working-class solidarity may be a hard sell for most health-care workers
September 9, 2020 12:00 PM   Subscribe

But over time, as I moved through medical school and became a practicing health worker, I’ve come to see the Professional as a figure of social control, a departure from the conventional usage of lowercase “professional,” which sees a professional as just someone with a job: Class Consciousness for American Doctors - Professionalism is the ideological terrain on which medicine’s culture interacts with its class politics (The New Inquiry)
With such great rewards at stake in the idea of Professional authority, the fierce allegiance with patients implied in working-class solidarity might be seen as excessive or even disloyal to the Profession. It draws a fine line between the health worker who has a good rapport with her patients and one who doesn’t see her patients as belonging to a different class, relating to them as equals rather than patrons. Reading Starr’s argument, one might assume that Professionalism is an analysis of the class status of doctors, but that connection is rarely explicit in the everyday experience of the medical professional. Class is certainly not part of our formal education on how to be a Professional, and it only rarely comes up even in the burnout discourse. Instead of elucidating medicine’s class politics, burnout and Professionalism put our personal experiences into small, localized frames. Our predicament is different and special, we are told, and this isolates us from other workers and their struggles. Professionalism is the ideological terrain on which medicine’s culture interacts with its class politics. It is the uninspiring cultural residue left over when class solidarity is unavailable. In order to understand Professionalism, you have to understand solidarity.
posted by not_the_water (30 comments total) 25 users marked this as a favorite
 
Thanks for this. A lot to chew on.
posted by flamk at 1:15 PM on September 9, 2020 [1 favorite]


This is fucking fantastic thanks so much for posting it.
posted by supercrayon at 1:44 PM on September 9, 2020 [2 favorites]


Perhaps my reading is being affected too much by existing crankiness (actually, there is no "perhaps" at all on this - that's definitely the case and I apologize if this is overly blunt) but as a former nurse, I'm extremely put off by the artificial dichotomy in this piece. For one thing, the author keeps using "healthcare worker" when they only ever mean "doctor."

Doctoring is a high-status position, so it makes sense that there would be barriers to understanding working class lives for a lot of doctors, but the idea that working class solidarity is a hard sell for "most healthcare workers" is laughable. The majority of healthcare workers - nurses, CNAs, lab techs, etc. - are themselves working class.

I have other thoughts, but I don't want to be overly harsh. This is a very frustrating read that made me feel a need to tack on a reminder that most healthcare work is working class, and the presentation of working class realities as Other here leaves a sour taste given that.
posted by Lonnrot at 2:06 PM on September 9, 2020 [62 favorites]


PS I don't enjoy writing acerbic things, and will note my frustrations are with the piece itself. not_the_water, you're fine, please don't let my comment make you feel bad. This is not a bad post! There are still things worth acknowledging and thinking about in the essay, and I add my frustrations in the hope that they can bring something else to consider. Often users here will react with kneejerk dismissive comments without engaging with links and I hope I am not doing that. I am trying to read and digest the piece, I'm just finding Sariahmed has a...maddeningly idiosyncratic POV that casually erases working class people within the field and that's just a nail in my skull as I try to work through the essay.
posted by Lonnrot at 2:15 PM on September 9, 2020 [7 favorites]


I’m a nurse too Lonnrot, and my experience is that many nurses don’t think of themselves as working class, and identify rather as a “professional”. Granted I am in New Zealand and not the States. But I found many aspects of this article to ring true for health workers, particularly those with academic credentials and registrations. For example:

“Through my experiences organizing with PPF-PA as a member equal to other members, I learned to think of Professionalism in medicine as a process of disciplining students and residents into conformity rather than as a moral compass or set of work standards.”

I have seen “profressionalism” used as a bludgeon to curb individual thought and expression, particularly aimed at those who coincidentally agitate for better working conditions.

Also loved this bit:

“In a widely circulated video on his YouTube channel, Dr. Zubin Damania joins others in calling for the use of moral injury to describe a sort of health-care PTSD. Moral injury is a phrase borrowed from the military used to describe the suffering caused by unresolved psychological conflicts arising in situations that erode a person’s integrity. He argues this alternative to “burnout” avoids blaming the victim.

...

In other words, our emotional experiences at work let us know intuitively that our system’s dysfunction goes deeper than access to health insurance. It is no longer controversial to connect our personal feelings of exploitation, isolation, and overwork with the systematic dysfunction that harms the people we care for.”
posted by supercrayon at 2:18 PM on September 9, 2020 [8 favorites]


Everything except management in a hospital is working class now. Doctors used to be an elite cadre but once management watched a dozen residents compete for an attending spot they knew they could just fuck everyone on wages and benefits.

