In my previous post I used a phrase from a Lee Robinson poem that had the line "finding each other nose to nose."
That prompted Bill to write:
" . . . reminded me of visiting New Zealand for an international peroxidase meeting. The organizers had the opening ceremony follow Maori tradition (because we were on Maori land in Akaroa). The ceremony included singing etc, but with the Auslanders kept separate from the natives, divided by an imaginary line. We were not permitted to pass until the proper time. Individually we came forward, described from where we came (both geographically & biologically...the names and origins of our parents) and touching noses (actually sharing breath) with one of the welcoming natives. I'm pretty self-conscious & thought I'd panic....but I didn't. Quite the opposite, I thought it was a beautiful expression of humanity; what's more intimate than sharing a breath with another?"
What Bill described is a great example of ritual, a subject that interests me in the context of the bedside examination of the patient. Rituals, anthropologists will tell us, are about transformation. The rituals we use for marriage, baptism or inaugurating a President are as elaborate as they are because we associate the ritual with a major life passage, the crossing of a critical threshold, or in other words, with transformation.
Examining the patient at the bedside has all the critical ingredients of a ritual: it is usually performed in a special space (the doctor's office or the hospital bed); it involves one person baring his or her soul and then baring his or her body and allowing another person the privilege of touch; the person examining is often wearing a special uniform (the white coat) and performs a systematic examination where the steps are somewhat mysterious to the patient and using instruments that are the tokens and talismans of the profession. If done well, skillfully and respectfully, the ritual earns the trust of the patient, and it also lays the foundation for the patient-physician relationship. If done poorly, or cursorily, or sloppily (applying stethoscope to the clothing and not to the bare skin), it does the opposite--it creates mistrust, or even a sense of being disrepcted.
My sense is that the wonderful technology that we have to visualize the inside of the body often leaves physicians feeling that the exam is a waste of time and so they may shortchange the ritual.
The dangers are twofold: at the simplest level you miss the opportunity to be present with the patient, to conduct a ritual that cements the relationship; on a more pragmatic level, you miss obvious diagnoses and obvious bodily findings that might obviate the need for further testing.
Much has been made of the Institute of Medicine's Landmark report on medical errors. But I don't think we even begin to comprehend how much a sloppy exam costs us in terms of missed diagnoses, unnecessary tests, and complications from tests (such as reactions to contrast for a CAT scan) that were never indicated.
When you were last examined by a physician, did it go well, and did you have a sense of participating in a skilled ritual, and did that matter?
Comments (7)
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Abraham Verghese
One of my favorite things I've read from you was about your training and how people in your country were trained to use aoo of their senses including smell in doing examinations. In this ever sanitized world we live in today, many people forget that but it is a skill. I once was introduced to a 99 year old physician who said that other than losing his ability to use his hearing, he was still doing ok in examinations.
Three years ago I decided to get a physical exam, a new yearly ritual that I wanted to begin as I turned thirty. My doctor was incredibly thorough, taking his time as he carefully checked my reflexes, blood pressure, eyes and ears. In my mind, all standard things of what makes up a physical. But he also examined my neck...
As he slid his fingers several times against my throat, I could tell that something was not going as expected. He had felt a few bumps in my thyroid and was concerned.
An ultrasound would happen the next day...
Several exams, surgeries and radioactive-iodine treatments later, here I am writing this post. If it hadn't been for the time and care that my physician took that day (a true ritual, indeed!), my cancer would have gone undetected. Let there be more doctors like him...
The last time I was examined by my doctor I already had had 103F fever, body aches, and zero appetitefor 3 days. I had to wait 1 1/2 hours at the clinic for him to see me. He took some time with me but he was obviously very busy that day. He ordered some blood tests. After not hearing from his office for 3 days, I called them, and was told the 1st test was negative, but it would be a few more days before the 2nd test came back. I waited a few more days,I had been sick now 10 days, still with 103 F, body aches, and zero appetite and called again and told the answering machine for his nurse that I had developed a new symptom, a cold feeling as I breathed in very low in my chest,around the xyphoid process along with a non-productive cough. The nurse returned my call late in the day, said the 2nd blood test was negative, said the doc had prescribed an antibiotic,although he did not give a diagnosis, and told me it was allergy season and I should take Claritin for my cough. I have never had allergies before and never since, and I do not believe that was an allergy. I believe I had pneumonia, which the doc did not diagnose, but luckily as soon as I started the antibiotic, my temperature dropped, the cough cleared, the funny feeling in my chest cleared. it still took me 2-3 weeks to recover. I think the doc missed how seriously sick I was, because he had too many other patients. You cannot examine someone properly and listen to their symptoms if you are rushed because your patient load is too high. I fear this is the case with too many PCP's and it will only get worse. I believe these high patient loads both for doctors and nurses are responsible for too many medical erros.
I like your point about the exam room being almost a sacred space with the doctor donning a distinctive uniform. In California, where almost all men have stopped wearing ties to work, my doctor is never without one. I find the formality reassuring, and was pleased recently to see my son's pediatrician doing the same. I wonder, however, why the room itself must be so stark and devoid of warmth.
Physician's ties, unfortunately, are full of germs.
As for the, well, sterile environment of many examining rooms, I think it's all those hard, shiny surfaces, which also happen to be easier to disinfect.
I like the Atlantic's timing with bringing you in, seeing as I'm applying to med school over the summer. Never read a health-care blog before, but I like the idea. When it comes to technology, I find it interesting that the tools designed to verify a diagnosis have been relied upon so heavily that they end up making the diagnosis more difficult. Defaulting to testing with technology ignores our own perceptions that don't have the constrained view of a computer code. Biomedical engineers design a machine with diagnosis in mind, but they often don't assume their devices stand alone as the sole means of diagnosis. Forgoing, or at least cutting short, the initial examination seems to effectively contradict the assumptions the engineer who designed the device has made.
Americans like traditions and rituals. It does not bring anything, but you all want to get fooled. Go to a doctor in Holland or Germany. You tell what the problem is, he listens and he may, or may not investigate. You get medicine, you get better, or not. End of story. Who needs to knock on my chest when my knee hurts?