On Touch

Narrative Inquiry in Bioethics is very proud to introduce our first posting by Jocelyn Streid. She is going to post regularly for us for the next year. Jocelyn is a Robertson Scholar and pre-med student at Duke University and is interested in medical humanities. Welcome aboard Jocelyn!

On Touch

By Jocelyn Streid 

“You must learn to touch the patient. So many doctors – they do not want to touch. We cannot take care of the patient unless we touch." 

When I was twenty years old, I shadowed a physician in rural South Africa. This was the advice she gave me as we stood before a patient suffering from HIV/AIDS. He had literally wandered in off the street, and now he sat before us – delirious, covered in a Kaposi’s sarcoma rash, and rendered silent by acute oral thrush. Still new to the smells of advanced HIV/AIDS, I could barely breathe. I imagined the wide berth people must have given him on his way here – to touch him was my last instinct.

As I read the narratives of CNAs in the Winter 2011 edition of Narrative Inquiry in Bioethics , I couldn’t help but think of the South African doctor’s words: “You must learn to touch the patient.” These contributors tell stories of touch – of bathing, of cleaning, of repositioning, of toileting, of feeding. It is physically intimate labor of unmediated contact, perfectly captured in Tracy Dudzinski’s term for herself: a “direct-care worker.”  Yet as physically exhausting it may be, the practice of touch can be one of the most rewarding elements of a CNA’s career. It is with pride that James Bradley writes, “I am a carer. A hands-on, at-the-bedside, hand-holding, bed-bathing, carer.”

The meaning of touch in healthcare settings has garnered more and more attention in the past several years, in part due to writer and physician Abraham Verghese’s discussion on the topic. In his essay “A Touch of Sense,” he observes that many doctors view the physical examination as “hardly worthwhile,” since the ever-increasing prevalence of technological diagnostic tools can render actual doctor-patient contact seemingly unnecessary.

Consequently, modern medical practice tends to isolate physical touch to less-glorified members of the healthcare team, forgetting its significance and exemplifying a larger societal shift away from manual work. Physical labor, after all, receives little cultural or financial recognition – blue-collar workers work with their hands; white-collar workers do not. The language used to describe this type of labor reflects the hierarchy. CNAs, it is sometimes said, do the “dirty work.” The implied dichotomies of clean/unclean and pure/impure suggest that the direct care offered by CNAs is inferior to the indirect care offered by other members of the healthcare team. Their work is perceived to be the performance of basic physical tasks with little recognition of the importance of those tasks. As Nanci Robinson explains, “When someone says they are a CNA…Images of caring, compassionate and educated people should come to mind, not someone holding a bed pan.”

Though CNAs work to retain the practice of touch in modern healthcare, much has been lost in its decreasing prevalence. When commentator Delease Wear describes her father’s time in the hospital, she recalls the CNA’s name and thinks of “the smell of the lotion she rubbed on his body.” Other professionals, however, are noticeably absent from her memory – “We never spoke directly to the medical director of the hospice. He was a phantom, rounding at 5 or 6 a.m.; we came to believe he did so to avoid speaking to families.”

Touch, then, is both a symbol of and a vehicle for good care. It is easy to see why patients might feel more alienated from their providers as touch becomes replaced by computer screens and diagnostic imaging. Verghese bemoans the loss of touch as a physician-patient ritual. He writes,

“With the explosion of knowledge, the whole human genome mapped out at our feet, we are lulled into forgetting that the ritual is cathartic to the physician and necessary for the patient, forgetting that the ritual has meaning and a singular message to convey to the patient. And the message, which I didn’t fully understand then, even as I delivered it, and which I understand better now, is this: I will always, always be there, I will see you through this, I will never abandon you, I will be with you through the end.”

CNAs fill a vital role many physicians have long-abandoned. They are those who comfort, those who provide, those who touch. I think of Tracy Dudzinski’s story of an elderly man for whom she cared. Their relationship, I am sure, was one of touch, and when he passed away, his son asked her to be a pallbearer for him. The importance of her touch extended past death; he had asked her to use her hands and touch his casket, even after he could no longer feel the contact. I can’t help but wonder what medicine might look like if more providers remembered that to touch is a privilege, and to be touched can be a gift.