Against the power of a doctor's touch
(I’m travelling—presenting at the wonderful HowTheLightGetsIn festival in Wales—so here is a slightly revised version of a paid-only post I sent out last year. New material coming next week.)
Many years ago, I gave my first presentation at TED, as part of a session called Feelings. My talk was on the nature of pleasure, and I felt it went well, but it wasn’t the hit of the session. This was the one by Abraham Verghese, a world-respected writer and physician. (See here for the text of his talk.)
Verghese is a great storyteller who moved the audience with his warmth and intelligence. He argued that something has been lost in modern medicine.
When we lean towards ordering tests instead of talking to and examining the patient, we not only overlook simple diagnoses that can be diagnosed at a treatable, early stage, but we're losing much more than that. We're losing a ritual. We're losing a ritual that I believe is transformative, transcendent, and is at the heart of the patient-physician relationship. … I'd like to introduce you to the most important innovation, I think, in medicine to come in the next 10 years, and that is the power of the human hand -- to touch, to comfort, to diagnose and to bring about treatment.
Verghese told a story about a friend of his who had a lumpectomy and was searching for the best cancer center in the country to get subsequent care.
And she found the place and decided to go there … Which is why I was surprised a few months later to see her back in our own town, getting her subsequent care with her private oncologist. And I pressed her, and I asked her, "Why did you come back and get your care here?" And she was reluctant to tell me. She said, "The cancer center was wonderful. It had a beautiful facility, giant atrium, valet parking, a piano that played itself, a concierge that took you around from here to there. But," she said, "but they did not touch my breasts."
Here are the first comments that popped up on the YouTube video of his talk. People were moved.
Verghese said a lot that I agree with, particularly about the need for doctors to listen to their patients. But his key message about the power of the doctor’s touch does not resonate with me, not in the slightest. I’ve rarely heard a talk that I disagreed with more.
The last time I saw my doctor in Toronto was when I slipped on some ice and banged up my shoulder. Did he touch me? Yes, but I wouldn’t have minded if he didn’t. It would have been just as good if he could get the information he needed from some futuristic scanner—something like the medical tricorder from Star Trek—that he could wave over my injury.
Actually, it would have been even better if I hadn’t had to visit at all. It wasn’t possible in this case, but one of the many things I like about my doctor is that he is comfortable dealing with minor issues over Zoom and email.
Does anyone like visiting the doctor? I think of it with the same warm feelings as an upcoming visit to the DMV. You usually have to wait because the doctor’s time is considered more important than yours. You might have to put on a weird robe made of paper that exposes your bum. You have to answer personal questions. And then there is the touching.
I’m reasonably comfortable about physical contact in general—lots of hugging with my kids—but not everyone is wired up this way, and even for people like me, it’s typically unpleasant to be touched by someone I’m not close to. And so I see the touching that the doctor does as a necessary evil.
Verghese does not. Now, he’s not talking about seeing people with banged-up shoulders. He has a reputation, he tells us, for dealing with sufferers of chronic fatigue. These are difficult patients. Medical treatment has failed them in the past; “they come to you fully prepared for you to join the long list of people who are about to disappoint them.”
So he treats them in a special way. On the first visit, he listens to their stories and tries not to interrupt—something unusual for a physician. The second visit is devoted entirely to the physical exam. Here is how he describes it with one patient.
I always begin with the pulse, then I examine the hands, then I look at the nail beds, then I slide my hand up to the epitrochlear node, and I was into my ritual. And when my ritual began, this very voluble patient began to quiet down. And I remember having a very eerie sense that the patient and I had slipped back into a primitive ritual in which I had a role and the patient had a role. And when I was done, the patient said to me with some awe, "I have never been examined like this before."
I get it. This is someone who feels dismissed or worse by the medical profession. To get a doctor’s full attention, first to the story of your suffering and then to your body, can be powerfully moving.
Verghese describes this as a ritual.
Rituals are terribly important. They're all about transformation. Well I would submit to you that the ritual of one individual coming to another and telling them things that they would not tell their preacher or rabbi, and then, incredibly on top of that, disrobing and allowing touch -- I would submit to you that that is a ritual of exceeding importance. And if you shortchange that ritual by not undressing the patient, by listening with your stethoscope on top of the nightgown, by not doing a complete exam, you have bypassed on the opportunity to seal the patient-physician relationship.
I don’t doubt his sincerity. But there’s something that worries me here. If the examination is a ritual, it is one with a tremendous power difference between the participants. All rituals involve power—you don’t interrupt the preacher or rabbi during the wedding ceremony; they’re in charge—but here, it’s extreme. The doctor asks personal questions and the patient responds; the doctor tells the patient to disrobe and the patient obeys; the doctor touches the patient and the patient does not object. Is it so surprising that the doctor, the one with all of the power, is the one enthusiastically defending the ritual? There must be something very satisfying in exerting this much authority and control, something hard to give up.
From my own perspective—that of the patient— there is no transformative ritual here, no “patient-physician relationship” that needs to be sealed. I see doctors as professionals who are paid to solve my problems, no different from lawyers, accountants, plumbers, and general contractors. They’re nothing like preachers and rabbis.
I imagine doctors reading this and tensing up, but I mean no offense. I respect doctors for their expertise, just as I respect members of these other professions. And I don’t deny that we are in an asymmetric relationship. I tell my doctor about how well I sleep and don’t expect him to reciprocate; he palpates my neck, and I don’t reach for his.
But this asymmetry is no different from what occurs in my other professional relationships. I tell my accountant how I make my money and don’t expect her to make a parallel disclosure. Such an asymmetry is just part of the practical demands of the job. If she described my financial disclosures as an important opportunity “to seal the client-accountant relationship”, I’d roll my eyes. There’s nothing special going on here. If there were an AI that could do her job just as well with less time and less hassle, I would use that instead.
And I feel the same way about medical diagnosis—if it could be done without a visit to the doctor, all the better. Verghese would miss his ritual. I wouldn’t.
I’ve been hard on Verghese, so I’ll end by being hard on myself. When I taught at the University of Arizona, the administrators insisted that the students were “customers” and should be treated as such. I thought at the time—and still think—that this idea is repellent. I love being a professor and think my relationship with students (and I’ll focus here just on undergraduates) is a special one, not something that can be reduced to this transactional framework.
But a critic can point out this is an asymmetrical relationship, one in which I’m in charge. I lecture, and the students listen; I ask questions, and the students answer; I grade the students, and they don’t grade me. When they meet with me, they come to my office, and I get the nicer chair. Our discussion ends when I want it to.
How much of my defense of this system rides on the basic human love of exerting power and authority? Do I have a good response to a student who tells me that she would stop going to my lectures and seminars the minute there’s an AI that does my job better?
I hope to struggle with this question in a later post. But I’ll end by returning to Verghese and the power of the doctor’s touch. Maybe my reaction is unusual. So I’ll ask:
That poll really forced a binary response. I think 'Sometimes' should have been in play.
I suggest you are in a special situation in that you see the doctor as an equal. For most patients he's god.