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Class Consciousness for American Doctors

Two years ago, I watched a hospital CEO and child psychiatrist interview an adult inpatient with schizophrenia. I heard that the patient had agreed to participate in a medical interview, a sort of lecture with an audience of 30 or 40 including nurses, medical students, residents and psychiatrists. The CEO would frequently look at the doctors in the front row with a big smile, but the patient seemed guarded and distrustful. After all, she was being interviewed by a stranger before an audience on a locked inpatient psychiatry ward. I’m not sure consent was a real possibility here.

I was a medical student at that time, still trying to calibrate my expectations to what counted as “normal” in medicine. In theory, I was supposed to be learning something from this session, but this didn’t feel like the respectable medical training sessions I had experience with; it felt more like a spectacle, or a joke, and the patient didn’t seem to be in on it. Perhaps my discomfort was out of place, I thought, and this millionaire child psychiatrist had special insight into adult schizophrenia. As a student, I was supposed to see the CEO as the consummate Professional who was able to, with little or no preparation, simultaneously conduct an intimate interview and deliver a lecture between business meetings. 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. If the CEO’s manner was social, he was simply promoting collegiality. His power, more so than his particular clinical skills, allows him the freedom to define what is socially appropriate, no matter the context. And everyone, including the patient and the health workers, is subject to these terms. So if the patient felt that this room of smiling Professionals was a hostile environment, then Professionalism required a conscious decision on my part to distance myself from her emotionally. I felt some obligation to entertain the CEO as exemplary.

Over time, I would learn to trust my own discomfort as an indicator of the toxic power dynamics that breed abuse for both patients and health workers. I became even more attuned to the pitfalls of Professionalism because of my membership in Put People First! PA (PPF-PA), a human rights organization made up of working-class people building power to win universal health care. 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. Organizing highlighted the ways medicine departs from any meaningful sense of collectivity and instead carves out social spaces that isolate health workers from our patients and from each other. Instead of assimilating whatever passes as “Professional” in medicine, PPF-PA helped me see more clearly the material bases for my relationship to patients and to health care’s profiteers and managers, as well as the contradictions that felt so acutely present in that psychiatry ward.

Despite the pressure I feel to assimilate into medicine as an industry, PPF-PA taught me that I had more in common with the patient than I did with the CEO. Her agency was diminished not just by the lock on the door but the social dynamic in the room, which made others and myself put aside her needs. Facing the hurt and isolation created by the class politics and the culture of Professionalism, a working-class solidarity in which doctors and the patients they serve are allies is an emotional, discursive, and practical alternative. Poor people’s movements and the analysis they bring to health care can ground us in that solidarity. Those movements have shown me that it will take a lot of emotional work for doctors to overcome the social habits medicine ingrains in us, and to see working-class people as partners in a common struggle rather than the “consumers” of our professional expertise. But we also have much to gain from doing this work; it can ground our craft in solidarity, and help us envision a health care system that belongs to workers and patients, not corporations or profiteers.

The health care situation has remained grim for millions of poor Americans despite significant legislative changes in the past 10 years. Framing the high number of uninsured Americans as our health system’s most fundamental problem, the Affordable Care Act (ACA) provided coverage to about 20 million Americans. This was partly through direct subsidies to private insurance companies and partly through Medicaid expansion, although 14 states have not expanded Medicaid. About 28 million Americans remain uninsured, and over 30 million are underinsured. Medical bills still bankrupt millions of Americans every year whether or not they have insurance, and our health care outcomes still lag far behind the rest of the Global North.

At the same time, as people working in this system get more clarity about its exploitative nature, we’re telling new stories about the emotions of health care work and the structures of health care work. The discourse on resident wellness and physician burnout, for instance, is blossoming. “Resident Wellness Is a Lie” was a popular and widely resonant take. In it, Jennifer R. Bernstein poignantly describes how working conditions in residency crushed her partner’s spirit, and she decries superficial “wellness” remedies like yoga and free ice cream. 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.

These perspectives are both analyses of one part of the working class, though that framing isn’t explicit, and the power of the entire class, including people who are homeless, undocumented, incarcerated, or otherwise excluded from work, is absent. Still, health care workers are telling more and more stories with health care’s political economy close to the surface.

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. Dr. Damania brings these ideas together when he describes the painful experience of watching people suffer and feeling helpless in our profit-driven health care system. Examining elderly patients assigned to beds in the middle of the hallway has always evoked that feeling for me — I wouldn’t accept that kind of care for my own parents. These narratives connect our pain with the pain of our patients.

