Why do I care?
Many of my friends have no idea what their parents do for a living. To me, this is shocking. Of the friends I grew up with, there is only one for whom I can confidently list her parent’s job titles―dentist and third-grade teacher.
My surprise likely comes from how often I heard about my parents’ jobs while growing up. My father is a radiation oncologist (fancy words for 'figures how much radiation to use to treat someone’s cancer') and my mother used to work as a radiation therapist (the one who actually operates a radiation machine). Not only did I hear stories about how my dad would leave little sticky notes with sweet messages for my mom at work when they first started dating (cute), but I would often hear stories about their frustrations with the healthcare system.
​
After years of hearing my parent’s frustrations about working in a hospital (and hospital-adjacent settings), I decided pretty early on in life that I wanted a career that had nothing to do with medicine.
​
Now, as I live with two of my best friends who are healthcare providers, I continue to be happy with my data science major. My friends Laran (she/her) and Kaye (they/them), a nurse’s aid and EMT respectively, love nothing more than to share stories about their workplaces. Laran's and Kaye's stories vary from incredibly heartwarming to frankly horrific.
To learn more about what it is like to work in healthcare, I interviewed my roommates and both of my parents. Particularly, I was most interested in the power dynamics that exist between my interviewees and their patients as well as between them and their coworkers. Consider this project an outsider’s peak into a few of the many corners of the healthcare system and the way these areas are run.
Thank your Nurses.
My first interview was with my friend Laran (she/her) who works as a patient care tech, or nurse’s aide, at the U of M hospital. She works on a cardiothoracic unit, with adult patients who have recently had surgery. At the time of the interview, Laran sat in what I call the “cozy corner” of my room. This corner consists of a circular chair covered by a blanket and an abundance of pillows. I sat in a chair opposite her, placed my phone on my desk, opened Voice Memos, hit record, and started off with a straightforward question.
“Can you describe what you do on a typical day at work?” Laran responded, that the main goal of her job is to assist nurses. That takes the form of hygienic care, like bathing patients, as well as helping to move any devices, tubing, or wiring that they're connected to as many patients Laran works with come to her unit from the ICU. Furthermore, Laran answers patients' call lights, takes patients' vitals, and has the responsibility to pass on anything concerning she notices about a patient to the nurses. Once she reports something to the nurses, Laran says that then "the nurses will pass that information up the chain of command."
​
Given Laran said the biggest part of her job is to assist nurses, I asked her to explain the biggest difference between her job and that of a nurse. Laran responded that nurses are allowed to administer medication and operate some medical devices, such as a left ventricular assist device (LVAD). She explained that the reason patient care techs are not able to perform these duties is that nurses have more training than a patient care tech position requires. ​
NOTE #1:
More training Equals more power
Now, this is not groundbreaking information. In every field, there are clear delineations of what one has the power to do based on the kind of training they have. Usually, these delineations are clear based on one’s title. For example, after graduation, I will be working at IBM which has different band levels. Since I will be starting at an entry-level position, I will be a band 7 employee. As I advance in my career, I will move up the band levels. For instance, my recruiter told me that in a year or two at IBM, I will likely be moved up to band 6 based on my performance.
At first glance, this makes sense. Those who have more education and expertise should be the ones making the decisions. However, as my conversation with Laran continued, it became clear that it is not easy to determine who in a hospital setting is the one with the most expertise.
​
When I asked Laran to elaborate on the previously mentioned “chain of command” she was easily able to list the hierarchical structure. Below, I have created a graphic that I find to be representative of her response.
However, as we continued talking, something struck a chord with me. I realized that another way the hospital hierarchy could be illustrated in a slightly different way.
Suddenly, I had many questions that I knew had no easy answer. How can those who spend the least amount of time with a patient be making the biggest decisions surrounding that patient’s care? Sure, an MD might be considered to have more expertise because they went to medical school, but what about the expertise nurses and their aides have both medically and about their patients as individuals? And finally, does it really make sense that a hospital has a comparable organizational structure to that of a corporate office?
NOTE #2:
The ones Making decisions spend the least time with patients
Finally, it struck me that despite the fact that the nurses and the nurses’ aides spend the most time with a patient, Laran says there is very little communication between these two the nursing side of the hierarchy and the PA, NP, and MD side of the hierarchy: “We nurses very, very, very rarely will contact doctors directly. They can and they do sometimes talk to doctors, but they work more closely with the PAs and the NPs coordinating care for the patients.”
​
Watch the video below to hear more about a time when Laran, the lowest on the chain of command, was the only one able to calm down an agitated patient and her thoughts on relations between those in her role with those higher up.
It's differnt in the field
Interestingly, when I spoke with my other roommate Kaye (they/them), I left with some different takeaways about the chain of command in their line of work.
With one conversation already under my belt, I felt more confident starting off my second interview. With Kaye set up in the same cozy corner and I at my desk I asked them the same question I asked Laran to kick things off, “Can you describe what you do on a typical day at work?” Kaye answered, that on a normal shift, they work basic life support (BLS). For Kaye, working BLS means most of their job involves taking transfers in and out of the hospital as well as between nursing homes and the hospital. Before this interview, I had heard them say that the bulk of their work is acting as "a glorified Uber driver."
In addition to regular transfers, Kaye says their toughest jobs are psychiatric transports out of the hospital ER into longer-term psychiatric care facilities. Though it is rare for Kaye to respond to an emergency call, they "do occasionally get a 'lights and sirens' call if we're in the area of an emergency call and there are not a lot of other EMTs and paramedics around."
