Eye to Eye Communication and Laying On of Hands: Anachronistic Medicine?
It is clear that there have been
and will be important changes in the way medical care of patients is being and
will be practiced in the future. With
the technological developments both in terms of communication by healthcare
providers with patients by way of the internet, the use of the internet for
patient self-diagnosis, the use of electronic medical record devices in the
medical office and hospital to store text and graphics, the diagnosis and
treatment with devices never anticipated generations ago and the continuing
systems of care which tend to limit the time physicians can take with their
patients, there is a real question as to whether the teaching of history taking
and physical examination to the students in the first years of medical school
is really anachronistic. Is the current
teaching of methods for developing the doctor-patient relationship that can
become emotionally supportive and therapeutic for the patient and in addition
lead to diagnosis and hopefully effective treatment becoming outdated?
We currently teach our students
to take time with the patient, to take a medical history or discuss the
patient's case sitting face to face, eye to eye and the importance of the hands
of the physician actually on the patient's body performing the classic
procedures of the physical examination.
But some may argue that much of this is unneeded, unnecessary,
impractical in this current age of medical practice. It is said that in this age of patient
autonomy and the patient's now access to medical information beyond that coming
from the doctor's office and with the limited time available with the doctor,
detailed sit-down history taking is unnecessary.
And, as far as the physical
examination is concerned, will modern technical devices such as ultrasound, CAT
scan and MRIs amongst others provide better sensitivity and specificity to the making
of a diagnosis than anything that hands or stethoscope on the patient's body
can accomplish?
Dr. Abraham Verghese, physician
and professor at Stanford University School of Medicine and recorded in an 18
minute video TED talk "A Doctor's Touch" , available through thislink, presents the contrary view that what we are currently teaching our students
is still what we should be teaching.
Watch and listen to the talk and then come back here and tell us your
view as to whether we should continue to teach the medical students in the way
Dr. Verghese finds is the right way or should we modernize to something
else. How do you want your doctor to
treat you? ..Maurice.
Graphic: GIF image by ANTHONY ANTONELLIS via Google Images
posted by Maurice Bernstein, M.D. @ 10:12:00 PM
6 comments
6 Comments:
Dr. Verghese opens with a story about a woman with massive bilateral breast metastases that went unnoticed despite four visits to healthcare professionals in the past four years.
His next anecdote (about a patient he personally knew) is about a woman who left what she regarded as the best cancer treatment center in America. Her reason? They never touched her breasts. The local private oncologist, on the other hand, made sure that on every visit he examined her breasts, cervical, and, *ahem*, inguinal region.
He later talks about the importance of ritual in medical care, and said something about how if you listen to a heartbeat over a patient’s clothes or don’t undress the patient, then you haven’t completed the ritual and have failed to seal the relationship.
Dr. Verghese interprets this as reflecting the increasing dehumanization of medicine and increasing reliance on data and machines. I, however, notice another, very conspicuous pattern, and it goes back to the issue of patient modesty.
I worked for two years as a CNA in a subacute setting, and I’m applying this fall to PA schools. I hate to say it, but I could totally envision myself doing everything mentioned above: not checking a woman’s breasts for cancer, not touching a woman’s breasts when she’s being treated for breast cancer, not exposing a woman’s breasts during auscultation.
The reasons I don’t want to do these things have nothing to do with modern technology or dehumanization. One reason is that I don’t want to get accused of something. I don’t want to be accused of misconduct to the medical board. I don’t want to be accused of being a pervert to the local gossip tree. The other reason is I don’t want to be put in the position of a patient requesting a female. As a CNA, I’ve been in that position many times, and it means I lose a lot of time trying to hunt down a woman who will agree to swap patients with me. As a PA, it might mean telling them, “No”, which opens up a whole other can of worms – I can just imagine patients arguing with me about it or writing nasty reviews about it on Yelp. If, on the other hand, I say nothing about checking the breasts for lumps, then really, nothing bad is going to happen… to me.
I’m not saying that’s what I’ll actually do when I become a PA, but I can easily see how one might slip into that pattern. It’s going to be a problem and I’m not sure how I will resolve it. Dr. Verghese has a very sophisticated and mature manner to himself. He has a deep, accented, and consoling voice. He’s handsome. I imagine he is a doctor that women are generally comfortable baring themselves to. I would be willing to bet Dr. Bernstein has that same sort of rapport with patients. I think older male doctors forget that we young men are largely regarded as immature perverts.
For the newly graduated male resident, being 26 years old is, in and of itself, enough to make some women nervous about intimate care. His own nervousness and inexperience will only compound the problem. It could be very easy for him, by sheer operant conditioning, without even thinking about it, to get into the habit of avoiding intimate care with female patients whenever possible. And that habit may never get broken.
-RDW
RDW, just as we teach our medical students about patient physical modesty, if you were not formally taught as a CNA, you will definitely be taught as a physician assistant about the responsibility for educating the patient regarding the need and value and getting the patient's implied or expressed permission before laying on hands or even eyes on parts of his or her body. Once this is accomplished, then the examination can proceed with the examiner providing an opportunity by explanations and requests for the patient to participate together in the process. Yes, this takes a bit of added time for this action as it has taken a bit of time earlier in the doctor-patient relationship to develop the patient's trust.
