Respect: Another Way of Looking at Class Structure

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:

1. 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).
2. 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.
3. 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.
4. 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.
5. 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.) 

The amount of respect and status bestowed on individuals in these groups has nothing to do with whether they are good or not. Although most exploiters are bad, many lose power and money and transform into other categories, usually victims.  Heroes and victims can be either good or bad, sometimes in the extreme. Observers shuffle back and forth between mild versions of the two states, typically living out their lives in variations of guilt, resentment, and smug contentment. Caregivers are generally good, just by virtue of their choices, but a caregiver who turns bad is bad indeed, typically transforming into an exploiter.

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?