My clearest memories of medical school and residency are the concrete chunks of time devoted to learning the physical exam.  Dr. Margit Bretzke teaching me her thorough approach to the breast exam.  Practicing till I could perform Dr. Mitch Einzig’s systematic newborn exam in my sleep.  Dr. Tim Ramer and his bolo tie demonstrating how to perform tactile fremitus and whispered pectoriloquy.

A disconcerting trend in medicine is the movement away from physical touch.  Every conference I attend preaches a new touch warning.  Don’t shake hands – too germy.  Don’t bother with 98% of the annual physical exam because it has no impact on patient outcomes – and you don’t have time for it anyhow.

Competing with our evidence-based touch aversion are the myriad variations of this story:

“I went to the doctor on Thursday about my knee.  He was in the room for maybe two minutes, had his hand on the door the whole time.  He asked me a couple questions and then told me to stop by the front desk to get my surgery scheduled.  He didn’t even examine my knee!  I’m never going back there again!”

Of course, the back story is that the physician glanced at the MRI before going in.  He already knew the diagnosis and treatment.  Time spent examining the knee is time taken from the twenty-five other patients crammed into his morning clinic.

The problem is that many patients feel that their medical story is an incomplete cliffhanger without a physical exam.  Patient satisfaction and patient confidence in their physician can have profound impacts on outcomes.

I continued to perform routine parts of the physical exam, checking the cranial nerves, eliciting deep tendon reflexes, even as the US Preventive Services Taskforce found they were unnecessary in the absence of symptoms.  Why?  Because touch connected me to my patients.  A reassuring hand on a man’s shoulder as I listened to his heart.  The gentle touch (after verbal warning) of a warmed speculum on a woman’s thigh to help her prepare for the pelvic exam.  A high five with a nervous two-year-old.

I’m sure the day will come when a handheld Star Trek machine can diagnose any ailment and dispense appropriate treatment.  I won’t practice that kind of medicine.

In the words of poet Stanley Kunitz, “Touch me, remind me who I am.”

Musical Moment

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