Touch and the Practice of Medicine
by R. Christopher Searles, M.D., FAAFP, Director, UC, San Diego Physician Assessment and Clinical Education (PACE) Physician Boundaries Program, and Assistant Clinical Professor, UCSD School of Medicine - Departments of Family and Preventive Medicine, and Psychiatry
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.