Thursday, September 6, 2012

Touch me in the morning. (Or not.)

me and my patient holding hands, 2010

Touch me in the morning
Then just walk away
We don't have tomorrow
But we had yesterday

Wasn't it me who said that

Nothing good's gonna last forever?
And wasn't it me who said
Let's just be glad for the time together?
It must've been hard to tell me
That you've given all you had to give
I can understand you're feeling that way
Everybody's got their life to live. 

~ from Diana Ross' "Touch Me in the Morning"

___________________________________________

When I enter a patient's room or approach their bed, the first thing I do--almost always-- is reach for their hand. For me, there's just something about that first point of contact through touch that seems to get things off on the right footing.

My style of touching patients is one that fits my personality. In general, I am more affectionate than not, so nothing about touching the hand of a person has to be forced or calculated. Sitting next to a patient on their bed (with their permission, of course) or reaching for their hands again at some other point in our encounter often happens, too. Again, part of that has to do with the fact that I believe touch is important. But a substantial bit is simply wrapped into my M.O. in general.

I'm reflecting on this this morning because a fellow health care provider asked me my thoughts on it recently. This friend had experienced an awkward interaction with a patient and, though it wasn't their intention, the patient was offended. He even likened this gentle interaction to being "patted like some kind of dog." That humble provider immediately apologized and told the patient that these words would be taken to heart.

And before anyone casts any judgments, it's best to agree that we weren't there. It's also fair to say that I know for sure that patting the patient "like some kind of dog" was not the intent behind that interaction.

So that moved us to this question of touching other human beings in the clinical setting. What is cool? What isn't?

Lord knows that I'm not an expert on the topic but since I am a "toucher" I gave this all some thought. I'm very interested to hear yours, too. I know my friend who had that experience would be as well.

I believe that "touching" patients and people has far more to do with just physical contact. It involves eye contact, instincts and even subtle things like variations in the intonation of the voice. My handshakes start out formally. In those first few moments, I do my best to make an assessment of what is and isn't okay with that patient.

There are some people who immediately cover my hand with their own which prompts me to do the same. Before I know it, we're in one of those cozy four-hand handshakes that quickly becomes the equivalent of being offered a warm blanket or some hot cocoa when entering someone's home. This might be the person who pats the side of their hospital bed and welcomes me into their personal space. Or even the one that gets a big hug from me as they're being discharged.

But then there are other patients who, though equally wonderful human beings, just aren't so keen on all the touchy-feeliness. My friend Psonya (pronounced Sonya) has said more than once to me that she is no big fan of being hugged. Though that's usually said in jest, I do often think of her and that preference in the context of my patients. Because Psonya happens to be quite warm and welcoming to others -- just not all up in her personal space. (That doesn't mean that as my friend and not my patient that she won't get hugged by me anyway.)

So the point? Wait, what was my point? Oh. The point I'm making is that there are people and patients who won't be too happy with hand pats and being tucked under covers before you leave their rooms. But that doesn't mean that they're cold or aloof. It just means that this isn't how they roll.

More than anything you just have to pay attention. Watch their body language, facial expressions and reactions to the things you're doing and saying. Sometimes it seems like things are all chummy but then a ripple of discontent might roll over the patient's face that tells you too back off of the whole "overly familiar" thing. That's when you autocorrect yourself and go back to the formal default.

I'll say that again. Formality is the default. If you're socially awkward, a not-so-spot-on judge of situations, or simply not one who feels natural in touching other human beings that you don't know well, formality is the safest default of all. But don't forget your other components of touch -- eye contact, facial expressions, and voice intonation.

At least that's my opinion.

Then there's the type of touch. Hands seem to be the safest and least likely to lead to offense. I'd be lying if I told you that I hadn't touched the face of a dying or critically ill patient or that I hadn't ever patted tears off of cheeks. And yes, I've even sat right beside one of my F.P.s in her hospital bed while listening to Sam Cooke on my iPod and dissecting whether his raspy voice came from just soul, cigarettes or both. I've pulled socks back onto cold feet and even scratched more backs than I am willing to admit. But all of these broaches across those personal-space barriers were done with close attention.

Now. To my friend who asked that question:

Do I always get it right? Nope. Just two weeks ago I was caring for a patient in the hospital who was dying. Her family was there every single day for every single moment I cared for her and after lots of hoops and confusion we arranged a discharge plan that worked best for this patient and her loved ones. In this instance, that was home hospice. The interactions with the family and the patient had been so tender, so sweet. The patient was so weak that I often took her hand and held it throughout our encounters without much physical reciprocity but her eyes and facial expressions seemed to appreciate it.

