Should Doctors Hug Patients?

After watching an awkward moment between me and a patient who insisted on trying to hug me with me finally prevailing by substituting the most maladroit handshake imaginable, a medical student asked whether it was just my personal preference to not hug patients.

I was busy doing something on the computer when the question
came and I recall saying clearly and firmly without turning around to face her,
“Doctors don’t hug patients”.  Even at the time it felt like an automatic and rather insensitive thing to say. We were on rounds, we were busy, and I distinctly remember feeling a little defensive. Secretly, I wondered if medical students are being taught something else these days about boundary crossings and boundary violations and whether the training that led to my near-absolute prohibition against hugging patients was old-fashioned. Am I a stuffed shirt?

I’m not apologetic about declining to hug patients, male or
female, even when they offer first. I never offer a hug to patients, and few
patients try to insist on hugging me. Most of the time they just accept my
offer to shake hands instead.

It’s hard for me to remember at what time in my training I
learned that it’s almost never appropriate to hug patients. I can dimly recall
back in the Stone Age days of my residency how my staff supervisor reacted to
hearing about a mental health care provider in the community who regularly
hugged patients. He derisively referred to it as “hug therapy” and though I can’t
remember his exact words otherwise, the tenor of the rest of his response made
it clear that hugging patients is definitely taboo.

I did some digging on the internet and PubMed on the subject of physicians, especially psychiatrists, hugging patients and really couldn’t find much.  I looked through my copy of
The Principles of Medical Ethics With Annotations Especially Applicable to
Psychiatry.  The most pertinent item I could find was in Section 2 and it says in part:

  1. 1. The requirement that the physician conduct
    himself/herself with propriety in his/her profession and in all the actions of
    his/her life is especially important in the case of the psychiatrist because
    the patient tends to model his/her behavior after that of his/her psychiatrist
    by identification. Further, the necessary intensity of the treatment
    relationship may tend to activate sexual and other needs and fantasies on the
    part of both patient and psychiatrist, while weakening the objectivity
    necessary for control. Additionally, the inherent inequality in the
    doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical.

I realize that hugging is not explicitly covered in the
above excerpt but hugging is a boundary crossing bordering on violation that
can represent a slippery slope. I also found an Ethics Primer of the American
Psychiatric Association on line written by Peter B. Gruenberg, M.D., see link http://www.psych.org/Departments/EDU/residentmit/dl01.aspx.

Dr. Gruenberg cautions psychiatrists about the slippery
slope of hugs and even holding a patient’s hand. By themselves and occurring
only rarely they are boundary crossings rather than violations. The warning is
that these can almost imperceptibly become part of a pattern which can blur the
boundary even further in the doctor-patient relationship. “Everything considered
it is best to avoid physical contact” is the advice given.

Yet Gruenberg acknowledges the inherent problem in always
avoiding touching patients. The therapeutic value of touch is undeniable,
though it’s difficult to provide clear rules about when it’s appropriate to use
it.

The right distance for the doctor patient relationship is
sometimes challenging to measure. As far as hugging goes, “when in doubt, don’t”.

There are other ways other than physically touching patients
to convey care, validation, and acceptance. Tone of voice, the act of sitting
down with the patient rather than standing over him/her on rounds, and just
listening can all help establish a relationship that is safe, respectful, warm,
and professional.

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