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Dialogues@RU is published annually
by the
Writing Program at
Rutgers, The State
University of New Jersey
Volume One
Spring 2002
The Routinization
of Health Care and the Professional Calling -
Page 4
by Megan H. Johnson
Related to Robert Bellah's concept of work as a calling is author Robin Leidner's opinion on the so-called "routinization of work," an idea vividly illustrated in Steve Lopez' depiction of a modern-day doctor's office visit. Leidner addresses this current trend in Fast Food, Fast Talk: Service Work and the Routinization of Everyday Life: The routinization of human interactions by corporations and other large bureaucracies can be seen as a disturbing trend, one that epitomizes the kind of depersonalization, dehumanization, manipulativeness, and superficiality that critics of late-twentieth century United States culture deplore. (178) Leidner's description of "routinization" paints it in an extremely unfavorable light, stating that it can't help but lead to "depersonalization, dehumanization, manipulation and superficiality." These terms mirror some of the issues facing doctors and nurses in the workplace today, as challenges brought about by HMOs and the nursing shortage limit the amount of personalized, individual attention that health care professionals can grant their patients. Time constraints often force doctors and nurses to resort to strict routines which bring about "depersonalization" in the manner that Leidner addresses. Steve Lopez describes the medical industry "routine" in "The Single-Doctor HMO," by partitioning a modern-day doctor's office visit, which seems to involve an hour-long wait, a "ten-minute once-over" and an examination of your "entire medical history" by an anonymous office staff of "bean counters" and "paper pushers" (8). Implied in Lopez's description of this "routinization" of health care is that the process is like that of an assembly line, in which the goal is to spend as little time as necessary in the completion of a specific, uniform task, with little concern for tailoring the process to any individual needs. Lopez doesn't even describe his visit as including a thorough examination, only a "once-over." Robin Leidner would view Steve Lopez's account of the doctor's office "routine" as exemplary of the current trend to routinize work through "depersonalization" and "dehumanization," resulting in more and more "superficiality," as is evidenced by Lopez's "once-over." Eva Havas touches on the dangers of routinizing the interactions between doctors and nurses and their patients in "Managed Care: Business as Usual," stating:
As the nature of medical care, which is increasingly a misnomer, becomes bureaucratized and "managed," one very real danger is that both providers and consumers may accept the impersonal nature of medicine and expect nothing more. There is undoubtedly a day-to-day wearing down of providers and patients that managed care can count on to limit the kind of patient care patients will seek or physicians will provide. (81)
Havas' appraisal suggests that over time, physicians, nurses and patients may all lower their expectations of health care, "accept the impersonal nature of medicine" and demand less of HMOs and the health care system in general. Beyond that, Havas implies that HMOs have a specific objective that routinizing health care can achieve, which is the "limiting of the kind of care patients will seek or physicians will provide." Implied in this conclusion is the fact that routinization and the limiting of care will also limit costs for HMOs, reflecting the concern that health care systems are currently more interested in the bottom line than in providing exceptional patient care. The routinization of health care is yet another negative factor hindering doctors' and nurses' ability to experience their work as a "calling."
Another important component of the culture of work in the health care industry is the extent to which health care providers can connect what they "do" with who they "are." In "Finding Oneself," Robert Bellah asserts his belief that work as a "calling" must "constitute a practical ideal of activity and character that makes a person's work morally inseparable from his or her life" (66). Bellah elaborates on the importance of a moral connection to work by stating that, in a calling, "one gives oneself to learning and practicing activities that in turn define the self and enter into the shape of its character"(69). According to Bellah's standards, those engaged in a calling would view their work as an extension of their very personality and value system, an arena in which to display their finest human characteristics. In turn, the work done on behalf of the calling would enrich that person's life. Traditionally, the work performed by nurses and doctors has been viewed in this light, in that their work has a mutually beneficial nature, with patients rewarding good service and concern with respect and loyalty that "give back" to the health care provider and boost morale. Nurse Madeleine Leininger reflects on the value of what she calls "humanism" in health care in her article "Humanism, Health and Cultural Values," observing that "...man's quest for reciprocal humanistic expressions toward life, towards other men, and towards being himself has been an important means for his self-growth, self-fulfillment and life aspirations" (38). Following this train of thought, people would be more likely to emotionally grow and fulfill themselves through pursuit of goals and activities that permit them to express their morals and values, and encourage positive interaction with others. Leininger further elaborates on the importance of a moral center in the work of health care providers, writing:
Traditionally, there has been an implicit normative societal expectation that health care professionals should be sensitive, warm, understanding, and compassionate persons who would be able to respond effectively to the health needs of people...[they] are generally expected to be compassionate towards people who are in a helpless position, empathetic towards those suffering from an acute or chronic illness, and supportive of those facing life crises...it is this attribute of "human compassion for others" that is generally perceived as the ideal and key reason why most health professionals enter the health field. (39)
While society has historically encouraged these ideals of sensitivity, warmth, understanding and compassion in health care providers, the current trends in the health care field seem to mitigate their usefulness, favoring protocol and cost-effective efficiency over empathy. While "human compassion for others" is a quality still desired by the community in its health care providers, the post-HMO workplace doesn't seem to foster its practice, leaving doctors and nurses to reduce involving their personal value systems in the work they do. In today's healthcare workplace, the doctors' or nurses' desires to be compassionate and concerned are often tempered by the logistics of their work: outside demands of paperwork, time constraints, and limits placed by HMOs on the type of care patients can receive. In the past, while the moral qualities of empathy, support and compassion that Leininger discusses have helped characterize the work of nurses and doctors as befitting of "callings," the bureaucratic influence of HMOs and the constraints of the nursing shortage have helped hinder doctors' and nurses' ability to morally connect with their work. Robert Bellah suggests using work to "define the self" by "practicing activities that...enter into the shape of [the self's] character," yet when a health care professional's inclination to be a "sensitive, warm, understanding and compassionate [person]" is mitigated by HMO protocol or burdensome responsibilities, doing so can be a daunting task. In Nurses in the Workplace, Marie Cowart discusses the impact of the industry-wide shortage on nurses' sense of moral connection to their work. Cowart writes that "providing less than optimal care for their patients caused nurses to have negative feelings and suffer from low morale. They were " 'dissatisfied,' 'disillusioned,' 'angry,' 'discouraged,' and 'burned out.' Nurses were able to develop less rapport with their patients" (11). In this way, the nurses' work was no longer an extension of themselves or something from which to take pride, as control over how they performed their job was taken out of their hands. These changes challenge the profession's very nature, as "a nurse's values often have a profound effect on the quality of care given to a client and the type of interaction that occurs" (Arnold 309). When a nurse's value system isn't nurtured, and his or her desires to be "compassionate..., empathetic...and supportive" (Leininger 39) aren't fully encouraged, the nurse can no longer view work as something "that defines the self and enters into the shape of its character" (Bellah 69). The type of person the nurse would like to be, and the type of person that he or she is forced to be in the workplace become two different personas. Limiting health care providers' ability to integrate their value systems into their work will ultimately limit their ability to establish a moral connection with it.