(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.
I suspect that I am in a slightly different space being as a health care professional. For me, the touch is not ritualistic (though there is certainly power involved). I touch for two reasons - to offer comfort and form a relationship, and to engage all my senses and focus my observations on the person's issues. When I do a top to toe assessment and touch people, they know they have my full attention. The body gives clues that can expand on the story that each person has to tell and I wouldn't want to miss anything by only engaging one sense - hearing. Of course, I also think people should be asked if they are ok to be touched. Before I lay a hand on anyone, I ask - and this is where the power differential comes into play I think - hardly anyone ever says no.
As an aside, I also teach at a University and do not buy into the student as consumer rhetoric. I find it slightly abhorrent to consider knowledge and education as a product. If it was, then paying your student fees would be enough to consider yourself "educated".
What odd timing. I was just talking to my sister about a new PSW at my mom's LTC who is very much about touch. There is an old gal who will just burst out into utter despair and start crying and crying, like wailing over the recent death of a loved one. Its hard to witness, but there is almost nothing that can be done to console her. But this PSW gives her a hug and sometimes, just sometimes has an impact to calm her down, which to be honest seems like a big win for the old woman. But thats so very different from my visits to the doc. She needs some sort of emotional comfort. When I go to the doc, I am for sure on team Bloom. I want my doctor to focus on the issue with as much emotional connection as the guy who changes my car's oil. Yes, I am bummed out of I have arthritis in my knee and cant live the active life I want with it, but I dont look to my doctor for emotional support for that. But I think some people do look for that.
One other thought. When my late wife was going through cancer care, she had a really great pain and symptom guy who took the time to talk about some of the challenges of treating and understanding pain. So much of the measurements were all so subjective of the "on a scale of 1-10, how is it today" kinda of thing. If you ask these questions in a windowless dark room vs a bright sunny room, or if the person asking the questions is cheery vs dower, he said these things would make a difference in the reports. Sure, classic observer effect, but if you truly think you feel better, dont you want the better observer ?
Decades ago, a very young girl had been seen by several physicians and specialists because she was experiencing excruciating head pain. After numerous tests and finding no physical cause, and wondering if it might be psychological in nature, she was referred to Psychologist, Stanley Jack Rachman, for assessment. After some preliminaries, Dr. Rachman said to her, “Well let’s have a look then. Could you tell me where it hurts?” He placed his finger tips on her head while she verbally guided him. “Wait a sec," he said, "whats this ridge here?” He began to trace a narrow ridge of skin encircling her head. He eventually realized that the girl had put an elastic on her head as a headband long ago and had forgotten about it. He sent his conclusions to the referring physician (to have it surgically removed) with the sardonically written suggestion that medical doctors should try putting their hands on their patients, now and then.
I suspect that Dr. Verghese's approach would work well for patients whose underlying condition had a strong psychosomatic component (upon edit, I see that commenter Ben Smith said the same thing).
Myself, I do prefer medical professionals to have good bedside manner, but it's not really critical. My favorite veterinarian was quite a gruff fellow, but he was an excellent vet. He easily diagnosed my cat who had previously stumped another vet, someone with a degree from a very prestigious veterinary college.
I think you said it yourself these are patients who aren't listened to. For diseases with a significant psychosomatic component specifically relating to not being heard, perhaps that is important and this kind of treatment will be useful for them.
If a person (or a close relative of his) is seriously ill, no way is he going to relate to the doctor in the same way as to a car repairman or a building constructor...
I'm rather a bit suspicious when someone tries to elevate personal preference into universal prescription. I'm rather slightly suspicious of the moral integrity of someone who tries to elevate a personal idiosyncrasy into a noble virtue. Especially more so when this is done without acknowledgement of why the practice of doctors (formerly predominantly male) touching patients (formerly predominantly female) has rightly gone out of fashion. I shudder to imagine what Verghese would be like as a psychotherapist!
Personally for me , a doctor's touch really matters. During my biannual visits to my doc, his routine inspections are comforting and assuring. Separately, when my Dad lost his appetite one fine day and went to see a gastroenterologist, he casually put a hand on my Dad's shoulder after listening to his symptoms and cracked a joke ; just seemed like a friendly gesture —but he was actually checking for a supraclavicular node. He found something right away, ordered a biopsy, turned out his hunch was right. Made all the difference. Touch can catch stuff tech might miss, plus it just feels more human.