If you are not capital or an agent thereof you are the proletariat and it's far past time for doctors, nurses, everyone up and down the chain to unionize the hell out of the health industry.
posted by Your Childhood Pet Rock at 2:20 PM on September 9, 2020 [12 favorites]


A few thoughts:

A lot of physicians would also consider themselves working class.

Mandatory reporting laws, and their abuse, reinforce the role of doctor as social control.

I've always had a hard time accepting medical education, although most of my objections are the same as with all modern educational institutions. Everyone is poorly trained, because they are over-trained by the educational equivalent of helicopter-parents. No one understands the difference between knowledge and wisdom. The machine controls everything, and so everyone has to be made to fit neatly in checkboxes, doctor and patient alike.

I've come to understand my role as a doctor is to protect people from the healthcare system, and its associated bureaucracies, while guiding them through it if they really need it. 'Do no harm' is a joke when the system is capitalist, because free-market always means war. The system as a whole cannot accept the balancing principle: 'just because you can do something, doesn't mean you should'. Just as the modern world cannot accept that the ends of a heaven on earth inevitably justifies the use of hell as the means.

I doubt most here would agree with me, but just as people need protecting from a healthcare system that has no working theory of health, only of disease, similarly people need protection from the medicalization of their mental health. The litany of DSM acronyms that accompany many of my patients is probably as disabling as their actual mental health issues, if not more.
posted by legospaceman at 2:26 PM on September 9, 2020 [6 favorites]


I think it makes sense to view doctors as a Leninist labor aristocracy. They are strictly speaking "working class" from an orthodox Marxist point of view of their relationship to the means of production, but it seems to me that they often see their interests as aligned more with those above them than those below, as is usual for people occupying that layer of society. That they are wrong about that doesn't change much.
posted by Steely-eyed Missile Man at 2:28 PM on September 9, 2020 [15 favorites]


I’m a nurse too Lonnrot, and my experience is that many nurses don’t think of themselves as working class, and identify rather as a “professional”

I agree that Nurses (especially RNs) are 'professional class workers', but down the chain Medical Assistants and office staff are definitely working class.

I thought it was a good article as well, minus that complaint that Lonrot brought up.
posted by The_Vegetables at 2:41 PM on September 9, 2020 [1 favorite]


Who is and is not a "professional" has always struck me as more or less an aesthetic judgement that in practice is used in a number of ways simply to exploit people more. I don't really find it a very useful category.
posted by Steely-eyed Missile Man at 3:03 PM on September 9, 2020 [2 favorites]


In The Acquisitive Society, Tawney talks about protecting the professions from the effects of industrialization, and in some ways about the industrialization of professions. I used to work in an ancillary health service that requires a grad degree and credentialing (boards), and it always felt like he was writing directly to me about how industry tries to to turn judgement and art into a repeatable process that can be standardized. Notwithstanding the enormous market consolidation happening in this age that is driving this considerably, or that many of the administrators who manage these “business units” have little understanding of their function. You end up where we are, with the bare minimum as standard because doing more is not in the time/money equation. I’m so glad I left that world.
posted by johnnydummkopf at 3:22 PM on September 9, 2020 [1 favorite]


After the way the right wing party of the US tried to kill off anyone helping people with Covid, pretty much everyone in health care is ready to start singing Who's Side Are You On?
posted by ocschwar at 3:52 PM on September 9, 2020 [2 favorites]


This is really interesting. I don't know enough about the medical profession to evaluate all of it, but I'm glad to have read it.

As someone who never really went to a doctor between childhood and getting a PhD, I've always found the "what do you do" question a strange transition. There's almost always a notable shift in tone when doctors find out that I'm an academic. Some of that is probably entirely reasonable. I can imagine them saying to themselves, "Great! I won't have to explain statistics to this guy or talk him out of homeopathy. That's five more minutes for the next patient." But, the transition always makes me feel like rank in involved. Growing up in a place where medical doctors were the most prestigious and highfalutin job anyone ever talked about, I always get a little bit annoyed when the shift happens. Given that I'm starting out looking like a professional class white guy, if one who doesn't maintain his shoes with much care, I expect the difference is more extreme for a lot of patients.
posted by eotvos at 4:41 PM on September 9, 2020 [1 favorite]


That's bizarre, I can literally never recall being asked "what do you do" by any doctor I've gone to see ever (not that I go to the doctor all that often...never if I can avoid it, but sometimes it can't be avoided). I think if it happened I'd make whatever answer I felt like and then say, "So what do you do?"
posted by Steely-eyed Missile Man at 5:04 PM on September 9, 2020 [1 favorite]


Related: the book Disciplined Minds
posted by eviemath at 5:40 PM on September 9, 2020 [3 favorites]


Do medical students not read House of God any more? That book has not aged well in a lot of ways, but it is fundamentally about the ways that hospital administrators abuse physicians and patients for profit. It's set against the backdrop of Watergate, and the parallels are ... not subtle. But fifty years on, and we're still dealing with the same fecal matter (in medicine and in politics).

