Installment 4 of the “Finding Normal” Study Guide

Working Class Professionalism

Did we mention anywhere yet that the recovery mentors make about $20,000 a year, working full time?
One of the major categories of deprogramming community acupuncturists has to do with understanding what professionalism really means. The acupuncture professional culture has managed to convince a lot of acupuncturists that their professionalism is defined by what kind of clothes they wear, what letters they put behind their name, how much they know (meaning the sheer quantity, regardless of whether or not it’s useful or meaningful), what other people think about them, and what their patients pay them. The acupuncture professional culture believes that all of these things are Very Significant.
The problem here is that I, as a working class person, suspect at a visceral level that those Very Significant Things are a load of crap. A bunch of working class patients feel the same way, which is one reason why it has been so difficult to bridge the gap between working class culture and acupuncture professional culture. If you find this observation jarring, ask yourself if these Very Significant Things are indeed very significant in the context of “Finding Normal”. Do the mentors put a lot of energy into what they wear, what letters are behind their names, the quantity of what they know, what other people think of them, or what they get paid?
In working class culture, professionalism is about your relationship to your job -- your job itself, not all that other extraneous stuff. It’s about putting your job first, making sacrifices of time and energy and effort to become really good at something, and taking pride in that.  A professional is someone who can put himself or herself aside, if necessary, to do his or her job really well, who can consistently rise to the occasion to do the job as it needs to be done. If you’re a working class professional, you believe that the work you do is worth doing, and that is why you do it, not just because you get paid for it. You care about doing it well, regardless of whether anybody is watching you or applauding you or thinking that what you do is important.  If you’re really lucky, like David Fitzgerald, you can say you were “born to do this shit”.
In hindsight, I survived for as long as I did as an acupuncturist, long enough anyway to figure out the community acupuncture model, in part because I just loved acupuncture as itself. I loved handling needles, I loved taking pulses, I loved watching people fall asleep and wake up feeling better -- hell, I loved restocking the cotton balls. I loved being in the clinic, period. Being working class was part of what made loving acupuncture enough to keep me in the field when a lot of my contemporaries were bailing out, because acupuncture was What I Did. And when you’re working class, What You Do is enormously important (in part, of course, because you don’t have that much else) . What You Do, as distinct from What Other People Think of What You Do. My grandfather was a gas station attendant -- not a mechanic, a gas station attendant. He pumped gas, cleaned windshields, and never learned how to drive. I remember him telling me he loved the smell of gasoline. I did not grow up with the expectation that other people were going to respect what I did for a living. I did grow up, however, with the expectation that I would respect it, love it, take it seriously.
So a community acupuncturist needs to love acupuncture for its own sake, in part because the community acupuncture model was designed by people who just really don’t get why status is supposed to matter. (We have tried to care about status, and money, and respectability, really we have. We just can’t do it.) Which brings us to the issue of handling failure.
On my fifth or sixth viewing of “Finding Normal”, I realized how many times the mentors refer, directly or indirectly, to the issue of people’s readiness for recovery. Part of the success of the mentor program has to do with the mentors’ care in choosing people to participate who are ready to stop using drugs. (They can’t choose perfectly, as Peni’s example indicates, but they try.) The mentors realize that they cannot make anyone ready, they can only support what readiness is already there.
I think that the professional acupuncture culture’s unhealthy emphasis on status and respect has confused this element in the minds of many acupuncturists.  On the one hand, we acknowledge that acupuncture stimulates the body’s own self-healing and self-regulating mechanisms, and we can’t make the body do anything it isn’t ready and willing to do. On the other hand, we think it’s part of our job to pressure, cajole or persuade people to value acupuncture, to give the treatment a chance, to follow through with what we suggest, and if they don’t do those things, we think we’ve failed. We think it’s our job to get them to want to come to see us. But we can’t get anybody to want to come to see us,  or to want to try acupuncture; we can only welcome and support the people who already want to see us, who already want to try acupuncture. We can make it as easy as possible for them. We can lower all the barriers, at least all of the barriers we know about and can reach. But we can’t force readiness any more than the mentors can. And because so much of acupuncture’s clinical success has to do with people’s willingness to stick with treatment over a period of time, we shouldn’t evaluate our success or failure based on factors that are out of our control. Such as other people’s readiness.
Part of defining your job means defining what constitutes success or failure. This is where I think the idea of working class professionalism can be helpful to community acupuncturists, because it allows you to focus on doing your job well, and enjoying your job, rather than getting overly caught up in how people are responding to you while you’re doing it. Oddly enough, this makes it easier for people to relax around you and to trust you, because they can feel that you do What You Do for your own reasons, and you’re not depending on them for applause or approval. It also allows you to save your energy for the people who are ready for you to help them, and thus attract more of those people, rather than wasting your energy trying to make people ready who aren’t ready -- and just making yourself tired, and less likely to attract anyone at all.
Michael Smith, the founder of NADA, once pointed out that you can teach anyone (anyone!) to do acupuncture in about 45 minutes. “There’s the sharp end, and there’s the dull end. You put the sharp end in the patient...” I laughed really hard at that, and not because he was joking.  Mystifying acupuncture doesn’t help anybody. Complicating what we do doesn’t make us professionals. This is what an acupuncturist needs to do: be present, be respectful, communicate the treatment plan clearly, hold the space, give a fuck, put the sharp end in the patient, and get out of the way. And then let go of the outcome.
Those are all things that we can practice doing, and we can get better with practice. If we fail at doing any of them, we can practice until we succeed.  We can take pride in doing those things well,  regardless of how anyone responds. These are the things that are our job, these are the things we can take responsibility for; everyone else’s readiness, that’s their job and their responsibility.  This is how we hold space for ourselves as professionals, while we hold space for our patients to heal.

