The Doctor's Touch - A Ritual in Need of Revival

January 9, 2012

How many of you have visited a physician and got sent straight to the laboratory for an investigation or have been prescribed medicine or a CT scan without the doctor laying a finger on you? If your answer is yes, dear reader, be assured that you are not alone. It was a thought provoking video that arrived in my mail a while ago which inspired me to pen this article. Dr Abraham Varghese, professor for the Theory and Practice of Medicine at Stanford talks about the transformative power of the doctor’s touch, the transcendental power of the human hand, of the ritual of physical examination. He is a firm believer in the old-fashioned physical examination of patients, the bedside chat and the power of informed observation.

Let’s take a look at the scene today. It is not uncommon to see patients being operated upon the wrong limb, having unexpected drug reactions because of wrong prescriptions and suing doctors as a result. In an era where, time is money, patient welfare seems to have conveniently been put on the backburner. A patient is nothing more than a statistic in a drug trial or profit spreadsheets. The higher your insurance coverage, the more expensive are the investigations ordered and the more expensive are the drugs prescribed. Did you know that the average time that elapses when a patient is talking to his doctor before being interrupted by the doctor is 8 seconds?

We have witnessed the gradual corporatization of healthcare in India. Medicine these days is generally not a non-profit venture. Hospitals are watching their profit margins and that means putting pressure on their doctors to see more patients in less time, order more tests, and generally make themselves and their practices financially not just viable, but highly profitable. Technology, data, metrics and the entire gamut of evidence based medicine devices have been touted as being a means to the end of the goal of cure. But in today's era of corporate healthcare do these means justify the end? My answer is no. In fact it is a vicious circle. With information explosion, and doctors who neglect the importance of conversation, patients sue and file litigations and to escape this, doctors have come to excessively rely on laboratory investigations and now practise what is infamously known as defensive medicine. Hiding beneath the cloak of modern laboratory investigations and the plethora of electronic apps available on smart phones and ipads has become quite common for doctors who do not trust their own capabilities or are plain incompetent.

Let’s examine this issue from two perspectives. From the perspective of the patients, they come to the doctor filled with uncertainty and hope and fear; and the clinical response, if determined purely by complex sounding laboratory investigations, however medically accurate, without any physical examination , the visit to the doctor may be emotionally insufficient for the patient. Sometimes, all that the patient wants is for somebody to listen to them, empathize and understand.

From the doctor’s perspective, I'm sure most physicians would love to spend much more time with patients. But there are only so many hours in a day. If we spend twice as long with a patient we will need exactly twice as many doctors. Healthcare is already becoming a huge burden on our economy. The solution for example, perhaps would lie in not running to the cardiologist when you get the flu and instead go to a general practitioner who is equally capable of treating your flu. This would allow a cardiac patient in greater need of the specialist’s time to avail the necessary attention and care.

Cicero once said, “The competent physician, before he attempts to give medicine to the patient, makes himself acquainted not only with the disease, but also with the habits and constitution of the sick man." When I went to medical school, my professors in a bid to drive home the importance of observation always stressed that the diagnosis of an ailment in a patient begins the moment he/she walks in through the door of your clinic. I strongly agree. There is nothing more soothing for a patient than to have a comforting presence, a patient listener who empathizes and puts a warm arm around the shoulder when he/she is confiding their darkest fears and being completely vulnerable.

A thorough physical examination of the patient is a kind of ritual and as such should be cultivated. To be touched from head to toe gently and thoroughly, to look at the patient while he/she is talking about their symptoms or stories , to look for those subtle uncommunicated signs in their body language, to hold their hand and tell them you understand and it will be okay- this is what builds the doctor – patient relationship. The greatest offering our patients give us is their absolute faith and trust. Touch, observation and conversation are 3 vital elements to establishing a successful doctor-patient relationship. Taking the time to spend a few extra minutes taking a thorough history and examining the patient saves time in the long run and offers information unobtainable by the gamut of tests.

Don’t get me wrong. Touch should by no means inherently trump rational analysis or technology. I definitely believe technology has a powerful role to play in the improved diagnosis and treatment of our patients. What I am against however is the obsessive reliance of the healthcare community on powerful diagnostic tools completely neglecting the patient as a whole. The existence of such powerful diagnostics tools does not invalidate the doctor using his senses to get some idea of what to look for in all that data.

Technology should not deny the patient as a human being. No doubt laboratory investigations serve as a valuable tool for diagnosis, yet as physicians we must not forget that unlike the corporate honchos sitting in their plush offices and counting profits, patients are not statistics, they are human beings. Without the ability to unflinchingly gaze at your patient when they are most vulnerable, touch, show compassion and empathize, we are doing our patients a great disservice.