"Professionalism" is absolutely used as a cudgel to beat down any whiff of unionization. Even aside from that, I would think it would be nearly impossible to unionize doctors anyway, because there is just this very very brief 3-7 years where you are working in straight up exploitative conditions* for minimum wage. It's widely perceived as a time-limited "pay your dues" (irony intended) after which you prance off into the sunset and live your best life as an attending.

*The dirty secret is that the exploitation continues after residency: it continues in each monthly departmental email about who is and isn't meeting their productivity targets; it continues in the Meaningful Use initiatives (now abandoned, I think, because the EHR people got tired of people snarking about Meaningless Use); it continues in the annual US News and World Reports leaderboards. The only way out is to opt out of clinical practice or open one of those $1000/mo concierge practices, neither of which actually achieves any working class solidarity.

The other issue, which is barely touched on in this article, is that there is a lot of Us vs Them thinking in medicine -- a lot is directed at patients in a sort of "this can't happen to me" magical thinking, but also a lot aimed at other health care workers (defined broadly). I'm just thinking back to the Neurology vs Neurosurgery, or the Neurology vs Psychiatry, or the Everyone vs Emergency Medicine, battles that form the core of residency training. Divide and Conquer, and make the business side so complicated that you need a small army of administrators to maintain the whole house of cards.
posted by basalganglia at 5:48 PM on September 9, 2020 [8 favorites]


If you are not capital or an agent thereof you are the proletariat

I thought it was capital, management, labor. Most labor is boring. Some is even risky. Some labor enables and encourages participation in management decisions, but it s distributed unequally. Capital has leveraged that inequality, stormed institutions with MBAs, and removed management functions even from the people who are empowered to manage.

Sure doctors could evict capital and run a hospital. Could they then run it in solidarity with transport, custodial, the kitchen? Class problems persist even without capital, what incentives are there for any management to know the pain on the other end of their spreadsheets and quarterly objectives?

Anyway, excellent point about US med school as a weapon against solidarity. The ranking and matching system invented by the AMA alienates doctors, even from one another. You advance in Med school by sabotaging your peers as such as helping people, to the point where doctoring is no longer about helping people. Although that is a natural axis of solidarity among hospital workers, caring for others.

That is the commonality between the operating room and the linen room.
posted by eustatic at 7:25 PM on September 9, 2020


I'm just thinking back to the Neurology vs Neurosurgery, or the Neurology vs Psychiatry, or the Everyone vs Emergency Medicine, battles that form the core of residency training.

Could you explain more about this for us non doctors? I'm curious what these battles are.
posted by medusa at 7:27 PM on September 9, 2020 [1 favorite]


I thought it was capital, management, labor.

According to whom? I tend to agree with the classification of management as guard labor, but that's still, you know, labor. Most managers don't have any stake in the system beyond their salaries.
posted by Steely-eyed Missile Man at 8:10 PM on September 9, 2020


Just as a counterpoint, most UK doctors are unionised and have a higher rate of union membership than the average for public sector workers in the UK. The unions (especially the biggest) both do very union-y things including organising strikes, but also defend a professional model for medicine. A lot of older doctors in the UK link the concept of professionalism to that of autonomy for doctors (ie a status which allowed to override management decisions), and hence that the erosion of professionalism caused by marketisation in the health service is what has increased 'burnout''.

The criticism of the current capitalist model is there too, but i think it's more looking towards that sort of "craft guild" model rather than a Marxist one.

I'm not particularly arguing against the article as I agree with a lot of it, but that the concept of professionalism is a really interesting one with an interesting history, and its relationship with capitalism I think more complicated than the article relates. For example, the British Medical Association opposed the creation of the NHS; two decades later, while criticising practicalities it was vastly in favour of it. 'Professionalism' adapted and changed in the new context, while retaining most of its characteristics.
posted by Vortisaur at 11:14 PM on September 9, 2020 [3 favorites]


I'm just thinking back to the Neurology vs Neurosurgery, or the Neurology vs Psychiatry, or the Everyone vs Emergency Medicine, battles that form the core of residency training.

