Demystifying Medicine One Month at a Time

Touch me or Touch me not?

A tug-of-war is going on in medicine right now between the past and the future. The present is confused and very unsure of itself.

Though I could be writing about health care in the U.S and the looming Supreme Court battle over the new health care law (ACA), I’m actually raising a much more intimate issue: Whether your doctor touches (examines) you or not.

Many pundits have weighed in on whether the physical exam has utility in an age when we have machines that can look inside the body and evaluate its physiology as never before.

Others have suggested that regardless of an exam’s diagnostic capabilities, performing a physical has intrinsic value: connecting with patients. It’s what they (you) expect. Touch is inherently therapeutic and offers solace.

Medical schools still teach the ancient art of the the physical exam:

  • Inspection. Looking at the patient.
  • Palpation. Touching the patient.
  • Percussion. Tapping the patient’s torso (chest + abdomen) to locate organs and detect extra fluid if present.
  • Auscultation. Listening with our stethoscopes.

These artful skills originated as far back as Hippocrates (though it wasn’t until 1821 that Laennec invented the stethoscope).

Listen to the talk from Dr. Abraham Verghese (Stanford doctor and author of the novel Cutting for Stone) about the rise of the iPatient and his call to return to fundamentals–not only as good medicine but as effective and therapeutic medicine.

Contrast Dr. Verghese’s approach with the experience of Dr. Bryan Vartabedian, a gastroenterologist, blogger, and social media authority from Texas.

Dr. Vartabedian

Dr. V has a history of herniated lumbar disks. He visited an orthopedic surgeon for a consultation, and this is what he wrote about his visit:

…through the course of my visit he never touched me.  We spent an extraordinary amount of time examining my MRI.  Together in front of a large monitor we looked at every angle of my spine with me asking questions.  I could see first hand what had been keeping me up at night.  I could understand why certain positions make me comfortable.  What we drew from those images could never be determined with human hands.  In my experience as a patient, I consider it one of my most thorough exams.

[You can read the complete post here.]

The contrast between the two experiences and the reactions to them could not be more profound. It leaves me wondering what the most important elements of doctoring are to pass along to my trainees. Losing the physical exam seems blasphemous. Yet sometimes I’ll admit it feels more like hocus pocus than a meaningful endeavor.

What are your views? Is it necessary for a doctor to touch you on each visit? Is a yearly physical crucial? Would a consultation with a doctor be valuable if all you did was talk?

11 Comments

  1. Carolyn Thomas

    Thanks so much for sharing with us this brilliant perspective from Dr. Verghese. I can scarcely believe that some physicians are actually debating this ‘to touch or not to touch’ dilemma as if it were and either-or situation.

    Example: I was sent home from the E.R. in mid-heart attack with a GERD misdiagnosis, despite presenting with textbook MI symptoms like chest pain, nausea, sweating and pain radiating down my left arm. All of my cardiac diagnostic tests were “normal”. The E.R. doc did not once touch me or approach my gurney in the E.R. (or even bother to introduce himself to me) but he did pronounce quite clearly: “You’re in the right demographic for GERD – this is NOT your heart!”

    Fast forward several horrific days of increasingly debilitating symptoms (buy hey! at least I knew it wasn’t my heart!) and finally a desperate return to Emergency. This time, the on-call cardiologist was called in. He sat beside my bed, held my hand, listened to my heart, then told me he was going to try doing a little test on me, with my permission. He pushed very hard on my abdomen with both hands, while at the same time leaning forward to look closely at my neck, just below my ear. What he was doing was called an abdominojugular test (previously known as hepatojugular reflux) and here’s how it works:

    Healthy people undergoing an abdominojugular test will have a temporary increase in the internal jugular pulse for just a heartbeat or two before the venous pressure returns back to normal. But a skilled physician can observe in the sick patient’s earlobe pulse the characteristic double flicker of a sustained elevated jugular venous pressure – a sign of active or impending cardiac crisis. After 30 seconds, he stood up and told me: “You have significant heart disease.” I went directly from the E.R. to the O.R. that morning because of a heart attack caused by a fully-occluded LAD.

    This 30-second, non-invasive, simple and effective cardiac test is, apparently, rarely performed in the E.R. anymore.

    Why not?

    Instead, docs rely exclusively on diagnostic technology, which we’re increasingly learning can be less-than-reliable in many female heart patients (who tend to suffer both single-vessel coronary artery disease and non-obstructive disease far more frequently than men do). The New England Journal of Medicine reported, for example, that women under age 55 are SEVEN TIMES more likely to be misdiagnosed in mid-cardiac event and sent home from the E.R. compared to their male counterparts presenting with identical symptoms.

    Good medicine requires both – high-tech AND high-touch.

  2. Wayne T. Johnson

    I don’t think that theoretically, it’s an either/or situation. How would you like to deal with a post office clerk who didn’t speak or look at you? Or a clothing salesman who fitted you for a suit without confirming the lay of the fabric by brushing his hands over it?

    And — given that far more people than is probably realized live alone and really are alone in the world — routine diagnostic touching can be therepeutic, just as being able to talk with the doctor for a while is. Being touched is one of the differences between being recognized and being processed.

    In a clinical situation, there’s no point in questioning a baby or an unconscious patient. And when someone says “We’re just feeling our way along,” they mean that they are relying on a second-resort tactic. But that doesn’t invalidate touching. Indeed touching can convey an impression of caring, which is one reason for seeking care instead of just taking an asperin. WTJ

  3. Frances Dalton, MD

    Touch is often not diagnostically necessary, but a psychological imperative for a patient. I can sit back and diagnose a condition just by talking, but I KNOW the patient would feel cheated if I didn’t do those ancient arts. And I feel guilty! Like I’m giving incomplete treatment.

