This is Part 2 of a 2-part series related to the power of touch in the clinical medical environment.
In Part 1, we review the history and philosophy of touch as an essential part of healthy infant development and the overall human experience.
In Part 2, we resume our interview with Stephen W. Russell, MD, co-president of the Society of Bedside Medicine and professor in the Department of Medicine at the University of Alabama, Birmingham.
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This interview has been lightly edited for length and clarity.
In my research, I found that interns really spend only 12% of their time with patients.1 These are the people who are at the beginning of their medical careers. Do you think an issue with the medical education system can explain why they’re not spending more time with patients? How might you fix that?
It’s fascinating that you bring that study up. Those data are from a 2019 study1 where we looked at interns — these first-year trainees at a medical school — in terms of time spent in the presence of the patient or with direct patient care. It was, as you said 12% [of their time]. Which begs the question, is this a new trend or is this something that has been exacerbated or worsened from a technology standpoint?
There was a similar study2 that was done shortly after the 2004 mandate of physician training hours, and about the same amount of time was suggested. In fact, there was a study that was done in the 1950s or 1960s, well before the age of telemedicine and EHRs, where researchers followed a smaller number of postgraduate trainees. What they found is that they spent less than 20% of their time in the presence of the patient.
So, if physicians are spending limited amounts of time in the presence of their patient, how can we make the most out of that time? I have had the experience of being in a physician’s office and [only seeing] the top of his head or her back [while] they’re sitting there typing on the computer. That’s not a critique of that individual physician — it’s the burden of charting and medical record keeping that needs to be done.
Our suggestion, then, is to figure out how can we use that time to more richly inform what the physicians are doing in the presence of the patient, and also how can we communicate that to patients in a better way.
If we have somebody who’s coming in with knee pain or shoulder pain, there’s a tremendous amount of good that can be obtained by touching the knee, feeling the shoulder, putting it through its ranges of motion, and then being able to communicate in real time with the patient, “This is what the exam is telling me, this is what I see and here’s where the next steps might be.”
In that setting, it may be helpful to step into the radiology suite to get additional imaging, but it’s also possible that the time spent touching the patient’s knee or feeling the patient shoulder can better inform both the physician and the patient of what the underlying diagnosis is and how we can more effectively treat that diagnosis.
In many ways, the physical exam and the power of touch is about communicating: it’s communicating from the patient to the physician that “This is my abnormality, and this is what my body is sharing with you.” The communication goes in the other direction as well, communicating from the provider to the patient that, “Your concerns matter to me. I’m listening to you, I care about what’s going on, and we’re going to search for the resolution together.”
It also communicates a deeper meaning which is, “I am in communion with you, and this is a ritual.”3
You can still spend 12% of your time in the presence of the patient, but if you’re communicating that, and looking at the patient in the eye and communicating to her what’s going on, then it’s much more likely that that 12% of time is going to be not only felt differently, as if it’s more time spent together, but it’s also going to be a richer experience for the provider and the patient together in getting to the same understanding of what’s going on.
Listening to you talk about this, it almost sounds like it’s a very ceremonial thing for you to go in and meet these patients and take care of them.
Absolutely, and I think that’s why Dr Verghese used the term ritual in his work. You think about religious ceremonies or spiritual ceremonies, and there’s a certain expectation among those that are stepping into that space and of those that are providing communion in that space. And while we, of course, are a secular organization, we see that same ritual taking place in the presence of the patient.
One way that I think people measure that is by provider satisfaction (How is the fulfillment of the physician who is undertaking that exam?) and by patient satisfaction (How is the patient satisfied with that particular experience?). Dr Artandi, some of our colleagues from Johns Hopkins, and I are a part of 3 institutions that are working under the support and grant funding of the American Medical Association Reimagining Residency Initiative to try and quantify that.
Our hypothesis is that if…postgraduate residents…are actually put in a position where their physical exam skills are assessed and evaluated, and then feedback is given, ultimately those residents will have better job satisfaction and fewer symptoms of burnout than the seemingly more recent model where it’s a constant battle to keep up with medical documentation and a constant battle to click regulatory boxes, as opposed to interacting face-to-face with the patient.
The results won’t be out until 2024, but we’re collecting that data right now among roughly 450 residents in our combined institutions each year over the course of the 4 years of this study. We hope that our hypothesis will be validated: that more time spent in the presence of the patient in a specific task related to interacting with, but also taking care of, the patient will lead to increased job satisfaction.
An article published in 20124 cited a litigious climate as one of the reasons why physicians have strayed from the physical exam and from touching patients where necessary. In your own experience — either in your practice or in talking with colleagues — have you identified this as a concern? What would your response be to those concerns?
We of course 100% endorse the appropriate clinical touch that is fundamental to the physician-patient relationship. In that January 2020 JAMA article5 there’s a schematic where it looks at all of the individual components that were evidence-based or that were based in expert opinion on what makes for an effective human interaction. Physical touch is on that list, but I think that the authors realized that as important as physical touch is, it falls under the larger category of communicating with your patient and empathizing with your patient.
We also recognize that when people are properly trained, and properly trained to know what to look for, that that touch is going to be more effective and more clearly communicated for the clinical value that it has.
