Bernard Lown, MD
At the beginning of every visit I would ask Mr. T, “How much longer?” He would shrug, chuckle, and repeat, “Any day now.” These playful words referred to his twice weekly psychoanalysis, which had been going on for more than twenty years. One day Mr. T surprised me by saying, “Dr. Lown, you understand me better than my shrink does. You know the real me. He only knows the imagined me.”
I have long puzzled about this remark. Mr. T spent about 2,000 hours with the psychiatrist. I saw Mr. T only once annually for about a decade. The hourlong visit included a physical examination, a veno-puncture, the recording of an electrocardiogram, and obtaining a urine sample. The conversation between us could not have consumed more than a half hour. Perhaps we talked a total of about five hours — a tiny fraction of the free flow of words exchanged with a psychoanalyst. I have heard similar comments from other patients.
More than fifty years of medical practice taught me much about how to optimize the communication between doctor and patient to enable a meaningful and intimate exchange. My consultations consisted of three equally divided stages: a formal history taken in my private office, a period in the examining room, and a return to the office for a summation, to provide a diagnosis and prescribe remedies. With some patients the initial intake was discursive, exposing a multiplicity of unfocused complaints. I felt uninformed about who the patient was, unclear about the reasons for the visit, and uncertain what was expected of me. The person behind the complaints remained hidden. The patient seemed to share my frustration.
In such instances, I would stop in the midst of the physical examination and once again probe the patient’s background, family, work, hobbies, and the like. Almost always the conversation grew animated, as though a spigot had been turned to allow a free flow of significant revelations. Doctor and patient were on the same page. The reason for the visit made sense. What accounted for this transformation?
A medical examination is an act of sanctioned aggression: pulling back eyelids to inspect the texture and coloration of conjunctivae; depressing the tongue to obtain a view of tonsils and uvula; stroking the neck to ascertain thyroid gland size; percussing and palpating the chest wall to expose the mysteries of the beating heart and oxygen-absorbing lungs. This is followed by squeezing the belly for other insights, then continuing the touching, pressing, and stroking until reaching the big toes. All the time hands pirouette over a stranger’s body without protest to an assault that custom has legitimized. This ritual is not merely an anatomic exploration but also a trust-promoting endeavor.
Upon returning to the office for the summation, diagnosis, and counsel, we were no longer strangers. The physical examination has been transformative. Rather than a hostile personal invasion, it was an encounter akin to lovemaking. The singular aspect for the near-magical transformation is in the touch.
The laying on of hands is the doctor’s oldest skill and part of his earliest professionalism. Until the 20th century there was relatively little else a doctor could offer most patients. With the passage of time a simple act of compassion was transformed into an art. Eventually touch also became a veritable scientific skill. The hand became an adept diagnostic instrument divulging information not otherwise obtainable. The ongoing technological revolution has displaced the physical examination, and the laying on of hands is no longer taught or practiced.(1)
I first became aware of the power of touch some fifty years ago. I had just started a fellowship in cardiology under Dr. Samuel A. Levine at the Peter Bent Brigham Hospital in Boston. The patient we were seeing had been diagnosed with subacute bacterial endocarditis (SBE), an infection of a heart valve injured by childhood rheumatic fever. A decade earlier, before the advent of penicillin, SBE was consistently fatal.
Mr. B had been sick for a month with chills and fever. Streptococcus bacteria had been cultured from his blood. He was a youthful-looking businessman in his late forties. In his home town of Auburn, Maine, the doctors were inexperienced in treating SBE, so they referred him to Dr. Levine, then one of the leading cardiologists in the U.S.
Before the consultation with Dr. Levine, Mr. B seemed unfazed by his grave illness. He exuded a salesman type of bonhomie. The moment Dr. Levine entered, he became visibly unfocused and agitated. This may have stemmed from the warning he had received from doctors back home that even in Boston he might still have a close call. It was evident that he was not listening to the great doctor. Dr. Levine must have realized this, for he moved closer to the patient, put his right hand on Mr. B’s left shoulder, their faces only inches apart. Levine then spoke in short, staccato sentences, each accompanied by a shoulder squeeze.