(Coming soon -- either the next installment or the one after that-- is scene by scene commentary. So now might be a good time to order the DVD of "Finding Normal" -- believe me, you won't regret it, even if I never wrote another word.)

This story was posted on July 15 2009 by Lisafer.

Comments

  • July 15 2009 at 11:17 AM
    Lisafer writes:

    w-c professionalism is also

    just another way of saying, “the Subaru guy”.

      0 likes
  • July 16 2009 at 12:27 PM
    obnicole writes:

    put the sharp end in the patient….

    great. i would LOVE to pull in the right people, give them a little training, and that’s it. they could be acu-techs. and they would be less worried about $ because they wouldn’t have to pay off what will eventually be >$200,000 in loans/interest?

    Loved this part:

    “...we acknowledge that acupuncture stimulates the body’s own self-healing and self-regulating mechanisms, and we can’t make the body do anything it isn’t ready and willing to do. On the other hand, we think it’s part of our job to pressure, cajole or persuade people to value acupuncture, to give the treatment a chance, to follow through with what we suggest, and if they don’t do those things, we think we’ve failed…..”

    that’s it! that’s it! the paradox. and i love the way you address it: be professional, care a lot, take away as many barriers as possible. and then those who are ready will hopefully find their way.

    i can’t wait to get the dvd.

      0 likes
  • July 16 2009 at 8:42 PM
    annmongeau writes:

    Upper Middle Class Professionalism

    Point of view of this post: These comments come from my experiences in work spanning 40 years as an RN in Iowa and Minnesota and my upbringing as the first of two daughters of a male MD and female RN in a medium sized town in Nebraska.  I have worked in teaching and private hospitals on general floors and in the ICU.  I have taught clinical nursing in 3 different programs in two states.  I was a family nurse practitioner in a community clinic for 6.5 years and early on I spent 2 years in a Ph D program in microbiology so I have had varying views of the health care culture of Western medicine in the midwest of the US.  While things have become less rigid and more human in recent years, I think the basic outlines of what I am going to say are still part of the Western medical culture in the US i.e. upper middle class (UMC) professionalism.  I also think this is the professional model in all developed countries and all disciplines requiring a bachelor degree or more past high school.

    UMC professionalism says that your worth is determined by how much school you have had, what degrees are behind your name, and how much power you have.  Power is determined by gender, the rank of the held degree, and the whiteness of your skin.  Note that 2 of the 3 are unearned.

    Within degrees there are ranks of power.  The surgeon out ranks the non- surgeon.  The brain surgeon ranks above the heart surgeon, for instance, but an MD of any type is the ranking professional over all others in the health care field, regardless of their degree. The MD sub-specialist out ranks the specialist who out ranks the generalist.  Because of advanced schooling and superior knowledge, professionals deserve a high salary determined by rank.  It is assumed that if you earned the degree, you are competent, which isn’t always the case.

    While doing a good job is valued, pride comes from the degree(s) and rank you hold and the praise and awe of others more than the work you do.  It is assumed in nursing, for instance, that one would want to continue to earn more degrees.  The most valued nurse is the advanced practice nurse (i.e. nurse practitioner, nurse anesthetist)  whose scope of practice overlaps with that of the MD rather than the PhD nurse who does scientific studies and creates new knowledge in nursing.  Degree inflation isn’t limited to acupuncture.  A clinical doctorate is becoming the nurse practitioner educational standard where a Masters used to be the standard.

    Have you ever noticed that scientific papers are never written in the first person, regardless of the discipline, and the authors don’t give their opinion/thoughts until the last paragraph where they all say words to the effect of, “It is the opinion of the authors that more studies are needed.”  The author spends the vast majority of the paper citing the words of others and doesn’t say “I think/have had the experience”  until the short conclusion.  This emphasizes looking outside of the self and to others as experts rather than to look at the HCPs own feelings/experience feeding insecurity.  The language used further depersonalizes the information.  I wrote most of this post in the impersonal voice of a scientific paper.

