Conflicted Health Care

Professionalism and Caring in an Urban Hospital

Ester Carolina Apesoa-Varano, Charles S. Varano

• Publisher: Vanderbilt University Press
• Year: 2014
• Print ISBN: 9780826520081
• eBook ISBN: 9780826520104
• Topic: Medicine
• Subtopic: Health Care Delivery

Anyone who has spent time in a hospital as a patient or family member of a patient hopes that those who attend to us or our loved ones are at their professional best and that they care for us in ways that console us and preserve our dignity. This book takes an intimate look at how health care practitioners struggle to live up to their professional and caring ideals through (or during?) twelve-hour shifts on the hospital floor.

From 3, 200 hours of participant-observation and 500 hours of follow-up interviews with twenty-one doctors, thirty registered nurses, twenty-one respiratory therapists, twenty medical social workers, and eighteen occupational, physical, and speech therapists, the authors create a complex picture of the workplace conflicts that different types of health care practitioners face. Though all these groups espouse caring ideals, professional interests and a curative orientation dominate in patient care and interoccupational relations. Because emotive caring is not supported by the organization of health care in the hospital, it becomes an individual virtue that overworked staff find hard to perform, and it takes on an ideological form that obscures the status hierarchy among practitioners. Conflicts between practitioners rest upon the ranking of each group's knowledge base. They manifest in efforts to work as a team or set limits on practitioner responsibilities and in differing views on unionization.

Chapter 1

The Professional Self

Maybe we are all professionals in different ways.

—ATTENDING PHYSICIAN

WHAT DOES IT MEAN to be a “professional” working among others who also claim this coveted status? To answer this question, I interviewed practitioners at length about what it meant to be a professional in their field. Here, I use the term “professional self” to refer to a set of core aspects that are collectively understood to be characteristic of members of an occupation in general and their role in the hospital. In using the term “self,” I wish to encourage readers to view the occupations I introduce in this chapter not as static categories or entities but rather as negotiated roles that are as much a product of one’s historically structured position in an organization as the ideological claims made by practitioners to defend or advance their position. As practitioners grappled with what they believed epitomized professionalism in their fields, their views revealed that the professional self is as much a field of conflict among practitioners as it is the answer to life and death for many patients.

The practitioners of each occupation I introduce below all thought of themselves as professionals, though the meaning of the term was subtly different among them in the context of larger occupational issues and their roles in the hospital. Still, in my interviews, three general dimensions of the professional self emerged recurrently across all five groups: (1) knowledge, (2) occupational norms, and (3) teamwork. The hallmark of professional work has always been the degree to which its actors enjoy occupational autonomy and exercise control over the labor process.¹ Their claims to autonomy and control rest on their possession of specialized, “esoteric” knowledge and their ability to abide by occupational norms without direct supervision or oversight. Unlike knowledge and norms, however, teamwork is an aspect of professional work that aligns awkwardly with occupational claims to autonomy and control over one’s labor, for how can one be autonomous and control one’s own labor if one must work with other practitioners claiming professional status on a team that is hierarchically structured? Because the teamwork component is difficult to reconcile, it is easily the weakest link of the professional self, highlighting practitioner vulnerability across a terrain of challenges. Rather than smoothing out occupational status rankings, the idea of teamwork actually heightens these differences and the tensions arising therein. Therefore, the subheadings I use are intended to evoke the central dilemma facing each group, rather than to offer any definitive characterization.

“Teams” at Hospital General were typically composed of attending physicians (who fulfill clinical, teaching, research, and administrative responsibilities), physicians in training (i.e., fellows and residents), registered nurses, and providers of allied or support services (all licensed), such as social workers, respiratory therapists, and physical, occupational, and speech therapists.² Yet the teams did not exist as formal entities created by hospital administrators or occupational directors (except in the case of, say, physicians, who were organized along seniority lines: attending, senior resident, interns, and so on). Rather, the term “team” was used more rhetorically—or, as Rachael Finn puts it, “discursively”—in referring to the collective activities of different specialists and different occupations in serving patients.³ There were some highly coordinated teams (e.g., operating room teams) and less coordinated teams (e.g., nonspecialized units), and “team members” varied, depending on shift schedules or who was on call to provide specialty services.

Lastly, I found it conspicuously notable that caring was rarely mentioned in my interviews when discussing professionalism. What could arguably be considered a central aspect of professional work—perhaps even one of the strongest defenses of professional privileges and power—seemed a distant and remote concern of practitioners. During my research, it was obvious how much practitioners cared about their patients and their work, but in terms of professionalism—as ideal or ideology—caring clearly ranked well below knowledge and the norms informing its use. This reinforced for me just how much caring has been humbled in the minds of hospital practitioners—even among nurses, for whom it has historically bestowed some degree of status, some measure of respect, and some ideological leverage in relation to physicians and other practitioners.⁴ Though a mixed blessing for nurses, who have long struggled for recognition and respect, it was also a troubling sign of just how estranged caring and the professional self were in Hospital General.

