Melanie: Grandpa, the way you practiced medicine seems like another lifetime ago! You talk a lot about the importance of a physical exam in diagnosing all kinds of problems, which is almost non-existent today.
Grandpa: The physical is not merely an anatomic exploration, but also a trust-promoting endeavor. It is the doctor’s most ancient tool. Beyond providing a wealth of information it is an act of bonding. The hand becomes an adept diagnostic instrument rapidly narrowing diagnostic options.
Melanie: Right, that seems like a joke these days. A medical assistant usually takes my blood pressure, my pulse, and my temperature and tells me to step on a scale, even though I’m wearing my shoes and all of my clothes! (I usually wear some serious heels, too.) One time, I still had a handbag slung over my shoulder.
At a specialist’s office, a new medical assistant didn’t bother with vitals at all, and instead, faced a computer while asking a series of disconnected questions with her back to me. I had to give information about my family history that I provided a million times before, because she couldn’t locate my record online. She actually asked if I had ever “experienced domestic violence” between questions about weight fluctuation and eating habits—still with her back turned.
Grandpa: The skill of ‘touch’—never mind taking a history—is not taught to health care providers at any level. One would think that evolutionarily acquired reflexes that enhance connectedness and trust would be emphasized in medical school. I found abundant research reports in nursing journals and those devoted to complementary medicine; but almost nothing about touch in the medical literature.
Melanie: If doctors have difficulty listening to patients and taking time to dive into actual complaints, the physical would naturally get short shrift.
Grandpa: Regrettably, the medical profession barely acknowledges its disappearance and is indifferent to the consequences. A medical treatise could be written on the diagnostic value of a handshake. It certainly provides a quick insight on personality if nothing else.
My respect for the physical grew with experience in doctoring. Some forty years ago a robust thirty-year-old man sought my counsel for breathlessness following modest exertion. He had seen several doctors without receiving an explanation. His physical examination was unrewarding, the electrocardiogram and pulmonary function tests were normal. While listening to his heart, I brushed against his right thigh and then to my utter surprise, I felt the forceful pulsing of an artery. Immediately I had him take his trousers off. There in the outer right thigh was a big coil of vessels (arterio-venous fistula). A massive amount of blood was being diverted from an artery directly into a large vein. This congenital anomaly was leading to heart failure, but a simple ligature restored him to normal. Though never again did I discover something as dramatic, I found the more thorough exam to be invaluable.
Melanie: Do you have all your patients “disrobe?”
Grandpa: Funny you ask. Once when seeing King Hussein in consultation in Amman, Jordan, he asked me whether he should take his trousers off. With utmost dignity I indicated that his majesty did not need to remove his pants. I can recall few other exceptions.
Sadly in several recent hospitalizations, though I was already disrobed not a single doctor bothered to examine me. If not heed an old voice, maybe young doctors would respond to Bruce Springteen and gift their patients with just “a little of that human touch.”
Copyright © 2012 The Lown Conversation
The Lown Conversation 
Hello Melanie and Dr. Lown,
Your story of the medical assistant asking if you had ever “experienced domestic violence” between questions about weight fluctuation and eating habits – and with her back turned to you! – made me cringe.
This is, sadly, standard practice in too many medical offices, often excused by the bureaucratic demands of record-keeping and paperwork. But there IS simply no excuse for not making at least minimal eye contact with another human being in a clinical setting. I wrote about this last year in “The Lost Art of Common Courtesy In Medicine” at: http://myheartsisters.org/2011/12/27/the-lost-art-of-common-courtesy-in-medicine/
Luckily, researchers are beginning to look at exam room etiquette as an area that needs looking at! Your lovely post begins to explain why it’s so important.
Thank you for sharing your terrific post about the lack of a bedside manner in healthcare today. Your own experience speaks volumes, and the fact that 78% of patients just want doctors to shake their hands is staggering. Our needs are so simple, so basic! As my grandfather said, “a medical treatise could be written on the diagnostic value of a handshake.” I look forward to reading more of Heart Sisters!
I am an MS2 at Indiana University and your post reminded me of this Ted Talk featuring Abraham Verghese: http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch.html
A classmate shared the video with me, and I have found it to be influential in my Physical Diagnosis training this year. Thank you for your post. I’m glad to have stumbled upon your blog.
This is a great Ted talk, and a nice complement to our themes. Abraham Verghese is spot-on. The power of touch and the art of listening are both powerful tools to enhance doctor-patient relationships—and with that comes trust, connectedness and healing. Thanks for sharing!