Years ago, the teenage son of a close friend asked to interview me about my job. He was a high school freshman with a class assignment and I was a doctor with some 15 years’ experience treating patients in emergency rooms and urgent care clinics.
I agreed, of course, and as he wrapped up his written list of prepared questions, he posed a final one that was spontaneous, a question not on his prepared outline.
“What do you like most about being a doctor?” he asked, simply and earnestly. He clearly wanted a genuine reply, not some canned response.
His attitude paused me. No pat, reflexive answer like “doing good” would suffice, it seemed. Instead his question made me think about something I had not previously considered: What did I like most about being a doctor? I considered my answer carefully, thought about it, maybe as much as a full minute of silence between us. Then I said the words I remember to this day: “I learn people’s secrets.”
Now, more than 25 years later, my answer still resonates within me. Patients’ secrets.
Patients share all kinds of secrets with their doctors, some deeply personal. Their worries and fears, for example—maybe concerns about money or a troubled teenager, or how to deal with an abusive relationship. Perhaps the private anxiety an elderly couple share about death and how the one still living might not be able to manage on their own. Such secrets of the soul doctors learn about by words, by talking.
Yet patients carry other secrets, the ones inside their bodies, whether illness or injury, hidden away, waiting to be discovered, needing to be revealed. The secrets their bodies tell me when I touch them.
Touching. The “physical exam” in medical parlance is, at its core, simply touching. Any such physical exam includes hearing, and seeing, too, often through the intermediary use of an instrument, say a stethoscope or a penlight, listening to heart sounds or looking into a throat. Those insights are real, of course, but a bit removed and less personal, less intimate, it seems to me, than touching by hand. My hands, any doctor’s hands that have learned to feel and probe the body to find its secrets.
I learned the basics of physical examination as a first-year medical student at Memorial Hospital in Pawtucket, RI. Dr. Mo Kahn, a pulmonologist, taught me the essentials. I had a physical diagnosis book, yes, with diagrams and pictures, but that is no substitute for learning in person.
Kahn had a quiet, professional demeanor that matched the steady and calm movements of his slender fingers as he demonstrated on his patient how to palpate the neck for lymph nodes or thyroid abnormalities. His soothing voice simultaneously addressed both the patient and his student, as he passed on knowledge and skills that can be traced back to the hospitals of Baghdad and the writings of Galen of Pergamon.
It is a humbling and terrifying sensation to put your hands on someone who is sick or in pain, or who may be afraid to learn what the doctor might find out. Through touching. A woman fears breast cancer after finding a lump and then allows the doctor, astonishingly, to touch her in a most private and intimate part of her body, searching for clues that might indicate a cancer, spreading terror in her body.
As I began to understand when working with Mo Kahn, doctors learn how to feel from others, who learned from their predecessors, who learned from others, and so on. How to feel and sense, and then to describe. Lymph nodes, like those glands in your neck that swell up when you have strep throat, have distinguishing characteristics: smooth or rough, acute or chronic, fixed in place or more mobile, tender or not, firm or fluctuant. We learn to distinguish those qualities and their implications by touching.
The physical relationship between a patient and a doctor fascinates me and has since the earlier days of my training. I’m moved by the trust patients put in me, allowing me to touch them. For me it is an intimate and interpersonal trade, the patient’s body and privacy yielded in exchange for my analysis and assessment. The medium of the transaction? Touching.
“Your prostate feels hot and boggy—it’s infected.” “This is the head of your arm bone here. You’ve dislocated your shoulder just as you suspected.” “Your abscess has grown and it is now consolidated. We need to drain it.” “See how your kneecap can go up and down and how the skin is bulging here? That’s fluid inside your knee joint that we should get out.” “I can feel the edge of your uterus right here. That tells me you are about 20 weeks pregnant.”
All by hand. The patient’s history is critical, naturally, the story that will point the way for my hands to follow. Yet it is through my hands that I connect with the patient’s body directly, and uncover its secrets. Through my doctor hands, and, without exaggeration, through the hands of my doctor ancestors, insights and knowledge passed on for untold generations.
IN GOOD HANDS
Dr. James Lynch was a third-year surgical resident at Rhode Island Hospital, another part of Brown’s medical program. I was a fourth-year student, about as green as could be, and he had three years of experience on me, and in surgery no less. But we were somehow on the same wavelength about medicine and he took me under his care. First he taught me a simple lesson, a general approach to the art of diagnosis.
