This is Part 1 of a 2-part series on the power of touch in the clinical medical environment.

In Part 2, we will resume our interview with Stephen W. Russell, MD, co-president of the Society of Bedside Medicine and professor in the Department of Medicine at the University of Alabama, Birmingham.

According to Aristotle, the first and most important sensation that human beings share with the animal kingdom is touch. Without touch, he posited, animals cannot exist.1 The philosopher took these theories a step further, linking sensory perception with the soul; the sensitive soul, in particular, renders animals capable of feeling pleasure and pain, and of the senses governed by this soul, touch or tactility was considered the “most pervasive and intelligent.”2


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Unfortunately for Aristotle, these theories of touch were quickly sidelined — by Plato who considered sight the superior sense2 — then surpassed by the next 2000 years of philosophical thought and a canon of optocentric Western philosophy.

Today, our understanding of touch is considerably more scientific than Aristotle’s early theories. Social touch is considered an important part of human development and has been described in the literature as a “powerful force”3 shaping everything from attachment to cognition to emotional regulation, beginning in infancy and continuing throughout our lives. Children who are deprived of normal sensory interaction may experience developmental delays, underscoring the importance of this seemingly simple action.4

The History of Touch

American psychologist Harry Harlow’s classic experiments with rhesus monkeys at the University of Wisconsin were some of the first studies in the 20th century to demonstrate the power and comfort of touch. Although Harlow’s research interests were an attempt to quantify the importance of comfort, love, and companionship in healthy infant development,5 Harlow’s wire monkey experiment demonstrated how the touch of a terrycloth “mother,” described by Harlow as “soft, warm, and tender,”6 led to positive developmental outcomes for the infant monkeys. In the data, he wrote, “make it obvious that contact comfort is a variable of overwhelming importance.”6

Less controversial was a study conducted by Nathan Fox, PhD, director of the Child Development Lab at the University of Maryland, and colleagues from Harvard Medical School and Boston Children’s Hospital. Their landmark study on the negative role of deprivation, the Bucharest Early Intervention Project,7 followed 136 infants who had been left in Romania’s impoverished orphanages.

Half of the infants and toddlers were assigned to Romanian foster families; the other half remained in their current care, and data from a control group of local children raised by their birth families were also collected. Over the next several years, the researchers found that children who had been born into and remained in an environment of neglect, including a lack of touch, experienced delays in cognitive function, motor development, and language, as well as changes in electrical activity brain patterns, measured by electroencephalogram.8

In 2015, a group of physicians from Johns Hopkins Medicine, Stanford Medicine, and the University of Alabama, Birmingham School of Medicine came together to form the Society of Bedside Medicine,9 a global community of physician educators who believe in the power of the physical exam.

“[We] realized that there was a need for a space where physicians could gather, virtually or in person, to essentially promote a culture of what we consider bedside medicine, or practicing medicine in the presence of the patient,” said Stephen W. Russell, MD, co-president of the Society of Bedside Medicine and professor in the Department of Medicine at the University of Alabama, Birmingham, in an interview. And thus, the Society of Bedside Medicine was born.

“We know that in an age of needing to be efficient with our time and needing to be good stewards of our resources, a well-rendered physical exam specifically focused on a patient’s chief complaint can oftentimes make the workup more streamlined, and it can also give patients…a more streamlined process of getting an answer,” he added. “But the process of getting that answer is actually valuable as well.”

In 2011, founding Society member Abraham Verghese, MD, the Linda R. Meier and Joan F. Lane Provostial Professor and Vice Chair for the Theory and Practice of Medicine at Stanford University gave a 19-minute TED Talk, titled “A Doctor’s Touch,”10 in which he made the argument that shortcutting the physical exam not only leads to physicians who “overlook simple diagnoses that can be diagnosed at a treatable, early stage,” but also leads to the loss of a ritual that Dr Verghese goes on to describe as “transformative, transcendent, and…the heart of the patient-physician relationship.”

Despite this, some physicians feel that the physical examination is going the way of the appendix: a vestigial remnant in the current times.11 Drs Verghese and Russell, though, disagree, writing in a Lancet comment that touch has never left the practice of medicine12 — and in fact is poised to change physician-patient communication for the better.