The “Good” Doctor

Dr. Whitmore, a woman in her fifties, is a pediatrician. While approachable and unassuming, she also exudes a certain strength and an air of authority. “It’s hard to be a good doctor,” she told me on numerous occasions. “It’s really an art.” Often, she reiterated that it is not just a matter of having the necessary clinical skills, but also how the doctor deals with problems and people. “We [doctors] are human,” she mused over coffee one afternoon, “even though people think we are perfect. There are professional doctors, and there are unprofessional ones—good and bad apples everywhere.” As I spoke with more physicians, it appeared that Dr. Whitmore’s views reflected those of her hospital colleagues, which raised more doubts than one might expect.

Physicians have epitomized professionalism both in popular culture and academic scholarship. Yet the physicians I interviewed were engaged in a larger debate that was taking place within the occupation, among medical leaders, and in current research, on the tenuous nature of their medical authority.⁵ This concern over authority arose amid controversies during the second half of the twentieth century, when physicians faced public condemnation for lacking ethics or a commitment to the common good.⁶ Since then, physician professionalism has met with growing skepticism. As Paul Starr observes, “While Americans express confidence in their own personal physicians, they are more hostile to doctors as a class. The desire to enter medicine as a career is undiminished, but there is great antagonism toward those who do.”⁷ While the public still holds considerable respect for physicians, the authority of the “all mighty doc” has been increasingly questioned, as calls for second and third opinions attest.

This history was not lost among the physicians I interviewed, a majority of whom thought that “being competent” was central to professionalism. Their responses, however, were far from simple. For some, competence was not easy to pin down. In the words of Dr. Janis, a surgeon:

My concern is that there are people that are not competent and don’t feel like they are incompetent. . . . They think that what they are doing is competent. I would say that there is a system problem there. The system [occupation] needs to figure out how to define competence. I think that one of the things that is not readily apparent to the nonmedical public is that medicine is by no means a clean, pure science. . . . I can give you a multiple-choice test and say, “Wow, you really know a lot about this fancy pathology, etc.” But what is not so easy to test is your ability to apply that at the patient’s bedside. It turns out that patients don’t present with multiple-choice type questions. With each passing year, it gets harder and harder to weed someone out who is not competent or unprofessional.

When pressed, physicians often equated professionalism to being a “good” doctor. As Dr. Thompson, a cardiologist, explained:

I guess it would be hard for me to say what that [professionalism] was, except from being a really good physician. A really good physician is somebody who is highly capable with what they do: they can elicit the kind of information they need from the person and then make a decision about what to do and how to determine what they have and how to come up with a good treatment. So [to do] all of that stuff and then do it in a respectful way—that would be my definition of a good physician.

While it was difficult for physicians to agree on the parameters of medical competence and how these might be effectively monitored and enforced, this reflected doubt not over the fundamentals of biomedical knowledge, but rather over how that knowledge should be applied by all hospital physicians. Typically, physicians emphasized their ability to channel complex abstract knowledge into effective intervention techniques to alleviate or cure disease. But ability did not always translate into competence, in light of their descriptions of a “good doctor” as an individual who was not merely technically effective but also morally sound. A good deal of symbolic power—and reputation—was at stake when this moral aspect of competence was in doubt, especially among others in the hospital who also identified themselves as professionals.

Affirming their medical competence, then, was only part of the story for physicians, who also spoke of occupational norms in defining a professional self. Dr. Johnson assured me that “professionals like physicians have good manners, have ethical conduct, and have good moral values.” In a similar light, another physician explained that a professional physician “is a person that is a ‘physician’s physician’ or a ‘gentleman’s physician,’ where you don’t see this [negative or bad] side of the man. . . . They are a true gentleman’s gentleman. . . . They’re cool, they are natural and likable, and they have a confidence about them. . . . and also they behave themselves in a good manner.”

Apart from the gendered nature of this physician’s view, professionals were held to normative rules guiding personal conduct and the presentation of self. Physicians considered this normative dimension in the context of a person’s moral character, manners, and virtues, including the ability to maintain healthy dose of “confidence” without appearing arrogant—something requiring self-discipline and control. This emphasis on occupational norms made sense particularly in relation to perceptions of physician abuse of power, given their authority in the hospital.⁸ Speaking to this issue directly, Dr. Barnes shared the concerns of most physicians I interviewed:

I define it as a physician acting appropriately . . . that you have integrity and honesty. Even when nobody is looking, you want to do the right thing. . . . Treating others with kindness and respect. . . . And this is a lot to accomplish daily. I would say that most physicians are not perfect in being this. . . . I think there haven’t been good examples set in the past because a lot of physicians have had a big power trip. . . . We [physicians] have a lot of authority, and then we abuse that authority . . . like yelling at residents and being mean to patients.

