Alpha Omega Alpha Medical Honor Society

The author is professor of medicine and co-­director of the Program for the Humanities in Medicine at the University of Virginia School of Medicine in Charlottesville, Virginia. She has been in a rural medical practice affiliated with the University of Virginia for the past 20 years.

One of the oldest and most effective acts of doctoring,(1,2) physical touch is a unique clinical tool used during the physical examination and therapeutic interventions, and it is used to establish and maintain interpersonal connections. However, physical contact between the patient and the physician has diminished since the invention of the stethoscope (3) and as the use of technology continues and aspects of physical examination are brought into question, the use of touch in the patient­physician relationship is at increasing risk. For instance, the diagnostic value of the annual complete physical examination in asymptomatic patients continues to be questioned,(4) and many diagnostic techniques using physical examination have been shown to have little diagnostic accuracy.(5) Other factors, including concern about sexual harassment, the legal repercussions of touching, and uncertain boundary issues, increase physicians’ reluctance to touch patients.

W.E. Osmun and colleagues demonstrated the appeal of comforting touch to many patients,6 yet public awareness of the diminished use of touch in medicine is reflected in a recent New York Times article, “Are Doctors Losing Touch with Hands-On Medicine?”(7) Questions about the physician’s role and patient’s expectations regarding touch need to be addressed. Such questions are pertinent, too, in the face of 1990 national survey data that indicate that individuals made 37 million more visits to alternative and complementary medicine providers (including massage therapy and other hands-on techniques) than to allopathic providers.(8) Rather than avoiding touch, the medical profession needs to recognize the value of touch and learn to integrate it, as appropriate, in patient care. Narratives from clinical practice and literary sources demonstrate, confirm, and remind us of the many ways physical touch anchors us in our lives, both as physicians and patients.

Touch in clinical practice: A clinical case

It was Friday; I was at home on vacation spending the morning reading. When I answered the telephone, I heard the voice of a friend who was the caregiver for her elderly Aunt Mabel, one of my patients. She apologized for calling me at home, but continued as she acknowledged the emergent nature of her call.

Aunt Mabel, an 85-year-old resident of the local nursing home, had decided to discontinue renal dialysis. For many months, she had been uncomfortable (an understatement) during and after each treatment, and she dreaded the 60-mile round trip three times each week to the nearest dialysis center. It was a long, painful, exhausting excursion. On many occasions Mabel had discussed the possibility of terminating dialysis, but she believed that to “quit” was to “kill herself” or commit suicide.

Mabel’s niece continued, “She wants to talk with you first before her decision is final. She can go to dialysis this afternoon, then see you on Monday, but it is such a rough trip for her. Can you see her today?”

As I walk into Mabel’s room, I see her in a wheelchair with her brother sitting in a chair beside her. She looks up at me, and says as I walk into the room, “Oh, my neck hurts.” So I stand behind her and begin to examine her to determine the cause of her pain. Her trapezius muscles are the fullness of my thumbs; she has lost so much of her body’s mass—there is almost nothing left of her. I take a deep breath as I settle into my awareness that today is one of the last days of her life. I suggest to her, “I can massage your muscles; it might help relieve your pain.” As I work to relax the tight muscles and soften the tender places, I ask how she is doing. When she offers no comment, I look to her brother who gives me a thumbs-up as if to say, “Please continue.” When I finish, I spend a few silent minutes with him before Mabel opens her eyes and says, “That felt wonderful. My neck doesn’t hurt anymore.”

While sitting still beside her, I notice a deep, peaceful place in me that feels relaxed and at ease: a place usually buried by layers of hurrying from one patient to the next and covered by the many distractions and details of clinical practice.

The experience of touch

Touch, the “laying on of hands,” is a skill of the physician as healer, and like other skills it can be learned, improved, and honed into a fine art. In Doctoring: The Nature of Primary Care Medicine, Eric Cassell describes four reasons for performing physical examination; one of them is the need to touch the patient. He argues that the physical examination, in and of itself, is a therapeutic tool of the physician.(9) Just as listening to the patient’s story is therapeutic, so too is touching the patient.

