Opinion
A PIECE OF MY MIND Diane Chang, MD, MFA Montefiore Medical Center, Bronx, New York; and Doctors for the 99%.
Corresponding Author: Diane Chang, MD, MFA (diachang @gmail.com). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
Scut I want to talk about scut work, defined as trivial, unrewarding, tedious, dirty, and disagreeable work; in other words, I want to talk about being an intern and the physical, backbreaking, day-to-day work of taking care of another person. During my last floor month as a resident, we had a patient who had been in the hospital for 2½ months: she had end-stage renal disease, obesity, and advanced COPD, was trached and PEG-ed, had deep vein clots and various bleeding and infectious complications. In addition, she had an extensive unstageable sacral ulcer, and, because of her anatomy, feces regularly got into the ulcer. The nurse’s aide, because she was not trained in wound management, would clean the patient but would go nowhere near the ulcer; the nurse would change the dressing daily, as ordered in the computer, but it was not her job to clean up patients, and neither could she, with six other patients to take care of. It was an impossible situation and an intolerable one. Only one nurse, and I don’t know how she did it, was able to keep the ulcer clean; she also gently rubbed the wound with clean gauze to help it debride. Because it was a priority for her, maybe, or because she was who she was, she performed this act that required vigilance and attention to detail. She was one of those nurses who have a fearlessness and practicality when it comes to wounds, smells, poo, and blood—what we keep scrubbed and hidden from normal society—and you have to admire their matter-offact way of getting things done that normalizes the breaking down of the body and human waste. It is a superpower that some nurses have. The small acts of care cannot be reduced into a set of hospital policies, and because of differences in ability, knowledge, perceptiveness, empathy, and personal limits, variability exists in how much health professionals do and care. I worked with an intern who, during her first floor month, took care of a 32-year-old patient with advanced HIV and intractable diarrhea. One day, my intern told me that she had, alongside the nursing aide, cleaned him up, as well as his bed and the floor. Why did you do that, I asked. It’s not your job. She answered that often, they did not clean him up right away, and she did not want the patient to have to lie in his own excrement for a minute more than he had to. Amid writing orders and discharge summaries, relaying information from consults back to the team, and learning how to be a physician, my intern also made it her job to clean up poo. The willingness to do this kind of work is an acknowledgment that problems start at the bottom, from the particulars of any given situation: we can’t draw blood, can’t insert an NG tube, can’t get an IV in—so the patient can’t eat, can’t get her meds. A special patience is required to do all of this because every human body is like a snowflake. This is why hospital CEOs should be
hospital janitors for a while, so that they can be intimate with the hospital trash and through this prism come to a better understanding of the physical reality of the hospital. A friend of mine went to medical school in the Netherlands, where every first-year medical student is required to do a month-long rotation as a nursing aide. She spent two weeks in gynecology and two weeks in pediatrics at a hospital in Suriname cleaning patients and changing beds. In this way, she was initiated to hospital life and the intimacy that caregivers must have with the human body. In our society today, the gap seems to be ever widening between those with advanced degrees and those without, between management and labor, between hospital executives and nursing aides. According to Crain’s New York Business, the president and CEO at Montefiore Medical Center received close to $5 million last year, making him the highest-paid hospital executive in New York City,1 whereas a typical home health aide in the New York metropolitan area makes about $20 000.2 Nursing aides, orderlies, and attendants in New York make about $33 000, higher than the national average of about $25 000.3 This is not a criticism of our CEO: he makes millions because this is the compensation for every other hospital executive who has brought innovative change to his institution. Willingly or not, we are all complicit in this lopsided system of income distribution. But when people who feed and bathe the elderly and sick, who cook and clean and change beds receive poverty-level wages, 4 we as a society devalue the backbreaking work of taking care of people. My friend who trained in the Netherlands describes herself as a hands-on type of person, someone who likes to do things. She told me the story of how, when she was an intern, she took care of a young patient transferred from the MICU whose urine had been positive for multiple substances. He was trached and PEG-ed and still unconscious when he arrived on the medicine floor. She saw him every morning, spoke to him, and examined him. No friends or family members ever came to see him that month. The team didn’t know why, after a prolonged hospital stay, he still wasn’t waking up and decided that he didn’t need to be on such a high dose of methadone. They titrated that down, and gradually, the patient began to wake up. By the end of the month he was just beginning to speak, and he told my friend that he had tried to kill himself. On the last day of the month, when my friend told him she was leaving, that a new intern would be taking care of him the next day, he cried and asked her to be in touch. Even when he was sedated and couldn’t speak, he knew that she had been in his room every morning checking in on him. The nurses work three 12-hour shifts a week, and the aides change, but he could count on the intern coming into his JAMA December 11, 2013 Volume 310, Number 22
Copyright 2013 American Medical Association. All rights reserved.
