I was forwarded an article from the New York Times today that reviewed a reflection published in JAMA written by a medical student. The student was reflecting on a clinical experience that involved a patient crying after receiving some particularly bad news and the attending physician reaching out and holding the patients hand while  the patient dealt with his emotions. The student offered this: 

Earlier in the year I had observed Dr C holding the hand of another tearful patient. After that patient encounter our group discussed with her the pros and cons of a physician taking hold of a patient’s hand. Some of us were more comfortable with doing so than others. Some students expressed concerns about the appropriateness of holding a patient’s hand and whether doing so might be deemed an intrusion into the patient’s personal space. After facilitating a discussion about the matter, Dr C concluded that a physician has to use appropriate judgment and be personally comfortable with holding a patient’s hand before extending his or her own.

He later found himself in a similar situation and allowed himself to connect with the patient through a caring touch as had his attending, Dr C.

The comments to the NYT posting are well worth a read, as they say much about the unevenness of the medical profession, the cynicism of patients, and the fact that many patients seek comfort from physicians and many physicians are willing to offer such comfort.

Here, we teach our learners the importance of connecting with their patients, through verbal as well as physical connections (as I documented here). Part of this education for the medical students  is to show a version of the film “The Doctor“. Among other teaching points, the main character (a physician) initially seeks out a physician on superficial criteria (physical attractiveness) and ends up trusting the physician who exhibits physical and verbal compassion.

We teach our students and  residents to connect with patients through lectures, modeling, and assessment while engaged in patient care. Always that means they need to exhibit excellent verbal communication. Almost always, that means a physical connection. It may be through the use of the stethoscope. It may be a hug if the situation calls for it. It also means we have to teach the learners to develop verbal and non-verbal skills so that if the physical interaction is unwanted the learner will understand that as well. In the words of one commenter:

It’s not the gesture–it’s the feeling.
One MD’s hand hold could be self-serving, creepy, lascivious. Another’s could be authentic, wise, and kind.
The problem may partially involve the difficulty cultivating self-awareness, psychological-mindedness and clinical judgment born of true interpersonal sensitivity. Boundary violations are usually justified by the MD, rationalized as ‘good’ for the patient. By the same token, feeling afraid of intense sadness and the emotional terrain of caring for people in great distress generates justification for ‘distancing’- to be objective means not to let anyone ‘get to you.’
Both are travesties.
There are no rules or care maps for this domain. Maybe a good role model is a start, maybe better medical education in grappling with strong reactions to patients- at least as assiduous as auscultating the heart- would help.

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