Hello friends,
I hope your holiday, New Year, and first few weeks of January have been restful.
This month’s newsletter is about a question emanating from a course I taught last semester, and how reading Weike Wang’s novel Joan Is Okay resparked it: What does it mean when we say healthcare work is work?
Before that, a few catching-updates:
During the holidays, I did some baking, and saw dear friends in Germany. With madness around us, creativity feels ever more stake.
There was a story that never made it to the final version of my book Lifelines. But it stuck with me, this story of two brothers, one who cared for the other after a tragic motorcycle accident. I wrote about it for an article in the journal American Anthropologist, called “Stable Condition,” to think more about the experience of stasis in a hospital.
In The Hastings Center Report, my ICU physician colleagues and I published a peer-reviewed paper about the phenomenon we’re calling “distressed work.” In contrast to accounts that frame distress as something contain within the individual (and thus a problem that individuals supposedly must solve on their own), we’re interested in how distress emanates from labor relations.
For PESTE, I wrote about nursing strikes, and how they enter into punditry around “shortage talk” — the constant invocation of a nursing shortage that tends to sidestep questions of labor politics.
In an edited collection on the links between food and bodies called Eating Beside Ourselves, I wrote about the intimacies of mechanical ventilators inside ICUs.
Make it Work
This past week, the New England Journal of Medicine published an essay that caught my eye. It’s entitled “On Calling — From Privileged Professionals to Cogs of Capitalism?” The essay explores contrasting framings of medicine: as a calling, and as a job.
We’ve seen lots about burnout in healthcare over the past several years. We know that like many institutions, hospitals are places where work won’t love you back, as Sarah Jaffe puts it. Media outlets trumpet both quiet and rage quitting among healthcare workers, usually to sound an alarm that our healthcare institutions in the US are hanging together by threads (which they are). Occasionally, news outlets will cover ongoing healthcare worker union actions, like nurses’ strikes.
The idea is that healthcare workers are increasingly seeing their work as precisely that: work. Not a calling. A job. And that there should be compensatory structures in place to acknowledge it.
Or at least, that’s how some workers want it to be, but the intensities of care work make drawing boundaries harder to achieve. (One often-invoked exception is travel nursing). Sorry, Max Weber (not sorry).
Framing healthcare work as work is a challenge that my colleagues and I have been thinking through. In our two-year qualitative study of pandemic clinical care work conditions in a hospital ICU, our interlocutors (including nurses, techs, and physicians) reflected deeply on the changing moral and material textures of their professions.
I describe calling healthcare work as a work as challenge because it’s somewhat easy to say “medicine is a job like any other” and leave things at that scale of equivalence. But when one speaks to healthcare workers — which we did in the thick of the pandemic — the story seemed more complex. Everyone knows that work can be a grind, even work you pursue because of a moral claim or feeling or fantasy. But many people we spoke with felt that medicine had become so misaligned with their commitments to healing that their profession felt increasingly unrecognizable. Their sense of commitment hadn’t faded; it was that healthcare’s operational rationales were shifting and a hospital’s management of a disaster spelled that out loud and clear.
What suffered in the wake was that the kernel of calling that one could hold on to in the worst of the work grind became harder to see and feel.
Many people we spoke with wanted to ensure that the impossible labor conditions of their jobs were recognized by C-suite execs in the hospital. And, they wanted these conditions to be acknowledged and compensated, because workers were performing their work under extraordinary circumstances. And this was because they brought to their jobs a commitment that was not easily replaceable.
So the either/or “it’s a calling or it’s a job” was, for many (but not all) of our respondents, more tangle than a binary.
The essay in NEJM touches on some similar ideas, but it ends on a different question. The author, Dr. Lisa Rosenbaum (a cardiologist and writer) assays “workism” in medicine (the elevation of work to a high social, personal, and moral good). The piece pays attention to generational differences that show up in medical training. During Rosenbaum’s interviews for the essay, she heard some attendings and faculty rue the ways that the kids these days (ie, medical students and residents) are behaving more like employees than members of an impassioned guild.
Like, some of these younger doctors think mandatory elements of a training curriculum are optional! Bad attendance! This can lead the old guard to think behavior unbefitting of the guild flags quiet quitting.
For me, though, a bigger question the essay provokes is: what’s at stake in framing medicine as work in the first place?
Not: “Is medicine work?”
But: “If we call medicine work, what then?”
This is a question I think we don’t ask enough, because it’s hard to do so. If you call medicine work and invoke “burnout,” you must confront the material stakes of burnout. This goes beyond exhausted and/or disillusioned workers; it touches on worst-case realities such as the high suicide rates among healthcare workers that remain under-addressed.
