Asking questions

When the nurse called my name, I hobbled painfully behind him to the examination room. My left knee was pathetically useless and my right knee did as best it could to keep me upright, except in those moments when she just simply gave out. It seemed in just a matter of days I had gone from moving at a fast pace, being active, going to the gym regularly to an abrupt stand still. My knees no longer cooperated. The pain in my joints was becoming increasingly intolerable. As the doctor looked at x-rays, and examined my knees, he looked at me ruefully and said there was nothing more he could do for me.

I am an academic. That means when my doctor tells me that my knees are shot and he can no longer keep them going, I start asking questions and researching my options. If I needed both knees replaced, I wanted to know what the risks were, what would recovery look like, and I wanted the best surgeon possible.

As with most academics, I did my research with a list of pre-suppositions that included: 1) the surgeon needs to be young, because that will mean that she/he is current on the most recent trends; 2) needs to have lots of experience in my particular surgery, and 3) has confidence in her/his abilities to do the surgery well. I did my research and selected a surgeon. That decision started me on a now four-month journey to have both my knees replaced.

Along this journey, I have had many discoveries and surprises; some pleasant, some painful and challenging, and some quite sobering. One of the most surprising to me has been my immersion into the health care system. Unsurprising to social workers and anthropologists, the world of surgical medicine is a well-developed system. Even in the fogged state of post-surgery and pain meds, it was quite startling to me to observe the hierarchy in this system and the affect the hierarchy had on my care.

At the top of this hierarchy, the surgeons, followed closely by anesthesiologists, and hospitalists (the doctors that manage a patient’s care in a hospital setting). At the bottom of this hierarchy are the CNA – certified nursing assistants, with the LPN – licensed practical nurses and RN – Registered Nurses somewhere in the middle. In my case, Occupational Therapists and Physical Therapist were heavily involved in my recovery. They seem to float in their own orbits, independent of the regular hierarchy.

One scene from my experience captures this hierarchical system rather well. About three days after my surgery, I developed serious complications and was quickly moved back from the rehabilitation center to the hospital. The nurses (RN) were compassionate and caring, ensuring that I was comfortable and that my vital signs were monitored. They hovered around as they waited for the internist – my hospitalist – to show up and assess the situation. This doctor was thorough, kind and thoughtful as he evaluated my options. His focus was evaluating the severity of the complications and developing a plan to address them. During these intense moments, the surgeon stopped by. Two things told me his arrival was imminent. First, all of the nurses around me, except for the supervisor, became anxious and began to step backwards toward the side door into my room. Secondly, I became aware of what the nurses had already heard. The sound of several pairs of footsteps emphatically marching down the hall toward my room. Within seconds, the surgeon and his entourage walked through the main door into my room. From their starched shirts to their polished dress shoes, they commanded attention when they walked in. Without any hesitation whatsoever, they took over. I don’t say that with irritation or harshness. I wanted someone in charge of my health that knew what he was doing, had the confidence and experience to make the difficult choices. And that’s what I had. Along with that package also comes a strong ego and arrogance. He’s good and he knows he’s good. He knows what it takes to accomplish the difficult tasks of surgery and recovery and makes no apology for demanding what he needs. Even as I reacted against his cocky, self-confidence, I also knew I could trust my health—my life to him.

It was the people at the bottom of this hierarchy, however, that were the true caregivers. Throughout these three days and as I returned to the rehabilitation center, there were the CNAs. They brought me my meals, they changed my sheets, my hospital gowns, they even bathed me and washed my hair. I can only speak from my own experience, but I have never felt so cared for; ever! Everyone of them in my almost three-week stay was gentle, kind and compassionate. Not one time did any one of them respond to me with harshness or lack of caring. My first shower came about a week after surgery. Maria came and picked me up from my room and helped me get my clothes together. Once she helped me to the shower, she gently helped me remove my hospital gown, putting me in the shower chair. With great tenderness she washed my body and shampooed my hair. As she carefully poured warm water over my hair to rinse it, my mind was drawn to the image of Jesus washing the feet of the disciples in John 13. She brought me to tears when she lovingly wrapped me in warm, fluffy towels. This woman didn’t know me from Eve, but she lovingly and tenderly cared for me.

As she helped me back to my room, I tried to communicate my gratefulness for the shower and for her care. We talked about the work that she does and she remarked that it was a gift to her to be able to take care of her patients. As I lay in my bed later that day, I pondered the contrasts between the different groups of people essential to my recovery. I am incredibly thankful for a surgeon that knew his job and did it really well and for people like Maria, who very caringly took care of my daily needs. One sobering part of this system, that raises a host of questions for me, is the contrast in compensation for each of these groups. The average salary for a Certified Nursing Assistant is $24,000; the average for an orthopedic surgeon; $424,000.[*] As someone that has spent decades getting an education and pursuing a profession, I get that my doctor has done the hard work of training and sacrifice to get where he is. I get that. But Maria has also made commitments and sacrifices and thousands like her. A patient’s ability to thrive and recover depends in no less part on people like Maria. Where is equity in this system?

My thoughts about this system came back full force as the system that I am most closely linked with took a hit this month. The university where I work has been hit with serious financial hard times and we are looking at layoffs, program cutbacks and other difficult financial decisions. We are a system of hierarchy too of staff, faculty and administrators. In tight times, how do we ethically make decisions about how the pie gets distributed or re-distributed. Faculty have worked long and hard to get an education, to invest their time and energies in research and scholarship. They often view themselves as the central cog in the educational system; one can’t educate without educators. But a university also cannot function without the staff to keep things going from maintaining technology, cleaning classrooms and bathrooms, scheduling classes, ordering textbooks and the list goes on. What does it mean to take care of faculty, as well as staff? How does a university do that ethically and equitably? I don’t have many answers, just lots of questions. I am, after all, an academic.

[*] Another systemic question for another day: what are the systemic frameworks that set up my doctor for becoming a surgeon and Maria for becoming a CNA? It’s safe to assume (I think) that they didn’t have the same options and choices before them.