The practice of this connectedness has been a source of politics for me throughout medical training, but my analysis has been informed by poor people’s movements rather than the academic spaces where advisors would often direct me. Members of PPF-PA who work in health care recently put out our own analysis of health care as a front of class struggle. This analysis places the exploitation of the entire working class, patients and providers included, at the center of these experiences. Class politics are one way to understand the structures that have led to this emerging “burnout” discourse. They call out the ruling class, those who profit from our shared experiences of exploitation, and they call on health care workers to join organizations of the poor in order to confront health care profiteers. (This evolving debate and untenable working conditions on the ground were the backdrop for recent actions by resident physicians at the University of Washington, which were met by widespread support from residents across the country, and even emboldened others to take action as well.)

Still, working-class solidarity may be a hard sell for most health care workers because of the primacy of Professionalism in medicine’s culture. I am not referring to the lectures we get in medical school about how to behave on social media or what to wear in the hospital — though these are the times when the ideology of Professionalism takes an explicit form. Rather, I am referring to the primary socializing process we experience in medical training, as I did while watching a millionaire CEO hijack a patient’s agency. Far more dangerous and coercive than the formal instruction we get about Professionalism are the everyday processes for forging personal work identities and disciplining our thought and behavior. On a panel just before my graduation, a residency-program director told us that even the ways we chose to construct our social lives would affect our experiences at work: “I went into residency thinking I didn’t want to spend any more time with these people than the 80 hours I spent with them in the hospital, and I paid dearly for having that attitude.”

Supportive relationships are indispensable for good patient care, but Professionalism demands much more. In The Social Transformation of American Medicine, sociologist Paul Starr describes the nature of professional authority and the social relations it produces. For technical expertise to turn into high income, autonomy, prestige, and other privileges, doctors had to shape hospitals, insurance, public health, and private institutions that might impinge on medical practice. Most of his book explores the historical process that enabled medicine to wield economic power and political influence. Professionalism is “also a kind of solidarity, a source of meaning in work,” he says, “and a system of regulating belief in modern societies.”

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.

Solidarity used to be just a romantic idea for me, but I was lucky to join an organization that, over five years and counting, has helped me practice and internalize it. PPF-PA was a huge part of my life throughout medical school, and it helped me overcome the isolation of professional training. One of my most important experiences with PPF-PA began in 2016, when we won our first major public victory.

For eight months, we fought for the Pennsylvania Insurance Department (PID) to hold their first ever public hearing on rate review, the process whereby the PID accepts or amends requests by insurance companies to raise premiums on ACA plans. The PID is the main regulating body for many kinds of insurance in Pennsylvania. Our work included a call-in day, several hundred petitions, and outreach across the state. When the PID finally announced that they would hold a public hearing, we had a huge celebration in Philadelphia. Later that summer, we flocked to the hearing in Harrisburg to tell our health care stories. For several hours of the day-long meeting, people told stories about people they had lost and suffering they had endured at the hands of insurance companies, whether personally or as workers in the system. When we finished our testimonies, the insurance commissioner, in a cool and professional tone, thanked the 30-some speakers for their bravery. Whatever the outcome, it was a huge moment for us.

What followed was outrageous. The average premium rate increase in Pennsylvania was 32 percent, one of the highest increases nationally. Some companies were granted permission to increase rates to levels even higher than what they requested. My exposure to public health prior to medical school made the commissioner seem familiar and relatable to me. But experiencing this loss with PPF-PA deepened my mistrust of the Professional as an archetype. Instead of holding the insurance industry accountable, she offered empty words while the insurance industry balanced their budgets on the backs of working-class people. Although medical professionalism has its particular quirks and I’ve never worked in insurance regulation, this system-level disregard for the perspectives of poor people felt familiar to me.

Despite the setback, this experience set us up to continue building our power as we collectively gathered its lessons and moved forward. That winter, I joined a study of volume one of Capital lead by members of PPF-PA and other groups that went on to help launch the Poor People’s Campaign: A National Call for Moral Revival (PPC). Health care surfaced again and again in that study, because the analysis was so appropriate to our campaign and the power dynamics we encountered in it. Our Health Care is a Human Right campaign and this study were the greatest influences on the growth I experienced prior to starting work in the hospital in 2017. The skills I was learning became a means to lift up the struggles of working-class people, not just something to sell in a transaction at work. Narrative medicine, affinity groups, and the other feel-good forums for individualized self-expression allowed by Professionalism made medical culture more palatable, but ultimately they felt dispassionate and shallow by comparison.

