You are seeing a 49-year-old female patient on a return visit following a triple endoscopy and biopsy of a right lateral tongue lesion with extension to the ventral surface of the tongue. The patient, an elementary school teacher, is a single mother of two adult children and has three grandchildren. She has come to the appointment by herself, by choice. As you gently, but clearly, explain the pathology diagnosis of poorly differentiated squamous cell carcinoma to her, she begins to cry—first softly, then uncontrollably. Your first inclination is to offer her facial tissues, and your second is to somehow physically convey your empathy and understanding to her, as she tells you how she doesn’t want to lose her life and her future with her family. Should you hold her hand, lay your hand on her shoulder, or give her a reassuring hug? In this time of social concern regarding physical contact, what are the professional proprieties to consider here?
Explore this issue:July 2018
How would you handle this scenario?
This is a delicate time in our society’s culture with respect to perceived unwanted physical contact between individuals (the “Me Too” movement), which can have particular implications for the medical profession. In this context, the patient–physician relationship could be considered one of an “imbalance of power,” with the physician holding professional sway over the patient. Yes, that must be acknowledged in the theoretical sense, but the patient–physician relationship is perhaps a singularly unique one with respect to physical contact, given the importance of the physical examination and the physician’s responsibility to understand and connect with the patient as a “person,” not just a body of anatomy and cellular physiology. The “laying on of hands” is an integral (and likely indispensable) part of the diagnostic and treatment processes, to varying degrees, of course, depending on the specialty and the diseases or disorders being evaluated.
Over the past decade or two, with increasing reliance on technology for medical and surgical diagnoses, some patients, and physicians as well, have come to consider the physical examination as marginalized. Abraham Verghese, MD, MACP, professor and senior associate chair for the theory and practice of medicine at Stanford University School of Medicine in Stanford, Calif., is a leading advocate for a return to “bedside medicine” and the importance of the physical examination. Dr. Verghese has written that “patients and physicians connect through touch and trust” (Health Affairs. 2009;28:1177–1182). Consequently, the gradual tendency to “diagnose by technology” has led to a decreased expectation by patients of a physician’s physical contact with them, thereby making any other type of physical contact perhaps either appreciated or worrisome. The days of Marcus Welby, MD, where hand-holding and a hug were commonplace, are now supplanted by concerns of patients reporting those same gestures as inappropriate contact by a physician. So, where do we stand and what can be made of the propriety of such contact with patients?