Keeping the Human Touch in Medical Practice

To the Editor: We welcome Gowda and colleagues’1 focus on physical examination and their invitation to engage in more meaningful discussions on its teaching. We highlight the interpersonal nature of physical examination. Although performance of physical examinations is traditionally reported as “on” a patient, we suggest an increased emphasis on physical examination enacted “with” a patient. Physical examination is not only a process of information gathering, technique, or hypothesis testing; it is an important form of communication and a key element in the delivery of patient-centered care. A core element of physical examination is human touch. Touch is a dominant form of nonverbal communication used in clinical care. Although nonverbal communication is addressed in many medical school curricula, the focus tends to be on body language and use of gestures rather than the intimacy of touch. Yet physical examination is a dynamic process of engagement.2 For example, as we examine a patient, we perceive on multiple levels—not just the presence or absence of physical signs, but also the patient’s comfort and emotional state. In turn, the patient responds to us—reading our facial expressions, interpreting the pressure of our fingertips, and responding to the gentleness (or lack thereof) to inform how he or she will proceed within the consultation. This exchange often happens at an unconscious level, yet awareness and attentiveness to these subtleties can, we suggest, make an important contribution to the doctor–patient relationship. We concur with Gowda et al about the importance of context. The majority of patient care is delivered in ambulatory care settings, where a focused examination is likely to be performed, and we welcome as appropriate the earlier introduction of instruction in this approach. Issues of context extend beyond specialty or physical location to incorporate issues of gender, culture, age, and prior experience of patient and doctor. Although these areas may be covered under professionalism, they also represent a form of embodied knowledge and experience that is rarely explicated during clinical skills teaching. We propose a wider consideration of physical examination teaching that moves beyond the technical to include the human experience. Martina Kelly, MB BCh BAO, MA Associate professor, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada; e-mail: [email protected] Wendy Tink, MD, BSc, FCFP Assistant professor, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada. Lara Nixon, MD, FCFP Assistant professor, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada.

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