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Opinion A Piece of My Mind
room every day six days a week, the constant in his life that month as he gradually woke up. A recent New York Times article 5 describes the future of home care: the Georgia Institute of Technology has developed Cody,6 a robot designed to clean and bathe patients; a Swedish robotics initiative created Bestic,7 an assistive device to help people who can’t feed themselves on their own; and then there is Paro,8 which stands for personal robot, a therapeutic robot baby harp seal covered in hypoallergenic synthetic fur for patients to cuddle with and to keep them company. Paro’s sophisticated sensors allow it to respond to voice and touch and also to learn new behaviors. But, as some researchers point out, what does it mean for our old and demented patients to be cuddling with a robot, singing to it, and telling it their life stories? What will it say about us as a people if we become participants in conversations in which our voices are never heard by another person, if robots are the target of our love and not each other? What happens, I wonder, when the robots malfunction? Acts of caring are sacred: feeding the sick and old, cleaning them, and tending to their wounds are in some ways as intimate as you can get with another body. In performing these acts, we bear witness Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Possible Conflicts of Interest and none were reported. Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of Montefiore Medical Center or Doctors for the 99%. 1. Benson B. Compensation soars for hospital execs. Crain’s New York Business. March 31, 2013. http://www.crainsnewyork.com/article/20130331 /health_care/303319977. Accessed November 12, 2013. 2. $20260, according to the US Dept of Labor. Occupational employment statistics: occupational employment and wages, May 2012: 31-1011 home
2400
to people naked and infirm, at the beginning of life or at the very end, or at the most vulnerable moments in their lives. Of course, the difference between an intern and a nursing aide is that internship is only for a year: it prepares us to ascend to the next rung of the medical hierarchy. We have profound experiences caring for people, seeing them every day, watching people get better or decline, and sometimes watching people die. And we will continue to engage with patients in this way after we graduate: we will work in prisons and methadone clinics; we will be doctors for people living in supportive housing; and some of us will work in the poorest countries on earth. We are, however, the ones with the privilege of writing orders, and some of us will even become administrators and hospital executives. We will all be well paid and have options. Therefore, I’m grateful to have spent a year doing scut work at Montefiore. And the people who, day after day for all of their lives, with or without complaining, perform the tedious, repetitious, and heroic work, whose lives are engaged with blood, bile, vomit, tears, and waste, who do the lowly paid grunt work of society and are regarded as replaceable: the janitors, the nursing assistants, the home health aides, the food preparers and launderers, the stockers and patient transporters: I salute you all.
health aides. http://www.bls.gov/oes/current /oes311011.htm. Accessed November 12, 2013. 3. $33460, according to the US Dept of Labor. Occupational employment statistics: occupational employment and wages, May 2011: 31-1012 nursing aides, orderlies, and attendants. http://www.bls .gov/oes/2011/may/oes311012.htm. Accessed November 12, 2013. 4. The 2013 US poverty guideline, published by the US Dept of Health and Human Services, is $23550 for a family of 4. Office of the Assistant Secretary for Planning and Evaluation. 2013 Poverty guidelines. http://aspe.hhs.gov/poverty /13poverty.cfm. Accessed November 12, 2013.
May 19, 2013. http://bits.blogs.nytimes.com/2013 /05/19/disruptions-helper-robots-are-steered -tentatively-to-elder-care/. Accessed November 12, 2013. 6. College of Engineering at Georgia Tech. Robotic Cody learns to bathe. http://www.coe.gatech.edu /content/robotic-cody-learns-bathe. Accessed November 12, 2013. 7. Hagman A. Bestic—an eating assistive device. http://www.robotdalen.se/en/Projects/Bestic ---a-feeding-robot/. Accessed November 12, 2013. 8. Paro therapeutic robot. http://www.parorobots .com/. Accessed November 12, 2013.
5. Bilton N. Disruptions: helper robots are steered, tentatively, to care for the aging. New York Times.
JAMA December 11, 2013 Volume 310, Number 22
Copyright 2013 American Medical Association. All rights reserved.