    Scientific knowledge is the gold standard.  It is taken for granted that being informed of the scientific facts will change behavior.  Further, the HCP considers him/herself so knowledgeable about the human condition, they assume they know best what the patient should be doing in many aspects of her/his life.  Thus, the mandate that the professional educate their patients and the assumption that advice will be followed.

    It is assumed that others don’t have the knowledge you do unless they have the same degree as yours.  Expertise is gained by getting the degree, although after that, experience in the field counts unless it’s obvious that you haven’t kept up in reading the professional literature and continuing ed in your field.  Games of one up man ship in citing journal articles are overheard in hospital halls.

    I think the assumptions of this model very easily hook acupuncturists in Western countries.  After all, what we learn in school is far from common knowledge so the urge to feel special and above and to bestow all we know on our hapless patients is strong - “for their own good.”

    Knowledge is gained by going to school for advanced degrees and keeping up with the scientific/journal literature in your field.  The biases and limitations of the scientific method itself are never discussed.  I doubt of most are even aware of them.  Knowledge gained in other ways is judged inferior.  There is ranking in scientific studies with quantitative studies far superior to qualitative studies.  Emotion must be removed as it is unreliable, introduces bias and invalidates results.

    Therefore, the health care professional (HCP) must be emotionally neutral and emotionally distanced from patients.  By virtue of the knowledge and power rankings, the HCP is “above” those they take care of.  Clothing, bearing, language, emotional distance, and an attitude of benevolence to patients is modeled by professors and encouraged as a part of professionalism.  Benevolence often becomes condescension, given the assumptions outlined.

    In an earlier draft of this post, I said “By virtue of the knowledge and power rankings, the HCP is above those they serve” in the previous paragraph.  Then I realized that is inaccurate as I rarely hear “those I serve.”  The phrase most often heard from all HCPs is “those I take care of” with all the paternalism and responsibility that implies.  This feeds into the patient education mandate as well.

    By birth, the children of the HCP are “above” others and must be taught to behave in quasi-professional ways to not embarrass the parent.  They will be favored if applying to the professional school of the parent, especially in the case of medical school, even if grades and test scores are lower than desired.

    Many rules have emerged regarding the emotional and physical distance between the HCP and the patient, mostly as a result of abuse of power by HCPs.  Because the workings of our bodies are still the stuff of mystery, there is a huge power differential between the HCP and the patient.  The emotional distance, the familiarity with bodies, some knowledge of the workings of our bodies, our society’s worship of advanced scientific knowledge and the ability to alleviate some suffering can lead the HCP to arrogance and impatience with those who know less.

    HCPs are allowed by society to touch patients in ways and in places that other strangers are not allowed to do.  This can breed in the HCP a familiarity and a callousness - an assumption of the right to someone else’s personal and psychic space.  Trained to watch for patterns and to identify and classify human behavior, individual patients cease to be persons and become members of a category defined with the underlying assumption that the HCPs point of view is the only valid one by virtue of more education.  Therefore, labels such as hypochondriac, needy and non-compliant are used.  Time pressures on all HCPs also feed this labeling/categorizing.

    Judgments about patients are in the chart dictations of MDs.  “This pleasant 45 yo woman comes in today complaining of ....”  “This argumentative 35 yo male…”  “This non-compliant 55 yo male…”  “This dependent, passive 60 yo woman…”  The impersonal voice of the scientific paper is used in charting.  While all that goes on between the HCP and the patient is viewed through each person’s own biases, charting is impersonal and the HCP’s point of view is thought of as objective.

    Non-compliance means the patient didn’t follow the treatment regimen set forth by the HCP.  Nursing has changed the definition to mean that the person didn’t follow the regimen due to other factors besides just not agreeing with it (inability to afford meds; no transportation, etc).  However, in practice, the label of non-compliance in nursing as well as medicine means that the patient didn’t follow HCP advice and is judged harshly for that.  It is too often only an after thought that a HCP would consider that the person may have had barriers to obtaining care or simply disagreed or found the treatment ineffective or unpalatable.

    When the patient acts against the advice of the professional, after becoming angry that the patient didn’t do as they were told, the HCP can wash their hands of responsibility and chart that the patient acted AMA (against medical advice).  This is also done to cover their butt in case of a suit.  The notion that a patient might chose a different course of treatment or even non-treatment and that they have the right to do so because it is their life, their body and they have a right to self determination is only recently being considered as a valid choice.  This has been hard won by many patient advocate groups consisting of patients who have objected to how they have been treated, who have experienced success with other forms of health care besides Western medicine, and who don’t want to experience the side effects of treatment.  Side effects are taken for granted by the HCP although an effort is made to find treatments with less side effects.

