BMJ 2014;348:g281 doi: 10.1136/bmj.

g281 (Published 17 January 2014)
Views & Reviews

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A shared wave is a clinical test of health—and humanity
The exchange of waved hands between doctor and patient can reveal much more than you might think, writes J Edward Fitzgerald J Edward Fitzgerald general surgery registrar, Association of Surgeons in Training, Royal College of Surgeons of England, London WC2A 3PE, UK
It was Saturday night as the general surgery registrar on call, and I was halfway through a three shift weekend stretch. In our emergency department the psychological darkness of the busy early hours was punctuated by the piercing call of a crash bleep. Switchboard’s disembodied voice rose from my pager and repeated itself loudly and firmly, summoning me to the surgical ward. Clerking interrupted, abrupt apologies given, notes abandoned, and three flights of stairs climbed, culminating in a breathless, anxious arrival. The medical and anaesthetic team was already there and made it clear that the immediate crisis did not require operating. Instead, I stood there, watching the battle unfold, wondering how I could help. Standing at the foot of the bed I looked down at the elderly patient, who was dyspnoeic and audibly wheezy. He looked back at me as the acute medical team took charge. Now was not the time to push in for a social chat. He was too ill, with too much happening, too many people, and too much noise. Instead I stood and raised my hand high over the medical crowd and gave him a friendly wave. He looked back again. Had he seen me? Then, hesitantly at first, slowly and shakily, he raised his wiry right arm off the bed and waved back with a half cocked, reciprocal greeting. It was a social exchange in which no words were spoken, but much was said. His brain could compute this visual stimulus and excite his upper motor neurones, which descend from his primary motor cortex through the brainstem and into his ventromedial spinal column. Across synapses, these triggered lower motor neurones in the anterior horn of his spinal cord, which in turn could exit unhindered in the motor roots of his spinal nerves. These lower motor neurones passed through his brachial plexus, carrying their action potentials to the neuromuscular junction. And his muscles had sufficient coordination and power to overcome gravity and wave back. Albeit medically correct and informative, reducing his actions to a series of successful transmissions across synapses misses the point. In such an adverse situation, what struck me was that he had the will to return this gesture and give me a wave. It meant he had not given up. He was still engaged.

What did my waving tell him? I’d like to think it told him that I was there for him, a friendly face in his stormy night. I’d like to think that despite the carefully choreographed chaos of the surrounding team, it told him that he was still an individual to be greeted and acknowledged, not any anonymous patient. There was a real problem, yes, but he was our focus, not the problem. I hope that reached him through the commotion. What did his wave back tell me? From a medical viewpoint, it told me a great deal. It told me his visual acuity was sufficient to focus on my gesture, that at least one ageing cornea was clear, and that he had sufficient retinal photoreceptors to stimulate his optic nerve. It told me that his lateral geniculate nucleus in his thalamus could receive these visual signals and that the optic radiations could convey them through to his visual cortex.

Although returning a wave may be considered a reflex action for many, it is a social reflex rather than the true physiological reflex arc we learn at medical school. Yet such a reflex gesture still has many merits. With the exception of being mistaken for the offensive Greek gesture called the moutza,1 a friendly wave may be a universal mode of visual language. It crosses cultures, languages, and doctor-patient barriers. This is understandable if the gestural origin theory of language development is accepted, with such gestures described as “behavioural fossils” coupled to our speech.2 The advent of functional magnetic resonance imaging allows these fossil remnants to be visualised. Processing takes place in the inferior frontal (Broca’s) and posterior temporal (Wernicke’s) regions, suggesting that gestures and spoken language are processed by a common neural system.3 Gesticulation seems to be deeply embedded within our evolutionary origins. The neuroscience and psychology of such non-verbal communication seeks to better understand the interaction of language and body. In the discipline of cognitive psychology, studies are beginning to unravel these complexities, with evidence indicating that gestures play a significant role in processing and learning language.4 Against this background, the power of a simple friendly wave should not be underestimated.
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BMJ 2014;348:g281 doi: 10.1136/bmj.g281 (Published 17 January 2014)

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There are many clinical tests described in medicine, but this so called waving sign is notable for also testing the examiner. Both patient and doctor require intact visual and neurological pathways, with higher cortical function to recognise and respond appropriately. But, crucially, the doctor must also demonstrate humanity and empathy in initiating the engagement. In doing so, the “assessment” may only take a few seconds, but the beneficial social outcomes will likely last considerably longer.

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. Follow the author on Twitter: @Diathermy Patient consent not needed (patient anonymised, dead, or hypothetical). Provenance and peer review: Not commissioned; externally peer reviewed.
1 2 3 4 Mountza. Wikipedia. 14 Dec 2013. Corballis M. The gestural origins of language. American Scientist 1999;87:138. Xu J, Gannon PJ, Emmorey K, Smith JF, Braun AR. Symbolic gestures and spoken language are processed by a common neural system. Proc Nat Acad Sci U S A 2009;106:20664-9. Goldin-Meadow S, Alibali MW. Gesture’s role in speaking, learning, and creating language. Annu Rev Psychol 2013;64:257-83.

Next time I find myself standing at the end of a patient’s bed, taking in the scene, be it arriving for the first time, directing a crisis, or merely pausing in passing, I will remember this quick test of my own humanity and acknowledge my patient with a friendly gesture. I hope they are “waving sign” positive in return.
I thank Sarosh Irani for neurological advice.

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