It could well be that this time element in a busy practice as well as wrong assumptions that the necessary and accurate physical findings can be obtained without undressing and finally, yes, the hidden concern by the practitioner that he or she might be consider a "pervert" could lead to the ignoring of this professionally important ritual. ..Maurice.
Yes, I've always gotten some kind of consent before touching/seeing a person's intimate parts. However, I've always had a nervousness about asking, especially when it's a female patient that's new to me, or a female patient who has a female family member present (often times it's the daughter that objects rather than the mother).
All of my patients were old and in definite need of intimate care, so I never worried about "pervert" accusation. However, I came to hate dealing with these situations because it is such pain to get a female CNA to switch with me – they’re in the middle of their own routines. Even though same-gender requests were the exception rather than the rule, I always dreaded that first attempt to see if I could check her incontinence briefs, because I knew the trouble that might be coming. When I was a floater I would usually not ask female patients if they wanted a shower because this was the one area where they did often want a woman. Getting a co-worker to take a patient that needs a shower was so close to impossible that it wasn’t worth trying.
I'm hoping that having the title of PA will make things different, but I'm not confident, given the number of people who don't know the difference between a physician assistant and a medical assistant.
Suppose I get a job working under a female physician. How will female patients react when they go to see another woman and end up having a young male "assistant" tell them he needs to expose them a little bit to listen to their pulse? How many will demand to see the woman? How will I deal with it when they do?
I can imagine three scenarios for dealing with the problem:
1) As in my work as a CNA, I have to regularly ask the female physician to switch with me, disrupting my productivity, disrupting her productivity, irritating my boss, and generally making me look like a liability that could easily be replaced by a predominantly female pool of PAs.
2) I have a female physician that refuses to switch, leaving me to regularly deal with upset and angry women.
3) As with the showers, I avoid the issue entirely. I listen to women’s pulse over their clothes or gown. I avoid bringing up the topic of breast exams except for the really high-risk groups.
Bringing this back to the discussion: given the three options above, I can see how a male PA would choose scenario 3. Time constraints would make the path seem even more enticing. Maybe my experiences as a CNA have distorted my perception of what it’s going to be like, but maybe not: in primary care, unlike my past work, I’d likely be dealing with patients who hadn’t gone through the modesty-shedding experience of having dozens of strangers help them with ADLs for years.
I’m probably over-thinking it. I’m sure Dr. Bernstein has a better understanding of what underlies the lack of touch and intimacy in care, but I thought I’d bring this up as another possible contributing factor.
--RDW
RDW, I appreciate your ventilation of your personal but also professional concerns. Maybe I can be a bit therapeutic.
You have to stick to whatever are your professional responsibilities and with the goal of being and acting in a beneficent manner to the patient and to attempt to accomplish that "good" for the patient despite your own personal concerns. Other professions have similar episodes of work where to accomplish an expected "good" there exists a personal unsettled feeling or even a personal risk: firemen or policemen may have the feeling of switching responsibilities at work to others in times of personal uncertainties but they know they have to personally accomplish the goal of benefit for those who they serve despite personal risk or discomfort.
Thus in your attending and professionally caring for those of opposite gender, you must proceed and do your work with your actions being directed toward the patient interest and not your own self-interest. But your patient interaction should always be with the patient's understanding your responsibilities and goals and with the patient's consent. Fixate on that and the goal. Obviously, if the patient instead rejects you simply for opposite gender modesty issues and the system cannot provide a replacement for you, it becomes then the responsibility of the patient for their decision and for whatever becomes the consequences.
I suspect those physicians who zip past the ritual championed by Dr. Verghese and the ritual which I agree with and teach my medical students are doing so because of limitation of time, dependency on modern diagnostic technology and having developed only superficial relationships with their patients.
Don't despair, continue on your road to become a PA. Your intellectual expansion, your longer term benefit for your patients and of course your salary will certainly exceed that of a CNA. ..Maurice.
RDW:
What a wonderful opportunity you have to become part of a growing need that patients have in seeking preference for gender in intimate care!
Instead of "despairing", you should see the unique challenge of becoming part of a new movement to consider patient dignity and respect. Consider the men who are embarrassed by female intimate care...and what a valuable opportunity you could be providing THEM with dignified care.
Why not look forward to being part of a valuable solution instead of being discouraged by what patients are telling you?
You should not ignore what you are learning. Trade with a female for female preference, and give a few men the chance for dignified care as well.
Good Luck!
Suzy
RDW:
What a wonderful opportunity you have to become part of a growing need that patients have in seeking preference for gender in intimate care!
Instead of "despairing", you should see the unique challenge of becoming part of a new movement to consider patient dignity and respect. Consider the men who are embarrassed by female intimate care...and what a valuable opportunity you could be providing THEM with dignified care.
Why not look forward to being part of a valuable solution instead of being discouraged by what patients are telling you?
You should not ignore what you are learning. Trade with a female for female preference, and give a few men the chance for dignified care as well.
Good Luck!
Suzy
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