way. He had developed a fine touch by closely observing the details of every exam. He could diagnose appendicitis with similar accuracy to CT, without the radiation, with very few labs, by simply listening to and observing the patient. He wasn’t perfect, of course, but when he was wrong, he had such a relationship with the patient that they seldom considered blaming him, much less suing.

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 the patient knew he meant it.

And before you jump to the conclusion that this guy was a real sugar daddy with the narcotics, 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. And he meant it! He wasn’t just disgusted with the junkies, like I so often am. 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’. It’s actually a variant of Chinese medicine called chi dong. They believe that the body gives off some kind of energy that the practitioner’s hands can line up, like an MRI, by passing the hands over an injured area. And believe it or not, some hospitals 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, we will eventually be replaced by speech recognition programs. And if touching is no more than colliding or coordinating energy ways that are interpreted by our neural pathways, we will be replaced by some sort of supersensitive scanner. But I don’t think that will happen unless we allow it by losing the skills that make us indispensable.

So why all the ‘touchy-feely’ talk? It’s July. Graduation from medical school is over and the first year EM residents are arriving. It’s time for them to become real doctors treating real patients. They know the basic science. Now it’s time for them to learn the art. What will we teach them? Will it be all science? Learn this lab test. Read this scan. Will we teach them to look at their patients through an intellectual ‘hole in the blanket’? Or will we encourage them to touch their patients, skin to skin, human to human. It is easy to get so caught up in the details of lab tests and X-rays, best evidence and the latest research that we forget that the patient is another human being. My advice to the new residents? When you meet your first patient, shake their hand. But then hold it a second longer. Look into the patient’s eyes. And when you ask them how they are doing, really listen. It’s great to be an emergency physician. Enjoy it.


# AwesomeSam Ko 2008-07-04 04:40
This post rings true to me. I'm a first year EM resident and will be sure to use touch to connect with patients. Thanks for the reminder.
# attending physicianDr Sourbutt 2008-07-08 23:56
Mark I get it...but do they sometimes think you are messing with them when you won't turn their hand loose? (especially when you are larger than they are e.g.6'8", 280#) Also here in the South gentlemen generally don't extend their hand to a female unless she initiates the gesture
# The Power of TouchDr Plaster 2008-07-09 13:14
I'm not suggesting anything kinky here. Sensitivity is always the key. And, of course, I would never suggest doing anything that could be interpreted as a 'come on' to the opposite sex. I'm simply suggesting that 'appropriate touching' is still a part of the healing process. Maybe it's a hand on the shoulder. But more than once I have hugged someone while they wept for a lost loved one. You are right. You must be sensitive to the culture and local customs. But we must not be afraid to step into the patient's world. Ask permission, if we must, but step up.
# touchingabdurrahman 2008-07-19 11:55
I can't agree less , considering the the amount of lierature and science that we have to digest to become well-rounded and uptodate , and after all this effort , someone will see u need to touch , guys give us a break we already drowning in the ocean of medical knowledge and sceince and now we need to learn to be intimate and touching .
what next in this overwhlming profession
# MDJolie Pfahler 2008-07-27 07:36
Thanks for the great comments Mark! I have tried to learn some "good touch therapy" when I have had a massage at a spa. Not that I massage patients. But any time a masseuse moves around a table, she/he places a hand on the client's leg or foot and then moves. This is a nice touch and a way to show the patient where you are and where you are going. I often touch or just place my hand on a patient's leg (below the knee) or on their shoulder. This seems comforting without being intimate or intrusive.
I find the science of ER to be the easy part (or easier part). The hard, important part of ER is relating, gaining trust and communicating. Otherwise, I would have been a surgeon.

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