Hugging It Out

Carlson and Nelson Endowed Director, Center for Individualized Medicine, and Vasek and Anna Maria Polak Professor of Cancer Research, Mayo Clinic in Scottsdale, Arizona

Patient zero is an active and charming older widow, measuring approximately 4’11 and weighing in at 90 pounds, who wisely moved to the dry deserts of Arizona from the East Coast with a rather indolent, but persistent, extramedullary myeloma in tow.

At our first appointment, she announced that we would begin each meeting with a hug because that’s what her hematologist out east always did. I happen to know that hugging hematologist – he is not a small person. Slightly bemused by the visual incongruity of the 6-foot doctor embracing this tiny lady, off-a-hugging I went. And, for the past five years, patient zero and yours truly have reenacted the ritual every time I enter and exit the consultation room.

I didn’t think too much about the ceremony until a few weeks ago when a retired, well-groomed business executive, sporting crisply pressed golf apparel, returned to see me. He had decided to move to Texas to be closer to family and was telling me about his plans to transfer care. After our usual exchange of pleasantries and review of his labs and treatment plans, he shifted somewhat uncomfortably in his seat, cleared his throat, and said, “Dr. Stewart, would you mind if I gave you a hug? My new doctor in Texas gave me a hug.”

What?

I’m just saying, hugging a diminutive grandmother is one thing, but wrapping my arms around a tall, reserved gent in golf shorts wasn’t in my repertoire. I went for it gamely, though it was an abbreviated and slightly awkward moment for both of us.

Now, I don’t know about medical school these days, but when I trained in Scotland in the mid-1980s, learning to hug patients wasn’t in the curriculum. In that reserved, taciturn culture, all public displays of affection toward anyone except your own children (below the age of 12) are viewed with high skepticism and raised eyebrows that seemed to say, “He has been in America too long; best cross the street.”

After the golfer left, I was basking in my newfound empathy when it dawned on me that the hugging thing was indeed more ubiquitous than I had thought. Maybe I should take a cue from the hugging hematologists of Hoboken and Houston and less grudgingly offer up the benign token of comfort and friendship.

So, I entered the next exam room full of ambition – only to find an all-business, 42-year-old lawyer with shiny black shoes, a thick portfolio of lab results, and audio recordings of our visits. He is a wonderful human being, but I sensed he would not appreciate my awakening.

Slightly deflated, I contemplated the outbreak of hugging hematologists coinciding with a media explosion of harassment accusations and an overdue and healthy debate on appropriate workplace behavior. It got me thinking – with respect to patients – when is a hug not just a hug? What, exactly, is the appropriate hold-and-release time? Are there eligibility criteria – age, performance status, past exposure, number of prior appointments, active visible infection? Can you rub a bald head in encouragement? Do the rules change according to geography and the social norms of the country in which the hug occurs?

On a trip to New Zealand, I participated in a receiving line that, depending on the Anglo-American, Maori, or Northern or Southern European origin of the participant, involved a bewildering array of formal handshakes, hugs, air kisses (sometimes one cheek, sometimes both), and nose rubs.

In retrospect, this desensitization marked my tipping point, but because this was a social event rather than a patient encounter, my unease lingered. What is an aging misanthropic hematologist to do?

I sought out my most-trusted, younger, more in-touch (pardon the pun) colleague to ask about his experience in contact with patients. With barely a second’s pause, he offered the following guideline: “Below the elbow when sitting, below the knee when lying flat.” He went on to explain this was the recommendation  he received in medical school in the 1990s regarding appropriate ways to comfort patients. The advice seemed eminently sensible, but guidance on hugging in 2017 was not forthcoming.

An online search was revealing; it turns out patient-physician hugging appropriateness is a common discussion point in online forums. The balance of opinion favored the friendly embrace when initiated by the patient – counterbalanced by some rather funny rebuttals from germophobic and olfactorily-sensitive doctors.

So, with a heightened sensitivity, I paid special attention as colleagues renewed acquaintances at the recent ASH annual meeting, where innocent hugging, back-slapping, and air-kissing were as common as plush carpet on the exhibition hall floor. I did get some quizzical looks as I confronted unsuspecting attendees with the question, “Do you hug?” As for the exam room, I deduced that the answer is, “Only when asked.” I’m hoping that’s right.

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