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jama.com
A PIECE OF MY MIND Diane Chang, MD, MFA Montefiore Medical Center, Bronx, New York; and Doctors for the 99%.
Corresponding Author: Diane Chang, MD, MFA (diachang @gmail.com). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
Scut I want to talk about scut work, defined as trivial, unrewarding, tedious, dirty, and disagreeable work; in other words, I want to talk about being an intern and the physical, backbreaking, day-to-day work of taking care of another person. During my last floor month as a resident, we had a patient who had been in the hospital for 2½ months: she had end-stage renal disease, obesity, and advanced COPD, was trached and PEG-ed, had deep vein clots and various bleeding and infectious complications. In addition, she had an extensive unstageable sacral ulcer, and, because of her anatomy, feces regularly got into the ulcer. The nurse’s aide, because she was not trained in wound management, would clean the patient but would go nowhere near the ulcer; the nurse would change the dressing daily, as ordered in the computer, but it was not her job to clean up patients, and neither could she, with six other patients to take care of. It was an impossible situation and an intolerable one. Only one nurse, and I don’t know how she did it, was able to keep the ulcer clean; she also gently rubbed the wound with clean gauze to help it debride. Because it was a priority for her, maybe, or because she was who she was, she performed this act that required vigilance and attention to detail. She was one of those nurses who have a fearlessness and practicality when it comes to wounds, smells, poo, and blood—what we keep scrubbed and hidden from normal society—and you have to admire their matter-offact way of getting things done that normalizes the breaking down of the body and human waste. It is a superpower that some nurses have. The small acts of care cannot be reduced into a set of hospital policies, and because of differences in ability, knowledge, perceptiveness, empathy, and personal limits, variability exists in how much health professionals do and care. I worked with an intern who, during her first floor month, took care of a 32-year-old patient with advanced HIV and intractable diarrhea. One day, my intern told me that she had, alongside the nursing aide, cleaned him up, as well as his bed and the floor. Why did you do that, I asked. It’s not your job. She answered that often, they did not clean him up right away, and she did not want the patient to have to lie in his own excrement for a minute more than he had to. Amid writing orders and discharge summaries, relaying information from consults back to the team, and learning how to be a physician, my intern also made it her job to clean up poo. The willingness to do this kind of work is an acknowledgment that problems start at the bottom, from the particulars of any given situation: we can’t draw blood, can’t insert an NG tube, can’t get an IV in—so the patient can’t eat, can’t get her meds. A special patience is required to do all of this because every human body is like a snowflake. This is why hospital CEOs should be
hospital janitors for a while, so that they can be intimate with the hospital trash and through this prism come to a better understanding of the physical reality of the hospital. A friend of mine went to medical school in the Netherlands, where every first-year medical student is required to do a month-long rotation as a nursing aide. She spent two weeks in gynecology and two weeks in pediatrics at a hospital in Suriname cleaning patients and changing beds. In this way, she was initiated to hospital life and the intimacy that caregivers must have with the human body. In our society today, the gap seems to be ever widening between those with advanced degrees and those without, between management and labor, between hospital executives and nursing aides. According to Crain’s New York Business, the president and CEO at Montefiore Medical Center received close to $5 million last year, making him the highest-paid hospital executive in New York City,1 whereas a typical home health aide in the New York metropolitan area makes about $20 000.2 Nursing aides, orderlies, and attendants in New York make about $33 000, higher than the national average of about $25 000.3 This is not a criticism of our CEO: he makes millions because this is the compensation for every other hospital executive who has brought innovative change to his institution. Willingly or not, we are all complicit in this lopsided system of income distribution. But when people who feed and bathe the elderly and sick, who cook and clean and change beds receive poverty-level wages, 4 we as a society devalue the backbreaking work of taking care of people. My friend who trained in the Netherlands describes herself as a hands-on type of person, someone who likes to do things. She told me the story of how, when she was an intern, she took care of a young patient transferred from the MICU whose urine had been positive for multiple substances. He was trached and PEG-ed and still unconscious when he arrived on the medicine floor. She saw him every morning, spoke to him, and examined him. No friends or family members ever came to see him that month. The team didn’t know why, after a prolonged hospital stay, he still wasn’t waking up and decided that he didn’t need to be on such a high dose of methadone. They titrated that down, and gradually, the patient began to wake up. By the end of the month he was just beginning to speak, and he told my friend that he had tried to kill himself. On the last day of the month, when my friend told him she was leaving, that a new intern would be taking care of him the next day, he cried and asked her to be in touch. Even when he was sedated and couldn’t speak, he knew that she had been in his room every morning checking in on him. The nurses work three 12-hour shifts a week, and the aides change, but he could count on the intern coming into his JAMA December 11, 2013 Volume 310, Number 22
