Touch and the Practice of Medicine
The use of touch in the clinical environment is as old as the practice of medicine
itself. From Hippocrates to Sir William Osler, the "laying on of hands" has been
an important tool as we discern and diagnose the ailments our patients present to
us. In medical education, time is spent teaching procedural touch to facilitate
the diagnostic or therapeutic process, but we know intuitively that the power of
touch between two people can present special challenges when combined with the necessary
touch required by physicians in their provision of care across specialties.
Touch is a form of communication between two people, just as the spoken word serves
this purpose. A pat on the back may mean "Good Job!" or a gentle hand on a shoulder
may say, "I'm so sorry for your loss." There are several kinds of touch that may
occur between a doctor and patient in the exam room. Procedural touch is
the way physicians often go about the business of doctoring. From auscultation of
the heart and lungs to more "intimate" physical exams. most medical specialties
use procedural touch within their scope of practice. This differs from the social
touch we use in our daily lives as an adjunct to verbal communication.
We use social touch to communicate consolation, congratulations, reassurance, or
as conversational markers to get our point across. Because social touch is part
of the human experience, we should expect that physicians will bring this form of
communication to the exam room, yet social touch is rarely if ever a focus of medical
education. There is an understandable expectation that trainees should know how
to use social touch. While many do, blending procedural and social touch at the
point of care can pose special risks that can range from simple misunderstanding
to inappropriate or even harmful touch. Learning to effectively use procedural and
social touch together is important in limiting risk and, when done well, can enhance
the power of the clinical moment.
Seeing the clinical moment from the perspective of the patient can be helpful in
navigating touch in the exam room. While the physician may perform a similar physical
exam on many patients each week and is aware of the procedural touch required to
complete the exam, for patients this may be the first time they have been examined
in this way. Patients often do not know how much touch is needed, what kind, for
how long, on what parts of the body, etc. Often, a brief explanation of why a particular
exam is clinically important, especially when examining sensitive areas of the body,
can make patients more at ease. Without explanation, patients are left to interpret
whether any procedural touch is adequate or appropriate. When social touch is added
to the equation, patients can be even more confused. While a physician can be fully
aware of where procedural touch leaves off and social touch begins, patients may
misinterpret the combination of the two types of touch, or the blending may in fact
lead to inappropriate touch. The wrong touch at the wrong time, even if unintentional,
can leave the patient feeling vulnerable, and is often very upsetting.
A Few Rules of the Road:
Use social touch cautiously. While touch is part of the
human experience, patients can feel particularly vulnerable in the exam room and
can easily misinterpret your best intentions.
Separate your social and procedural touch in the visit.
While it may be appropriate to reassuringly touch the upper arm before an exam,
doing so during the exam may lead to some confusion or make the patient uncomfortable.
Apply the procedural touch needed to complete your exam, and save the social touch
for a more appropriate time.
Before procedural touch, explain what you will be doing
and remember that silence is not consent. While you may have done this exam five
times that day, your patient may not know what lies ahead. Let them know, and be
certain they understand before beginning.
During procedural touch, continue to augment with a verbal
explanation of what you are doing and why, especially if your exam involves sensitive
areas of the body. By sharing your knowledge you can increase a patient's comfort
level and enhance their trust in your expertise.