PPF-PA’s campaigns continued, though my participation was largely on hold during board exams and my first clinical rotations. In the winter of 2017, I was on an internal medicine rotation when I had my second strange encounter with the CEO. He hosted a specious fireside chat with Hillary Clinton at an invite-only event held near the hospital, while the uninvited staff were allowed to stream it. Stationed in a conference room with a recent technology upgrade, my assigned team watched the interview on four different mounted flat-screens. The event took place in the “Caring Dome,” a giant tent, where Clinton told our CEO a story about how frequently her husband ate fish, likely in part of a conversation about the healthy foods the CEO was trying to promote in the cafeteria. In the opener for this event, he referred to the attendees as the “who’s who” of health care innovation. I couldn’t help but laugh at the absurdity: the CEO awkwardly socializing with a recently defeated Clinton, inside a tent intended to exclude the hospital workers, who didn’t see the event as particularly interesting or relevant. The whole event was the butt of many jokes among residents I would go on to work with throughout the year.

As I was exposed to some of the unserious excesses of the Professional world, PPF-PA continued to grow. A year after winning the first hearing, we demanded hearings that working people could attend. In response to continued pressure from us and our allies, the PID announced nine town halls, to be held in different parts of the state. PPF-PA was preparing to make sure every event was attended by our members and other impacted people. The PID came planning to deliver flat informational sessions framed with apologies on behalf of the insurance industry, followed by a chance for audience comments and questions. Their narrative was about “balancing” the interests of insurance-company growth and solvency with people’s basic needs. But like the first time, we were prepared to push back against this false narrative with our own health care stories.

By this point in the campaign, I had already been living in central Pennsylvania for my third year of school, when students first enter the clinical setting. The nearest town hall to me was in Sunbury. I did some tabling at the library where it would be held to promote it. One person I met taught me an important lesson about the difference between Professional politics and working-class politics. The man came into the library and saw my sign about health care. He asked whether I thought the ACA was a good thing. I said, “We should keep it, but get something better,” a statement I thought sounded reasonable. He lost some trust, but was willing to stay. He said he preferred to go without coverage. He used to live in Colorado, where he got his insurance from Kaiser Permanente, which advocated for the ACA. “Obama was wrong to force people to buy something they couldn’t afford.” He just paid the $400 penalty for going without insurance. “Frankly, I don’t think we should ‘Put People First’ … It’s such a generic message — such a lovey-dovey, liberal idea. Liberals don’t even know how to love each other, they can’t sit down with their families for an hour without fighting.” He would come closer to the table to answer my follow-up questions, but he eventually lost interest in my attempts to stay connected with him. When I asked him to say what he had to say to the PID, he said he didn’t have anything to say and walked away.

Reflecting on the conversation now, I should not have led with praise for the ACA, which hurt him personally. At the time, I thought, wrongly, that most people would agree that the ACA did some good. Leading with policy rather than relationship, I may have sounded like a Clintonite or an insurance commissioner. If he thought we didn’t have anything in common, perhaps it was because I reminded him of a politician. I wish I identified sooner the things we had in common, and that I understood my status as a health worker as a point of political connection. He clearly had a story to tell, and he was passionate, so he would have been a strong leader in the fight against insurance profiteers. But the conventional wisdom of the reasonable health care Professional failed me here.

The Sunbury town hall was the following week. PPF-PA members helped me prepare testimony about our experience with the insurance department and my father’s own battle with his insurance company while undergoing cancer treatment. At subsequent town halls across the state, the bureaucratic discourse about the balance of market forces had to reckon with the lived experience of hundreds of Pennsylvanians. Perhaps frustrated that people attending the town halls were calling for a human right to health care and accountability for the insurance industry, the PID started to put less and less work into them. The Philadelphia-area town hall required a car to attend. They didn’t show up for the fifth town hall, in York, a city in south-central Pennsylvania, so the local Health Rights Committee had to hold their own. The remaining four that had been announced were simply canceled.

Our slow struggle on the ground continued to grow after that, with campaigns like this and with the launch of the PPC, and the CEO from that hospital continued his moneymaking ventures. Last year it was reported that he was in the running for a job with Amazon’s new health care venture. When a more famous doctor filled that position, I thought perhaps it was because the CEO was invested in patient care. I was wrong. He went on to take a job at Google and abandoned any pretense of interest in the health of working-class people. In the end, the CEO used his social capital to move from making a few million dollars at a hospital to doing the same in another industry.

