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?
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?
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,” and not just a body of anatomy and cellular physiology.
Human touch can be a form of body language not dissimilar to a smile or a head nod—it can convey a sense of understanding and connection. However, depending on the patient, the strength of the mutual patient–physician relationship, and the context of the particular encounter, one must consider the important elements of proper, ethical, and professional physical contact with the patient outside the conduct of the diagnostic physical examination. If one considers the fundamental concept of physician physical contact to be respectful, comforting, and appropriate, these three guidelines can be considered prior to initiating a gesture that involves touching the patient.
There are two other, equally important, principles to be considered: respecting the patient’s person and self-determination. Given the complexity of the human psyche and personality, patient acceptance of a contact gesture from a physician depends a great deal on their definitions of personal space, their view of the professional relationship, the power differential perceived in the relationship, and their need for comfort or friendliness demonstrated by a gesture contact. Most physicians, through intrinsic and experiential awareness, insight, and understanding, should be able to discern when an empathetic or friendly gesture would be appreciated by the patient and, perhaps more importantly, when it might not be appreciated.
Given the above considerations, an otolaryngologist may wish to exhibit caution and temperateness by asking the patient if she would appreciate and agree to a contact gesture of support and empathy, and inquire what would be an acceptable gesture to the patient, if the patient agreed. A light touch on the arm or shoulder, held for a short time, might be a simple way to convey one’s professional empathy and an understanding of her anxiety and worry. Conversely, it is almost always acceptable to express your concern to the patient through appropriate words and an encouraging and hopeful facial expression.
Of greater ambiguity is whether or not to initiate or accept a “hug” with the patient. Since this is more contact than a touch on the arm or shoulder, it should be considered with greater discretion, and more often is a product of a solid, long-standing patient–physician relationship, in which a clear understanding of the intent, purpose, and propriety of the gesture has been affirmed by both patient and physician. Another word of caution: Regardless of the gender of the patient and of the otolaryngologist, if there are only two persons in the examining room, with the door shut for privacy, a misstep could come down to patient versus physician, and the differential of power may not favor the physician in this situation. If one is considering offering or extending a contact gesture of support or empathy, it might be better delivered in an environment where other, non-biased individuals are present. Unfortunately, the medical profession is at some risk for scrutiny regarding physical contact considered to be inappropriate, so a heightened sense of propriety must be exerted at all times.
Otolaryngologists should be, or become, aware of certain circumstances that might be more nuanced than others with respect to physical contact with patients. For instance, some elderly women may not prefer a handshake of greeting, or if so, would prefer a light contact (not a very firm one). Some patients may have a fear of transmission of microbes from a physician’s hand to theirs, so many physicians may wash their hands in front of each patient or indicate that they have used sanitizer to cleanse their hands before initiating a handshake. It may be a bit awkward to wash, then shake hands, but this may be appreciated by more patients than we know.
Additionally, many, if not most, physicians will introduce themselves to family members in the room and may offer to shake their hands as well. Remember to inquire whether anyone in the room might not be listed on the HIPAA form, and have the patient add them to the form. As the husband of a female physician, the author is aware of additional concerns our female colleagues have to deal with, including unwanted physical contact from male patients that may well be worrisome enough to terminate the relationship. Female physicians may well need to be more constrained and careful about contact gestures with male patients than will male physicians.
There are a number of cultural considerations in giving contact gestures of welcome or support to patients, as many cultures vary in their receptivity to contact and opposite gender touch. Respect for other cultures, and observation of their mores, requires knowledge of the cultures and an appreciation of how best to accommodate the patient’s cultural or religious boundaries. The touching of a female—both married and unmarried—in some religious patients, especially Muslim, may be considered inappropriate. When entering the room, the male otolaryngologist must take in the gestalt of the situation, and, if in doubt, should not attempt to shake hands with the female patient, especially if they are in traditional dress.
Owing to the increase in medical mission trips by otolaryngologists in the past two decades, more otolaryngologists are becoming aware and knowledgeable of some of the restrictions on patient contact. One can rarely go wrong, if uncertain, by presenting a pleasant smile and proffering a polite greeting instead of a handshake. This author, even recognizing the presumed “assent” to a physical examination by being present in the examination room, has taken to always asking for permission to perform the physical examination. This sets the stage for beginning the professional contact for the head and neck examination. For female patients who have a covered head, one has to be a bit more specific about the examination requests, and be comfortable with performing the examination with the head covering on the patient—it can be done quite well, in fact. For a married woman who is covered, it may be appropriate to also request a head-nod assent from the husband or father of the female patient for good measure.
A good piece of advice is to always be cautious about offering a gesture contact of support to a patient of another culture without a clear understanding of cultural boundaries and mores. Respecting a patient’s personal space and preferences is an important professional consideration that includes proffering a contact gesture after the assurance that it will be accepted by the patient. When in doubt, a smile and words of support and empathy are usually acceptable in most circumstances.
Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.