“Mr. B, we have identified the bacteria that is the cause of your illness.
“Mr. B, we have effective medication that absolutely destroys the infection.
“Mr. B, I am certain I can cure you.
“Mr. B, within six weeks you will return to work.
“Mr. B, you will live a normal life.”
The air was crackling with electricity. On display was the high art of a consummate magician. Each shoulder squeeze was transformative. After the second squeeze Mr. B’s smile was celebratory. With the last squeeze he appeared ready to don a track suit and jog a marathon.
I followed Mr. B for more than thirty-five years. He often recalled this episode. He remembered a surge of energy and mounting reassurance with each squeeze. At the end he harbored not a scintilla of doubt that he would fully recover.
Touch, as both word and act, has long evolutionary antecedents. Over our distant past expressive feelings have been embedded in language. Many words are freighted with emotional meaning and convey information about the interpersonal. When we exhaust the power of words, we extend them with touch. The significance of touch is captured in our vocabulary. How touching! Keep in touch. Touch wood. Touched a chord. Lost touch. Out of touch. Empathy is ultimately a connection with the other, affirmed through touch, which may range from a handshake to a stroke or caress.
An enduring evolutionary challenge was how to convey empathy, which involves an attempt to connect by narrowing the space separating two people. More powerful than connecting as an abstraction is connecting as a reality. Its most consummate form is touching, whether a brush of fingers against fingers or sublime lovemaking. It is realized by integument aligning with integument. Probably touch served as a communicating system before language eventually replaced it.
A recent study suggests that touch constitutes a sophisticated differentiated signaling system. The experimenters hypothesized that complex emotions can be communicated through touch.(2) The emotions constituted a wide spectrum, encompassing anger, fear, happiness, sadness, disgust, love, gratitude, and sympathy. Participants included 248 students recruited to touch, or to be touched by, people unknown to them. The touch was to convey one of the particular eight emotions. The individual touched was blindfolded and unaware of the gender of the toucher. The person doing the touching could exercise a number of options regarding the body part to be touched, including head, face, arms, trunk, and back, as well as choosing from a repertoire of touching options such as patting, stroking, squeezing, brushing, or applying various degrees of pressure. Each touch was limited in duration to five seconds. The outcome was surprising. The recipient correctly identified the emotion being conveyed in 50 to 78 percent of the trials, instead of the 11 percent expected by chance. The outcome for touch was similar to that involving facial expressions or verbal cues.
Touch for communicating feeling or beliefs has an ancient lineage. It has been practiced by North American Pentecostals. The “laying on of hands” for anointing the sick is part of charismatic Christian rituals. It pervades therapies of all sorts in China and East Asia. It is integral to the practices of alternative and complementary medicine that have grown ever more accepted in the developed world. Generally, touch therapy is dispensed in conjunction with various relaxation and meditative practices. The number of medical conditions for which these have been applied are ever growing and include chronic pain, anxiety states, headaches, fibromyalgia, osteoarthritis, carpal tunnel syndrome, and agitated states accompanying Alzheimer’s disease. Touch therapy is also used to help patients receiving complex and uncomfortable medical procedures and even to reduce excessive arousal in premature infants. (3)
Social scientists have demonstrated the positive effects of touch during a host of diverse interactions. For example, students are more likely to participate in class activities if teachers touch the back of their arms. Athletes’ performance improves with high-fives or hugs from teammates. A waitress receives a larger tip if she touches the customers’ arms or shoulders. Touching a bus driver may be rewarded with a free ride.