Working in a hospital and organizing with PPF-PA was a bit dizzying. Moving between both settings created a cognitive dissonance, but it prepared me to deal with the even more intense experience of residency, which I started almost a year ago. I now make sense of these experiences as a kind of alienation, which I first learned about in a PPF-PA study group focused on volume one of Marx’s Capital. As we learned, health care workers are exploited as all people required to sell their labor are exploited. David Harvey, professor of political economy, explains this in plain terms in one of his lectures: “What Marx is trying to do here is to set up an accounting system which goes beyond the ways in which the bourgeois typically calculate and typically argue. You can be very highly exploited in a labor process, but the capitalist can have a low rate of profit. So when you go to management and say ‘Hey, I’m being highly exploited. I don’t like this,’ and the management says ‘Well just look at my rate of profit — it is very, very low!’ if you’re naive you’ll say, “Oh yeah I see, you’re not making much out of this, are you? Poor you, I’ll work even harder.’ Marx says you better watch out. You better be looking at the rate of exploitation.” The study of this exploitation reminded me of arguments the PID made whenever PPF-PA challenged its relationship with the insurance industry: The health of the insurance market is equally important to and compatible with the health of people. The pressure put on hospital social workers and residents to discharge people quickly seems to be rooted in the same logic of scarcity. It’s extremely difficult to challenge this dynamic in the safety-net hospital where I work. Most of my colleagues and I are just trying to keep our heads above water, and not thinking about how to address our system’s structural failings. Social isolation makes it easier for us to blame ourselves, our colleagues, or even our patients. Movements of the poor and dispossessed offer a way of thinking about these issues that overcomes this isolation. It has helped me to think about how we can stop taking out our frustration on each other, and take aim at the system instead.

Poor people’s movements can help orient the efforts of health workers by tying the fight for dignity in our health care system to other struggles of the whole working class. Sheilah Garland-Olaniran of the Illinois Poor People’s Campaign described it succinctly at a recent event at the People’s Forum in NYC: Wages are so low for most people already that capital has to seek new “markets” that still have unharvested value. Every area of life that should rightly belong to everyone must be privatized in order for capital to continue to accumulate wealth for the ruling class. Health care is one of those areas of life that hasn’t yet been taken over fully. There are many reasons for the rise of Medicare for All and the movement to make health care a right rather than a commodity. One of them is the popularity of Medicare, evidence of an enduring common sense that health care should be treated like air or water. But dehumanizing social relations in our labor are what happen when capital tries to squeeze more and more profit out of an industry whose fundamentally human character is somewhat resistant to full automation. Burnout, then, shouldn’t be taken as an indicator that we haven’t yet filled the gaps in our otherwise great health care system. It should warn us that this basic part of normal life is being threatened. The proof, Garland-Olaniran points out, is that national health services in places like Germany and the U.K. are also under constant threat. This story of privatization is what connects our own traumatic experiences at work to the harm and indignity suffered by our patients.

Social isolation has the effect of putting declassed “Professional” societies rather than working-class organizations at the center of our politics. This isolation affects the historically reactionary American Medical Association but also the American College of Physicians, which recently came out in favor of single payer in a historic victory for the movement. This phenomenon is very much related to the isolation we experience at work. Howard Waitzkin was perhaps the first doctor to combine personal narrative with an explicitly Marxist analysis of modern health care work. In “Doctor-Workers: Unite!” he describes a conflict with his employer near the end of his career after he skipped a mandatory training module. Waitzkin develops this analysis further in “Health Care Under the Knife,” where he argues that isolation and burnout are both fundamentally about alienation. In our work environments we experience separation from the human relationships and creative aspects of caregiving that make health care meaningful. “The work of caring for patients has become alien not because we don’t have caring people, insightful managers, smarter metrics, or even enough time (although all these would certainly help),” Waitzkin says. “Rather, alienation in health work has expanded to affect most health workers because we have lost control of the purpose, content, design, and products that we generate in our work.” The widely shared experiences of trauma in health care work described by Dr. Wible and Dr. Damania should lead us to similar conclusions: that the problems of capitalism affect everyone in health care. This way of thinking about our material situation helps us to make sense of our painful experiences in a way that can bring us closer to each other and closer to our patients.

To make the best of this simmering “burnout” moment, we need deeper connection to organizations of the poor. While Professionalism may deny the painful conditions we share with our patients, solidarity can help us take responsibility for it. Organizing as a working class can give us the sense of belonging we need to face our current crisis, and the fights to come. Professionalism gets in the way, teaching us to intellectualize our problems rather building solidarity around them.

Editor’s note: A version of this piece was initially published on The New Inquiry.

Image credit: courtesy of The New Inquiry

Karim Sariahmed, MD Karim Sariahmed, MD (2 Posts)

Resident Physician Contributing Writer

Albert Einstein College of Medicine

Karim is a PGY-1 in the Montefiore Primary Care and Social Internal Medicine Program and a member of PPF-PA.