Could you explain more about this for us non doctors? I'm curious what these battles are.


Mostly about who is the primary service (i.e. responsible for a patient's day-to-day needs and eventual discharge plan) and who is consulting (i.e. focuses on their area of expertise to answers a specific question) -- and also how interesting vs idiotic a consultation question is perceived.

As neurology residents, we had a lot of resentment for the neurosurgeons, whom we perceived as calling us in just to take a history because they couldn't be bothered to do something as basic as talk to a patient or their family. I once got consulted because "patient is crying post-op," and when I hinted that maybe they needed better pain control rather than a neurologist, the surgery resident threatened to call a stroke alert. (That's not how it works, buddy.) I mean, I still remember this, 5 years later.

Ditto neuro vs psych, because a lot of admissions to the hospital could go either way, so there would be arguments about "well, this could be this [super rare neurological illness that's only been described in a single case report] ... or it could be an exacerbation of this patient's known bipolar disorder."

And everyone hates on the ED because the ED is the source of most admissions, i.e. the source of most pain in residency. A good senior resident, like a good goalie, is one who can block as many admissions as possible. "Winning the game" = getting through a call night with no admissions (or no consults, or no patients at all on your service, depending on how strict you wanted to be).

It's mostly jocular or at the level of college sports rivalries, but I do think it sets up the idea of The Doctor Against the World that a lot of people then carry forward.
posted by basalganglia at 4:20 AM on September 10, 2020 [8 favorites]


Most U.S. doctors are, if not capital, at least the owners of their own labor, as they are equity or at least de-facto income pass-through partners of a practice group, rather than employees of hospitals or other larger entities that physically host some of their practice activities.

Some U.S. doctors are capital in the common sense, through physician-owned practice groups with tons of equipment and non-physician employees. In some states, notably Texas, the regulations are set up to favor physician-owned hospitals.
posted by MattD at 5:11 AM on September 10, 2020 [2 favorites]


I really liked this article because it brought up several linked topics that I've heard little public discussion of. Also refreshing to hear from a doctor who has alligned themselves with working on systemic problems and using activist solutions.

Lonnrot I appreciate your critique of the frame. Hey, I'm a nurse, and I work in a public healthcare system, so totally agree. It's disappointing that the author sees themselves as aligning with the working class but doesn't name the working class coworkers who run the hospital. There are other holes in the article too, but the quality and complexity of the discussion in this thread points to what important topics this person raises.

I perceive the role of physicians as shifting: an increasing number are subject to managerial control. They've also had a big shift from male dominated to - if I'm remembering right, female dominated at least among incoming new doctors. They are undergoing a status shift in some part connected to capitalist pressures on the healthcare system. Everyone who provides healthcare in the US is also being made extremely aware of the failures of our current status quo at the moment.

Thanks to Eviemath for that book recommendation - Disciplined Minds.. The topic of professionalism seems to be a richer one than I'd thought of before.
posted by latkes at 6:46 AM on September 10, 2020


I thought it was capital, management, labor. Most labor is boring. Some is even risky. Some labor enables and encourages participation in management decisions, but it s distributed unequally. Capital has leveraged that inequality, stormed institutions with MBAs, and removed management functions even from the people who are empowered to manage.

In traditional Marxist analysis your're either capital or labour and that's it really.

The extreme rise in the compensation of executives has effectively created a class of people whose interests really are aligned with capital despite being paid for their work. This works because if you're making $3m / year, which is not even high for a C-suite salary in a mid-sized American company, then it does not take very many years to have sufficient wealth that your interests are permanently those of capital. This has a more permanent effect than just getting paid in proportion to shareholder returns because the latter just makes you a well paid employee who is paid to make the boss money. If they pay you enough to make you rich then not only your perceived but also your actual class interests are aligned. If they really were just guard labour, their solidarity with capital could be attacked but give them capital...

Most U.S. doctors are, if not capital, at least the owners of their own labor, as they are equity or at least de-facto income pass-through partners of a practice group, rather than employees of hospitals or other larger entities that physically host some of their practice activities.

Some U.S. doctors are capital in the common sense, through physician-owned practice groups with tons of equipment and non-physician employees. In some states, notably Texas, the regulations are set up to favor physician-owned hospitals.


In the first sense, they're a sort of super-labour that captures all the value of their own labour but very little of that of others. Note though that a hospital physician group that doesn't own their own facilities and equipment is really just a sort of union that collectively gets terms from the hospitals they work in. They can't typically stop working and still make a return which is a pretty fundamental difference.