So what happened? I took this to mean that the family was in a similar place. But this family had some cultural mores that I hadn't given enough thought to observing. As they left, I knew that I'd not see her again. I knew that. So I squeezed her hand and she gave me a weak smile with eyes at half mast. Then I approached the sister who'd been standing vigil for that whole week and gave her a hug. And the minute I put my arms around her, I knew that this was not the best idea.

Her body stiffened and her right shoulder slightly guarded her from allowing me to get to close. I immediately took that cue and went back to the formal default. I shook her hand and those of the other family members, too. Then I simply stood and watched them disappear down the hall in their soft and brightly hued fabrics from their African homeland. I winced at my ignorance and the lumpiness of that last moment.

So no. I don't always get it right. But I try to pay attention and learn from the things that happen.

And perhaps a pat upon the head could be perceived the wrong way by someone. I will think of that the next time I bring my hand near the head of a bedridden patriarch, keeping that lesson on a post-it note in my head for later.

Because all of these interactions are lessons. Lessons in better ways to humanize what is often cold and concrete. The science is what it is. But the human beings are each different and ever-changing. They are individuals who want their doctors and caregivers to just stick to the facts on some days, to hug them like they mean it on other days, to play rock, paper and scissors early in the morning sometimes, or maybe, depending on the day, to just get them an ice cold Sprite from the soda machine.

That part isn't science. That part is human.

So we strive to connect those dots. The human ones to the science ones to the formal ones to the familiar ones. And on some days, if we just keep paying attention, we'll get it right.

That's all I got today. Weigh in, alright?

***
Happy Thursday.

Now playing on my mental iPod. . . . Ms. Diana Ross sings it like the diva that she is!

44 comments:

  1. I can only imagine that so many of the interactions in a hospital setting are cold and clinical that the element of touch brings in the humanity of the doctor-patient relationship. I agree that reading the person's body language is key, but how good must it be to feel a touch in a hospital that does not bring pain? (dressing change, blood draw, etc.). The respectful touch reminds them that you see them as a person, not just the diabetic ulcer (or whatever) in room X.

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  2. I don't think patting is ever really cool unless the other person is a child. It seems condescending. "There, there," it seems to say. We pat children and dogs. It's an awkward kind of touch.
    But a hand on a hand or a shoulder- that's different. But it has to be genuine. It can't be a stab at some sort of therapeutic relating. I think that some people have the sensitivity to be able to tell when it's appropriate and some people just don't.
    I'm sure you do.

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    1. I can see that. Other than patting away tears with a tissue, I think I probably agree that patting could be taken wrong. And you're right, whatever it is, it can't be forced.

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  3. I'd made the decision to move my daughter to hospice. Shortly after I arrived, the nurse said that the medical director would be in later to meet with me. We'd just left the hospital environment, and I didn't want to see another doctor, hear another doctor, talk to another doctor... I just wanted to be left alone. A few hours later, the doctor walked in. Until she introduced herself, I didn't know she was the doctor. She wasn't wearing a lab coat or carrying a chart, so I thought she was a counselor or a volunteer or something. She pulled up a chair directly in front of me, scooted up so close that our knees were touching; then she took both of my hands in hers, introduced herself and said, "We're gonna get through this together." It was the first time since my daughter got sick that I didn't feel like a line had been drawn in the sand. Feeling like the doctor was on our side meant the world to me. I will never forget this gesture of kindness as long as I'm breathing. Is it okay to reach out and touch someone? Like you said, there are many variables to consider. But I think "touchers" can be life changers.

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    1. Wow, Nance. I didn't know that about you. I am glad that this doctor was able to give you what you needed in that moment -- less formality and more empathy.

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  4. I'm glad that you work with interns and are a wonderful teacher as well as an amazing doctor. This issue is so important. I wish it were a course in med school (or maybe it is?) ~ I believe that your approach makes patients feel validated, whether they are "touchy" people or not. As Mama D. said above, the tender touch must be a welcome relief in contrast to the more unenjoyable ones!

    I've got some reading here to catch up on today as I've been away for two weeks taking care of my 86-year-old dad. I will savor each post, so it may take a few days!

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    1. Hey lulumarie! I hope your father is doing okay and I always appreciate you reading.

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  5. I sympathize with your friend Psonya. Despite being raised in a very affectionate household full of warm embraces and "I love you"s at the end of telephone conversations, I don't like being touched. Hugs are awkward and uncomfortable to me - especially when unsolicited. It's a personal phobia though (along with a fear of children and getting my picture taken), so I'm trying to work through it since I know it bothers others more. Thank you for recognizing that not all patients welcome this gesture - and having the sensitivity to not judge it but contemplate how you can serve them better.

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    1. See? Even more evidence that very caring people just sometimes don't like being touched. Duly noted. Thanks for reading, Charmayne.