In the comment you published in the Lancet,6 you mention that the goal of the Society is to “reinvigorate the beside clinical encounter.” Could you expand on how you’re hoping to accomplish that?
One of the things that I believe was probably lost on me in my training…is that the physical exam has rigorous data that underlies it. It’s not as if the physical exam is quaint, or is something that is strongly provider dependent as to whether there’s value in it or not. We base a lot of our information on data generated by Steve McGee [MD, professor emeritus of medicine at the University of Washington in Seattle].
He published a book called Evidence-Based Physical Diagnosis,7 that gathered together studies that looked at certain medical conditions and determined how we can best evaluate these medical conditions. Using a very well-recognized statistical model, he realized that certain physical exam techniques have a very good ability to help us understand what is going on; there is a tremendous value in being able to recognize which exams are helpful in a clinical encounter and which exams may be less helpful.
There are certain measures that we consider objective measures, such as radiology tests; some are helpful in answering clinical questions and some are not. We think that the craft of being an effective physician — and this is true whether you are a surgeon or a psychiatrist or a primary care physician — is being able to understand your tools and…what questions your tools can answer.
We would submit that absolutely we want to incorporate technology when it’s a tool that helps us answer the question, but we also want to teach our residents and trainees that there are tools in your physical exam toolbox, so to speak, that help you answer that question. When we talked about reinvigorating the physical exam, we talk about putting it in its proper place in appropriate diagnosis, then teaching residents to understand when to use the physical exam and when to complement that with additional data.
What’s fascinating to me is that the power of touch is seen across all of those domains. It’s not as if a radiologist who is doing a procedure refrains from the power of touch; I’m sure there’s data and patient experiences where people say, “Well, I was having this procedure done, and I just felt the sense of comfort.”
Perhaps their heart rate decreased, or they felt emotionally reassured, just through that human interaction. There’s training involved in being able to provide appropriate reassurance, but it’s a very natural human emotion. It’s important to give physicians the space to recognize when that can be an effective and therapeutic technique.
Dr Verghese’s TED Talk8 shows such a fundamental understanding of what we can do as providers in a clinical space, even when the so-called cure is not readily at hand. I think COVID-19 is a great example that. One of the true tragedies of COVID-19 is the physical distancing that has had to take place for public health reasons, some of which is occurring near the end of a person’s life.
We lost the ability to allow families in a space where they can be with their loved ones. Having a physician provide that space for families to grieve and be present is something that’s critically important, not only to the practice of medicine but also to being effective stewards of the job that we’ve been given: to provide healing, and where we can’t provide healing, to at least provide care. When people are physically separated, it’s really difficult to do that.
It’s been great to see over the last 12 months that folks have become more science-based, but also more creative, in being able to provide important physical presence between family members and patients, and patients and providers, in the midst of having this illness.
It helps to expose, and perhaps unroot, what we’ve known all along: regardless of what you’re doing in a clinical space, that human element can never be stripped away. It’s fundamental to what we do; it’s true for chaplains in the medical space, it’s true for families in the medical space, and it’s true for providers in a medical space. If we can educate people how to be in that space and interact in a safe and effective way, there is tremendous therapeutic benefit of doing that.
What is your top advice for physicians who are looking to refocus their clinical practice to bring touch back into the exam room?
It starts by being fully present with your patient during the clinical encounter across all domains, and then using your knowledge base as a physician and using the observations that you’ve had from that physical encounter, to educate your patient about what you think is going on and what you feel the next steps are, either from a reassurance standpoint or through gathering more data. I think in that setting, being fully present and then being able to communicate your observations clearly with patients automatically re-engages providers and patients.
It also allows the space for patients to ask questions and clarify what their original goals of the clinical encounter were. If a physician summarizes what they think is going on, and the patient says, “Well, thank you for telling me about that, but what I was really interested in was this,” we have a chance to refocus. There’s an intentionality about it that for most people is not second nature, but perhaps that’s a good thing: that allows us to not examine patients or interact with patients in a rote fashion, but in a really intentional fashion.
References
- Garibaldi BT, Zama J, Artandi MK, Elder AT, Russell SW. Reinvigorating the clinical examination for the 21st century. Pol Arch Intern Med. 2019;129(12):907-912.
- Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013;28(8):1042-1047.
- Verghese A. Culture shock—Patient as icon, icon as patient. N Engl J Med. 2008;359(26):2748-2751.
- Singh C, Leder D. Touch in the consultation. Br J Gen Pract. 2012;62(596):147-148.
- Zulman DM, Haverfield MC, Shaw JG, et al. Practices to foster physician presence and connection with patients in the clinical encounter. JAMA. 2020;323(1):70-81.
- Russell SW, Garibaldi BT, Elder A, Verghese A. The power of touch. Lancet. 2020;395(10230):e63. doi:10.1016/S0140-6736(20)30170-7
- McGee S. Evidence-based physical diagnosis. 2018; Elsevier.
- Verghese A. A doctor’s touch. TEDGlobal 2011. Accessed April 28, 2021.
This article originally appeared on Clinical Pain Advisor