The power of touch

Touch delights the senses: A patient has an intense frontal headache. Her son was killed a few months previously; her grief is palpable. I place my right hand across her forehead to provide support before I examine her neck. Immediately she relaxes and says, “That feels wonderful! I’ve been so out of touch with everyone and everything.”

Physical touch is a special sensation that awakens us to ourselves and reminds us that we are alive. In May Sarton’s novel, As We Are Now, Caro, the protagonist, is an elderly woman who must live in an adult home. She is isolated from the things she loves, deprived of the things that make her human. She is completely alone. She says: “I cannot even imagine what it would be like to feel a tender caress—my skin is parched like a desert for lack of touch. . . . What I am getting at is that in a place like this where we are deprived of so much already, the small things that delight the senses . . . seem necessities if we are to survive.”(10p60) Here, Caro realizes touch has the potential to stimulate and remind her of the aliveness of her soul.

In Tuesdays with Morrie, Morrie, a sociology professor dying of ALS, is still teaching Mitch, one of his students. Morrie is no longer able to use his hands, so Mitch adjusts his glasses for him. ‘”Thank you,” Morrie whispered. He smiled when my hand brushed up against his head. The slightest human contact was immediate joy.”(11p83)

Touch offers the possibility of human connection: One elderly man said to me as I began to evaluate him, “That feels wonderful, we old people rarely get touched.”

Touch is necessary during all phases of life, but it is not always available. Lewis Thomas in The Youngest Science writes “Ordinary people, even close friends, even family members, tend to stay away from the very sick, touching them as infrequently as possible for fear of interfering, or catching the illness, or just for fear of bad luck.”(1p56) And Mary Pipher in Another Country recognizes “the old need conversation, touch, children, and pets,”(12p255) especially when they lose their sources of physical contact as spouses die and other close personal relationships end.

Walt Whitman wrote of his experience as a volunteer nurse in Civil War hospitals in “Drum-Taps: The Wound-Dresser”:

The hurt and wounded I pacify with soothing hand,
I sit by the restless all the dark night, some are so young,
Some suffer so much, I recall the experience sweet and sad,(13p445)

Touch anchors Whitman in his experience and connects him to others as he comforts them. Physicians, too, witness pain, devastation, and loss. Physical touch encourages communication and support, and acknowledges the common ground of human suffering.

Touch orders pain and chaos: In the poem, “The Look,” from her collection, The Father, Sharon Olds chronicles her father’s dying. We explore her experience with him when, unable to sit up or reposition himself, he requests, perhaps demands, a “Back rub!”

. . . His skin shocked me,
silky as a breast, voluptuous
as a baby’s skin, but dry, and my hand
was dry, so I rubbed easily, in circles,
he stared and did not choke, I closed
my eyes and rubbed as if his body were his soul . . .
. . . I let the full pleasure
of caressing my father come awake in my body,
and then I could touch him from deep in my heart,(14p17)

While touching her father, the speaker discovers something new about him—”his skin”—and about herself—her pleasure and heartfelt emotion toward him. Touch offers the opportunity to bring order to the difficult, distressing, and chaotic experience of her father’s dying.(15)

Touch offers personal meaning: As I offer my hand to an elderly patient, he takes it and holds it. Minutes pass. He pats and squeezes my hand as he tells me about his life and asks about mine. Something has changed—I am no longer just shaking hands.

The practice of medicine is fast paced, and slowing down and noticing all that is present is a difficult transition.(16,17) Arthur Ginsberg in “Line Drive” describes his process of giving “bad news” to a patient.

I had come from a dying man’s room.
What I said, addressed the cancer
eroding his brain, how his right side
would become limp, he would slowly
slip into a coma. And, I pointed out
the silver shadow on black film from
the foot of his bed, staying at
bed’s length from him and his widow-to-be.
And, I said too little, too quickly
for the quivering ears and lips
where death was digging in, and,
I forgot to touch or be touched.(18p103)

In the second stanza, he describes his arrival at a little league baseball game after work and his connection with the aliveness in the air. But just then a line drive is hit into the pitcher’s stomach, and the pitcher drops to the ground. In the third stanza he writes:

He dropped like a stone but was, in moments,
surrounded by Billy and Peter and Rob and
the first baseman holding his head, his sobbing,
coaxing him to breathe, you’ll live, it will be o.k.
I knew I must go back to the man
dying in white linen and say nothing more
than the warmth of my hands in his.(18p103)

While at the game, the physician realizes his own need for tenderness, compassion, and connection. He wants to be a physician, but also a person. Touch offers him a way to contact both himself and the patient. These “touching” experiences allow the physician personal growth and discovery.