Physical Therapists are also doctors. They re one of the few who are allowed and encouraged to touch and manually manipulate limbs. They can calm pain.
Great post Paul Bloom. I share your sense of ick. The details of my critique may be different but the Ultimate explanation may be the same.
Physical sensitivities don't generally confuse me. I don't mind the touching in itself or by people. It's the circumstances that do. I preach to the choir saying my evolved biology and of cognition is one of those circumstances as is it is for others. It's a physical reality surprisingly easy to better understand - a compounding understanding -long available as it turns out - a "news to me" situation.
I think the creepy not creepy doctor misappropriates ritual like he misappropriates everything else - just enough to provoke inquiry or gain attention. I think he's activating sexual jealousy and fantasy to get men, maybe young men, to get and go to a doctor. I think he's covering for an exaggerated fear about breast cancer and genetics and an administrative orientation that seems to need that nebulous extra space. I can appreciate this, particularly around cancer and it's high risk populations.
I don't think he's suggesting a slave like compliance but maybe a little. Ideally, I think, he's trying to give space for everyone to find their ease while shifting about the sticks and carrots. Just how much Foucault and feminine Freud, broadly speaking, is being operationalized here?
It does seem designed to play against my livelihood and relationships otherwise unrelated. That bugs me as no one told me yet I seemingly didn't need to be told. But I did. The junk psychology has almost always failed on me.
Which gets me to wanting to be part of finding a solution to an understandable frightening historical genetic development as it may have been at risk to an genetic intellectual enthusiasm akin to getting stuck in a casino - nature made hermetic. I'll blame Dawkins, that limey bastard 😉
----------
My naughtiness is in posting like a drunken quickdraw to feed off of the feelings of regret and tension. I transmute them into creating better knowledge for me around the violin work I do but keep private. That research project, solo administration twisted and inside-out, will have to change soon. Very soon, really. I think I have enough.
The ending was mystifying to me. Does anyone go to lectures and seminars that aren't strictly obligatory and written assignments aren't accepted as compensation? Why? Obligatory attendance has been a constant pain in med school, and the team-based learning method, being cheaper, has been increasing, and this makes hours spent at the uni ever worse a value proposition. Very few people talk at the speed I read, and almost no-one formulates their thoughts with the same precision, while also performing for the assembly, as their written word.
What's the value proposition of listening someone talk while being uncomfortable, onseself? I can understand listening to Sam Harris and Paul Bloom discuss reasons to be sceptical of empathy while exercising, doing chores, or playing video games, but other than that, who can bother being tied to a sound source while not being able to occupy the rest of their attention and body?
Also, how does one lecture? Either one assumes everyone is already following the latest research and so what's left is to share personal experience and anecdotes, which are seldom as riveting as we ourselves feel, or one assumes an intermediate level of ignorance from the audience's part, leaving the most advanced in the audience bored while helping those fully ignorant very little. And lecturing to those fully ignorant doesn't seem like a reasonable thing to do, at all, handbooks and video tutorials exist. Both books and tutorials let the learner skip the unnecessary fluff and speed up the process, unlike interaction with humans does.
The lecture, the seminar, the team-based learning seem like activities undertaken because tradition tells us to, not because there is any utility in anyone doing so. Should dr Bloom be advocating for the end of lecture?
Agreed. As a teacher I have a singular interest: provide a value added skill set to each student. I can be friendly and courteous when I do that, but that’s secondary.
Time and time again it is showing up in research that people recover better - from pain and mental health conditions yes, but also from cancer and other much more 'organic' diseases when there is an enhanced 'therapeutic alliance'. Because humans are fundamentally social beings - the same way that we are fundamentally diurnal and fundamentally bipedal - we know that people heal better from illness when they respect their circadian rhythm and they have adequate movements. The same is probably true with healing that it happens best when we have a social relationship with the person who is perceived as healing us.
That poll really forced a binary response. I think 'Sometimes' should have been in play.
