Hell is Paved With Good Intentions

Human test subjects from the Tuskegee Syphilis...
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Recently I worked in an occupational health setting, at a clinic for employees of a call-center: a warehouse of a building filled with rows of Dilbert-like low cubicles with people on telephones, fielding customer complaints. Women workers would come in to clinic with bladder infections from not wanting to take bathroom breaks. They have to clock out for bathroom breaks and they get penalty points if they take too many bathroom breaks during one shift. Too many points and they get fired. Taking a diuretic for high blood pressure, or being pregnant, can be bad for job security at this site. Not surprisingly, stress-related health problems like headaches, heart palpitations, and depression are commonly diagnosed at this employee clinic. The purpose of work-site clinics such as this one is to maximize the bottom line for the company—keep workers as healthy as possible, and then fire them when they aren’t healthy anymore. The clinic is also designed to reduce the overall health care cost to the company. The irony, of course, is that many of the employees say they have to keep their jobs to keep their health benefits so that they can get health care for job-induced health problems. These are all issues not unique to this particular company.

This is much different work for me than all the clinical work I’ve done within the health care safety net. Although there are overlaps. For one thing, many of my homeless young adult patients worked for call centers like this when they were transitioning out of homelessness. These are the sorts of low-wage, low-skill, entry-level jobs available to people without a college degree, without work experience. Working at the call center has increased my understanding of what my homeless young adult patients meant when they spoke about such work: it’s a job, it pays the bills, but it’s depressing work because almost everyone is angry at you on the phone and you have to be nice to them or you’ll get fired. It has given me a new appreciation for how stressful it can be for all of those anonymous help desk people I have to deal with at times.

Ours is the only country in the world to primarily tie health care to work. Blame Rosie the Riveter. Employer-sponsored health care started in our country during WWII, when the scarcity of workers, combined with a national wage freeze, made the benefit package—including health care—a way for companies to attract and retain employees. It continued even after the war—and wage freezes—ended. People came to expect it.

What started off as a good idea has turned into a bad one. Employer-sponsored health care drags down our national economy. It does this by limiting entrepreneurship—people are less likely to strike out on their own to start a small business if they can’t afford health insurance in the private market. It is also a drain on the national economy since we have more disgruntled—and therefore less efficient—workers staying in jobs they hate just to keep their health benefits. It contributes to the fracturing of the US health care system due to multiple health insurance companies vying for business with companies offering health plans—and drives up overall health care costs through increased insurance company administrative costs. Some of these problems are addressed in the Affordable Care Act, but since our health care system is a highly complex adaptive system, powerful interest groups such as insurance companies have already plotted ways to circumvent these changes and continue making huge profits.

To use another famous quote from George Bernard Shaw’s “Maxims for Revolutionists”: “Hell is paved with good intentions, not bad ones.” I am always wary of occupational health programs due to the complex ethical issues involved: role conflict, invasion of privacy, and paternalism/coercion related to health promotion activities. I also remember that the notorious Tuskegee Syphilis Study had its roots in an otherwise well-meaning occupational health program. It began in 1932 in Macon County, Alabama, still one of the poorest counties in the US. Funded by a Northern philanthropist family and operated through a local Agricultural Extension program, it provided comprehensive mobile health care—including screening and treatment for syphilis (commonly called ‘bad blood’)—to poor black farm workers. These men had access to very little health care. Well-planned and well intentioned, the occupational health program was a success until the Great Depression forced a major scale-back of the program.

The rest of this is perhaps a familiar story, but one worth repeating. The US Public Health Service, and subsequently the CDC, stepped in to take over the program, under the guise of a treatment and research project for syphilis. The doctors told the study participants, all poor and mostly illiterate black men, that they were receiving first-rate medical care—including treatment for bad blood—for free. Eunice Rivers, a black public health nurse from the area, helped recruit and retain participants. She did community-based outreach to black churches and schools. At her suggestion, the researchers offered the men free burial. This was highly valued since the greatest disgrace was to die so poor you couldn’t get a proper burial. The men were deceived and received no treatment for syphilis, even though penicillin was available as an easy cure. The study continued until 1972, when a San Francisco-based journalist—tipped off by an internal CDC whistleblower—persevered to bring the public’s attention to the awful facts of the study. Some of the white male doctors and researchers involved still see nothing unethical in what they did. Eunice Rivers needed a job and she sincerely thought she was providing good nursing care to “her men.”

