August 3, 2010 1 Comment
Christopher Reeve once said, “To be able to feel the lightest touch really is a gift.” A recent article by Danielle Ofri in the New York Times, No Longer on the Doctor’s Checklist, but Physical Exam Still Matters, discusses the importance of the laying of hands during the physician-patient encounter. In one of my recent posts, Defensive Medicine Supersedes Quality Medicine, I reflect on the lost art of the physical exam. As a physician in the new age of technology and increasingly advanced imaging studies, I am much less attuned to the more subtle aspects of the physical exam than my predecessors. Nevertheless, the physical exam is still an important part of good patient care and medical practice.
The stethoscope has been a timeless symbol of the physician’s touch. Now, in the emergency department, the ultrasound can have the same therapeutic effect – as I place cool gel on a patient, find the landmarks of her ribs, and use ultrasound to look at her liver, lungs, heart, and kidneys – it often has a calming effect. Patients ask to look at the screen, where they can see the beating of their own hearts. Family gather round to watch with a sense of curiosity and wonder. Some ask if they, too, can see their hearts.
Part of interacting with and examining patients involves the human touch. We are the first to hold – and examine – a newborn baby after he emerges from the womb. We are often the last to touch someone in their final moments of life. Listening, palpating, and performing certain maneuvers provide us with vital information about a patient – whether their lungs are filled with fluid or pneumonia, whether their abdomen is benign or peritoneal, whether they are suffering from peripheral or central vertigo. These interactions tend to help patients by putting them at ease, slowing their breathing rate, and calming their nerves.
The flip side of this is that some patients become very uncomfortable and nervous during this part of the encounter. It is quite understandable. In fact, this is exactly how I felt when I examined a patient for the first time. We had practiced as medical students on one another, but this was not the same. As I listened to the heart of my first patient, an elderly man with several comorbidities, I felt like an imposter in a white coat.
As physicians, we have a unique window into our patients’ lives. We gain insight into their physical conditions and disease processes, and we also gain insight into their emotional side. As I have progressed in my career, I have become more comfortable with this intrusion – I respect it, treat it carefully, and use it only to provide the best care possible for my patients.
My very first experience with human touch in the medical setting was with a cadaver during my first year of medical school. She had been an elderly woman, a former teacher, who chose to donate her body so that I could learn anatomy. A thank you and a poem about her, written at the end of my first year of medical school, follow.
Our donor was, in a sense, our first patient, our first teacher, and the first person who chose to put himself or herself in our hands – literally – for better or for worse. In lab, our dissections revealed unique aspects of our donor’s anatomy: abdominal wall adhesions from a gall bladder surgery, mysteriously diseased lung tissue, and an unrepaired hiatal hernia. Ironically, the more we learned, the more I realized how little we really knew about our donor: about the way her body functioned while she was alive, about the true manner and cause of her death, and about the unusual manifestations of disease which we discovered. Even intimacy has its limitations: in the case of our donor, and in the case of our future patients, we will never be able to fully understand the intricacies and the complexities of their anatomy, their illnesses, and their lives – but that is part of what makes medicine so fascinating.
I would like to extend a thank you to all of our donors who make this rare and great sacrifice: these people must have had a great faith in medical education, in medical students, and in the doctors we will become.
Separated by a layer of latex,
our fingers trace a cautious line
along the border of her diaphragm.
Steel ridges pierce her sternum:
a delicate cage of cartilage
splinters down the middle.
We pry these uneven shutters open
to reveal soft, supple lung lobes,
still as stone;
twisting cardiac vessels,
a surprising bulge of stomach,
compressed, void –
above all, trespassing;
and her heart,
a silent cavern.
Our hands approach,
her dress of broken ribbing,
her delicate bodice of pleura,
dark blossoms of diseased tissue.
to misalign –
it is exceedingly easy
in this room,
where our hands and our scalpels
defy most boundaries.
the most treasured secrets
are carefully tucked away
in the creases of her hands,
the wrinkles near her eyes–
will never reside here,
in this room of strangers,
where, separated by a layer of latex,
we finger paint our landmarks
onto a foreign map.