    Failure is personal.  It is assumed that your knowledge should be adequate so either you as the HCP did something wrong or the patient did.  A lot of energy is put into finding out where the patient failed to follow the treatment regimen and into doing more patient teaching to avert this in the future.  Fear of future failure will often drive the HCP to seek more knowledge/consult a colleague as the result of a treatment failure.  The CEU circuit feeds on this fear.  The fear of failure was carried to absurdity by the oncologist I met in the 1980‘s who thought he “lost” when one of his patients died of cancer.  You might laugh at this statement until you consider what this man talked his patients into enduring so he wouldn’t “loose.”

    In my experience, HCPs who have chronic illnesses or who have been hospitalized for any length of time, especially with something serious or as yet undiagnosed, become much more respectful of patients.  Becoming hospitalized is a crash course in vulnerability and a good education about the power of the HCP, although the MD who is a patient receives more respect from HCPs than other HCP patients.

    I’ve been working on this post for 3 days.  It’s time to stop.  The more I think about what I’ve seen the more connections I make and the more I see how the system reinforces itself and the bigger this post gets.

    In the 70’s I saw the cover of the medical student newsletter at the U of Iowa.  It showed an elaborate rather old fashioned machine with a meat grinder at one end and a conveyer belt coming out the other end.  There was a line of casually dressed college students of all heights, some women, mostly men, mostly white with the tools of their hobbies (guitars, bikes, knitting, etc) dancing merrily into the meat grinder.  These were the ones starting the first year of med school.  Out the other end on the conveyer belt were cookie cutter figures all the same height, looking straight ahead, dressed in “Sunday best” with white coats and stethoscopes.  Great visual for the socialization process of the Western MD. It applies to the educational socialization of all the HCPs.

    I agree with Lisa that this is the model of professionalism the acupuncture profession follows, knowingly or unknowingly.  I think working class professionalism serves both the patient and the practitioner much better and is much more real, honest, and respectful to both parties.

      0 likes
  • July 17 2009 at 10:02 PM
    ns009 writes:

    categories

    I’m all for genuine work ethic, empowering patients, analyzing socioeconomic
    and cultural barriers to healthcare, and understanding healthcare reform in
    historical context. I’ll add yet another essay, including some respectful
    questions. Why draw lines in the sand? I’m not sure the boundaries are that
    sharp in real life. How does creating black/white good/bad categories further
    the goal of increasing access to acupuncture? To me the question is how we as
    community acupuncturists can participate in the broader dialogue of healthcare
    reform and encourage more voices to join the table.

    Sure, I can see room for improvement in acupuncture education (a new
    board exam and credentialing body? what a thought!). I’d like to see things
    better organized, less bloated etc. But I’m convinced I was being indoctrinated
    into a culture with deep moral flaws. The acupuncture profession is a work in
    progress. As individuals, my teachers had good intentions. In the past, the
    battle was to bring acupuncture and Asian medicine to this country. Perhaps
    that fight came with extra baggage. I believe it’s possible to keep moving
    forward, make access practical, and still appreciate the past and value
    inclusion.

    Some of my teachers and classmates wore lab coats, most didn’t. Sure, uniforms
    and degrees can have associations. But that can be seen as a historical and
    sociological topic rather than an ethical issue. I wouldn’t say those who tried
    on lab coats were bad people. Good intentions, different strategies. Sometimes,
    those who chose lab coats cared a lot about empowering others, and were also
    sensitive to perceptions of authority. Call it magnetism instead if you prefer,
    but holding a healing space for others is more about trust and clarity than
    equality. The patient-practitioner relationship is inherently unequal, which is
    exactly why communication, presence, and awareness of paternalism are so
    important. Lisa has shared some fascinating and useful reflections in this
    series. Why not focus on articulating barriers to care and nuances of clinical
    interaction without casting negative judgments on huge categories of people?
    There are enough thorny problems in the system. Targeting culture/people casts
    a broad swath that can be more alienating than community building.

    Many so-called “working class” jobs have disappeared over the decades,
    outsourced or downsized or technologized. People don’t fall neatly into
    categories, considering the pieces of personal history, past jobs, current
    jobs, aspirations. What about people who might be defined as working class, but
    who don’t necessarily self-identify with that category? It’s not necessarily a
    zero sum game. Many people want to improve their financial security and strive
    toward a better future. Yep, or yup, upward mobility and striving are pretty
    common even if politically incorrect. Inclusion makes more sense to me than
    promoting or arguing about particular class labels. Bottom line, community
    acupuncture can help improve healthcare for everyone.

      0 likes
  • July 20 2009 at 8:07 PM
    Lisafer writes:

    so much to think about

    Wow, Ann, thank you. There is just so much here to digest. This argumentative 41 -year -old female learned a boatload of stuff she didn’t know, but it sure makes a lot of things make more sense.

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