In my previous post I used a phrase from a  Lee Robinson poem that had the line "finding each other nose to nose."

That prompted Bill to write:

" . . . reminded me of visiting New Zealand for an international peroxidase meeting. The organizers had the opening ceremony follow Maori tradition (because we were on Maori land in Akaroa). The ceremony included singing etc, but with the Auslanders kept separate from the natives, divided by an imaginary line. We were not permitted to pass until the proper time. Individually we came forward, described from where we came (both geographically & biologically...the names and origins of our parents) and touching noses (actually sharing breath) with one of the welcoming natives. I'm pretty self-conscious & thought I'd panic....but I didn't. Quite the opposite, I thought it was a beautiful expression of humanity; what's more intimate than sharing a breath with another?"

What Bill described is a great example of ritual, a subject that interests me in the context of the bedside examination of the patient.  Rituals, anthropologists will tell us, are about transformation. The rituals we use for marriage, baptism or inaugurating a President are as elaborate as they are because we associate the ritual with a major life passage, the crossing of a critical threshold, or in other words, with transformation. 

Examining the patient at the bedside has all the critical ingredients of a ritual: it is usually performed in a special space (the doctor's office or the hospital bed); it involves one person baring his or her soul and then baring his or her body and allowing another person the privilege of touch; the person examining is often wearing a special uniform (the white coat) and performs a systematic examination where the steps are somewhat mysterious to the patient and using instruments that are the tokens and talismans of the profession. If done well, skillfully and respectfully, the ritual earns the trust of the patient, and it also lays the foundation for the patient-physician relationship. If done poorly, or cursorily, or sloppily (applying stethoscope to the clothing and not to the bare skin), it does the opposite--it creates mistrust, or even a sense of being disrepcted. 

My sense is that the wonderful technology that we have to visualize the inside of the body often leaves physicians feeling that the exam is a waste of time and so they may shortchange the ritual.

 The dangers are twofold: at the simplest level you miss the opportunity to be present with the patient, to conduct a ritual that cements the relationship; on a more pragmatic level, you miss obvious diagnoses and obvious bodily findings that might obviate the need for further testing.

Much has been made of the Institute of Medicine's Landmark report on medical errors. But I don't think we even begin to comprehend how much a sloppy exam costs us in terms of missed diagnoses, unnecessary tests, and complications from tests (such as reactions to contrast for a CAT scan) that were never indicated.

When you were last examined by a physician, did it go well, and did you have a sense of participating in a skilled ritual, and did that matter?