About a year ago I got a tattoo of the staff of Asclepius
from a shop in Hudson to commemorate the end of my career in medical
publishing. It's cute and I still like it. While
weeding my garden yesterday and contemplating the end of my professional life, I
tried to think a bit more deeply about the meaning of this image and the value, if any, of spending three decades providing primary care doctors -- the major physician caregivers -- with information.
I had just completed a contract with Medscape, which involved writing captions and an article on survey results
for physician compensation, and, no surprise, the survey shows that primary care physicians (family docs,
general interns, and pediatricians) are the lowest paid among all specialties.
The highest earners are the surgeons and interventionalists. (Of interest, dermatologists fall slightly
above the middle in compensation but in our Medscape surveys are the happiest
physicians.)
In considering the different specialties and the disparities
in how physicians are rewarded by our society, I began to conceive of a
slightly different American class system, which determines a person's cultural status
not by income but by respect based on the visibility of a person's successes or
failures within specific groups. A key element in this structure is the low regard given the caregivers in our society. As with all my theories, this one is
half-baked and will not stand up to any rigorous investigation, but I thought
it was worth a blog entry.
The following are the five categories in my new class system,
with examples of participants, ranked highest to lowest by respect according to
our society's values --- or lack of them:
- Exploiters: Most corporate leaders, wealthy indolent heirs, people in financial services, major criminals, and long-term politicians. Some major religious figures, media personalities, performance and conceptual artists, and all cats. Although exploiters can be feared and hated by their victims, they have attained the greatest respect in our culture because of the high visibility of their success (ostentatious display of money, power, tooth and claw) and their considerable resources (money, power, tooth and claw) to conceal any failures. On the rare occasions where non-feline exploiter failures are exposed (e.g. Madoff, Nixon), their fall in cultural respect can have extreme consequences -- massive public humiliation, jail, and in some cases death, although this doesn't always happen (e.g. Limbaugh).
- Heroes: Cops, firemen, soldiers, surgeons and medical interventionalists. Heroes (except for surgeons) are not always rewarded well financially but they are ranked second in cultural respect because their successes are dramatic, immediate, and highly visible. Failure can be fatal for non-surgeon heroes and is not associated with a reduction in public respect. Surgeon failure might be fatal to their patients, in which case they do risk being sued, but not necessarily lose their place in the respect ranking.
- Observers: Most of the working and middle class, including nearly everyone who spends more than four hours a day looking at a screen and all editors, figurative artists, academics, and dermatologists. This very large group falls solidly in the neutral center, because it bestows cultural respect and disrespect, rather than having either. Neither its minor failures nor successes are very visible, and are vaguely noted only by small circles of family and friends.
- Caregivers: Most primary care physicians, nurses, teachers, social workers, baby sitters, religious professionals who practice what they preach, parents or anyone who cares for family members, plus a few short-term politicians. This group doesn't make much money, and any cultural respect paid is usually lip service. Their success relies on improving the lives of victims (see below) and it is slow and rarely visible. If they fail their victims, however, they are typically scapegoated and severely punished.
- Victims: Infants, toddlers, dogs, patients with chronic or fatal illnesses, small farmers who rely on the weather, people who get cheated sexually or financially, addicts, students in impoverished areas, and any adults without jobs and money for whatever reason. Victims have no success at all and only their failure is visible, which, except for very small children, dogs, and local farmers, is often considered to be self-imposed or caused by their caregivers. Rarely are exploiters considered causal in a victim's failure, although they usually are. Some victims are momentarily saved by heroes. Observers frequently contribute money to prop them up, but like heroic action, the success that this produces is typically brief and not visible. In general, victims are served long-term only by caregivers. (In the past one or two victims have lifted themselves visibly into the exploiter class by their bootstraps, although unfortunately no one knows what a bootstrap is anymore.)
My Place in the Class
System
I've been lucky enough so far not to be a victim (but Old
Lady Gaga lurks in the shadows). I never
had the interest or nature to be an exploiter, but I was too much a physical
coward to be a hero and too emotionally helpless to become a caregiver. My
career as an editor, writer, and publisher puts me solidly in the observer
category.
The best I can say about my place in the respect system is
that I have been a caregiver cheerleader, counting some good friends and
children in this best of all groups and spending most of my working life
providing high-level information that will save time for the family doctors,
general internists, and pediatricians -- the physician caregivers.
Caregivers: The Best Class
With Nearly the Least Respect
Caregivers, who do not turn into exploiters, have made
active life decisions to engage and not to be observers and to provide services
for both the real and imagined victims.
Caregiver incomes, no matter what profession, are nearly
always low, because they typically rely on society for salaries and they don't
kill anything and they don't steal. And,
the more victims there are, the more caregivers are needed, and the less money
there is available to pay them. So the
more work caregivers have, the less money they make.
Their success depends on the consequent improvements for the
victims they serve. If they succeed, however, they are rarely credited with
success because their actions are non-heroic, slowly progressive, and rarely visible.
(The student goes to college five years after his teacher took a chance and
gave him an A on a badly written history paper because his intelligence was
obvious in its ideas; the patient with high blood pressure controls it with
weight loss and exercise after months of badgering by her family doc; the
mental patient goes back on his meds after he's considered what his social
worker said in the emergency room a week before.)
More often then not, however, in spite of caregivers' best efforts,
they fail the victims, sometimes because victims are lazy or criminal but most
often because of intransigent barriers to success: genetics, poor environment, severe
emotional or physical illnesses, financial downturns, catastrophes, just lousy
luck, and, of course, exploitation. Unfortunately,
when something seriously bad happens to a victim under someone's care, that
failure is often visible (student drops out, psychotic kills himself, patient
has a heart attack, child is abused), and because the real causes are
unresolvable, the caregivers are often blamed and subsequently humiliated, yelled
at, fired, attacked, or sued.
So maybe there should be a sixth group--a highly loud and
visible Monster Nagging Uber Caregiver, reminding the exploiters, the heroes, the
observers, and the victims that the best chance our culture has is not only to
pay caregivers a decent income and give them the deep regard they deserve, but
to transform everyone into well-paid, publically respected caregivers. Each of us a brother's keeper. Now, where's my next victim?