We were in a corner of the emergency room, a small alcove that had an X-ray viewing box, a device that allowed you to put an X-ray up to its light in order to review the film up close. It was a tiny rite of passage to learn how to take an X-ray film and snap it up under the flange at the top of a viewing box so that it would stick there in one quick movement, ready for inspection.
Lynch had directed me there for something else entirely. For the relative quiet, perhaps, where he could explain to me his thoughts on diagnosing patients, sharing generational knowledge.
“Mike, you’ve got three key components in any diagnosis—the patient history, your exam, and any labs or tests,” he said, counting off on his fingers. “But you don’t need all three to make a diagnosis. Right? Just one of those can make your diagnosis. You understand?”
I was listening intently. He was confident, and I had no doubt he knew what he was doing. I put his words into long-term memory and nodded. He added, “Don’t get distracted by the noise, by extraneous details. You know, stuff you don’t really need. Keep things basic. Get it?”
I did get it and at the same time, I saw that I was becoming part of long history of shared knowledge and insight. I was a recipient then but sensed at the time that I would one day pass along Lynch’s idea to others. But he had more to offer. Lynch taught me about my hands, too.
He showed me how to examine the abdomen, something I’d done briefly before with Mo Kahn, but Lynch showed me in depth. In this case it was a possible acute abdomen, a medical term describing an abdomen that had a potentially serious cause, one that might need surgical intervention. First, he told me the general approach. “Be gentle, always gentle,” he said. “You’ll find out much more, especially in the acute abdomen.”
Then he showed me, moving my hands under his, talking about the sensitive pads at the tips of the fingers. I’d read how to place my right hand and fingers on the patient, and then to use my left hand to press down, thus allowing those fingertips of the right hand to sense and feel without the desensitizing effect of exerting pressure. I’d read that, understood that theoretically, but he actually showed me how to do that, his own hands gently instructive on top of mine. He honored the age-old technique and gave it its due, passing along to me its necessity and its value, in a manner that reflected both his reverence for the process of shared learning and the knowledge that can be gained from the patient.
His patient, now my patient too, was a middle-aged man with belly pain and a fever. But we didn’t necessarily need his history or any labs, as Lynch had previously taught me. Right now we were focused on the physical exam, which by itself might yield the diagnosis.
I tapped the side of the patient’s belly, gently pushing it toward the middle, which elicited pain on his other side—“referred tenderness” in medical argot. I had the patient take in a deep breath while my hand pressed under his liver to check for gall bladder pain—“Murphy’s sign,” negative in this case. Then, following Lynch’s teaching, I gently palpated the patient’s right lower abdomen, my right-hand fingers under my left.
“Watch the patient’s eyes,” Jimmy whispered. “Always watch the patient—how much does it hurt? Does pain seem to come and go? Is the patient’s reaction consistent? Or is there no subjective discomfort at all? You need the whole picture.”
I resumed my exam and gradually pressed deeper, slowly moving my fingertips a bit side to side, and then felt the plum-size outline of the patient’s inflamed appendix. And the patient cringed as I did so. An acute appendicitis for sure.
Afterwards, Lynch corralled me, enthused about his role and my response. “There,” he said, “you’ve got it now,” his hand tapping reassurance on my forearm. “That’s all there is to it. Just keep doing it.”
I was thrilled, of course, with this newly honed skill and pleased to have found that appendix right where it belonged, McBurney’s point in the textbooks reaffirmed. I’ve diagnosed scores of appendicitis cases since then, whether obvious or less so. Hints of the diagnosis might come from an obturator sign or psoas finding, or the specific tenderness on a rectal exam pointing the way to a retro-cecal appendicitis. Yet that first one I touched stays in my memory.
Jim Lynch was a notable mentor for me, but there were others, too many to remember or cite, medical teachers who shared their own thinking and experience, part of the tradition I was entering. Though I’ve never worked formally in a teaching hospital, I share what I’ve learned, from others or on my own, when the opportunity arises.
HUMAN TOUCH
Decades after my time at Brown, my emergency medicine training long behind me, I was practicing in a busy urgent care office in Washington, DC, and worked at times with a newly minted physician assistant, Elizabeth. She would ask me questions about patients, and impressed me with her enthusiasm to learn.
So when she came to me about a 30-year-old man with an abscess on his back, I was eager to help and to show her how to do a procedure she had never done before, an incision and drainage, or I&D in our terminology.
