I myself had become vaguely aware that many of my own doctor visits did not require me to remove so much as a mitten. But I thought that maybe Mom was exaggerating. After all, her experience of good medical practice came from Dr. Kutz, a legendary family doctor who made house visits in which he prodded and poked patients as they lay in their beds. "You can't get that kind of attention these days," I chided her.
During a recent hospital stay, however, I learned, as I have so frequently since her passing last year, that, once again Mom was right. Doctors don't much touch their patients any more.
My story began with terrifying chest pains. An EKG quickly ruled out a heart attack -- phew! But the EMTs urged me to go to the hospital to be checked out. I wound up staying for three days during which I had a chest X-ray, blood tests, a sonogram, a CT scan and a very fancy MRI. Eight different doctors visited me. Only one, however, did more than shake my hand; his physical exam consisted of a casual, one-second tummy-squish.
Now I am headed for surgery -- the docs are removing my gall bladder and rummaging around in my pancreas. Once again, I donated blood for testing and underwent a more elaborate CT scan. Physical? Not on your life. The surgeon gave me another tummy-squish, and my regular doctor listened to my heart and lungs. He's a pretty nice guy, so I asked him: "Why don't doctors conduct physical exams of their patients anymore?" His answer: "We have precise pictures of everything inside you, so we don't need to."
Technology only partly explains why touching patients seems to be going the way of the buggy whip. There are time pressures. The average length of a doctor's appointment these days has scrunched down to 13 minutes, according to the National Ambulatory Medical Care Survey. That's barely enough time to say, "Hi, how are you," order a blood test and fill out all the required paperwork. Second, many doctors are not trained in, tested or re-tested on taking a patient history or conducting a physical exam. A study in the Journal of the American Medical Association examined stethoscope skills among 453 practicing physicians and 88 medical students. Whatever their age or experience, the doctors correctly recognized only 20 percent of heart problems. Given that, maybe we patients are better off with those high-tech images.
Still and all, says Kenneth M. Flegel, professor of internal medicine at McGill University in Montreal and senior associate editor of the Canadian Medical Association Journal, "There are good reasons why we should not be giving up on the physical exam." For starters, he maintains, there's a lot doctors can learn by listening to patients' complaints and taking a history. Signs of illness he or she detects by poking, palpating, feeling, measuring and merely looking can help zero in on what might be wrong. A 2003 study of 100 patients in the hospital published in Lancet, the British medical journal, found that 26 percent had signs identifiable on physical examination that led to important changes in treatment. Of these, only 54 percent had conditions that could have been detected by laboratory testing or imaging.
Only after a physical exam has narrowed possibilities should technology come into play. That's when "testing is the most discriminatory," says Flegel. And, I would add, more convenient. When physicians order a wholesale battery of tests upfront, patients (unless they're already in the hospital) have to scurry to labs and facilities all over town -- and wait days for results. The costs of unselective testing are high. Aside from the direct expense -- $1,100 to $2,700 for an MRI, $680 to $3,000 for a CT scan and $400 to $4,500 for an echocardiogram, imaging is increasingly turning up "incidentalomas," dots, shadows or tiny benign tumors -- that most likely are no more important than freckles but may require further testing. I'm a perfect illustration of the phenomenon. My CT scans showed two tiny thingums on my liver. The liver specialist, Dr. Eric Jensen, assured me that these probably don't amount to anything, but I may have to undergo another CT scan in a year or so. Doctors rely on imaging not so much because they fear a lawsuit, he says, "in case you had cancer and we didn't diagnose it," but simply to find out what's going on. So my insurers will be stuck with another hefty bill.
Patients also find a doctor's examination reassuring, says Flegel. "It's the healing touch," he says. Danielle Ofri, an M.D. who writes for the New York Times, insists: "Touch is inherently humanizing, and for a doctor-patient relationship to have meaning beyond that of a business interaction, there needs to be trust - on both ends. As has been proved in newborn nurseries, and intuited by most doctors, nurses and patients, one of the most basic ways to establish trust is to touch."
Some medical schools are attempting to reverse the no-touch trend. At Stanford, graduates and trainees must master 25 different bedside exam skills, from palpating a spleen to testing ankle reflexes. Yale has also revamped medical school training to emphasize the physical exam after a 2002 study of graduates revealed that many had never been observed taking a history or conducting a physical examination. But by and large, doctors continue to rely mostly on imaging, which means that you could reasonably avoid visiting your physician's office and merely have a discussion with him or her via Skype.
What is a patient to do about this? Go with the flow? Demand an examination? "Just ask," counseled Dr. Jensen, although he pointed out that there's no way he could feel my liver thingums or assess their growth (or lack thereof) merely by touching. Dr. Flegel says that a patient certainly has the right to ask a surgeon to examine the part on which he or she is going to operate. I tried this with the guy who's going to rummage in my pancreas, and he immediately complied. "If you're in the hospital," says Flegel, "you should tell any residents who come around that you insist on being examined by your attending doctor." Most doctors will find the request flattering, he says.
Sadly, not every doctor is accommodating. My cousin tells me that when my mom once asked one of her physicians why he never touched her, he squeezed her thigh and asked, "Is this enough touching for you?"
Had I known about that at the time, I would have given him a touch he wouldn't have forgotten. And told mom to get herself a new doctor.
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