The Doctor will not Touch You – clinical medicine at a juncture(Abhijit Das)

We are currently going through a cataclysmic event in modern history. The SARS-Cov-2 pandemic has struck with an unprecedented global scale and ferocity: within a span of 6 months, the virus has infected more than 6 million people and continues to spread unabated around the world. This extraordinary pandemic has brought in one definitive paradigm shift in the behaviour of humanity – a “new normal” of “social distancing”. It has changed how we work, how we shop, how we travel, how we play; in short how we interact socially as Homo sapiens. There is a strong possibility that SARS-CoV-2 infection may become endemic in the global population for the next couple of years – with waves of infection ebbing and flowing through the seasonal variations, as seen in common cold and flu viruses. Hence, the new normal of “social distancing” is likely to be a standard fixture of everyday life in the foreseeable future. This will have an unsuspected victim – the practice of clinical medicine.


The basic tenet of modern clinical medicine is based upon the clinicians’ proximity to the patient. It has its roots traced back to the Hippocratic era (about 460–370 BCE), when the world-changing idea of basing medical practice on observation of disease symptoms in the patient, rather than on religious or philosophical beliefs, was introduced. It got its modern shape by the efforts of the Paris physicians in the beginning of the 19th century who initiated the focus on physical examination. It was further aided by the discoveries of Auenbrugger (the percussion technique), Laennec (the stethoscope), Erb-Babinsky-Gowers (Neurologic examination and the percussion hammer), and Riva-Rocci (the Sphygmomanometer), which made the direct evaluation of physiological parameters easy and practical.1 All these together, along with the practice of bedside-teaching, evolved into the consultation models in modern clinical practice: the “rituals” of history taking, examination, diagnosis, and the formulation and negotiation of a treatment plan. Through this ritual the clinicians exercise the social contract inherent within the practice of medicine – healing and/or relief from the suffering of sickness and disease. In a sense, the clinical examination is a solemn continuation of the tradition of “healing touch,” pivotal in traditional and holistic medicines; and the role of a clinician as a healer. Touch is our most ancient sense and the role of touch is firmly anchored in our society, from Isaac blessing his son Jacob by laying hands, and Jesus curing countless sick people of their ailments through touch. Touch is thus essential in the social interactions to communicate, soothe, and heal. Dr Varghese has aptly summarized the role of this “healing touch” in medical practice – “When we are sick, we become infantilized; we seek the reassuring touch of the surrogate father or mother… At the end of this ritual, physician and patient are no longer strangers but are bonded through touch…… fully connected with the science and knowledge of our time. That bond moves the patient toward healing—not just of the body, but of the psychic wound that accompanies physical illness.”1 Despite the bombardment of technological advances, proliferation of electronic medical records and “chartomas,” which threatened to take us away from the real patients, we somehow maintained this “healing touch” – through the vestiges of clinical examination. The clinical examination is the gateway to a special form of human relationship – an intimate bond specific to the clinician and his/her patient – a privileged access to the moments of greatest human emotions (birth, illness, injury, suffering, recovery, disease, death) – unfurled in the sanctum sanctorum of the examination room. Now this entire institution of clinical medicine, this doctor-patient relationship, is under threat in the new era of “social distancing” as the doctors and the patients are kept separated to avoid the “touch”.


Pandemics and emergencies have a peculiar property – “they fast-forward historical processes. Decisions that in normal times could take years of deliberation are passed in a matter of hours.” The same is happening with clinical medicine. In a matter of days, the revolution in telemedicine has exploded across the globe by the sheer necessity of social distancing enforced by the pandemic.4 The doctors across the globe are adopting telemedicine as their daily work routines have undergone complete metamorphosis – patients are stuck at home and medical offices have become no-go areas like a nuclear exclusion zone. In USA, these virtual health-care interactions are projected to cross 1 billion by end of this year as the govt has authorized an expansion of Medicare that would cover telehealth. In the GP surgeries across the UK, probably the last bastion of clinical medicine, there is en masse conversion to remote video consultations, up from a mere 1% in the year ago; and the NHS has fast-tracked approval of digital providers to ramp up their offerings in an unprecedented speed. The virtual visits, started at first as a matter of safety, are rapidly becoming the cornerstone of the overburdened clinicians’ and hospital trusts’ go-to plan to treat the routine illnesses. So far, it seems that the patients are happy and approximately 94–99% of patients were reported to be ‘very satisfied’ after a video-consult, with 95% stating that they would use video-consults again.2 Among the doctors, nearly 90% of participating clinicians felt that clinical decision making was successfully accomplished using video-consult.2 With these kind of results it is very likely that telemedicine is here to stay as the “new normal,” and the two-century old stethoscope, the ubiquitous hallmark of a clinician, the icon of “therapeutic touch,” is probably going to face its ultimate extinction.


However, there is one problem for telemedicine (and hope for die hard clinicians) – the telemedicine devices can replace everything except human touch. The data shows that although telemedicine consults were potentially more convenient for patients, but they were not considered superior to a face-to-face consultation.2 Also, we need to see how the telemedicine survives the “hype cycle” of technology adoption. Every new technology starts with a meteoric ascent toward the “peak of inflated expectations,” then crashes to the “trough of disillusionment,” and then rises slowly along the “slope of enlightenment” before ultimately arriving at the “plateau of productivity” — when we finally figure out how to use the technology effectively. Hence, it remains to be seen how, without the physical touch, the clinical medicine, as we know it today, survive this pandemic and we, the clinicians, continue as Tele-healers.

References:
1. Varghese A. A Touch of Sense: Patients and Physicians Connect Through Touch and Trust. Health Affairs. 2009;28(4):1177-1182.
2. Thiyagarajan A, Grant C, Griffiths F, Atherton H. Exploring patients’ and clinicians’ experiences of video consultations in primary care: a systematic scoping review. BJGP Open. 2020 Apr 3. pii: bjgpopen20X101020.

Author details.

Biography:
I am a Neurologist working at the Walton Centre NHS Foundation Trust, Liverpool, UK. He completed his education in India and USA. I have keen interest in Functional Neuroimaging, Artificial Intelligence (AI), Telemedicine and their applications in neurology. I enjoy reading and long-distance running.

Conflict of Interest:
In the past, Dr Das served as a consultant for developing a Tele-Rehabilitation platform in collaboration with Tata Consultancy Services, India. He owns equity in start-up companies involved in Biotechnology and AI.

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