“The hallmark of the Tuskegee Study, and a key to its 40 year life, was its culturally-sensitive, community-based approach,” wrote Stephen Thomas in his article “The Legacy of Tuskegee: AIDs and African-Americans” (Jan/Feb 2000, Body Positive Magazine.) This is a good reminder of how good intentions—and good approaches to health care—can go to hell.

I feel uneasy about working in an occupational health setting, and I doubt I’ll return to work at that employee clinic. I didn’t feel right patching the workers up to return to their high-stress, low-paying jobs, sitting in the endless rows of cubicles under flickering fluorescent lights. But this means that I am rapidly running out of morally acceptable (to me) places to work within the US health care system. Perhaps next I will try jail health.

Those Who Can’t, Teach

swamp

A familiar phrase, and one that I think about often as I teach. It is appropriately humbling, an antidote to hubris. The phrase originates from George Bernard Shaw’s play “Man and Superman: A Comedy and a Philosophy,” from the main character’s “Maxims for Revolutionists.” The phrase is included in a section on education and reads, “He who can, does. He who cannot, teaches.” It is accompanied by: “A fool’s brain digests philosophy into folly, science into superstition, and art into pedantry. Hence, a university education.”  In his lengthy introduction to the play, Shaw writes, “(…) what we call education and culture is for the most part nothing but the substitution of reading for experience, of literature for life (…).” Shaw had a very unhappy childhood educational experience in Dublin, Ireland, was largely self-taught while living in London, and became a life-long ardent believer in socialist reforms.

In a practice discipline such as nursing, the tension between education and practice—between teaching and doing—is ever present. Further complicating this tension is the emphasis on nursing research in university-based nursing schools. Nursing is considered a minor (or wanna be) profession. As Patricia Benner and her co-authors state in their book Educating Nurses: A Call for Radical Transformation (Jossey-Bass, 2009), for the past thirty years nursing faculty and administrators have focused most of their attention on developing nursing research. Benner attributes this to the pressure to increase the prestige of nursing within academic settings. I am still unclear just what “nursing research” does to increase the prestige of nursing—or even what it means. Is nursing research any research having to do with nursing practice or workforce issues? Is it any research having to do with anything as long as it is led by a nurse?  I gave up teaching nursing research because I felt like a hypocrite since I didn’t understand or value it. In my experience, research methods classes taught in schools of nursing are not very rigorous, especially when compared with research methods courses in schools of public health or psychology.

Now nursing practice I do understand and value. I am an accidental nursing educator, and an occasional health services researcher. My first and real love is clinical work as a nurse practitioner. To apply Shaw’s maxim: I can and I do, but I also can’t and I teach. While my students value this clinical relevance, it isn’t valued within my school of nursing. This isn’t unique, as I hear a similar lament from my nurse educator colleagues at other top-rated schools of nursing. It also isn’t unique to nursing, as my academic physician friends tell me the same thing happens in schools of medicine.

Both the Educating Nurses and the IOM Future of Nursing Report emphasize the need for lessening the existing disconnect between classroom theory and clinical practice in nursing education. They point out that many nurse educators have not practiced nursing in many years and, therefore, have a hard time including appropriate classroom experiential learning. Much of nursing theory courses are taught with an overreliance on endless PPTs, busy work, and an emphasis on rote memorization. Nurse educators teach the way they were taught. It is not teaching; it is torture.

One of the most influential books on my own teaching of nursing is Donald Shon’s Educating the Reflective Practitioner (Jossey-Bass, 1987).  It doesn’t mention nursing at all, but is nonetheless applicable to nursing education. In the book he talks about professional practice as more of an art that a science, and emphasizes the teaching of reflection-in-action, a sort of higher-level critical thinking.

Here is his opening paragraph from the book:

“In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique. In the swampy lowland, messy, confusing problems defy technical solution. The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest might be, while in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and nonrigorous inquiry?”

Contrast this with an unfortunate statement in Educating Nurses: “Critical thinking alone cannot develop students’ perceptual acuity of clinical imagination; and cynicism and excessive doubt are often the by-product of the over-use of critical thinking.” The authors have obviously misunderstood the definition of “critical” as applied to critical thinking, where “critical” is understood to be the “exercising of careful judgment or observation.” It is having an inquisitive spirit, questioning underlying assumptions—including one’s own assumptions—of being able to think about thinking. Critical thinking is the opposite of Shaw’s fool’s brain and is necessary for effective swamp work, the terrain of most nursing practice.