I suspect that I am in a slightly different space being as a health care professional. For me, the touch is not ritualistic (though there is certainly power involved). I touch for two reasons - to offer comfort and form a relationship, and to engage all my senses and focus my observations on the person's issues. When I do a top to toe assessment and touch people, they know they have my full attention. The body gives clues that can expand on the story that each person has to tell and I wouldn't want to miss anything by only engaging one sense - hearing. Of course, I also think people should be asked if they are ok to be touched. Before I lay a hand on anyone, I ask - and this is where the power differential comes into play I think - hardly anyone ever says no.
As an aside, I also teach at a University and do not buy into the student as consumer rhetoric. I find it slightly abhorrent to consider knowledge and education as a product. If it was, then paying your student fees would be enough to consider yourself "educated".
I suggest you are in a special situation in that you see the doctor as an equal. For most patients he's god.
This is unfortunate. Patients should be in partnership with their physicians.
What odd timing. I was just talking to my sister about a new PSW at my mom's LTC who is very much about touch. There is an old gal who will just burst out into utter despair and start crying and crying, like wailing over the recent death of a loved one. Its hard to witness, but there is almost nothing that can be done to console her. But this PSW gives her a hug and sometimes, just sometimes has an impact to calm her down, which to be honest seems like a big win for the old woman. But thats so very different from my visits to the doc. She needs some sort of emotional comfort. When I go to the doc, I am for sure on team Bloom. I want my doctor to focus on the issue with as much emotional connection as the guy who changes my car's oil. Yes, I am bummed out of I have arthritis in my knee and cant live the active life I want with it, but I dont look to my doctor for emotional support for that. But I think some people do look for that.
One other thought. When my late wife was going through cancer care, she had a really great pain and symptom guy who took the time to talk about some of the challenges of treating and understanding pain. So much of the measurements were all so subjective of the "on a scale of 1-10, how is it today" kinda of thing. If you ask these questions in a windowless dark room vs a bright sunny room, or if the person asking the questions is cheery vs dower, he said these things would make a difference in the reports. Sure, classic observer effect, but if you truly think you feel better, dont you want the better observer ?
Thanks as always for the thoughtful columns
Decades ago, a very young girl had been seen by several physicians and specialists because she was experiencing excruciating head pain. After numerous tests and finding no physical cause, and wondering if it might be psychological in nature, she was referred to Psychologist, Stanley Jack Rachman, for assessment. After some preliminaries, Dr. Rachman said to her, “Well let’s have a look then. Could you tell me where it hurts?” He placed his finger tips on her head while she verbally guided him. “Wait a sec," he said, "whats this ridge here?” He began to trace a narrow ridge of skin encircling her head. He eventually realized that the girl had put an elastic on her head as a headband long ago and had forgotten about it. He sent his conclusions to the referring physician (to have it surgically removed) with the sardonically written suggestion that medical doctors should try putting their hands on their patients, now and then.
Haha. Bet he didn't get another referral.
I suspect that Dr. Verghese's approach would work well for patients whose underlying condition had a strong psychosomatic component (upon edit, I see that commenter Ben Smith said the same thing).
Myself, I do prefer medical professionals to have good bedside manner, but it's not really critical. My favorite veterinarian was quite a gruff fellow, but he was an excellent vet. He easily diagnosed my cat who had previously stumped another vet, someone with a degree from a very prestigious veterinary college.
I think you said it yourself these are patients who aren't listened to. For diseases with a significant psychosomatic component specifically relating to not being heard, perhaps that is important and this kind of treatment will be useful for them.
If a person (or a close relative of his) is seriously ill, no way is he going to relate to the doctor in the same way as to a car repairman or a building constructor...
I'm rather a bit suspicious when someone tries to elevate personal preference into universal prescription. I'm rather slightly suspicious of the moral integrity of someone who tries to elevate a personal idiosyncrasy into a noble virtue. Especially more so when this is done without acknowledgement of why the practice of doctors (formerly predominantly male) touching patients (formerly predominantly female) has rightly gone out of fashion. I shudder to imagine what Verghese would be like as a psychotherapist!
If you've read any of Abraham Verghese's novels you'd understand why human touch and ritual is important to him.