The neurobiology of touch is now being unraveled. Current studies have identified three neural responses believed to account for the positive effects of friendly touch. These include activation of the parasympathetic nervous system, reduction of cortisol blood levels, and the release of oxytocin
Parasympathetic nerve activity moderates the adrenalin surge provoked by the countering limb of the autonomic nervous system when confronting threats — the so-called fight or flight response. Parasympathetic nerve activity signals various organs through the free-roaming vagus nerve by lowering blood pressure and slowing the heart rate. Handholding and hugging decrease circulating blood levels of adrenal gland hydrocortisone secretions. The hormone is released in response to stress, which increases blood glucose and mobilizes fat and protein. A friendly touch, especially therapeutic massage, additionally enhances blood levels of the neuropeptide oxytocin, popularized in public discourse as the “cuddle hormone” since it promotes feelings of devotion, trust, and bonding. This cascade of responses may originate in the orbital frontal cortex, which lights up with friendly touch. This area of the brain also responds to sweet tastes and pleasant fragrances and has been designated the reward center. (4)
One would imagine that evolutionarily acquired reflexes that promote humanitarian behavior by enhancing connectedness and trust would be emphasized in medical school curricula. In preparing this essay I found abundant research reports in nursing journals and those devoted to complementary medicine. But there is almost nothing about touch in the medical literature. Touch as a diagnostic and therapeutic tool is taught in only 7 percent of medical schools, and the majority of the teachers in those few schools are not physicians but social or behavioral scientists.(5) Doctors have been seduced by electronic medical records and diverse imaging technologies. The iPatient is far more in sync with the scientist-doctor than the meandering, uncertain, time-consuming flesh-and-blood substitute.(6)
Bruce Springsteen sang about wanting just “a little of that human touch.” Regrettably the medical profession barely acknowledges its disappearance and is indifferent to the dire consequences. While a student at Johns Hopkins Medical school sixty-eight years ago, the physical examination was a mainstay of the art of medicine. We identified great clinicians by their consummate skill in extracting nuggets of diagnostic information at the bedside. In several recent hospitalizations, I was seen by a number of physicians, none troubled to do an adequate physical examination.
Among older physicians I encounter dismay and despair. As one states: “Overreliance on advanced technologies has crippled physicians’ use of the mind and the five sensory faculties to make a diagnosis. Jumping from the patient’s chief complaint to a host of tests and procedures has become virtually routine. When that approach fails, the physician typically orders more tests and seeks numerous consultations.”(7) It is widely acknowledged that medical students are apt to regard the physical examination as an arcane curiosity irrelevant to doctoring.(6, 8, 9) Present-day medical culture could not have produced a Sir Arthur Conan Doyle. Sherlock Holmes, the sleuth of small clues revealing the big malady, is foreign to contemporary medical culture.
In my view the greatest loss resulting from abandoning intimate interactions with patients is the loss of human bonding that engenders confidence and trust. Listening and touching connect two human beings, helping to define their distinctive identity as human beings. It is the only warmth provided in life against the cold blast of alienation and the transience of our existence.
“Touch me” is the final poem in the collected works of Stanley Kunitz, Pulitzer Prize recipient and twice poet laureate of the United States. This excerpt captures what I am trying to convey:
Summer is late, my heart
Words plucked out of the air
some forty years ago
when I was wild with love
and torn almost in two.
Scatter like leaves this night
of whistling wind and rain.
It is my heart that’s late
It is my song that has flown.
Darling, do you remember
the man you married? Touch me,
remind me who I am.
1. Lown B. The Lost Art of Healing. 1996 Ballantine Books. New York.
2. Bakalar N. Five-second touch can convey specific emotions, study finds.
NYT August 11, 2009.
3. Peters R. The effectiveness of therapeutic touch: a meta-analytic review. Nurs
Sci Q 1999; 12:52-61.
4. NPR news. “Huma Connection Start with a Friendly Touch” Steve Inskeep,
host, September 20, 2010
5. Older J. Teaching touch in medical schools. JAMA 1983; 251:931-933
6. Verghese A, Horowitz R. In praise of the physical examination. Editorial,
7. Fred HL. The downside of medical progress: the mourning of a medical
dinosaur. Texas Heart Institute Journal 2009;36:4-7.
8. Verghese A. Culture shock: patient as icon, icon as patient. NEJM 2008;359:2748-2751
9. Jauhar S. Restoring the physical to the exam. NYT January 29, 2002.