The clarion call of the hour is to return to our roots, to revive the dying art of history taking and the ritual of physical examination, to amalgamate the best of both worlds- a humane approach and technology for the betterment of our patients. Without this humane approach, we physicians would cease to be "healers" in the true essence of the word. Let’s use our humanity or what’s the point of having it?
 

Dr Deborah D'Almeida Archives:

 

By Dr Deborah D'Almeida
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Comment on this article

  • Sheena, Mangalore/UK

    Mon, Jan 16 2012

    Very good article and an eye opener to all medical professionals where ever they are serving the sick and needy!
    Recently I watched a programme on the BBC HARD TALK programme questioning a well known Heart surgeon from Mangalore based in Bangalore ‘’ are you a doctor or a businessman???as he is opening his business empire around the world .Doctors may portray themselves as if they are doing a favour to the needy but they are more importantly in the money making business than treating the sick.

  • A.K.MUHIUDDEEN, Muscat / Mangalore

    Sun, Jan 15 2012

    HAT'S OFF&KUDO'S TO DR.DEBORAH D'ALMEIDA FOR HER COURAGE TO WRITE THIS WONDERFUL BITTER PILL OF TRUTH, WHICH IS DIFFICULT TO SWALLOW AND DIGEST,IS AN EYE OPENER FOR ALL THE MEDICAL FRATERNITY,WHO IN THE NAME OF MODERN HEALTHCARE,HAVE FORGEOTTEN THIS HUMANITARIAN PROFESSION, WHERE THE TRUE SPIRIT OF TREATMENT IS *TOUCH OF FEELING IS ABSOULUTELY A TOUCH OF HEALING*. THE ROOT CAUSE FOR THE COMMERCIALISATION OF HEALTHCARE STARTS FROM THE ADMISSION LEVEL TO MEDICAL COLLEGE,WHEREIN DAY BY DAY RISING OR TOWERING COST TO GET A SEAT FOR MEDICAL COLLEGE,BY PAYING HUGE SUM AS CAPITATION OR DONATION,AS WELL AS COLLEGE FEES. HERE LOT OF UNSCRUPULOUS DALALS OR AGENTS WORK AS MIDDLEMEN OF THE SO CALLED MEDICAL COLLEGES IN COLLECTING HUGE AMOUNTS FROM THE ASPIRING MEDICAL STUDENTS. IT IS BUT NATURAL THESE DOCTORS TURN GREEDY TO RECOVER THE SUM WHICH THEY INVESTED TO BECOME A DOCTOR. AT THE SAME TIME THE DOCTORS SHOULD NOT FORGET THE HIPPOCRATIC OATH,A PART OF MEDICAL ETHICS, WHICH THEY HAVE TAKEN DURING THEIR GRADUATION TO SERVE THE COMMUNITY WITHOUT ANY EGO OR BIAS,RATHER THE ABOVE OATH SHOULD NOT BECOME A OATH OF HIPPOCRISY(FALSE FAITH). IN THE COMMUNITY DOCTORS&PATIENTS COMPLIMENT EACH OTHERS. WITHOUT EACH OTHERS INVOLEMENT BOTH WILL NOT SURVIVE MONETARILY OR PHYSICALLY. END OF THE DAY *A HAPPY PATIENT IS LOYAL TO THE DOCTOR*,HENCE DOCTOR PATIENT RELATIONSHIP PLAYS ULTIMATE ROLE IN *CARE&CURE*or*CARE&SHARE* PHILOSOPHY.LET THIS BE A FACT FINDING ARTICLE RATHER THAN FAULT FINDING ONE.

  • Dr Kusuma Kumari G, Nellore/Kodadka

    Thu, Jan 12 2012

    medicine has beocme an industry. Thats the whole problem its all money now people are put to tests woirth crores fo rupess eevryday in india high tiem doctors stat diagnosing diseases clinically and dont get addicted to tests

  • Shekar Moily Padebettu, Udipi/India

    Wed, Jan 11 2012

    Really Dr.D'Almeida an excellent write up and an eye opener for commercialization of health care and corporatization of medical education field.Unwarranted Laboratory tests,investigations are becoming regular feature of present day medical field the moment you enter the clinic/hospitals,many of them could be avoided.But No way to escape.Many of the diseases can be diagnoised even without some of the unwanted tests/investiogations provided doctors show professionalism rather than their profit motive.Very well said and written Dr.D'Almeida.Keep writing.

  • Dr Ahmed M, Mangalore/UAE

    Wed, Jan 11 2012

    Very good article.I think taking a detailed history from the patient and a thorough physical examination is enough to diagnose more than 90% of common diseases. That was our practice in good old days in India. But now the things have changed. People will not spare the Physician if he makes any wrong diagnosis. He has to be 100% sure, otherwise there is a risk of facing court cases or attacks by an angry mob of patient's relatives.If a patient presents with head ache,the doctor has to do a CT scan so that he will not miss an early stage brain tumor. This is called defensive medical practice.The other reason for ordering unnecessary scans and blood tests is money(commission from private labs).