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  6. I'm a bit shy so hugs from strangers can be awkward. It's not really that I mind so much, but if I don't know it's coming I don't know how to react. Usually a touch on the hand or a hand on my shoulder is fine. Hugs from friends and people I know well is okay too. But I can see getting a bit put off by a pat on the head, especially from a stranger.

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    1. I'm impressed that the patient actually admitted how he felt!

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    2. I am too, because I probably wouldn't have said anything. Your friend seemed to have handled it well.

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  7. It is such a difficult, personal area, but you are so right: Formality is the default.
    And I appreciate that...because I'm formal, and being addressed with formality gives me a sense of control and the sense that I'm respected.
    I've been hospitalized an unusual amount of times since I turned 30. I'm only 36.
    It was okay when the OB sat on my bed, because that was a happy occasion, and she was a woman.
    If I were single, alone, and in pain, I might appreciate more touch.
    Otherwise, the hospital bed is my personal space...part of my personal bubble. I'm okay with and even prefer doctors not shaking my hand if I'm in bed, as long as they introduce themselves.
    Eye contact and voice intonation are enough.
    -Amy

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    1. Real talk, Amy. Thank you for weighing in with such rich insights and perspective from a patient's point of view.

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  8. I agree with Ms. Moon. I once took a friend of mine to an appointment where she received her diagnosis of breast cancer. The doctor walked into the room and sat right next to my friend, put an arm around her shoulder and told her she was sorry, so sorry. I sat on the other side, and we both held her and all cried a little. I remember feeling SHOCKED at the doctor's empathy as nothing in my experience caring for my daughter had been so intimate. I believe that the gentle touch that you speak of is essential to "care," and I'm certain that your natural inclination is a boon for your patients.

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    1. It's a hard call sometimes, you know? I wonder what it was that made the doctor feel okay doing that. Hmmmmm.

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  9. When my doctors approach me with a hug or a pat on the back or a warm handshake I instantly let my guard down and feel a sense of peace. There is nothing worse than when a doctor, or student, or nurse refer to you as, "room 53". When a doctor extends a hand or offers a hug it makes me feel like a person and not just a job responsibility. I am lucky in that quite a few of my doctors are warm and genuine just like you, Dr. M. I have to admit tho I wouldn't feel comfortable hugging every practitioner that walks into my room. It takes time, I think, to build a close relationship with your doctor, just as it takes time to build a relationship with anyone. When things are rough and the news is bad I prefer an honest interaction, and it sure is nice to receive a hug from a doctor instead of a quick run down of information. I don't know if I'm making any sense here...I guess what I mean to say is that when the relationship and time are appropriate there's nothing nicer than a warm hug especially from a doctor that I love and trust.

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    1. I like the idea of building that trust and working your way into someone's personal space. For some, that's a quick process. For others it takes longer. Thank you for your insights!

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  10. It is a difficult call to make isn't it? Defining when to touch and when not to touch is hard, but some, like you, have the intuition for when and where to touch. I am a toucher too, but I try very hard to read the patient and family and acknowledge that "that is not how some folks roll" as you said. You are bound to get it wrong once in a while, but even so, I bet the patient and family understood what you were trying to do.

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    1. Yep. It's all a work in process. Especially the human sides of medicine--we both know that.

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  11. I believe touch has the power to heal. I see it all the time at the Shelter. These men are so seldom touched by anyone; they are, in fact, shunned by so many of us. But at the Shelter they experience unconditional acceptance where our volunteers are willing to grasp a hand or arm and listen to what the men are willing to share. We started a weekly Yoga class at the Shelter a few years ago. In the beginning when I taught the class I avoided doing any kind of partner poses because I was afraid they would not want to touch each other. One night I just tried it and it was their favorite class EVER. That forum somehow gave them permission to touch and be touched and they loved it.
    As for doctor/patient, my doctor and I hug every time we see each other. And it works for me!
    Love, Coach B

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    1. Yoga! Wow, Coach B. That sounds so amazing. Have I told you lately how amazing you are? I was so happy to see your face yesterday. You truly are one of my favorite souls. I look forward to coming to the shelter. Perhaps I will come with one of my small groups for Yoga (although that could be extremely comical. . . .)

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    2. My friend, you have not lived until you have practiced Yoga at the Shelter...it will change your life.
      Love, Coach B

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  12. I'm going to hug you. Twice. :)

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    1. It's a deal, Psonya! Love you dearly, sister.

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  13. Great post. I agree that it's a matter of reading the subtle cues from a patient (or family member) and trying to follow them. I will often instinctively reach out to hold the hand or touch the shoulder of someone in distress, and while most of the time the person will respond in a positive way, there are also the somewhat awkward times when their body stiffens and it's clear that I've crossed an invisible line. I think learning to recognize that is important but oh so difficult.

