Conflicted Health Care

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Conflicted Health Care, written by Ester Carolina Apesoa-Verano and Charles Verano, is a fascinating look at interactions between various team members caring for patients in a large academic medical center in California, interactions to those likely to be quite similar at other hospitals across the country. The book explores the interdisciplinary dynamics between doctors, nurses, social workers, and therapists (respiratory, occupational, speech, and others), as well as the reasons for tension that can arise among them. It also explores the difference in how the missions to “cure” versus “care” are perceived and executed by the different team members. Although one might think that these goals would be recognized and pursued with equal zeal by the different team members across the disciplines, the authors discovered that this is often not the case, and that members of different disciplines often see these institutional goals quite differently.

Conflicted Health Care should be required reading for senior management of hospitals and health-care systems in general. It provides insight into aspects of the patient experience that are not always at the forefront of attention, and into some of the reasons that the collaboration between various care-team members from different disciplines can become strained. It also offers an opportunity for reflection on how one’s own institution addresses the dual missions of cure and care, and how the goals of each are recognized and acted upon by hospital staff members across the different disciplines.

I interviewed Dr. Apesoa-Verano about Conflicted Health Care:

What made you decide to focus on the interactions between the different care-team members in the hospital setting?                             

Few studies have focused on more than two practitioner groups. Many have looked at physician-nurse interactions, and others have considered other dyad interactions. I felt that the hospital context involves so many different practitioner groups that it is important to consider various groups, all of whom contribute to patient well-being, treatment, and recovery. I also was interested in the status hierarchy of the hospital and how the knowledge base of each group was relevant and often contested in the course of patient care. And you know, I have four children and I look to practitioners for their expertise certainly, but also for how they care for them emotively. By looking at five different practitioner groups I thought I might uncover how emotive caring was meaningful to them in the context of their more, can I say, “technical” responsibilities and professional ideals.

What were you expecting to observe before you started your field work, and what surprised you the most?

This is a really good question and I would say that I had many expectations. For example, I anticipated dedicated practitioners, conflict between groups based on how to treat patients, people who sincerely cared about patients, disagreements and personal issues, and a really active bustling place. I also expected people to care and notice that I was there, following people around, and to be questioning why I was there and what I was there for. Ethnographically, some of these expectations were true but one of the things that surprised me the most is how much I blended in the background and people didn’t even ask who I was. I also was surprised by how peculiar was the degree of evident activity or care across different places in the hospital, some places like the OR seemed to me like it was running on a high-octane drill and then other med-surge wards seemed like slow moving ghost towns even though there were patients and practitioners there all the time. In a similar light, I was surprised by how time seemed to move so slow or so fast on some days. Sometimes I felt like I was in a casino, you know, when you walk in and then you leave and you have been inside for how many hours and you do not know if it is day or night outside, or what the weather might be like, that sense of having been inside a shell and then coming to find noisy streets and all that you knew about how things are “outside.” I was equally surprised by the massive number of unnamed folk hiding in the guts of the building, or some sporadically appearing to clean up, take bodies away, etc. that keep the hospital running.

Theoretically, I was surprised by things I heard during the interviews, for example, how divided physicians were on unionism. I never expected to hear physicians so passionately in favor of unionism. But I was also struck by how conflicted practitioners were over their caring and professional ideals, which the union issue ignited. The book is not only about conflicts between practitioners but conflicts within practitioners. And I was surprised how clearly these internal conflicts were expressed by people I spoke with, even as they did not recognize them as such.  I sought to analyze how these internal conflicts were related to strained relationships between practitioner groups.

One of the more interesting observations in your book was the distinction between curing and caring of and for patients, and how members of the different professional groups related to this dichotomy. Especially striking was your impression that the hospital administration adopted “curing” as an institutional goal, but seemed to relegate “caring” to the realm of personal responsibility, albeit one to be encouraged. How did you find this dichotomy affected the interactions between the different professionals comprising the care teams, and how do you believe that making caring more of an institutional priority would affect the work of the care teams?

Well, first off, “care teams” as I note in the book, is more a rhetorical allusion than a formal organizational form, except in some particular cases such as surgery or ER, but as I argued specifically in the boundary work chapter, caring unites practitioners in ways that no other ideal does. Anyone who comes to medicine and health care comes through caring, it’s the calling that beckons to all, even if some sneak in for the money, they soon find out that it’s a lot of work and stress that money alone doesn’t relieve. Every practitioner notes that caring is important to their work, though they think about it differently. I also think that many practitioners may pursue medicine and health care because of the opportunity to deploy expert knowledge in affecting life and death. They may view what they do as a technical issue, not to the extent that they ignore the caring aspect of their work, but what drives them is more about applying knowledge to solving problems of life and death.

This is where caring becomes systematically subservient to curing: curing represents solving the riddle of life, caring represents the ideal of life. The hospital encourages, even aspires to the ideal, but it must solve the riddle or close its doors. And this is where the conflicted health care we write about is experienced by all practitioners. As we argue in the teamwork chapter, caring is not recognized as a ticket into the team, rather medical knowledge and skills are valued. Therefore, most care work is quietly relegated to the background of patient care, and this is why most practitioner groups are seeking to emulate physicians even most continue to grapple with caring.