In a wide-ranging exclusive with Haymarket Medical Communications, Dr Russell shared his perspective on the power of touch in medicine.

This interview has been lightly edited for length and clarity.

There’s really been a shift in medicine towards the embrace of technology, from electronic health record (EHR) systems and computers for use in the exam room to the advent of big data. How do you think that this has moved the practice of medicine away from touching patients during the physical exam?

There is a lot of data that has emerged from the early 2000s to the 2010s — and this actually dates back to the 1990s — where physical exam skills have decreased.

One example of this is in cardiology. There was a study13 that [was] looking at how medical students compared with graduate medical students — so residents to cardiology fellows to cardiology attendings. And what they found is that the farther along than a person went with their medical training, their physical exam skills did not significantly increase, and in fact, there was a decrease in physical exam skills among residents compared with medical students.

So that data suggests that the physical exam skills, which are not routinely emphasized in graduate medical education, and are not routinely assessed in graduate medical education, tend to worsen over time. Whether that’s related to the EHR or the burden of additional charting and data documentation — and there’s some suggestion that that’s the case — very few people doubt that physical exam skills have decreased.

As residents and student practicing physicians spend more time relying on digital data, relying on laboratory data, and other non-patient-related or patient proximate data, it becomes a self-reinforcing cycle. People tend to spend more time thinking about what they consider objective data — the X-ray and the laboratory data — as opposed to some of the skills that they can directly glean from patients themselves.

Recognizing that this was a trend, in 2015 a group of physicians who were interested in the physical exam and…in the doctor-patient clinical encounter gathered together in Palo Alto, California, at the Stanford Skills Symposium, hosted by Stanford School of Medicine…. That has grown into the Society of Bedside Medicine, which now is an organization that has international representation as well as multiple academic medical centers in the United States, who are all gathered together to think about not only the culture of bedside medicine and promoting that, but also, the research, scholarship, and understanding of what the bedside physical exam can tell us as objective markers and as objective data.

Part of our mission is not only to build the culture of bedside medicine, which we think is critically important, but also to recognize that physical exam skills and performing medicine in the presence of the patient is not an antiquated 20th-century approach. There’s quite a good bit of information that can be gleaned from interacting with the patient and performing the physical exam on the patient.

I’ve been using interchangeable terms — either bedside medicine or practicing in the presence of the patient — because many people don’t see their physician in a hospital setting. They may see her in a clinic or in an emergency room setting, and so it’s important for us to recognize that wherever clinical medicine is practiced between a provider and a patient is considered the bedside.

That spreads into telemedicine as well, which brings up a little bit of a conundrum because sometimes it’s really difficult to reestablish that power of touch.

In January 2020, one of our founding members, Dr Verghese and his colleague at Stanford, Donna Zulman, [MD, assistant professor of medicine, general medicine disciplines,] published what we consider a seminal piece in JAMA14 which looked at how providers can prepare themselves for interacting with the patient.

It boiled down to [a few] individual techniques that providers can use to get themselves ready for the patient; things such as preparing with intention, listening intently to the patient, summarizing what the patient is talking about, and empathizing with the patient’s concerns. Each of those have a very intentional and very specific process by which patients and providers can work together to achieve a common goal.

Two months later, the world shut down due to the pandemic, and we’ve found that these techniques — they’re not just expert opinion, but they’re actually culled from the medical literature and from a cross-discipline literature search looking at…other professions where people need to interact with other people in a very intentional and goal directed way — can be transmitted into the telemedicine space.

So, while telemedicine is extremely helpful in certain situations, such as during the pandemic where patients can get in to see their physician physically, we do recognize that telemedicine has its limits.

[We recognize] that when you lose that physical touch, you lose that ability to not only make good direct eye contact with your patient but also have a reassuring encounter where a physician and a patient are interacting in what we would consider more traditional way.

It seems that patients are liking telemedicine in general,15 but do you see that creating a challenge for you and for other physicians who want to have that physical interaction with patients?

