My two college-aged children remind me daily of the various things that I have lost touch with—like recently, when I argued that Pearl Jam was new rock music, not classic. They laughed, knowing I still think Facebook is a hip social networking medium. Yet, there is part of my life that will never become outdated, and for which I will never lose touch—I will always be a physician. I have been practicing primary care for a quarter of a century in which I care for patients through all manners of personal turmoil and triumph. Certain aspects of my training as a young physician remain timeless and trusted:
- to look patients in the eye as they initially share their concerns, then, as time passes, they would share their life stories, not just their ailments;
- to listen, knowing that patients were allowing us a privileged view into their lives;
- to use touch, forming bonds, and deepening the human connection between two people, not just the sick and healer;
- to make ourselves present, both physically and mentally, so that we could respond to our patients’ emotional needs.
After years of treating, crying, praying, and sharing with my patients, making connections had kept me fulfilled and was something that I looked forward to. I also had become a “hugger”: if I forgot to provide at least one hug during our visit, patients would ask me what was wrong. Some have been patients for decades, noting “I love you” as often as “thank you”. I had been fortunate to have such deeply positive patient relationships. Despite the countless hugs in that time, I don’t think I ever fully appreciated personal touch. I had never imagined it would be lost.
Then COVID-19 struck.
These past months have been tumultuous, affecting all members of our communities. Some are fearful, some deniers, most anxious and many panicked; we likely have all recently interacted with patients in each of those groups. This pandemic has changed how you and I now care for all of those patients. We can no longer take touch and connections for granted. Our patient connections are possibly the most important factor in maintaining our resilience. It is ironic that during this stressful time in which strong patient relationships would help support us, we must separate ourselves from those same patients.
Lost touch is a phrase that one might use to describe someone living in the past. I wonder now if it is a phrase that will describe health care of the future. Human connections are deepened through our senses. Hence the challenges parents of a deaf or blind infant face while trying to build their family unit. On a different level, consider what we might miss when we consult with a patient through purely audio means. We might miss the downward glance the patient makes when noting “I feel fine.” or the glistening of his eyes when he shares “The pain is still manageable.” Having video may help to some degree, but still, touch is lost.
Direct eye contact is non-existent during a telephone visit and seemingly inconsequential when viewed as an image projected from my camera onto their smart phone. I can’t look directly into the eyes of my 22-year-old patient and tell her that the graduation party she is planning is risky. I can’t reach out to hold the hand of my middle-aged patient whose mother is sequestered in a local nursing home nor can I hold the husband who just lost his wife to the breast cancer she had been battling for the last six years.
Now, when we interact with patients directly, we are buffered by layers of barriers. I had one such face-to-face office visit last week. We both commented on how unnatural it felt. She in her mask and I in my mask and face shield. We did manage a laugh when my shield fogged over and I had as much trouble hearing as she often does; yet, this was a woman I had been treating for years. The barrier between me and my patient are miniscule compared to the emotional and physical obstacles between a hospital patient and staff who have never met, or for any new patient in the office. We stay at least six feet apart, the physician asking questions, moving closer only long enough to perform the minimally required physical examination. Masks, gloves, and gowns serve as a wall, blanketing out emotions.
I have colleagues who trained with me during the HIV epidemic who still wear gloves even for contact with healthy patients; I also have many recent trainees who did the same even prior to the pandemic. How many practitioners will routinely don varying forms of PPE in the future? How many patients will expect it? Will we be able to maintain our skills as healers of both mind and spirit with these additional barriers between us?
In order to maintain connections with our patients despite this sensory deprivation created by a lack of touch, we must hone our verbal communication skills. Physicians will need to improve their active listening skills. When questioning the patient via a tablet in a different room, or through a camera at our desks, it will become more important for us to use summary to confirm we caught the patient’s thoughts. We will need to watch the patient with intention as they speak and avoid the temptation to scan email or texts, so that we can ascertain the patient’s emotions. Once our patient’s feelings are revealed, the words we use to convey empathy will likely need to change. Some may find it simplest to say, “I wish I could show you my support,” or “I wish I could hold your hand.” Others might spell it out, “It must be terribly hard to go through what you are going through during this pandemic. Some find it hard to show you encouragement without an embrace or a handshake. Please know that I am here for you.” Those who relied on the power of touch will now need to articulate their support.
How will the impact of lost touch affect students’ and trainees’ ability to be servant physicians? Students have already been impacted as their clinical rotations abruptly halted, after administrators removed them from harm’s way. Many had been relegated to reading about patients, having small group discussions about diagnoses and diseases. They missed the opportunity to feel a pulse with their unsheathed fingertips or the warmth of an elderly woman’s hand as they squeezed it to provide comfort. Those students missed out on sitting close to their patients to listen to the stories that make each patient a unique individual, and not just a list of problems. As of July, many students resumed their clinical duties. How did they approach their face-to-face encounters with patients? I worry that even once the fear of contagion lessens, learners will hesitate to offer a hand in greeting, and will spend less time at their patient’s side listening to their unique personal anecdotes. Some students and even trainees may look for specialties that don’t require much direct patient contact. In addition to their own experiences providing direct patient care being affected, these learners have less exposure to the very activities that make some specialties so impactful. Due to distancing, they may not be there to witness the oncologist’s careful discussion of treatment options, or they miss the surgeon giving the news of a successful cancer resection. We may see a decrease in the number of trainees seeking specialties in which such impactful communications may be the norm.
My concern is not only for Internal Medicine, or primary care, but also for all medical professionals. How will the loss of touch impact any physician’s ability to escape burnout? While physical touch is not the only means clinicians use to convey compassion, it is an important method many use to build rapport with their patients. Yet, we can rally, and remind ourselves and our learners of the increased importance of listening to and empathizing with patients. Seasoned clinicians and learners alike, can still develop meaningful bonds with their patients, even in the face of a pandemic. In so doing, we can maintain our patient centered care, reduce the danger of physician burnout and mitigate the effects of lost touch.