Not to be pessimistic but the current state of health care is unlikely to institutionalize caring equitably, much less as a priority. Caring continues to be a superficial gloss in marketing campaigns and medical training, compared to the predominance of biomedical science and the curative orientation. Should caring become a legitimate partner in health care, then the teamwork ideal(ology) would be transformed into a more collegial partnership among practitioners and not simply a slogan such as “teamwork.”

You describe the pervasiveness of “boundary work” among hospital care-team members, that is to say, a situation in which one professional within the care team questions or even challenges the decisions or actions of another professional who is clearly acting within the area of his or her responsibility. One example that you provide is that of a nurse criticizing the way in which a woman was told by the resident physicians that she might have a brain tumor and need surgery. You point out that this type of boundary work is often very beneficial to patient care because it leads to a healthy discussion of different care (and cure) options, and yet it is not specifically enshrined within the hospital care-team design, often falling into an ill-defined grey zone, which can put those who transgress these boundaries at personal risk. You also point out that growing efforts to unionize the different professional groups participating in the care teams may actually make this more difficult going forward. How do you think that this blurring of boundaries might be woven into the culture of hospital team work so that it is formally recognized and valued, rather than left up to the individual or allowed to erode?

A sociological truism is that informal relations and normative codes are frequently more characteristic of organization life than formal rules and codified standards of behavior, if only because they are more political and socially feasible when performed “under the radar” than when publically stated and expected. Boundary work functions in this way under the current status hierarchy and will likely continue to as long as some practitioners and administrators and the larger public believes that some groups deserve to be “superior” to others. This will unfortunately reproduce the status hierarchy, as we point out clearly, but in lieu of any significant transformation of professional status hierarchies that some scholars have advocated for, informal boundary work may be what we’re stuck with. It is unlikely that these distinctions will erode, as medical schools, health training, and the hospital context reinforce this hierarchy without flinching or reflective candor. To weave this new culture of caring into the practice of hospital team work, strikes me as a political act as much as a powerful moral act that may not yet compel enough health care workers to demand more equitable professional relations. Still, it’s not inconceivable that a “new professionalism” that includes caring in its mandate could not be integrated into alternative medical schools or hospitals, and supported through workshops that are explicitly designed with this goal in mind.

On the other hand, there may be organizational contexts in health care that are more conducive to the blurring of professional boundaries than others, and here I am thinking of settings in which there is a unifying ideal that transcends professionalism, a “loftier” ideal that all practitioners embrace. Perhaps a religious orientation, a feminist ideology, some form of collective ownership, even an ethnic or nationalist ethos; some ideal that might temper or mitigate professional exclusivity or rivalries. There may also be social contexts under which a blurring of professional boundaries integrates caring more effectively, and here I’m thinking of periods of war or civil strife, or perhaps disease epidemics, or even severe economic crisis or political upheaval. Certainly not something we’d like to see, but a siege or survival orientation may blur boundaries that otherwise would characterize health care as usual.

It seemed that you found that nurses faced the greatest challenges to being accepted as equally respected members of the care teams. On the one hand, the nurses you spoke with craved a higher professional status that was inevitably linked to knowledge or technical skills, but on the other hand much of their work was hands-on in ways that didn’t demand these skills. This prevented the nurses from demonstrating the possession of these skills and from then converting this recognition into the coin of a higher professional status. Because of the nature of nursing work, it appears that there is little chance of enhancing their status within the current care paradigm. What do you think might be done on an institutional level to change this?

This has been an interesting paradox that I’ve tried to understand for many years now going back to my Master’s thesis and that I have addressed in a few publications on nursing. I currently have an article under review that addresses this question head on. Based on a secondary analysis of the nurses I interviewed in the book, I found that along with talking about their medical knowledge and skills and their roles as intermediaries among health care practitioners and advocates for patients, they also spoke of the caring knowledge and skills they deployed in patient care. By defining caring as a knowledge based and skilled activity, they were in effect elevating the status of caring (and possibly the occupation itself) within the paradigm of health care and medicine. While this may have rescued a sense of themselves as professionals and brought dignity to their care work that has been unrecognized and undervalued by the hospital, it remains to be seen whether this redefinition of caring could be institutionalized in any meaningful way. It’s possible that if caring were to be viewed as a knowledge based and skilled activity, one that has a measurable impact on patient well-being, recovery, etc. (and there is some evidence for this) that the entire care paradigm might be reevaluated and revised in ways that enhance not only the status of nurses, but more importantly the status of caring. This might mean that caring would be integrated more fully into medical education and training, that it would move from hospital advertising campaigns to the bedsides of patients, that it would define the actual content and concerns of onsite workshops and no longer obscure the social control function of these events.

I don’t mean to sound Pollyannaish about this, and we certainly tried to be as reflective as we could in the book and not merely prescriptive in this regard. But the fact is that practitioners spoke thoughtfully and sincerely about caring in their work and the conflicts they struggled with would not have emerged so poignantly if caring did not matter in their professional lives as health care providers. I suspect we haven’t seen the last of these conflicts…nor the caring ideal.

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