Physicians often found themselves having to reconcile the control and autonomy characteristic of their high-ranking positions with the negative stereotypes of their conduct with other practitioners and patients. Being a professional meant maintaining an uncorrupted self in light of the many external pressures and temptations for self-benefit that those with power and authority frequently face. “You have to be as honest and ethical as the day is long,” one physician said with a smile, “even when no one is around.” Occupational norms were quite difficult to enforce, given the autonomy physicians enjoy in what they do and how they do it, and the potential abuse of privilege seemed to haunt their professional self.⁹ As one of the department chiefs confided, “No physician wants to be told how to behave.” Nor do they want their control over their labor challenged. Along with expertise, ethical behavior is central to defending this control.

Physicians also told me that being a professional entailed teamwork. When asked to elaborate, most physicians said that professionalism involved providing good management and direction to other staff regarding patient care. “You have to be able to deal with people,” one physician explained, “in a way that your decisions and management are respected.” In relation to other practitioners, physicians exercised more authority in deciding protocol for any particular patient—they were the leaders of the team. As one of them put it:

We must all work together. . . . We are a team—the nurses, the other staff, social workers, etc. . . . It is important to get along like a team, but we all do different aspects of the puzzle. . . . We all do our little part and we [physicians] are the ones who decide on everything, and we have to make sure that others [nurses, etc.] know that, but they’re a really important part of the team.

The professional self had to find its place in a web of highly interrelated groups of practitioners in the hospital. As team leaders, physicians still had to grapple with their reliance on others; they had to recognize the power disparity and frequent antagonisms with other groups on the team while simultaneously establishing rapport with those groups and garnering their support. Getting along with and being part of the team were important, because without the cooperation and good faith of the other groups, working relations among the team members could easily deteriorate, which would then potentially undermine their patients’ recovery and ultimately the physicians’ authority as good—competent and ethical—leaders.

In light of their reputations as “power trippers,” the physicians’ professional self revolved around them being uncorrupted, benevolent leaders, which required some ideological tinkering in order to integrate competence, occupational norms, and teamwork. Compared to other practitioners, what is noteworthy about the physician professional self is how individualistic it is; as they enact their role, they are far more insulated from the purview and control of others than practitioners in the other groups.¹⁰ Apart from medical review boards and HMO regulations, it is up to the physician to exercise the personal diligence, composure, and self-control necessary to “measure up” to their professional standards. Even the “uncorrupted benevolence” of team leadership evokes a personal character trait rather than any quality that arises in relation to others. Ultimately, this moral individualism is what separates the professional self of physicians from all the other practitioners in Hospital General.

The “Expert” Consultant

Larry Dawson, a man in his early forties, has been a physical therapist for about ten years. He and his colleagues begin each day shift by gathering in the main room, where they receive their assignments and the manager briefly reviews the “load” (schedule of patients) on a whiteboard. After hearing of my interest in professionalism, Larry remarked, “Well, you’re in the right place. You know, there’s so much talk about being professional these days.” He paused. Then, nodding his head, he added, “But really what matters to us is that we are the experts in rehab and we fulfill an important role here [in the hospital].” As we headed to see his first patient, he continued, “I mean, doctors really come to us for our recommendations. They consult with us because we are experts in physiotherapy.” Viewing himself as an expert consultant was important to Larry, and I wondered if other OPS therapists thought likewise.

Larry’s views had “baggage,” both with a small “b” (reflecting floor politics) and a large “B” (reflecting occupational history). OPS therapists emerged as an offshoot of physicians, who delegated less specialized aspects of medical rehabilitation and treatment to them at the turn of the twentieth century. Their initial title as “reconstructive aides” during the years following World War I actually captured the essence of OPS therapists’ role in assisting patient recovery alongside nurses and under the supervision of physicians.¹¹ Like nurses, OPS therapists have historically sought to upgrade the occupation by asserting their ability to use expert knowledge effectively.¹² By the 1970s, OPS therapists could legally provide services outside the hospital, independent of physician supervision. Advancing toward professional autonomy in the early 1980s, OPS therapists were granted the legal right to provide therapy without physician referral.¹³ And, most recently, the professional association for physical therapy has moved toward requiring a doctorate for its therapists in clinical practice.

This struggle for independence invariably showed among the OPS therapists I interviewed: they unanimously viewed knowledge as critical to their role as expert consultants to physicians and other groups like nurses.¹⁴ As Melinda, a speech therapist, explained, a professional speech therapist is “someone who is very committed to their profession and stays current on research, new techniques, etc.” The therapist “knows well what the patient’s needs are . . ....

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Contents
• Acknowledgments
• Introduction
• 1. The Professional Self
• 2. Teamwork in the Hospital
• 3. The Dilemma of Caring
• 4. Caring Reconsidered
• 5. When the Day Is Done, It’s Still Work
• 6. Crossing the Line
• 7. Unions: “The Elephant in the Room”
• Conclusion
• Notes
• Bibliography
• Index