​
Then just as I did in my previous interview, I asked Kaye the biggest difference between the responsibilities they have as an EMT and those of a paramedic. They responded, “The biggest difference is a gap in schooling and the level of care they can provide. As an EMT, I have about three months of EMT school. For paramedics, it takes about an associate's degree level of time and effort. And so they are able to do a lot more. They carry a lot more medications, they are able to do more extreme interventions. And if there's ever a paramedic on the scene, I would defer to them.”
​
Without even specifically asking about the chain of command, Kaye had already brought the topic up on their own. Taking the natural cue, I then asked, “Could you describe to me the levels of authority you encounter in your job? For instance, who reports to whom in what circumstances?” And just like Laran, Kaye was able to give me a clearly defined chain of command at their workplace.
Eager to find out more about how these levels interact, I asked Kaye to describe what happens if their ambulance were to show up to a “lights and sirens” call and no one else was there. I learned that if Kaye and their partner are the first medical responders to arrive on the scene, then they are automatically THE authority on everything medically needed until another medical unit that is either higher ranking or has more seniority arrives. Kaye stressed the importance of the hierarchy they described when it comes to an emergency setting, “the chain of command is really important. It is something that makes sure that things get done effectively. And everything gets controlled.”
Though working as an EMT is still within the realm of medicine, I realized there were a couple of key differences between Laran and Kaye’s jobs. The people who work in Laran’s unit in the hospital work together to take care of many patients at once. However, the opposite is true for those working in an emergency vehicle. For the most part, Kaye and their partner are only responsible for one patient at a time. Furthermore, most of the care Kaye performs happens in more of a vacuum than does Laran’s job. Kaye’s work takes place in an isolated, barebones hospital room on wheels. The other difference between Kaye and Laran’s job is that Kaye treats one patient for only hours at a time, while Laran works with patients that may be in the hopsital anywhere from days to months.
Considering the accelerated environment Kaye works in compared to Laran’s I found a greater justification both for the necessity and functionality of the strict chain of command Kaye operates in.
NOTE #3:
some healthcare hierarchies make sense the way they are
Insurance companies are where?!?
Finally, I turn to my conversation with my parents. The ones who initially started my interest in this topic.
​
As a reminder, before having kids, my mom Denise (she/her) worked as an X-ray technologist and radiation therapist and my dad Stephen (he/him) has worked as a radiation oncologist for 31 years.
I asked them both the same hierarchy questions I asked Laran and Kaye. Expecting similar answers to those of Laran and Kaye, I was surprised when my dad gave the following response, “The hierarchy has changed over time, but the only thing that has remained the same is that we always literally not figuratively put the patient first so they get to choose what they want, or whether they're comfortable with the treatment. The difference now is that frequently the type of insurance a patient has determines to a good degree what type of treatment they will get.” So, from my dad's perspective, insurance companies are at the top of the organizational structure.
My previous interviews were more focused on organizational structure, but I could tell this one was going in a different direction. This conversation was going to focus more on a patient’s power in a healthcare setting.
Wanting to learn more about “literally putting a patient first” I wanted to ask my dad what happens when a patient challenges his authority by questioning if his treatment plan is the best. Specifically, I asked him how he handles patients bringing something to him that they’ve found online about their illnesses. Given how easy it is to find yourself in a WebMD spiral even when you don’t have cancer, I was not surprised to learn that for my dad it has become a frequent part of his job to contend with information a patient has found online, whether it’s true or not. He says that “I sincerely tell them that I'm glad they're taking part in their own care. And then I try and help them understand how, whatever piece of information they found, fits into the bigger picture. I'd say 90% of the time they are pleased that someone acknowledges that they're working hard on their own behalf and that they can piece it together.”
However, the same conversation does not always go as smoothly. My dad says that occasionally someone is unwilling to collaborate with him in figuring out where the information they have found does or does not fit into the reality of their health, “But the other 10% of the time they're so nervous about their illness they are unable to let you try and fill in the rest of the picture for them and feel that they need to have just one thing they're holding on to like a life preserver in the ocean.”
Something that came up in my previous interviews with Laran and Kaye that I had originally brushed off because our conversations took a different turn was a patient’s right to deny treatment. As someone who’s never considered denying treatment, I wanted further insight as to why someone might do that.
​
My mom had some interesting insight on the matter and says that it’s a complex matter, especially when it comes to cancer treatment. For example, she mentioned that sometimes patients she worked with didn’t want treatment themselves, but they would go ahead with treatment anyways because their families wanted them to. Other than that, from her experience, “When I worked with people, I used to see them every day and most of them were pretty jovial. I think by the time they got to the radiation part that we helped them with, they fully knew what was going on and what they could or couldn't control.”
​
With the goal of continuing to understand more of the patient-provider relationship, I switched the conversation to asking more about how aware my parents are of the gap in the knowledge there can be between what they know about a patient’s illness and treatment from their education and job experience and what the patient understands.
​
My dad responded that when he is first meeting with a patient he tries to learn about them, like their lives and occupations, then often uses analogies based on that information when talking to them about their illness and treatment plan. He also says he, “...talks to people as if I am a friend sitting across the table playing cards” which helps make the information in their conversations more accessible and approachable from a patient standpoint.
At this point, my mom also brought up that in her experience, some patients would direct questions to her rather than to a doctor because they “didn’t want to bother the doctor” or felt more comfortable with her because they would see her much more often, sometimes on a daily basis, “...when I did the treatments of patients daily, they would more talk to us, I think because they knew or they felt like we were on a lower scale than the physician. Between us and the nurses that they saw, to them, we were more approachable than the doctor.”
This reminded me of what Laran had said in our conversation that although doctors might have more education and be considered THE experts, those who work more closely with patients are experts too, experts on the individual patients. The ones who are spending the most time with the patient get more information from the patient, but have a lot less power when it actually comes to the treatment plan.