Have you had your 
four-a-day today?

Five-a-day is so old hat. 
Time for a new campaign.

On YouTube Charlotte Diamond sings that “four hugs a day - that’s the minimum” is what we need (don't watch this straight after breakfast - Ed). And she tells us how to do it and whom to hug. Neuro-economist Paul Zac prescribes eight hugs. I don’t know how either measures the effect, but there does seem to be evidence that hugs, or at least warm physical touches, benefit our mental and physical health.

Our fellow primates spend a large amount of their time on social grooming, which has been shown to be essential for group co-operation. A research study concluded that the more a basketball team high-fives, the better their performance. And we know that it is easier for people who are deaf or blind from birth to live a happy life than it is for those who lack the sense of touch. A touch, or a hug, makes all the difference when you are low, and it celebrates your highs.

Touch is the first sense that develops in utero, and we cannot grow up happy or healthy without it, but it is notably under-researched compared with other sensory modalities. The sense of touch is mediated by oxytocin through the hypothalamus so it is not surprising that touch affects the way we feel. We normally release oxytocin in response to hugs, and Paul Zac links this with the expression of empathy. The response is depressed if you are stressed, and may be absent in people who suffered abuse as children. Both of these are situations where normal trust and empathy are reduced or absent.

If hugs are the answer to the human condition, where do doctors stand? A BMJ search will bring up 158 entries for ‘hugs’. Rule out authors named ‘Hug’ and you are left with a handful of personal accounts by patients, some of them doctors, of how much a hug meant at a moment of heightened emotion, or how a caring touch would have made bad news easier to bear. So we may recognise the therapeutic value of hugs, but do we consciously make use of it?

Doctors have a licence to touch patients, and doctors who touch get better ratings from patients. But we depend increasingly on technical investigations to make a diagnosis, so physical examination becomes ever more perfunctory. It isn’t just the patients who may be losing out; the benefits of touch are reciprocal. As doctors’ working environments become more impersonal, the more important the experience of touching a patient may be to the wellbeing of both sides.

The boundary between a professional touch and taking advantage of a patient is, well, a touchy subject. The GMC deals with many cases where doctors are felt to have overstepped the boundary, but doesn’t give anything more than advice on intimate examinations. It seems that doctors, in general, wherever they trained, have similar views; refugee doctors face many cultural differences in the way medicine is practiced in Britain, but apparently touch is not one of them. So the boundary is largely set by patients. A male doctor lays a consoling hand on the arm of a female patient. In Britain today, that’s sympathetic practice; in Victorian Britain, an affront; in Saudi Arabia it might be a capital offence.
Britain may appear to have embraced touchy-feely, but lots of us are hug-deficient. Many elderly people are starved of human touch. The price of self-realisation is high: in our unwillingness to make the compromises essential to living comfortably with others, families break up and people drift away from community groups. It hasn’t made us happier. You can have 500 facebook friends but no-one to turn to for tea and sympathy. And a hug.

Patients’ trust in doctors has been eroded by the transgressions of a small minority of our colleagues and the fall from grace of celebrities. Any touch may be misinterpreted, so we take precautions. When I trained, we rarely thought of offering a chaperone to a patient but now it’s mandatory. Let’s hope that it doesn’t come to compulsory videoing of consultations to check for inappropriate contacts.

Dentists rarely have a problem. Since they work with assistants they have built-in chaperones, and few people get a thrill out of having their teeth filled. Sex workers, whose business is erotic touch, make a distinction between what they will do with clients and some touches – generally kissing on the mouth – reserved for affectionate relationships.
Can anything substitute for human touch? Autistic professor of animal science Dr Temple Grandin developed a ‘hug box’ to give her the embraces she could not accept from human beings. Bionic arms can now give their wearers a sense of touch. Robotic surgeon Da Vinci will soon be able to feel the texture of tissues.

Maybe future generations will find e-hugs as warming as being held in someone else’s arms. But till then (and I’m not sure I want to be part of that ‘then’) how do doctors manage the precarious balance between clinical examination and a warm human contact? With caution, of course. Explaining the nature and purpose of a clinical examination and carrying it out gently but professionally. Assessing how comfortable a patient is with closeness, their emotional state and their vulnerability.

Not all of us are huggers. But finding a warm but acceptable way of sharing a social touch is important. I always shake hands with patients when I introduce myself. It may not be the form of greeting used in the patient’s culture, but it is polite in mine, and though some patients have been surprised, none has ever rejected my hand, and I feel it has got the relationship off to a good start. Others always find a reason to check a patient’s pulse, a clinical examination which is not far from a handshake. But GPs can’t hug everybody. So, Jeremy, how about a public health campaign for four-a-day?

This article first appeared in The Sessional GP magazine.

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