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University Of Connecticut Health Center User on 05/11/2015
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Opinion A Piece of My Mind
room every day six days a week, the constant in his life that month as he gradually woke up. A recent New York Times article 5 describes the future of home care: the Georgia Institute of Technology has developed Cody,6 a robot designed to clean and bathe patients; a Swedish robotics initiative created Bestic,7 an assistive device to help people who can’t feed themselves on their own; and then there is Paro,8 which stands for personal robot, a therapeutic robot baby harp seal covered in hypoallergenic synthetic fur for patients to cuddle with and to keep them company. Paro’s sophisticated sensors allow it to respond to voice and touch and also to learn new behaviors. But, as some researchers point out, what does it mean for our old and demented patients to be cuddling with a robot, singing to it, and telling it their life stories? What will it say about us as a people if we become participants in conversations in which our voices are never heard by another person, if robots are the target of our love and not each other? What happens, I wonder, when the robots malfunction? Acts of caring are sacred: feeding the sick and old, cleaning them, and tending to their wounds are in some ways as intimate as you can get with another body. In performing these acts, we bear witness Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Possible Conflicts of Interest and none were reported. Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of Montefiore Medical Center or Doctors for the 99%. 1. Benson B. Compensation soars for hospital execs. Crain’s New York Business. March 31, 2013. http://www.crainsnewyork.com/article/20130331 /health_care/303319977. Accessed November 12, 2013. 2. $20260, according to the US Dept of Labor. Occupational employment statistics: occupational employment and wages, May 2012: 31-1011 home
2400
to people naked and infirm, at the beginning of life or at the very end, or at the most vulnerable moments in their lives. Of course, the difference between an intern and a nursing aide is that internship is only for a year: it prepares us to ascend to the next rung of the medical hierarchy. We have profound experiences caring for people, seeing them every day, watching people get better or decline, and sometimes watching people die. And we will continue to engage with patients in this way after we graduate: we will work in prisons and methadone clinics; we will be doctors for people living in supportive housing; and some of us will work in the poorest countries on earth. We are, however, the ones with the privilege of writing orders, and some of us will even become administrators and hospital executives. We will all be well paid and have options. Therefore, I’m grateful to have spent a year doing scut work at Montefiore. And the people who, day after day for all of their lives, with or without complaining, perform the tedious, repetitious, and heroic work, whose lives are engaged with blood, bile, vomit, tears, and waste, who do the lowly paid grunt work of society and are regarded as replaceable: the janitors, the nursing assistants, the home health aides, the food preparers and launderers, the stockers and patient transporters: I salute you all.
health aides. http://www.bls.gov/oes/current /oes311011.htm. Accessed November 12, 2013. 3. $33460, according to the US Dept of Labor. Occupational employment statistics: occupational employment and wages, May 2011: 31-1012 nursing aides, orderlies, and attendants. http://www.bls .gov/oes/2011/may/oes311012.htm. Accessed November 12, 2013. 4. The 2013 US poverty guideline, published by the US Dept of Health and Human Services, is $23550 for a family of 4. Office of the Assistant Secretary for Planning and Evaluation. 2013 Poverty guidelines. http://aspe.hhs.gov/poverty /13poverty.cfm. Accessed November 12, 2013.
May 19, 2013. http://bits.blogs.nytimes.com/2013 /05/19/disruptions-helper-robots-are-steered -tentatively-to-elder-care/. Accessed November 12, 2013. 6. College of Engineering at Georgia Tech. Robotic Cody learns to bathe. http://www.coe.gatech.edu /content/robotic-cody-learns-bathe. Accessed November 12, 2013. 7. Hagman A. Bestic—an eating assistive device. http://www.robotdalen.se/en/Projects/Bestic ---a-feeding-robot/. Accessed November 12, 2013. 8. Paro therapeutic robot. http://www.parorobots .com/. Accessed November 12, 2013.
5. Bilton N. Disruptions: helper robots are steered, tentatively, to care for the aging. New York Times.
JAMA December 11, 2013 Volume 310, Number 22
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University Of Connecticut Health Center User on 05/11/2015
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