    Patients will often come from another provider and state they they didn’t so much as examine them. So, it’s important.

    The OTHER thing I do which is psycholgically important, and patients never see it coming but are pleased, is that if they have pain in the RIGHT ear, I tell them, “First let me look in the LEFT ear for comparison.” They feel this approach is very thorough. And quite frankly, it can be helpful to me sometimes.

  4. Jason Kahn

    Very inspiring talk, thanks for sharing! Also, as a primary care doc, somewhat intimidating. I cannot schedule two 45 minute visits, one for a history and one for a physical. I have found, after listening to this talk, that I am much more aware of the “ritual” of the laying on of hands and have tried to make this explicit duing my visits. I have felt the value. But the challenge of incorporating this wisdom in an era of increasing need for access, 15-30 minute visits, and “EMR”‘s will remain significant.

  5. Bohdan A Oryshkevich, MD, MPH

    The evidence clearly points out that there is no correlation between back pain and imaging. One operates on disk disease not to improve the MRI image but to relieve the symptoms, the functionality, and the long term prognosis. The MRI is only one factor in the process. The MRI does not necessarily correlate with clinical findings.

    That patient should have been examined.

    A baseline documentation of pain and dysfunctionality is FUNDAMENTALLY necessary to demonstrate that the patient was incapacitated by his condition and that the surgery was necessary or indicated. Operating on an MRI image with poor outcome is perfect grounds for a malpractice suit. If the surgeon in his defence can document that the patient was incapacitated (through a thorough physical exam), then he has a chance of defending himself. Redundant imaging (that has positive findings that have been ignored or acted upon in an inappropriate manner) and testing which is then either ignored or acted upon in an inappropriate manner are leading grounds for malpractice.

    Clearly technology has helped. But it also has a cost, not financial but in the alteration of practice. We have not yet adjusted to it.

    Imaging cannot be everywhere. It is expensive and it takes time. So one has to maintain skills and judgment independent of technology.

    I sent a young woman with ultra classic appendicitis symptoms and signs. Yet, she too underwent a CT scan and while waiting for the results ruptured her appendix. She paid a price. An exploratory lap has a price also but fewer long term consequences.

    My sister had very straightforward pyelonephritis yet did not undergo a simple exam that would have revealed kidney tenderness. Yet, she too went on to a CT with delayed and then suboptimal care requiring hospitalization. A UTI which cost $25,000 for no reason at all.

    Our system of health care spends 2.6 trillion dollars per year. We spend as much money on our health care system as all the other countries combined. We are bankrupting our country while providing health care that is inefficient.

    Our overuse of technology is behind that low performance at very high cost.

  6. Pranab

    Have you read Vinay Khosla’s take on taking Medicine to all tech on Techcrunch? Check it out here: http://techcrunch.com/2012/01/10/doctors-or-algorithms/

    I think it is quite the other spectrum of Dr. Verghese’s words and might as well be the future of Medicine…

  7. Dan Krebs

    I love this topic Dr. John! I had great expectations of learning about the hallowed physical exam when I got to medical school. But then I got to third year and listened sadly as our course director of my internal medicine clerkship poo-pooed physical exam as being a non-specific and non-sensitive time waster and therefore unworthy of passing on to us in any rigorous fashion. No surprise then that I felt my physical exam teaching as a 3rd and 4th year pretty lacking. It’s a great thing to discuss because it relates to everything from over-testing (no pediatric surgeon in my peds hospital will take a patient to the OR for appendicitis without a CT now) and the perverse incentives of the fee-for-testing model to the doctor-patient relationship. Even the old-school docs are not immune: I remember as a medical student working with an about-to-retire cardiologist who talked me through all sorts of esoteric sounds he heard on a patient’s heart and how he knew exactly what valvular disorders these sounds implied. After telling me his assessment with confidence in his exam skills I could only dream of, he STILL ordered the echocardiogram. Another area where it has deteriorated resident and medical student education is with bedside procedures: now, ultrasound assistance has become the standard of care for paracentesis and thoracentesis, which means IR needs to be involved in our institution, which means it is harder for residents to learn these procedures. Why rely on percussion and auscultation of the pleural fluid level when you can see it with ultrasound?

    I’m not sure what the answer is, but what I am pretty sure of is that the physical exam is fast becoming a dying art because it’s simply not taught anymore.

  8. Nancy Kane

    I only know that my (bone marrow) transplant doc, an extremely gifted physician, always took my hand when he entered the exam room, or hospital room, or whatever. He even told me that he felt that an initial handshake was extremely important, not only to make contact with the patient, but also to assess. He also was the only doc I ever had to detect a heart murmur, just through extended listening. (He also complained that young docs were not taught how to listen anymore.)

    I believed everything he told me, including that I would be ‘just fine’. I went on to be cured of chronic myelocytic leukemia, and I’m still going strong 15 years later. Thank you, Emanuel Cirenza!

  9. McKinley Yearta

    In most cases, appendicitis requires surgery, especially if treatment is not applied at the earlist stage.

  10. Joella Spyres

    Appendicitis is considered to be a surgical illness. Due to its severe character, the treatment for appendicitis often involves surgical intervention. Judging by the speed of development and the gravity of the illness, appendicitis can be either acute or chronic. Acute appendicitis evolves very fast and can lead to complications. Chronic appendicitis is less serious and slower to develop. Although there are other options, the safest treatment for appendicitis is considered to be surgery.

  11. Chester Liam

    It’s an interesting topic, the question is what is more beneficial for a patient’s health? I guess without physical examination that would make the consultation a bit complicated. But I’m not closing the doors that technology innovation in the future will open a possibility to diagnose any uncertainty in a persona without any touch. I’m futuristic indeed, but the reality, old practice should still live on.

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