I think what we’re realizing that is there’s a real interdependency between providers and patients. Within that interdependency, there are times where certain conditions demand a face-to-face encounter: new concerns, new complaints, acute concerns such as pulmonary problems that may be related to COVID-19 or types of pneumonia, and abdominal problems. Things that require a physician being able to distinguish between, “Is this a chronic problem or is this an acute problem?”

We are also recognizing that in the interdependence between physicians and patients there are some situations where a remote visit is ideal. If a patient has the capabilities for remote blood pressure monitoring or remote blood sugar monitoring, then a remote visit can be very helpful as a touch point to continue to meet patient needs. We don’t see it as a way to replace the in-person exam, but rather as a way to complement it.

It’s also a nice way to triage patients. One of my colleagues and the co-president of the Society of Bedside Medicine, Maja Artandi [MD, clinical associate professor of medicine, primary care and population health at Stanford University,] runs Stanford’s Express Care. They have found quite a need to be able to triage patients using the video visit to determine if this [visit] is something where reassurance or next steps can be provided, or if the video visit is something that can help the physician determine if the patient needs to come in and seek a higher level of care.

That seems like a great way to incorporate technology, especially because technology isn’t going anywhere.

Exactly. I think that that’s a really important point too, because [we] recognize that technology is an integral part of the provider-patient relationship. It doesn’t have to be one or the other; they have to be interdependent and integrated.

An example is something that’s called point of care ultrasound (PoCUS). There was a study done in an emergency room setting where patients who had PoCUS — perhaps looking for fluid in the lungs, perhaps looking for fluid in the abdomen, or perhaps trying to more specifically locate a vessel or a vein that needed to be cannulated in order to do the next step of the workup — in the emergency room setting were shown to be more satisfied with their care and were shown to perceive that the physician spent more time with them.16

And in many ways, that’s an excellent example of bedside medicine because it allows the ultrasound machine to look beyond what our eyes can see and what our fingers can feel, so that we have a better understanding of what the patient’s needs are.

References

  1. Bremer J. Aristotle on Touch. Forum Philosophicum. 2011;16(1):73-87.
  2. Kearney R. Philosophies of touch: from Aristotle to phenomenology. Research in Phenomenology. 2020;50(3):300-316.
  3. Cascio CJ, Moore D, McGlone F. Social touch and human development. Dev Cogn Neurosci. 2019;35:5-11.
  4. Ardiel EL, Rankin CH. The importance of touch in development. Paediatr Child Health. 2010;15(3):153-156.
  5. Association for Psychological Science. Harlow’s classic studies revealed the importance of maternal contact. Published online June 20, 2018. Accessed April 27, 2021. 
  6. Harlow HF. The nature of love. American Psychologist. 13(12):673-685.
  7. Nelson CA, Fox NA, Zeanah CH. Romania’s abandoned children. Deprivation, brain development, and the struggle for recovery. 2014; Harvard University Press.
  8. Weir K. The lasting impact of neglect. American Psychological Association. Published June 2014. Accessed April 27, 2021.
  9. About Us. Society of Bedside Medicine. Accessed April 28, 2021.
  10. Verghese A. A doctor’s touch. TEDGlobal 2011. Accessed April 28, 2021.
  11.  Horton R. Offline: touch — the first language. Lancet. 2019;394(10206):1310.
  12. Russell SW, Garibaldi BT, Elder A, Verghese A. The power of touch. Lancet. 2020;395(10230):e63. doi: 10.1016/S0140-6736(20)30170-7
  13.  Vukanovic-Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. Arch Intern Med. 2006;166(6):610-616.
  14. Zulman DM, Haverfield MC, Shaw JG, et al. Practices to foster physician presence and connection with patients in the clinical encounter. JAMA. 2020;323(1):70-81.
  15. Reynolds KA. Survey: telehealth on the rise, popular with patients. Medical Economics. Published May 21, 2020. Accessed April 28, 2021.
  16. Diprose W, Verster F, Schauer C. Re-examining physical findings with point-of-care ultrasound: a narrative review. N Z Med J. 2017;130(1449):46-51.

This article originally appeared on Clinical Pain Advisor