Personally for me , a doctor's touch really matters. During my biannual visits to my doc, his routine inspections are comforting and assuring. Separately, when my Dad lost his appetite one fine day and went to see a gastroenterologist, he casually put a hand on my Dad's shoulder after listening to his symptoms and cracked a joke ; just seemed like a friendly gesture —but he was actually checking for a supraclavicular node. He found something right away, ordered a biopsy, turned out his hunch was right. Made all the difference. Touch can catch stuff tech might miss, plus it just feels more human.
Physical Therapists are also doctors. They re one of the few who are allowed and encouraged to touch and manually manipulate limbs. They can calm pain.
Great post Paul Bloom. I share your sense of ick. The details of my critique may be different but the Ultimate explanation may be the same.
Physical sensitivities don't generally confuse me. I don't mind the touching in itself or by people. It's the circumstances that do. I preach to the choir saying my evolved biology and of cognition is one of those circumstances as is it is for others. It's a physical reality surprisingly easy to better understand - a compounding understanding -long available as it turns out - a "news to me" situation.
I think the creepy not creepy doctor misappropriates ritual like he misappropriates everything else - just enough to provoke inquiry or gain attention. I think he's activating sexual jealousy and fantasy to get men, maybe young men, to get and go to a doctor. I think he's covering for an exaggerated fear about breast cancer and genetics and an administrative orientation that seems to need that nebulous extra space. I can appreciate this, particularly around cancer and it's high risk populations.
I don't think he's suggesting a slave like compliance but maybe a little. Ideally, I think, he's trying to give space for everyone to find their ease while shifting about the sticks and carrots. Just how much Foucault and feminine Freud, broadly speaking, is being operationalized here?
It does seem designed to play against my livelihood and relationships otherwise unrelated. That bugs me as no one told me yet I seemingly didn't need to be told. But I did. The junk psychology has almost always failed on me.
Which gets me to wanting to be part of finding a solution to an understandable frightening historical genetic development as it may have been at risk to an genetic intellectual enthusiasm akin to getting stuck in a casino - nature made hermetic. I'll blame Dawkins, that limey bastard 😉
----------
My naughtiness is in posting like a drunken quickdraw to feed off of the feelings of regret and tension. I transmute them into creating better knowledge for me around the violin work I do but keep private. That research project, solo administration twisted and inside-out, will have to change soon. Very soon, really. I think I have enough.
The ending was mystifying to me. Does anyone go to lectures and seminars that aren't strictly obligatory and written assignments aren't accepted as compensation? Why? Obligatory attendance has been a constant pain in med school, and the team-based learning method, being cheaper, has been increasing, and this makes hours spent at the uni ever worse a value proposition. Very few people talk at the speed I read, and almost no-one formulates their thoughts with the same precision, while also performing for the assembly, as their written word.
What's the value proposition of listening someone talk while being uncomfortable, onseself? I can understand listening to Sam Harris and Paul Bloom discuss reasons to be sceptical of empathy while exercising, doing chores, or playing video games, but other than that, who can bother being tied to a sound source while not being able to occupy the rest of their attention and body?
Also, how does one lecture? Either one assumes everyone is already following the latest research and so what's left is to share personal experience and anecdotes, which are seldom as riveting as we ourselves feel, or one assumes an intermediate level of ignorance from the audience's part, leaving the most advanced in the audience bored while helping those fully ignorant very little. And lecturing to those fully ignorant doesn't seem like a reasonable thing to do, at all, handbooks and video tutorials exist. Both books and tutorials let the learner skip the unnecessary fluff and speed up the process, unlike interaction with humans does.
The lecture, the seminar, the team-based learning seem like activities undertaken because tradition tells us to, not because there is any utility in anyone doing so. Should dr Bloom be advocating for the end of lecture?
Agreed. As a teacher I have a singular interest: provide a value added skill set to each student. I can be friendly and courteous when I do that, but that’s secondary.
Time and time again it is showing up in research that people recover better - from pain and mental health conditions yes, but also from cancer and other much more 'organic' diseases when there is an enhanced 'therapeutic alliance'. Because humans are fundamentally social beings - the same way that we are fundamentally diurnal and fundamentally bipedal - we know that people heal better from illness when they respect their circadian rhythm and they have adequate movements. The same is probably true with healing that it happens best when we have a social relationship with the person who is perceived as healing us.