I suffer with herniated lumbar disks. L4-L5 bulges and ruptures on occasion. If you catch me on the wrong day I have a little curvature to my back representing the spasm that makes me miserable.
I saw an extremely well-referenced orthopedic surgeon in consultation recently. But through the course of my visit he never touched me. We spent an extraordinary amount of time examining my MRI. Together in front of a large monitor we looked at every angle of my spine with me asking questions. I could see first hand what had been keeping me up at night. I could understand why certain positions make me comfortable. What we drew from those images could never be determined with human hands. In my experience as a patient, I consider it one of my most thorough exams.
“How very sad,” they say clutching to their black leather bags. “What would Osler think?” Not sad. Different. The way we examine patients is changing.
So what will become of the physical exam? What role will touch have as medicine becomes more precise?
As physicians we originally touched to understand patients. The ritual and mystery of the exam had the added feature of leading patients to believe that so much could be understood with our hands. But many exam maneuvers were more relevant at a time when there was no better way to understand a patient. Now we romanticize touch and all that it once represented.
Advanced diagnostics will continue to change the relationship we share with patients. Technology will separate us while at once creating the opportunity for a new type of connection. And I suspect that touch will ultimately evolve to fill a deeper, non-diagnostic role. It’s purpose and meaning will be very different a century from now.
Many struggle with the separation. But perhaps we will need to move further away from patients before we can truly understand the importance and meaning of human contact in medicine. Brian Christian in The Most Human Human suggests that “the inhuman has not only given us an appetite for the human; it’s teaching us what it is.” Perhaps the automation of medicine will help us understand our true role. Machines may ultimately help us learn what constitutes a real human connection.
Link to The Most Human Human is an Amazon affiliate link.
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Bryan,
I love this post, it is very wise. It isn’t just the “laying of hands” that matters, but more–it’s the connection in the exam space for which we long. The sense of partnership, sincerity, empathy, and compassion that we search for in our doctors in this fortunate, technology-rich time. Technological advances do improve diagnosis and care. But when the doctor explains what they see and “feel” instinctively when reviewing a scan/study/result, we want the combination of their smarts and their humanity to grace the decisions they make and the advice they give. Clinical insight is human. Clinical acumen can be improved. You’re right, when we figure out where the fulcrum lies between the two, we may hone our true role as physicians of the future.
My last pregnancy was so strange – new provider – did use a doppler to listen to the baby’s heartbeat. Didn’t measure me. Never palpitated my stomach to feel the baby’s position. They just used the results of the ultrasound machine and the weekly BPP’s that I was receiving because of being on insulin.
My previous provider in prior pregnancies always laid hands on me – feeling to see if the baby was head down. She was much more accurate in regards to weight estimates than my countless ultrasounds were.
Hi Bryan (and hi Wendy), Enjoyed this post from various angles. I have noticed in debate about eHealth and telemedicine, that traditionally leaning doctors typically bring up the issue of the physical exam as a game-stopper for new technologies. Patients on the other hand don’t mention the absent physical exam so much as the absent doctor; the idea that the physician isn’t present makes them think of an Orwellian, machinelike relationship. This difference in commentary is already interesting. Doctors are mentioning a tool, ie the exam, and patients are looking for the relationship. I know that I’m generalizing but this trend does exist and in a recent questionnaire type survey, French patients expressed concern at the idea of telemedicine for that reason.
Dr. V and Esteemed Company,
Wow, our recent book interests seem quite intertwined. I’m reading Michael Chorost’s World Wide Mind, and he spends a good deal of time on touch in the context of transitioning to a new future.
Surprisingly, he describes the centrality of touch and offers how a plugged-in future will enable more touch, not less. It caught me off guard, especially because I’m with you about the romanticism of medical days gone by.
I have really GOT to get on this Most Human Human thing.
As always, I enjoy your thoughts.
-Aaron
Excellent post. However, did that MRI of your lumbar spine REALLY tell you anything a thorough hands-on exam by an expert doc couldn’t? Did it significantly change medical decision making? Is the $1000+ MRI a fair value relative to the $100 physical exam + expert doctor’s time?
I am saddened by the lack of physical contact. As a patient, I get a feel for my physicians based on their approach to physical examination. My physicians get a feel what I am experiencing based on my response to their touch. I can use words to describe the sinus pressure that I have felt for months, however my words seem hollow when allergy testing comes up clear and sinus CT shows no anomalies. Flinching with the lightest touch upon physical examination gives a much more complete picture than the paper and films. Or so it feels to this patient who is beginning to feel a bit like a hypochondriac…