  • Prajwal Mathias/Pinto, mangalore bangalore

    Wed, Jan 11 2012

    Dear Debbie
    very nice article .Keep up the good work
    Regards
    Prajwal

  • E P Cutinha, Mangalore

    Wed, Jan 11 2012

    All Doctors especially those working for 'Nursing Homes' should read this article.

  • A. S. Mathew, U.S.A.

    Wed, Jan 11 2012

    The pharmaceutical companies invest
    millions of dollars to create new
    drugs and most of them are dangerious drugs, then advertise
    (actors acting like Doctors) in
    T.V. and exhorting the public to
    request their doctors for that
    particular medication. The drug
    companies and Doctors are getting
    rich, and later on many of these
    drugs are banned due to deaths and
    other complications.

    While working in a hospital, it was
    surprising to see the tons of
    x-ray film used, and 90% of the
    x-ray reading was negative. How many thousands of dollars are
    made by this unnecessary tests by the doctors and hospitals? It seems like the new
    circus has gone up to the far
    expensive tests of MRI and CT scan.
    The Doctors simply decorate the
    chest with stethoscope, but even to
    diagnose anything other than simple cold, a battery of tests
    are conducted and the bill will
    lead the patients to the CCU. The
    vast majority of the Doctors and
    hospitals are to grab as much money
    they could from the sick people.

    The medical industry has created
    total fear in the hearts of the
    people, and even the simple gas
    pain is considered as heart attacks
    and the headache as brain cancer.
    How many unnecessary operations are
    done and thousands of deaths?
    Who has time to touch the patients
    and to act like a Doctor of the
    old time?

  • ad, mangloor

    Wed, Jan 11 2012

    A very interesting and thoughtful scenario in the med.system of today. While acknowledging the good, I want to highlite some of the unethical things done to med. care.
    First of all,medical welfare has become a big buisness around the world on the on-set of med. corporations and insurance companies. While the health systems are blessing, it has also become cash cow for those who profit from it.
    Should profit be the motive of medical field? I would certainly argue that profit motive has overridden the sheer health of the patient.
    While money buys best of the best, I am worried, only the affordable can live at the cost of the unaffordable.
    While universal care is needed, we must accept the fact that it is not entirely possible but the medical profession can make a immence contribution to this cause.
    Dr.Deborah you have shown some thought provoking thoughts for this profession.
    Let the patient be the priority over the money of this noble profession.

    We are living in a sad world where from water, air and the like have become commercial ventures let alone the med profession.

  • Deborah Dalmeida, Mangalore/Antigua

    Tue, Jan 10 2012

    Thank you everyone for the generous appreciation.

  • Kurt Waschnig, Oldenburg Germany

    Tue, Jan 10 2012

    A very interesting article and thank you Deborah for all the information. I enjoyed reading your article so much.

    I speak from my own experiences Deborah, it is the usual procedure to send patients straight to the laboratory for an investigation or have been prescribed medicine or a CT scan without the doctor laying a finger on you.

    Of course there are many situations where a personal approach is necessary to examine the patient physically.

    Dr Abraham Varghes is a firm believer in the old-fashioned physical examination of patients, the bedside chat and the power of informed observation.

    The reality shows that doctors are overworked and it is normal that physicians work around 70 hours a week at hospitals in Germany.

    Physicians are exposed to stress and emergency situations nearly the whole day at hospitals and there is no time for the old -fashioned physical examination.

    “In an era where, time is money, patient welfare seems to have conveniently been put on the backburner. A patient is nothing more than a statistic in a drug trial or profit spreadsheets.”

    You are right and I would like to mention there have been lots of attempts to change the dangerous situation in hospitals but up to now in vain.

    “Let’s take a look at the scene today. It is not uncommon to see patients being operated upon the wrong limb, having unexpected drug reactions because of wrong prescriptions and suing doctors as a result.”

    One often can read about those mistakes and therefore as you describe there must be a change for the safety and well being of patients.

    The patients should be seen with his/her anxiety, dignity, wishes and hope to get cured.

    Patients need doctors who listen to them, explain, take time for them, encourage them to pluck up courage and to fight against their disease.

    And patients need psychologists and priests who support them in a critical phase of life.


    Medicine and technology has made tremendous progress and it has been working for patients excellently but we need more humanity in medicine.



    Best regards



    Kurt Waschnig Oldenburg Germany

    e-mail: oldenburg1952@yahoo.de

  • 'Boniface D'Souza, Manipal /Bangalore

    Tue, Jan 10 2012

    Dr.Almeida congratulations for your thought provoking write up on modern day medicine, I feel that the traditional family physicians concept is the cure for such ills.

