Patients rapidly detect the difference in the caring relations that connect them to nurses and to physicians. Nurses serving in American health care no longer usually wear the starched white uniforms, caps, and badges that once distinguished them. But they typically introduce themselves by their first (not their last) names and wear inconspicuously serviceable clothing. Physicians, in contrast, typically wear white coats or scrub suits, carry stethoscopes, and insist on being called “Doctor.” (High-ranking nurses, it is true, sometimes blur the line by wearing white coats and carrying stethoscopes.) Dress and demeanor signal differences in what patients can expect from nurses and physicians.
As Danielle Ofri’s vivid sketches of her experiences on the way from medical student to staff physician at New York’s Bellevue Hospital indicate, junior physicians share many of nurses’ responsibilities: taking vital signs, inserting intravenous taps, calming agitated patients, and more. One major difference, however, is precisely the physician’s public responsibility for decisions concerning diagnosis, treatment, medication, tests, and patient management. “Contrary to the stereotype,” comments Ofri,
doctors do not lack for emotions. The medical student is too embarrassed to ask a patient to undress for a physical exam.
The intern is sweating and cursing because the IV won’t go in on the seventh try and she hasn’t seen sunshine in three days.
The resident is angry at the cocaine addict whose refusal of a CT scan will make him stay late again and miss, once again, putting his kids to bed. The attending [physician] is nervous on rounds because he’s a bit “rusty” with his inpatient skills and the residents might get wind of his ignorance. (Ofri 2003: 238)
In some sense, physicians bear the stress of combining caring with responsibility for the outcome. The combination, Ofri points out, can create surprisingly powerful connections between doctor and patient:
A unique bond is created, I learned, after you accompany someone through a lifesaving experience. Just by being near him and touching him during that near-death episode, I felt like I’d been privy to a singular intimacy. Mr. Wiszhinsky couldn’t just recede into the multitudes of old men in the hospital, and I couldn’t be just another medical student in the team. Not after we’d been so close to death together. (11)
Life-and-death responsibility weighs heavily on physicians, both in the midst of their training and later.
In addition to tending lives, however, physicians must also cope with complex changing organizational and financial environments. Within the health-care professions, physicians have long occupied the highest ranks. As compared with nurses and other health-care professionals, they have generally enjoyed greater discretion, higher compensation, and larger influence over the work of their fellow caregivers. Nevertheless, they share the problems of other paid caregivers outside of households in two crucial regards. First, massive changes in the financing and regulation of paid care in the
United States have deeply altered relationships among physicians, patients, and third parties. Second, like other health-care workers, physicians engage in delicate negotiations to match their provision of life-sustaining services, their compensation for those services, and the meaning of the physician-patient relationship: clearly intimate in some regards, but sharply bounded by technical, moral, ethical, and economic limits. Drawing distinctions between strictly business attention and personal concern therefore causes physicians great trouble. Like other caregivers, physicians face a dilemma. They consider themselves professionals, working above and beyond commercial considerations, and yet they draw their income from treating the sick.
Exactly how the dilemma operates, however, changes as the organization of health-care changes. David Rothman’s historical account of physicians’ compensation during the twentieth century reveals major shifts in the connection between medical services and payment (Rothman 2002; see also Starr 1982; Tomes 2003; Walsh 1977). Until recently, American physicians set their own fees, which often varied by the patient’s ability to pay. Such discretion came at a cost, precisely because doctors collected directly from patients who often felt free to delay their payment (what physicians called “slow pay”) or not pay at all. Indeed, in the 1920s and ’30s, physicians (and their wives) forced to keep up respectable appearances, pay for their offices, and meet other expenses, repeatedly protested against a double standard. The public expected them to rise above monetary concerns, yet at the same time demanded they pay their own bills on time.
As Rothman reports, “Doctors were required to pay the baker, butcher, and candlestick maker immediately, but they, in turn, had to suffer slow pay.” He quotes a physician’s wife’s complaint in a 1932 Harper’s Magazine article: “I had to put the grocer off. What I meant but did not say, was that if any of several patients who owed my husband goodsized and overdue bills would only pay him we would pay our own bills with joy” (113). Yet if they complained too loudly about missed fees, physicians were accused of greed and avarice. In fact, during this time some physicians supplemented their
comfortable but not spectacular middle-class incomes with more dubious strategies, such as kickbacks from referrals, selling drugs or eyeglasses to their patients, or owning their own hospitals where they sent their patients. Nevertheless, the profession as a whole distanced itself from money-grubbing practices. It promoted the image of the genial, patient, caring family doctor that graced magazine covers of the time.
After 1966, the commercial reorganization of health care boosted American physicians’ income spectacularly, while at the same time transforming the physician-patient relationship. Three key changes made the difference: Medicare, new forms of billing, and benefits from pharmaceutical companies. Under Medicare, physicians’ fees were not set by the government but by professional definitions of a customary and reasonable rate. As Rothman points out, that doctrine was “a give-away, an open invitation to doctors to bill at the highest possible level (for example, using the best-paid physicians in the community as the standard)” (115).
