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It’s Not a Proper Doctor’s Visit If Nobody Touches Me

August 2, 2010

Not too long ago, I went to see my primary care provider (a nurse-practitioner), and felt after the appointment that something was missing, that in some manner I did not receive proper and complete care. How was my experience incomplete? The lack of a physical exam. A nurse had taken my blood pressure (twice, actually), but never once did my NP actually lay a hand on me, nor was I ever on the exam table. There was no opening to say “aaaaahhhh,” no deep breaths on each side.

Nothing was *wrong* that prompted my visit. I just needed to talk to my provider about something I was experiencing and make a plan to deal with it. We had a conversation, face to face on equal footing (a positive, I think), about my concerns and a plan for tackling them. Logically, nothing about the reason I was there suggested a need to listen to my heart or lungs, or to look in my ears, nose, or throat. And yet, I still felt as though something was missing, as though something had been neglected.

Dr. Danielle Ofri writes about this very issue today in the New York Times, in the piece “Not on the Doctor’s Checklist, but Touch Matters.” She notes, of course, the very thing I had decided on my own – that the hands-on approach was not strictly necessary for my care. Ofri writes:

Despite a long and storied tradition, a physical exam is more a habit than a clinically proven method of picking up disease in asymptomatic people. There is scant evidence to suggest that routinely listening to every healthy person’s lungs, or pressing on every normal person’s liver, will find a disease that wasn’t suggested by the patient’s history. For a healthy person, an “abnormal finding” on physical exam is more likely to be a false positive than a real sign of illness.

I know all of this. I knew it at the time of my visit, and when I considered what felt absent afterward. I really like my NP, recommend her frequently, and have a comfortable working relationship with her with regards to my health. I was reminded, though, of this talk I went to by Dr. Abraham Verghese (author of My Own Country, and Cutting for Stone), and the emphasis he placed on touch, on ritual, on the difference between curing and healing, and the ability of physicians to heal the sense of violation of an injury or illness can bring through high-touch methods of engaging with the patient. Verghese’s words really rang true for me, and perhaps primed me to notice the lack of touch at my own provider visit in the first place.

As I noted in the Sunday round-up, Verghese was recently interviewed for PBS about this subject, and spoke about current Western medicine’s reliance “on technology, in a system that stresses cognitive knowledge and machines over the skill that comes from touch and feel.” Similarly, Ofri concludes 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. ..Which is why a doctor’s visit never feels complete without a physical exam. It is a crucial part of the doctor-patient relationship that cannot be underestimated. One doesn’t need a scientific study to prove that.

It’s comforting me in some way to have this absence I felt validated by physicians, even though my logical mind knows that there was no necessity for, no clinical diagnostic purpose which would have been served by, a look in my head and a listen to my chest. I’m not even a very touchy-feely person, so it’s unusual for me to give such matters a second thought. Perhaps it’s just the habit, the ritual, of those aaaahhhs and deep breaths. It’s observing the proper forms in a way, an opening in which I say, “I will let you into this space of mine, from where we can work on my health.” I can’t explain it in evidence-based scientific terms, but according to Ofri, I may not need to – the need for humanization through touch is, perhaps, enough of an explanation for us all.

8 Comments leave one →
  1. August 3, 2010 8:18 am

    I also heard Verghese’s interview and his take on touch. His novel, Cutting for Stone echoes the need for touch in that context as well. I’d probably share your sentiment as well, it seems pretty removed to have a visit without any physical exam. I may have to pay attention to that on my next visit to my doctor.

  2. Becky permalink
    August 3, 2010 9:35 am

    There was an interesting study done a few years ago that looked at public expectations for annual exams and what constitutes “good” or necessary preventive care from a patient perspective, published in the Annals of Internal Medicine. Interestingly, patient interest in related “routine” testing was moderated when the charges for those tests were included for the patient’s consideration –
    http://www.annals.org/content/136/9/652.long

    An editorial related to the article (http://www.annals.org/content/136/9/701.long) concludes “After seeing a physician, my grandmother would routinely gripe, “All he did was talk to me. He didn’t take his stethoscope out of his pocket or draw a drop of blood!” Was Grandma missing something of value? The regular laying-on of hands and stethoscope (and maybe phlebotomy needle, too) is not a needless ritual if it fosters trusting clinical relationships and ensures that patients receive effective counseling and preventive interventions. Annual examinations provide the opportunity to plug cracks in the system and assure that patients are getting indicated preventive care. While some say that we should abandon annual examinations and squeeze prevention into visits for other reasons, patients implore us not to.”

    • August 4, 2010 8:26 am

      Thanks for sharing those, I’ll have to give them a read!

  3. August 3, 2010 2:43 pm

    @ Walker

    Cutting for Stone is a beautiful book. Verghese is a brilliant physician and artist.

  4. Brian Wooton permalink
    August 3, 2010 5:50 pm

    From my end, I know that the odds on me picking up something on a physical exam that neither one of us expected to see or hear is a few times a year tops. I picked up a Charcot foot the patient didn’t know he had, but I expected to see it from what he told me.But that’s not what’s being referred to here.

    I always check heart and lungs because I know that’s what’s expected of me. I always put my hand on their shoulder. Maybe I should always do an HEENT, because we both know it’s for show, but it’s an important show.

    • August 4, 2010 8:25 am

      Brian , that’s the thing, isn’t it? I know it’s not strictly necessary, and usually not even that useful. And yet it still feels missing if it isn’t done.

      I would be interested in what you think about the time factors involved, too – when I was a kid, the providers I saw always did this as a routine at the beginning of each appointment. Does that happen now? If not, maybe people won’t expect it so much in the future.

  5. CountryMidwife permalink
    November 22, 2010 9:39 pm

    I’m late here, but I totally disagree — I think much of hands-on exam is ritualistic, and paternalistic too. WE medical providers know SO much more about your body than YOU. If you look at the USPSTF guidelines most are also specifically not evidence-based, meaning performing them is not beneficial in public health because early detection of problems does not change outcomes but only increases further intervention, cost and worry. Good health care is mostly counseling. If you’re coming for a pap and pills and report no health problems what is listening to your lungs REALLY gonna change? My two cents as a nurse-midwife anyhoo…

    • November 23, 2010 9:13 am

      Perhaps I didn’t convey it clearly in the post, but I *know* it’s not always strictly necessary or even useful. That’s what I meant to explain with: “my logical mind knows that there was no necessity for, no clinical diagnostic purpose which would have been served by, a look in my head and a listen to my chest.” And yet, it still feels like something is missing if it doesn’t happen.

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