  • G.N.Bangera, Mijar/Muscat

    Tue, Jan 10 2012

    Doctor touch will cure any sickness this is the art god gave to the hand for treating the sick get medicine GOD cure all sickness by the grace

  • James D' Almeida, Mangalore

    Tue, Jan 10 2012

    Hi Debbie,

    Congratulations for a well written article. Wish all the modern day medical practioners follow the healing touch. Kind words which will assure the patient to relieve of his/her ailment to a great extent. Wish you all the best in your future medical persuits.

    Love, Dad and Mom

  • David Prakash D'souza, Niddodi/Abudhabi

    Tue, Jan 10 2012

    A very good article Dr Deborah.A touch from Doctor surely makes the difference. As Mr Mathew pointed out that Jesus would have healed from a distance, but most of the occasions he touched them and healed them. And in Mark 16:17-18(AMP)17 And these attesting signs will accompany those who believe: in My name they will drive out demons they will speak in new languages

    18They will pick up serpents and [even] if they drink anything deadly, it will not hurt them they will lay their hands on the sick, and they will get well.
    So the last part of the scripture says they will lay their hands on the sick and they will get well, so utmost importance is planced on the laying on of hands in simple terms touching some one.
    Let us pray that each and every doctor will realise this and give utmost importance to the patients, because God made man in his own image and likeness, every one is important irrespective of his cast, creed or religion or his financial status and background. When Doctors are moved with compassion as Jesus was moved we can see more miracles and healings over this earth.
    Once again thanks a lot Dr Deborah for this article.

  • Tony Crasta, Mangalore/Sydney

    Tue, Jan 10 2012

    The article by Dr. Deborah presents an honest and truthful assessment of the scenario that exists today in the medical field with regard to Doctors handling majority of their patients, either in their own Dispensaries or in the Hospitals they work for. As she rightly conveys, the present lot of Doctors are so busy and tied up with their work schedules, they hardly give any attention or attach any importance to giving personal touch - an empathy and concern - to the patients under their care. I liked the article very much.

    In this context, it is worth noting the outstanding example of the late Dr. Fred Hollows, who was an eminent Eye Surgeon with an Australian background, and when he carried out hundreds and thousands of eye operations in Nepal, irrespective of his patients` economic background, he always considered each and every one of them were very important, and he conducted these operations with such a care and minute detail, as if he was operating on the Prime Minister or the King of the country. Perhaps, the present generation of Doctors would do well to take a leaf or two from Dr. Hollows example.

  • A. S. Mathew, U.S.A.

    Mon, Jan 09 2012

    Very touching-informative and
    timely article spreading a wider
    light in the dark room of the
    modern day medical industry. The
    medical profession, if taken as a
    divine profession by the medical
    community, then it will do miracles
    in the healing process of the
    patients. If a caring and affectionate doctor gives water to a patient, miracles can
    take place due to the trust and
    relaxation of the patients.

    We must be open-minded to follow
    anything good from the neighbour
    or from a far off place. Even though I am living in the U.S. for more than 40 years, and a lot of
    things are far greater here when
    compared to other countries but the worship of money has gone far
    beyond any rationality and moral
    guidlines. The worst place is in
    the medical industry. That trend
    is being adopted in the Indian
    medical profession, which can be
    very counter-productive and far
    dangerous.

    JESUS might have said to many of
    the sick people who came to Him for
    healing " you are healed, and go home", but we can see that JESUS
    touched them with compassion.

    I pray that GOD will raise up a
    battalion of Doctors with that spirit of
    compassion for the sick people
    in India.


  • Hilda, Mangalore/Bahrain

    Mon, Jan 09 2012

    Wish all the docs have the same view. First thing the docs ask is "You have Insurance" and if yes then starts the list of tests you need to know before the doc decides on what to give you for a simple cold and flu. I have two kids and I rely more on Grandma's old homemade kashaay's simply because they are the best according to me. Good article Dr. Deborah.

  • Neville Fernandez, Mangalore/Antigua

    Mon, Jan 09 2012

    Well written Deborah. So true in these "modern" times!

  • Dr. Lavina Noronha, Mangalore

    Mon, Jan 09 2012

    Dr. D' Almeida, An excellent write up on the need for a healing touch in modern medicine in order to combat commercialization of health care and corporatization of medical education. Yes, technological aids and tests should complement not replace the good old physical examination. Additionally, medical education should encompass good communication and observational skills, treating patients as “people” with respect and dignity (despite their age or economic background), looking beyond the diagnostic labels to truly respond to the “dis-ease” people often experience. It is heart warming that there are a number of professionals who truly care despite the lacunae in the system. May their tribe increase a hundredfold.


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