Gesticulation

I sat on the edge of the patient's bed and made a grand, sweeping circle above my head with a pointed finger, asking in an exaggerated voice, “What is the name of this building?” I had seen H90.2 - conductive hearing loss unspecified in her chart, and no hearing aids on her bedside table. She turned to Dr. Newman, my attending on the geriatrics consulting service, with a quizzical look. “Why is he asking about helicopters?”

Before medical training, I had not given much thought to the role of hand gestures in communication. I knew that I used them often; my colleagues pointed out just how saturated my conversations were with wild gesticulations. I blame my upbringing. I had the wonderful opportunity to live in Northern Italy as a teen and came to appreciate the value of a well-timed “mano a borsa.”

Undeterred by the initial misunderstanding with this patient, I started bringing my hand to my mouth repeatedly. “Have you been eating OK?” The patient blushed and said, “Doctor, you are too young to be blowing me kisses!” We all laughed.

During my medical school training, I learned that hands could convey a surprising amount of information. I was trained to watch for Beau's lines, Osler's nodes, and clubbing. I remember learning about peripheral nerve palsies and the “hand of benediction,” named after the characteristic hand gesture of the first pope, Saint Peter.

This theme continued on my geriatrics rotations. It turns out that you can in fact tell a lot about someone from their handshake, as grip strength can be a nice proxy for frailty. Hand tremors can also help distinguish movement disorders, from Parkinson's to essential tremor. Joints of the hand can suggest rheumatoid arthritis versus osteoarthritis.

As clinicians, we often use our hands to communicate “metaphors of medicine” to our patients. Our hands squeeze into a fist to emphasize the beating heart, we poke our arm to signify an injection, we point to parts of our body when eliciting a pain history. While certain gestures can have wildly varied meanings and provoke confusion depending on cultural context (avoid making the peace sign while in Great Britain), the literature suggests that, at least among physicians, there are a more limited number of gestures used to construct visual models of anatomy and physiology.

And in an age of increased masking, gestures may improve communication with hearing-impaired patients who read lips. (For patients who use American Sign Language, a translator is essential. The same is true of patients whose preferred language is not English—clinicians should not rely on gestures in place of a translator.)

Despite such evidence, that day I felt as if my gesticulations were alien signals being constantly misinterpreted. I was about to sit on my hands when I decided to give it one more try. I wanted to ask about the patient's two daughters, so I held up two fingers.

Suddenly, the patient struck my hand with a fist and just left it there, outstretched and barely touching mine. I was perplexed. Had I misinterpreted our conversation? Was the patient offended? I saw Dr. Newman smiling out of the corner of my eye. Once again, she held her fist out at me, but she didn't seem angry. Slowly, a realization dawned upon me. I covered her fist with my palm, and she smiled.

Rock beats scissors, but paper beats rock.