Rosenbaum sticks with “workism” as her central concern, and thinks through the ways that calling medicine-as-just-another-job has certain affordances. One is structural critique. Namely, if we claim that doctors are now “cogs of capitalism,” we can scale up from the cog to the system and make a claim on healthcare writ large. A trainee doesn’t attend a mandatory session, a doctor pulls their hair out over billing, and eventually, we can arrive at the conclusion that capitalism suffuses the entire enterprise of medicine.
This line of thinking isn’t wrong. But, the thing that truly worries Rosenbaum in this essay is the following question:
Has medical training been so stripped of meaning that the only natural response is to see it as a job? Or when you treat medicine like a job, does it become one?
She continues:
I understand that physicians’ beliefs about work are personal; whether medicine is a job or a calling has no “right” answer. What I don’t fully understand is the fear I felt, while writing this essay, about saying what I actually think. Why does believing that the sacrifices trainees and physicians make are worthwhile feel increasingly taboo?
So it’s one thing to speculate on medicine’s corporatization, and we need more of that for sure. But the sticky thing that this essay ponders is why the author — a physician — fears expressing the idea that medicine retains a kernel of “calling” because it’s work that involves sacrifice. And, why she fears expressing the sacrifice to be worthwhile, because society needs healthcare workers and one can find fulfillment in meeting that need.
Why might it be uncomfortable to ponder this?
Is calling medicine “a job” the profession’s third rail?
Awkward Silences
The NEJM essay captivated my attention because I had just finished a novel I’d been wanting to read for a while: Joan is OK, by Weike Wang. I was aware that the novel centers on Joan, a young ICU attending physician working in New York on the cusp of the pandemic. But I didn’t know much else about it before picking it up.
People demand a lot from Joan — her family, her co-workers — and they frequently suggest that her ways of inhabiting the world are too narrow. This is all wrapped up in questions of Asian-American aspiration and, relatedly, in anti-Asian hate (both which research shows shape how Asian-American physicians experience their workplaces in the US.). The novel explores these tensions both within and outside the bounds of Joan’s family story.
The book asks questions about what it means to be raised in the US as an immigrant’s daughter, and how to be in the world when everyone says your success should stem from your own fortitude yet they nonetheless want to lay claims to it. Hospital medicine is where the novel devotes a good amount of time exploring how one’s chosen divisions between life and work become central to relationships in their fullness of intimacy and absurdity. (In an interview, Wang discusses finding inspiration for the book in absurdist literature, from Kafka to Sayaka Murata’s Convenience Store Woman.)
Joan is by all accounts an outstanding critical care attending physician for whom work is one form of life. And…this seems ok to her. To the physicians around her, this is her defining feature. They make assumptions about her moral universe and life story (and about Asians and Asian-Americans writ large) in relation to her constant presence at the hospital. But when she takes too few breaks from working in the ICU, this raises concerns among her co-workers, as well as the HR Department who sweeps in, concerned about her mental health. Wang’s crafting of these encounters between robotic human resources agents and physicians is delicious and eerie, and reminds me in spots of Olga Ravn’s The Employees or Sarah Rose Etter’s Ripe.
The book accounts for Joan’s lives outside the hospital, too. She’s a doctor, sure, but she has places to go and be and think and wonder that don’t have to do with the hospital. She hangs out in her sparingly furnished apartment, opens mail, visits her family, and walks to and from work.
But Joan often returns to the hospital and the ICU, and this is one way the story gets propelled forward.
Sometimes we see Joan by the bedside of her patients and she cares about them. As the attending physician, she teaches residents by the bedside, too. But, what’s so interesting to me is how Wang draws out much of Joan’s hospital time outside the ICU, in office-like settings. Joan is often in the cubicles of a windowless room she shares with other ICU attendings.
The flicker between hospital and office space permeates her relationships, especially with her boss, a senior physician in charge of the ICU known to her and to us as “The Director.” This relationship situates her in another non-clinical space in the hospital, another office.
The Director’s office has a skyline NYC views (“The office faced northwest and had an uninterrupted view of the Hudson from bank to bank.). There’s a secretary, and a Nespresso machine (though Joan prefers the coffee from the hospital cafeteria).
I read these encounters as shot through with the complexities of medicine as the sign of the corporation. These are complexities that trouble the neat division between medicine as work and medicine as calling.
For example, Joan and the Director swim in awkwardness when he summons her to his office to praise her (over)work and to offer her a raise. The Director fumbles to articulate a script, a very basic one, in which a person with power in an institution informs a junior employee that the company is rewarding them for their value. That they have a future in the institution. That the institution desires them, because it desires their work.
