Touch has been used in healing since ancient times. Touch can be a way of connecting with our patients, a way of expressing compassion. The tender holding of a hand or a gentle touch on a shoulder, can say a thousand words and our patients know that we care. That in itself can be healing, as long as we are honouring the body we touch.
Some consider the art of physical examination of less value than modern diagnostic techniques, but I believe that our patients, particularly our older patients, expect the ritual of examination to be a part of their visit to a doctor, knowing that if it is not done, something will be missed. A friend, who recently died from bowel cancer, had not been examined physically by the doctor she initially went to see complaining of a mass in her abdomen, delaying the diagnosis, perhaps too long. An ED colleague told me that often the diagnosis is missed by treating doctors because the clinical examination has not been thorough or has been omitted.
So, it is of vital importance that the art of clinical examination is not lost, replaced by investigations or in our hurry, simply not performed. The human body will tell us so much about what is wrong, both through history taking and examination. Couple this with exploring the patient’s psychological response to illness and their priorities for treatment, and we have a clearer understanding of our patient’s needs. Our amazing diagnostic technology can complement clinical acumen, but should never replace it.
Recently new guidelines on patient examination were published by the Australian Medical Board, discouraging unnecessary medical examination. The question to be answered is: what constitutes unnecessary examination? The major intent was outlining strict guidelines about inappropriate, particularly sexual, examination. With the full consent of a patient and appropriate sensitivity, a thorough clinical examination may reveal problems of which the clinician and possibly the patient were previously unaware.
How we go about examining our patients is of vital importance. No patient should feel in any way abused by an examination, no patient should feel degraded or embarrassed, no patient should experience unnecessary discomfort or pain. As students, we are taught the mechanisms of physical examination which we rely on to support our clinical reasoning. We are taught the fine nuances of neurological examination, the complexities of interpreting heart sounds and how to distinguish between skin lesions. Watching an experienced physician examine a patient can be likened to an artist at work, but in our training, are we taught to honour our patients’ bodies, to treat them always with dignity and tenderness and to have awareness of our patients’ fears and discomforts around being touched?
When I have been for a massage, my therapist sets her room so the temperature is just right, she uses aromatherapy to sweeten the air, she covers me in soft heated towels and covers my eyes with a warmed silk eye pillow. I feel safe and nurtured. I know that she will not judge my body, that she will not in any way hurt me. How different is this to the way many of us have been treated as patients, and how lovely it would be if we were all offered the same tender loving care, and offered it to and from ourselves.
I was interested to read a study which described teaching first year medical students to give a therapeutic massage to their fellow students. It had been set up for them to learn living musculoskeletal anatomy. The findings showed that integrating surface anatomy and massage therapy, in an experiential course, resulted not only in significant gains in their knowledge of anatomy, but increased understanding of inter-professional health roles, encouraged the development of greater comfort while administering physical examinations, increased confidence in clinical practice, and enhanced student well-being.
As they were also the recipients of massage, they would have developed an understanding of the importance of asking for consent and encouraging feedback if discomfort was experienced, of what is uncomfortable, of how they liked to be touched and communicated with, and of the different feeling in their own body if the masseur was rough, hurried or disengaged.
The experience of touch on our own body enhances our understanding of how best to touch others. Practising massage can encourage the students to become more aware of the non-verbal cues that may tell us if our patient is in physical or emotional discomfort and also removes the simple anxiety about touching another without all the stress of having to “get it right”.
In all of Medicine, but in particular when we touch another, we need to be aware of what we ourselves bring into the consultation. Are we able to be completely present with ourselves and with our patient, fully aware of all that they are saying or that their body is telling us, or are we distracted, impatient, hurried or judgemental? Are we concentrating fully on them or thinking of the last patient, an argument with a partner or the study we need to do? Is our own body distracting us, in pain, fatigued or suffering from a hangover?
We cannot underestimate the healing power of a tender touch, of a smile, a gentle word, but we need to be ever aware that our touch, our attitude and our words may also have the potential to be harmful. Touch may invoke a feeling of being nurtured, but in some it may invoke memories of past hurt or abuse. What may seem innocuous to us as clinicians may be an unpleasant trigger for our patients.
Asking for permission to touch, explaining the reasons for touch, reading body language, offering to suspend the examination if requested and at times avoiding examination when it will cause too much distress, are essential if we are to avoid in any way harming our patients. Negative experiences of doctors can lead to lasting distress and discourage patients from accessing the care they need.
Writer and physician Abraham Verghese talks of the importance of not by-passing the clinical examination, because in doing so we are losing a ritual that he believes is transformative, transcendent, and is at the heart of the patient/physician relationship. He goes on to talk of the power of touch in Medicine and that a physician’s hands may touch, comfort, diagnose and bring about treatment.
Touch may be healing if in that touch we honour, value and respect our patients and their bodies, and honour and care for our own hands and open the heart behind them.