Conclusion

That touch is an important and powerful aspect of the patient and physician relationship is not a new idea. One aim of this paper is to simply remind practicing physicians and medical educators of the power of touch in all of our lives and in medicine. Physical touch is a skill that can be learned and developed, and the AAMC’s document on “Medical Professionalism” points out that physicians in training also need to learn when touch is appropriate and when it is not.(19)

Medicine faces a challenge as it looks to provide effective and compassionate medical care. Using physical touch appropriately, physicians can convey strength and stability, kindness and compassion, ease and comfort to patients during times of suffering and crisis. Medicine’s “hands-off” attitude makes the profession seem cold and uncaring to many people. Medicine could help itself by asking: What does the public want from medicine? What do patients want or need from physicians? Why do so many patients turn to alternative medical providers? The more thoughtful integration of touch into clinical practice and medical education is an important way for allopathic medicine to improve its image.

Acknowledgements

Thanks to Kathryn Montgomery, Christine Peterson, Marcia Childress, Rita Charon, and Eve Bargman for their reviews of previous drafts.

References

1. Thomas L. Leech Leech, Et Cetera. In: The Youngest Science: Notes of a Medicine Watcher. New York: Viking Press; 1983. pp 51–56.

2. Lown B. The Lost Art of Healing. New York: Ballantine Books; 1996.

3. Reiser SJ. Medicine and the Reign of Technology. Cambridge (UK): Cambridge University Press; 1978.

4. Gordon PR, Senf J, Campos-Outcalt D. Is the annual complete physical examination necessary? Arch Int Med 1999; 159: 909–10.

5.Wipf JE, Lipsky BA, Hirschmann JV, et al. Diagnosing pneumonia by physical examination: Relevant or relic? Arch Int Med 1999; 159: 1082–87.

6. Osmun WE, Brown JB, Stewart M, Graham S. Patients’ attitudes to comforting touch in family practice. Can Family Phys 2000; 46: 2411–16.

7. Zuger A. Are doctors losing touch with hands-on medicine? New York Times 1999 Jul 13: D1, D9.

8. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: Results of a follow-up national survey. JAMA 1998; 280: 1569–75.

9. Cassell EJ. Doctoring: The Nature of Primary Care Medicine. New York: Oxford University Press; 1997.

10. Sarton M. As We Are Now. New York: WW Norton; 1973.

11. Albom M. Tuesdays with Morrie. New York: Doubleday; 1997.

12. Pipher M. Another Country: Navigating the Emotional Terrain of Our Elders. New York: Riverhead Books; 1999.

13. Whitman W. Walt Whitman: Complete Poetry and Collected Prose. New York: The Library of America; 1982.

14. Olds S. The Look. In: Olds S. The Father. New York: Alfred A. Knopf; 1992.

15. Connelly JE. “Back rub!”: Reflections on touch. Supplement to the Lancet: Literature Ageing 1999; 354: sm2–sm4.

16. Connelly JE. Being in the present moment: Developing the capacity for mindfulness in medicine. Acad Med 1999; 74; 420–24.

17. Epstein RM. Mindful practice. JAMA 1999; 282: 833–39.

18. Ginsberg A. Line Drive. In: Belli A, Coulehan J, editors. Blood & Bone. Iowa City (IA): University of Iowa Press; 1998.

19. Core Curriculum Working Group. Medical Professionalism. In: Graduate Medical Education: Core Curriculum. Washington (DC): Association of American Medical Colleges; 2000. p 11.

The author’s address is:

Program for the Humanities in Medicine
University of Virginia School of Medicine
P.O. Box 800761
Charlottesville, Virginia 22908
E-mail: jec8k@virginia.edu