But the script falters. The scene is one of two people who share a particular attachment to their careers. Yet one of them is more senior and has tilted his balance between “calling” and “job.” And so they struggle for words. There’s friction that prevents the Director from being just a slick suit who says something like “Your performance is excellent, and we want to reward you for it.” I mean, he does eventually say something like that, and that’s the point - he activates his doctor-as-manager self and eventually can say the words. But before that, it’s not smooth at all. The Director and Joan hold the moment together with lots of silence. The sheer fact of money — lots of it coming Joan’s way, if the Director’s insinuations about a raise are true — interrupts the scene’s potential fluidity. Not because money is uncomfortable, but because it’s absurd. Maybe the Director sees himself in Joan, a former star attending who rose through the ranks. It is not certain that Joan sees herself in him. This reciprocity is not guaranteed.
And still, the Director cannot be so easily dismissed as an empty suit. Joan describes him:
Prior to med school, he had studied linguistics at Oxford, a story he liked to tell new recruits during meet and greets, over drinks. Medicine was a calling, he’d say, and sometimes you had to wait for this call while pursuing something else. Don’t rush into medicine, else you’ll be miserable; find new interests, challenge yourself with the unknown, etc.
He casts medicine as a calling, yet in his praise of her work, he compares her seemingly infinite work-time as an album’s cassette tape with two sides that one can play back to back:
How he viewed my constant and comforting presence in the hospital was like that. From Joan A to B, he said, then from Joan B to A. My being a tape was music to his ears.
When HR forces Joan to take time off from work, she appears in his office again. This surprises him.
What are you doing here? he whispered. You’re supposed to be on leave. Tomorrow. He nodded solemnly and asked if there was anything he could still do for me. Nespresso? A handshake? I asked to stay and he said that decision was out of his hands. But what if I never told anyone and just never left. I could order a sleeping bag and store it under my desk. Shower with wet wipes. They’ll make an example out of you, he said. How? I asked. It wasn’t possible to make an example out of a model minority. The director doubted it too but still urged me not to take any chances. What HR frequently said to them, the directors, about the proper running of a hospital: if you do not respect the corporate form, the corporate form will not respect you. He repeated this with a shudder.
The Director must inhabit the corporate form, the form of medicine as corporate work. And, also, he (seemingly) detests the corporate form.
Joan wants to inhabit medicine as a job with meaning. But when that aspiration can’t sit easily with the hospital’s labor structures, her relationships to the hospital get caught in the misalignment. There are uncomfortable silences and grasping for words and images. Doctors must move through their relationships to each other and to themselves via this misalignment.
Teaching Work
The power of Wang’s novel, to me, is its ability to anchor the indeterminacies of medicine-as-work in relationships. I want to conclude with some thoughts on how this indeterminacy between medicine and work shows up beyond the medical journal and literature, in a space that connects to both: the classroom.
Last semester I taught an undergraduate seminar called “How Hospitals Work.” The course was about the everyday work of hospitals, and we focused on the working lives of a hospital’s people: patients, families, and providers. Starting with Chekhov’s Ward No. 6, we thought through the intimacies of labor in clinics. We tracked how those intimacies shape historical accounts of hospital-based labor movements. We were moved by graphic memoirs about HIV care work in the 1990s, by ethnographic accounts of hospitals in the thick of war, and by news stories of the horrific centrality of hospitals to the war in Gaza.
I was struck by the ways that in seminar discussions, simply naming healthcare as work — like any other work — was not an easy move. Why was this? It wasn’t that medicine was exceptional as a profession, the students felt. There are lots of jobs that meld moral commitments with difficult labor (and many that are compensated far less).
But there was something iffy for them about fully casting medicine as work, because of the ever-present remainder of medicine being a calling.
On the first day of class, I asked the students what they expected to learn during the semester, and what they were curious about. Some thought they might learn how to chip away at the challenge of how to make hospitals work better. If hospitals weren’t functioning properly, surely there were some solutions. But, we also committed to a principle of descriptive before prescriptive effort. We had four months to track how people are already working in hospitals, and sure, we could venture some prescriptive ideas, but only with descriptive fidelity.
I also said that the class title was a cue for us to think labor. That we were going to think about work, with hospitals as a case study, which was a different pursuit than asking how hospitals could work better.
This was a bit of a surprise, it seemed. And the surprise emanated from this friction of possibly seeing medicine as work. The students certainly were cued into questions of labor, particularly in the second half of 2023 when union activism in the US made labor struggles more frequently readable headlines. We watched and read about nurse strikes, for instance, and we talked about unionization drives in other domains in North Carolina.
But, still, some thought: “Isn’t healthcare a calling?”
The unspeakability of work was showing up here, too.
Maybe, we thought, medicine-as-work is not so much “unspeakable.” Maybe medicine has an ineluctable element of vocation in its sinews: work’s remainders. At stake in understanding a contemporary politics of medicine would be understanding how people live out relationships amid that assertive remainder…awkwardly, uncomfortably.
Thanks for reading, and till next time.
-Harris