The act of touching a stranger deviates from our social norms. We are taught to be friendly, close, but not to touch. Personal space is a valuable commodity, perhaps even a personal right. This makes the act of violating the social agreement so difficult to the unititiated. If you have ever seen a medical student examine a patient, it evokes the palpable discomfort of a teenager discovering their body – curious, nervous, embarrassed, but eager. As physicians, we snicker at their discomfort, shake our head at the novices, but they are doing what all normall, well-socialized citizens would do in that situation. They feel awkward knowingly and willingly breaking the unspoken social agreement that you do not touch strangers. As we move through medical training this awkardness rapidly fades. The discomfort of seeing naked strangers becomes routine. Touching strangers, examining them – this too becomes just a part of the job. It ceases to be odd until you try and explain your daily activities to a non-medical friend or loved one. Only then do you realize the isolated and special world that you live in, one that exists outside of the typical social norms.
Getting used to the role is facilitated by the garments that we wear. These coats are for the benefit of the patient, to be sure. They equate the white coat with doctor, and they realize that the interactions they have with us are private, professional, and for their own good. The garments assist in defining the roles. It is not me, a small young female, examining the patient, it is their doctor. There are some physicians I know who like to “step outside of the role” and wear a suit or casual clothes. This approach may work for them, but for me, the coat (or scrubs) defines boundaries and allows the relationship with my patients to proceed. We have created a layer to slowly separate ourselves (people, citizens, strangers) from our roles (doctor, patient, surgeon).
Beyond the mere touching of bodies comes the more complex issue of invasion – performing procedures, the act of surgery. Again, we challenge ourselves to detach from what we know societally and to allow ourselves to break from the idea of causing discomfort in order to facilitate the broader goal of healing or cure. When learning to do invasive procedures on an awake patient, you realize the depth of the doctor-patient relationship. You both put aside your natural inclinations to run from these acts and instead you trust one another. Most physicians will not forget their first NGT, foley catheter, central line, chest tube, or surgical incision. Some of these are smaller invasions, and some are larger, but they are all a challenge to your role as citizen and a testament to your role as a physician. In order to allow these actions, we create barriers to buffer these experiences. Some of these barriers are for protection or to create sterility, but I believe they also serve a dual purpose, which is to allow us to separate ourselves from the patient as a person and to focus soley on the task at hand.
As I walk from the hospital ward to the operating room, I shed my white coat at the OR hallway. I put aside my physician role and I become a surgeon. I don my surgical cap and grab a mask and am on my way to a part of the hospital accesible only to OR personel. This is not a place for medical doctors, physical therapists, or nutritionists. This is the operating room and you must slowly peel away your other roles to enter. Here in the OR you create a fresh barrier – you don not just your surgical mask and hat, but your surgical eyes and mind. You greet the OR team and the patient and then once the patient is asleep, you clean them and begin the process of draping. Depending upon the surgeon, this can be a simple and functional process – clean, drape, create sterile field – or an obsessive and compulsive routine. But again this draping, this creation of a physical barrier, allows us to separate ourselves mentally and visually from the patient as a person and focus on the patient as on organ system. We block out everything except the operative field. We focus only on what we are there to do, not on whom we are doing it. We adopt our surgical mindset. And this is what allows us to cut. What under other circumstances would be a violation becomes a noble act of healing.
Once the incision is made, we encounter the most complex layers of all – the physical layers of the human body. Our focus today is on the skin – this most superficial of layers, but don’t be fooled by its fragility. Do not dare underestimate the power of the skin. Without the skin we would die. This thin layer is an active agent in our lives, and it is an amazing, dynamic, living system. Your skin reflects and accumulates your experiences, it is a living record of your life, your exposures. It can heal and regenerate but it also has a memory. The sun exposure you had as a child lingers on in the cells of your skin. The scars you acquired climbing a tree as a youth remain. Your skin is a living, breathing, fossil record of your life. But one that is not stagnant, it is one that can heal. We do not wear every scratch, injury, or tear forever, only the deepest injuries leave marks. Some consider these blemishes war wounds, others unsightly reminders of past traumas. To me the skin is a meaningful reminder of the life lived, and a reflection of our experience. It changes with age from the miraculously resilient skin of a newborn to the sagging, paper-thin skin of the aged. But to me each wrinkle holds a lifetime worth of laughs, frowns, or looks of puzzled bemusement.
To treat the skin as a simple layer that must be pierced in order to dig deeper is to miss the tactile, physical, and also figurative barrier we wear on our outsides each and every day. The skin is our largest organ and without it, wounds can not heal (see skin grafts), without it thermoregulation is lost and fluid balance is in disarray (see burns), and without it we can not protect ourselves from the environment (see epidermolysis bullosa). It is delicate, but incredibly strong. As a surgeon, I have the honor to pierce that layer at each surgery. Some treat the skin incision as a rapid swipe of the scalpel, while others treat it with respect. Regardless of the setting, it is the first layer we encounter and the last one closed at the end of the procedure. We do not announce “incision” when we cut the fascia or the muscle. It is always announced at the first moment that the scalpel begins to cut the skin. It is the only remnant that the patients see of their surgery, for good or bad. It may be superficial, but it is very very deep.