The Science of Observation Through The Senses

Do you feel like your therapist listens to you? Is there an appropriate time for a health care professional to touch you?

Listen to me, because I'm right here!

That’s an important question. In Washington State, touch between therapists and clients are limited to appropriate therapeutic touch, such as a handshake. However, I hold a license as a Registered Nurse, and there have numerous times when clients have shown me a wound that wasn’t healing, a mysterious rash on the arm, or presented with a cough that sounded more serious than the client was treating it [don’t worry: I always present my credentials, and ask a client if s/he would like my professional opinion on their medical question]. I might ask permission to touch near a wound to feel the temperature of the skin, or smell it to see if it is infected [or ask them to take a sniff if it’s within reach].  While I would never overstep the scope of my practice, I keep “Nurse Imei” ready for work when I’m in the therapy office, because it allows me to practice the best kind of medicine I know: the science of observation through the senses.

In an article posted on CNN.com, Abraham Verghese MD, Professor of Medicine and Senior Associate Chair for the Theory and Practice of Medicine, Stanford University, wrote:

The truth is, I love and embrace technology, and have no desire to return to the pre-CAT scan and pre-MRI days of old. But I see no reason to let new technology make us lose the abilities we have had for over a hundred years to make sophisticated diagnosis at the bedside. Indeed, it should make us so much better.

I feel the same as Dr. Verghese. I too love technology and how it has enhanced medical practice. But it shouldn’t prevent or distract us from observing the client with out own eyes, ears, hands, and olfactory nerves. What does this mean for those of us who conduct therapy sessions over the phone, or handle triage in this manner?

If you are thinking of trying therapy over the phone or Internet, your therapist should be thoroughly trained to conduct sessions in this manner.  My telephonic nurse triage training gave me excellent experience in listening to patients because I could not see them. I can’t see a grimace of pain, but I can ask and help a patient evaluate their pain level using an appropriate pain scale. I can’t see if there is blood in their urine, but I can ask a client to describe a color or a smell. I can hear over the phone is someone’s breath is labored, or if their thinking is foggy.

If you are a client attending F2F psychotherapy sessions, it is important that your therapist look — or attend — to you. Attending is a developed skill, requiring hours of learning to observe a person’s normative behaviors, both physical and emotional, while they are describing issues that arise. Even if your therapist takes copious notes, a good therapist is watching body language, eye movement, changes in the tone or strength of your voice, the shifting of your body when you are uncomfortable with a subject, and even the presence of sweat and color changes to your skin. It’s not uncommon for a trained counselor to mention when s/he believes you’re not being honest about your problems.

As an RN, I feel exceptionally lucky to have additional tools of observation to bring to the table. Many of these help cast light on the overall picture of mental health. For example, knowing the complications of long-term sleep issues on the heart, as well as its connection to the incidence of depression, would lead me to prioritize a client’s complaint of poor sleep because his partner wakes him up when he snores. With more observation and interviewing, I could find out that the client has sleep apnea, a condition that contributes to depression, heart disease, and problems with a relationship.

I received a book as gift at Christmas, “The Naked Lady Who Stood On Her Head” by psychiatrist Gary Small and Gigi Vorgan. The stories highlight the many physical observations an MD notes, and they are often so many, I wonder how those without more medical experience (such as a physician or a nurse) function holistically in the mental health office. I must conclude that the best therapists I know rely heavily on observing through their senses, and documenting everything that seems unusual or unexplained. Anything falling the medical category gets noted and referred to a physician.

The corporate client who walks into an office with the smell of body odor and urine alert any therapist to inquire about the patient’s strong odor as a contrast to his normative grooming habits. But if you were trained to detect the smell of ketones on the breath of a diabetic experiencing the beginning of a sharp rise in high blood sugar, these are skills that can’t be as effectively used over the phone or Internet. And that is an important problem in the world of telemedicine.

When Telemedicine Isn’t Going To Work

A woman who has the smell of alcohol on her breath while going through treatment for alcoholism is not going to be detected if she contracts for telemedicine sessions. It is the practitioner’s responsibility to determine who should receive “old fashioned” health care in-office, and the convenience of telemedicine sessions should not be offered to everyone.

Technology has not caught up with our imagination. Some day we might have “smell-o-vision”, but as of today, we can’t smell through the phone. Someday, we’ll have more home devices that can measure heart rates and give us audio of a minute’s worth of auscultation (currently, there is an app that can do this for the heart, but it has not been approved for professional use). Until then, clients and providers should consider when therapy sessions are appropriate for phone and Internet, and when they should be seeing a helping professional face to face.

What do you think? What happens when clients leave the medical office saying, “My doctor didn’t listen to me, ” or “She barely even took a look at my symptoms”? How can we integrate crucial emerging telemedicine technologies with the need for old-fashioned observation?

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