I went to New York City this past December to meet a close friend for lunch and to walk along 5th Avenue to get into the holiday spirit. Understandably, the Big Apple, and especially Grand Central Station, were more crowded and harder to navigate than usual. During the 4-hour time that I was either purposefully walking to lunch or purposelessly strolling and peering in department store windows, only one person bumped into me and, without making eye contact, hastily muttered, "Sorry." How is it possible to intermingle with thousands of people and experience only a minor collision?


Boundary has become a buzz word these days and, depending on the circumstance, it either relates to the importance of maintaining it, what happens when you inappropriately cross it, or the difficulty dealing with it when it is blurred. I was surprised to learn that there is a field that addresses the issue of boundaries and the spaces between them. The term proxemics was introduced by biologist and anthropologist Edward T. Hall in 1966 and is defined as the study of set measurable distances between people as they interact.1 


The focus of research is how people use space and how various differences in that use can make us feel more relaxed or more anxious. These distances are divided into three categories: intimate personal distance (1.5-4 feet) for interactions among good friends or family members; social distance (4-12 feet) for interactions among acquaintances; and public distance (12-25 feet), used for public speaking. Under normal circumstances, we allow people to enter our personal space by granting permission, either with a verbal "go ahead" or through body language. We, as clinicians, need to understand the territory of personal distance and the boundary we cross when we take care of patients. 


I felt that my patients were never more vulnerable and giving than when they told me their story and allowed me to touch them. We as health care providers cross a personal boundary every time we examine a patient. We automatically assume that we can cross into a patient's personal space because it is part of our job. Not only do we cross into the space, we go to its inner limit with the act of touching. We would probably cringe and withdraw if a total stranger came up to us and merely placed his hand on our arm or tapped us on our shoulder to get our attention. Yet we essentially do just that when we begin physically assessing patients.


Do you remember what it felt like when you first started to learn the million different steps in the physical exam? Was it really possible to learn them all? As students, we read all about how to perform the physical examination and then we practiced on each other. I recently pulled A Guide to Physical Examination, the Barbara Bates bible, off my bookshelf and opened to the first page, which provides an overview of the PE exam of an adult.2 She describes that after performing a survey by observing the patient's general state of health, the next step is to take the vital signs, beginning by measuring the pulse.


You have now been directed to cross over the personal space boundary between you and your patient—no questions asked. If measuring the pulse is the gateway to the rest of the exam, shouldn't some thought be given to this moment, perhaps acknowledging what is about to happen to the patient or requesting permission from the patient to cross this critical safety barrier? Or, at least, shouldn't we recognize that a personal space boundary does exist and think about ways to cross it less intrusively or with more awareness of this trespass?


I remember watching a cardiologist colleague as he introduced himself to the patient and began his physical examination. Without breaking eye contact, he took the patient's hand and began taking the patient's pulse. The image of the gentleness of that physician as he unobtrusively gathered the first very important information about the patient is still with me, 30 years later. It seemed such an obvious and nonthreatening way to obtain a more accurate measurement than the customary way of taking the patient's wrist, palpating the pulse, and practically counting out loud. I wonder how much lower the pulse rate was when my cardiologist colleague took it than it was when obtained in the more direct manner we were all taught.


Dr. Abraham Verghese, noted author with emphasis on the medical humanities, is on a mission to bring back the lost art of the physical exam in which touch plays a crucial role in gathering data.3 In obtaining information from our patients, we need to understand the concepts of space and distance, the boundaries in between, and how to cross them. If you don't already, directly asking for permission is a good place to start. When theory is combined with practice, as Dr. Verghese says, "it earns trust and serves as a ritual that transforms two strangers into doctor and patient." JAAPA


Sarah Zarbock is the editor in chief of JAAPA.

REFERENCES


1. Hall ET. The Hidden Dimension. Garden City, NY: Doubleday; 1966.


2. Bates B. A Guide to Physical Examination. Philadelphia, PA: J B Lippincott Co; 1974. 


3. Grady D. Physician revives a dying art: the physical. New York Times. October 12, 2010. http://www.nytimes.com/2010/10/12/health/12profile.html. Accessed January 11, 2011.