I helped her set up the typical sterile field and get the equipment set out. I told her I would show her how best to anesthetize the area around the abscess on the patient’s mid-back, which was the size of half a red delicious apple, with a soft, gushy center ripe for I&D. And then I would lead her through the procedure. But first I spoke to her about her patient, in private.
“He needs to trust you. To feel confident in you.”
In the exam room with the patient, I explained to him what we were going to do and that I’d be supervising.
“Who’s doing this, you or her?” the patient asked.
“She’ll be doing it but I’ll be right here and we’ll take good care of you, I promise.”
I showed her how to inject for a circumferential block, infiltrating the numbing medicine just under the skin, and how it was easier to do that when withdrawing the needle rather than the other way around. And I told her to do it slowly because it hurts the patient much less, if at all. Once she determined that the area was numb, by touching it and confirming with the patient that there was no pain sensation, we were ready for the I&D.
She took the No. 11 blade with her gloved hand and I reminded her what we had discussed outside the exam room: “One firm incision at the edge of the fluctuant area, then straight across to the other edge—many people don’t make it big enough. Cut in the direction of the skin lines to minimize scarring later.”
She made a hesitant, tentative stab with the scalpel and a thin line of yellow-green pus slowly oozed out around the blade. She looked at me with questioning eyes. I said, “OK, good,” to reassure the patient, and then put my own gloved fingers over hers on the scalpel. I pushed down through her fingers on the blade, firmly and confidently, and then drew it straight across the width of the abscess.
Putrid material flowed out in a rush, a malodorous miasma burning the air and stinging our eyes. Together we mopped up the copious drainage with gauze, and flushed the wound with saline.
I told the patient we were nearly done, but had one more thing to do to make sure there were no hidden pockets of pus deep inside the abscess. And that it would hurt. Elizabeth picked up the pliers-like tool and poised it over the opening. I made a twisting back-and-forth motion with my index and middle fingers spread apart, pantomiming what she needed to do inside the wound. I said, “Tell the patient this might hurt but that you will be quick and then it’ll be over.”
Of course, the patient heard me and he said simply, “I’m ready, go ahead.”
She put the Kelly clamp inside the wound, spread open the two ends, and twisted a few times, mimicking my vigorous demonstration, and you could hear the faint popping sound that she could feel, too, as she broke through old scar tissue. No more pus, just a little blood trickling out. She flushed the wound again, and I held the gauze strips for her as she packed the cavity to staunch any further bleeding, and to keep the wound open but bandaged over until the patient returned in a couple of days to be rechecked.
Back in the office, I summarized for her: “Tell the patient everything you’re going to do, follow the skin lines, and make a deep and wide incision. Be reasonably aggressive like you were at the end. Incise confidently. Now just do more of them.”
She gave a quick nod, the satisfaction of accomplishment on her face.
Whether diagnosing an acute abdomen or draining an abscess, using your hands is part of the essence of medicine, and many touches are notable. Like massaging a trauma patient’s heart hoping to stimulate it into beating spontaneously. Or sticking a gloved finger in a knife hole in the heart while your buddy sutures around it. Or the first time you feel the tip of an enlarged spleen, made palpable by your leaning over the patient and pushing up the lower left rib cage from behind with your other hand.
The slippery-viscous feel of joint fluid, a lubricant scientists would love to replicate. The exquisite sensitivity of a broken rib. The anatomy of a broken hip as opposed to a dislocated hip, each distorted in its own way. An abdomen painfully and tightly distended from a bowel obstruction. Lymph nodes swollen by mononucleosis. Body parts all, diseased or injured, but parts patients allow me to examine, to touch. To touch and to assess, and thus to diagnose and, ultimately, to treat.
Medicine has been called a demanding mistress, though that saying has always left me puzzled and seems to have very little deeper meaning. Instead, I prefer to think that medicine is a sacred trust, two words that denote a complex interaction between doctor and patient, a sacred and time-honored bargain. A trust exemplified in the shared experience when a doctor touches a patient.
And those two words describe as well the tradition of passing along skills and knowledge from doctor to doctor, honoring the tradition begun by Hippocrates of Kos: teaching and learning passed from generation to generation, and the importance of using touch to reveal the secrets of the body.
A high school freshman asked me years ago about what I liked most about being a doctor. My answer then came unbidden, a surprise revelation to me at the time. Through the decades I’ve felt privileged that patients still share their secrets with me. And I see now, writing about my experiences, how hard it will be to give that up one day.