Physicians’ income also rose as a result of the development of new surgical procedures for which physicians billed item by item rather than according to time spent. Rothman explains:
If psychiatrists, pediatricians or internists had to set their fees with an eye to the clock—for example so much for 50 minutes—surgeons (or dermatologists or gastro-enterologists) could ignore the clock and bill for the procedure: a transplant (50 minutes but $15,000) or a wart removal (one minute $300) or a colonoscopy (10 minutes and $500). (116)
Finally, although less significantly, drug companies began providing physicians with in-kind benefits, such as dinners, free travel, vacations, and occasionally, honoraria for lectures.
Since the 1980s through the 1990s, increased surveillance by health maintenance organizations (HMOs), insurance companies, and hospital administrators further transformed physician-patient relations. Physicians confronted patients who themselves had little choice but to shop on the basis of price and service, an unprecedented shift in American medicine. Rothman reports physicians’ complaints that patients “unceremoniously drop them as soon as their companies change plans, refusing to pay a full fee when they could pay a $10 co-pay fee” (119). More important for our purposes, the changed commercial aspects affect the actual quality and scope of treatment:
The HMOs did something else as well: they subverted the trust between doctor and patient. Consumers, alert to all these changes and understanding the general rules of the managed care game—if not knowing the exact details of the contract with the physician sitting across from him—worried, appropriately, whether the physician was withholding treatment or a referral because his concern with own income was trumping his concern for his patient’s welfare. (118)
On their side, physicians also sought to escape the limits set by bureaucratic control of health care. (Another escape from HMOs and insurance, but not bureaucracy, consisted of becoming a fulltime doctor on a company staff, treating solely the company’s employees; see Draper 2003). Most dramatically, during the late 1990s, physicians in the Pacific Northwest started organizing high-end medical practices; those practices soon drew the labels “boutique,” “concierge,” or “retainer” medicine. Patients paid a substantial entry fee (ranging from $1,500 for an individual to $20,000 for a family) in return for guaranteed rapid access to their physicians, longer office visits, and personalized care. The system offered doctors opportunities to withdraw from insurance plans, governmental feesetting, and extensive paperwork while gaining access to a privileged clientele.
Critics, however, complained that boutique medicine compromised a crucial principle: provision of the same quality of medical service to every patient regardless of income or social standing. Although the American Medical Association Council on Medical and Judicial Affairs replied that this new sort of patient-physician contract might actually help patients “establish trust in a physician,”
clearly the new move separated well-heeled patients from other recipients of health care (quoted at Medical Rants 2003).
A closely related trend produced “boutique” hospitals, luxury settings in which patients can opt out of regular hospitals and receive extravagantly personalized care. In these for-profit hospitals, that typically specialize in high-revenue procedures, such as heart care, patients’ perks include gourmet meals, spacious suites, and daily massage. At the Rancho Mirage, California Heart Hospital, for instance, “a gourmet chef visits patients individually to learn meal preferences. The staff aims to create a hotel or resortlike decor with [guest suites] painted in teal and fuchsia.” (Stringer 2001: 3-4; see also Japenga 2000)
Boutique hospitals and medical practices highlight a significant pattern: caring labor generally increases in value to the extent that givers of care adapt its delivery to the recipient’s identity and cir — cumstances—when they recognize the recipient as a distinctive individual, take account of other persons in the recipient’s life, and modulate the treatment according to the recipient’s tastes or fears. That is true both of use value (the extent to which the effort actually enhances the recipient’s welfare) and of commercial value (the price commanded by the service on the current market). On the whole, caring gains value through personalization.
To see the point even more clearly, we can draw an analogy to the world of health care from the world of luxury hotels. Anyone who has ever smiled at being recognized by a headwaiter will instantly understand why luxury hotels make great efforts to individualize their service and give signs of acknowledging their clients as distinct personalities. Indeed, in her study of luxury hotels, Rachel Sherman shows that “caring labor is one of the central features of hotel service” (Sherman 2002: 2). Here hotel workers’ caregiving consists of personalized attention. She offers three striking examples of personalization:
• A housekeeper’s noticing that a guest ate a peanut butter cookie provided for him in the evening, but left the chocolate chip one untouched; the next night she left him two peanut butter cookies.
• A housekeeper known for going through guests’ garbage to see what kind of candy they ate and what magazines they read, in order to enter their preferences into the guest’s database record.
• The staff had remembered not only [a traveler’s] name and her husband’s, but also the name of her two dogs. (5-6)
Sherman documents the luxury version of a very general phenomena. As our examination of child care shows clearly, however, personalization of intimacy also exists when prices run low. To be sure, many critics have thought that any commercialization of care eliminates the individual attention, the flexibility, the very intimacy of caring relations. Furthermore, ethical codes governing relations between clients and physicians, psychotherapists, clergy, lawyers, nannies, personal trainers, celebrity assistants, and others who professionally provide personalized care struggle to shield the provision of effective, personalized care from the dangers of excessive intimacy.11 Yet our survey shows that even in settings of intense commercialization, the characteristic synthesis of localized media, particularized transactions, and meaningful relations continues to thrive.