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    1. You hit it right on the head, SD. It's all a work in progress.

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  14. I'm not a touchy feely kinda girl-I cannot lie. My own personal philosophy with respect to taking care of patients is to not insult their intellect : people of all walks of life- from the pinnacles of education and on down KNOW when you are patronizing them/assuming that they will not understand their disease process and treatment/ minimizing their role in taking ownership of their health. They KNOW.

    The best rapport builder , in my experience, is to do your best to make your patient feel like you see them/acknowledge them/ and want to genuinely help them understand what they can expect....but you know, if they request a hug...I'll oblige them...it happens ;-)

    Maria, fellow Meharrian

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    1. Well getting anesthesia always terrifies me. I think your job is particularly hard in that you have to build rapport and allay a whoooole lot of concern. I am not sure I want my anesthesiologist to hug me. I need them to walk in as the bad-ass they are and convince me that I'll wake up when this whole thing is over! LOL!

      Kimberly, fellow Meharrian

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  15. It depends on the doctor. If I sense you actually care and we've developed a relationship, I'm cool with it. But if you're clearly rushing around, throwing your idea of "care" at me... I need you to step away. I also don't like people I haven't met (or internet met LOL) getting too familiar with me too quickly. My baby face means I get underestimated a lot. It angers me. If we've not developed a connection, a handshake is best.

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    1. Excellent points--especially because you and many other non-healthcare providers here represent real patients.

      Hey! Did Psonya let you hug her? LOL!

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    2. LOL! I'm pretty sure she did! I automatically hug people I like. I didn't even find out she didn't like hugs until AFTER I met her. And then I was confused. Did we hug??? Did she hate me for that??? LOLOL

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  16. Great post and very well written.

    As someone who's being in and out of exam rooms 2-6 a week, I can tell you that it's one of the first things that I remember about a doctor when I reflect back at the end of the week.

    I think you're right; touch matters and establishes some type of connection between a doctor and the patient. But thinking over the past six years, I remember more instances of a soft (condescending?) touch before a doctor left me in an exam room crying then I remember of moments when a handshake really communicated that someone cared. Maybe it's because, in my mid-twenties, I'm a lot younger than most doctors, and it's easy to feel like I'm being treated like a child. Or perhaps it's because exam rooms make me feel vulnerable and no one wants to be left in an exam room feeling even more vulnerable than before.

    For me, what helps the most (or at least gives me the most connection with a doctor or anyone else for that matter) is words -- spoken and even unspoken. Looking at all my posts tagged "doctor's office" (such as http://hiddencourage.wordpress.com/2012/08/16/when-doctors-grieve-with-you/), that seems to be the recurring theme.

    Communicating that you understand and that you're still here is important; what language we use is different for different people. It takes time and attention, and I can tell when someone's taken 30 seconds to try to figure out what I need before they do or say something. I think that's the key. That open-ended acknowledgement that it's okay that it's a difficult moment makes it safe to be in the moment even if there's much unknown.

    Abigail

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    1. Wow. Thanks for sharing this, Abigail.

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  17. I'd rather not be touched beyond a handshake. But then again, we've been blessed with good health and see our docs 1x a year. If my health, or that of a family member, were to take a turn for the worse and we received more regular medical attention, I would probably welcome a hug or a shoulder touch as more of a relationship develops. If someone were to pat me I would be irate.

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    1. But what about a pound? Or a fist bump? Just kidding! Seriously, though, it really does come down to us paying attention to what our patients need. Thanks for weighing in, Nerd Girl! Did you see that Psonya is going to let me hug her? Ha ha ha.

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    2. LOL! I did indeed. One day I'll tell you the story of the first time I hugged P. She probably doesn't remember it, but I do :)

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  18. I always appreciate a hand.
    I'm a hugger and sometimes I can tell it's not welcome and I apologize for being a hugger, but you know, I'm not really sorry at all.

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    1. Some of us are just the Huggy-Bear type.

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  19. The doctors and nurses and chemo people treated my dad like a rock star...he so deserved it!..They also treated my mom, my 4 sisters and myself with love...they knew we were all in it for the whatever what was to be..We appreciated every hug and we gave them in return.

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    1. Love that. Especially the part about your dad being a rock star.

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  20. My favorite doctor hugged me after my very first visit to her office. Her nurse did too. I was terrified that day because I have a history of abuse and I had to come clean with it in order to be examined properly. I cried after the experience because of the relief of getting past that point and because of the compassion I felt from both of them. It means a lot to me when doctors show their humanity. S. Jo

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    1. Wow. Just wow. I am so glad that you felt like you could trust them with that information and with that response.

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