If they have their own practice that's different.
posted by atrazine at 8:11 AM on September 10, 2020 [2 favorites]


If they really were just guard labour, their solidarity with capital could be attacked but give them capital...

And the possibility of capital, or even just being respected by holders of capital, suborns many an imagination. The Revolt of the Engineers describes this for one of the other skill sets that literally professes, that is, swears an oath (which seems to be fairly modern for engineering and endogenous, which is interesting. Maybe the Revolt is yet to come).
posted by clew at 9:22 AM on September 10, 2020


Harvey disagrees and explains through his lectures that "working class labor interests" is not the basic category of Marx's Capital, and this is at a major point of his lectures.

Disciplined Minds also explains how the white-collar professional does not somehow break Marxian theory, but is perfectly consistent with it.
posted by polymodus at 12:11 PM on September 10, 2020 [1 favorite]


physician-owned hospitals
Yes, but you can have physicians who think and act like physicians, who work well in teams, who think about outcomes, and you have have MD-MBAs who tell us to have our 80 year old stroke patients suddenly learn telehealth to keep our numbers up in clinic during the pandemic. (This is separate from specialty; personally, I know ***ists and ***-surgeons who fit both.)

On another topic, there are tons of barriers to solidarity: It's hard when MD education often requires you physical moving state every 1-4 years for the middle and late part of your education, making it harder to create meaningful change. It's hard with the wide, wide range of competency and internal and state board protections in every licensed discipline, which allow incompetency to persist. It's hard for me to support residents that I don't know personally when I have literally had inbox messages after an r/medicine post that says my entire profession (nurse practitioners) should be shot into the sun. All I want to do is be part of a good team, let the residents focus on education, go to and help with student education when applicable, (because why work at a teaching hospital otherwise), continue to avoid RVUs (and help the docs do so!), and, finally, work on my testing protocol paper and get the damn door-to-intervention times down.

After a bit of browsing on that linked website, there's some additional good points made in this article about the closing of Hahnemann.
posted by cobaltnine at 12:29 PM on September 10, 2020 [3 favorites]


eviemath's link to Brian Martin's review of Jeff Schmidt's Disciplined Minds is a pretty good summary of the arguments made in the book. To pick out some highlights from the review:

> Jeff Schmidt provides an answer in his book Disciplined Minds: professionals, including teachers, are selected and molded to have politically and intellectually subordinate attitudes, thereby making their creative energies available to the system. In short, "professional education and employment push people to accept a role in which they do not make a significant difference, a politically subordinate role."

> The first step in Schmidt’s argument is the claim that professionals - including police, doctors, lawyers, teachers and many others - think less independently than nonprofessionals. He cites opinion polls taken during the Vietnam war showing that support for the war was greater among those with more higher education.

> Schmidt argues that what really makes an individual a professional is not technical knowledge, but rather "ideological discipline."

> A key to creating docile professionals is professional training. Through their training, budding professionals learn to orient their intellectual effort to tasks assigned to them. Schmidt has a wonderful expression for this: "assignable curiosity." Children are naturally curious about all sorts of things. Along the road to becoming a professional, they learn how to orient this curiosity to tasks assigned by others.

> How to survive [professional training]? Well, how can captive soldiers survive what is commonly called "brainwashing"? The US Army has a manual on resisting indoctrination when a prisoner of war. As Schmidt amusingly notes, this manual wasn’t written for students, but "students in graduate or professional school should be able to put such resistance techniques to good use." (p. 239). A person who maintains an independent, nonconforming outlook in any institution, including a prisoner-of-war camp, is seen as deviant and threatening. The keys to resistance are knowing what you’re up against, preparing to take action, working with others (organization!), resisting at all levels, and dealing with collaborators by cutting them off from key information and attempting to win them over.

Some of this aligns with Karim Sariahmed's article:

> I learned to think of Professionalism in medicine as a process of disciplining students and residents into conformity rather than as a moral compass or set of work standards.
posted by are-coral-made at 2:45 PM on September 10, 2020 [3 favorites]




It's hard when MD education often requires you physical moving state every 1-4 years

Not just MDs! I know what you meant, but as someone very close to a DO, it's a pet peeve of mine when people use "MD" as shorthand for "doctor," when DOs comprise a non-trivial fraction of the doctor population and despite having to learn everything MDs have to learn (and more! although the usefulness of the "and more" is quite debatable) get shit on all the time during the academic part of medical education, although my understanding is that once you're out and practicing the prejudice is considerably less.
posted by Steely-eyed Missile Man at 8:54 PM on September 10, 2020


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