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Ethics Talk: Illuminating the Importance of Workers Who Earn Low Wages

Learning Objectives
1. Identify key ethical values or principles at stake, as described in the program
2. Distinguish among factors of ethical, clinical, legal, social, and cultural significance
3. Articulate how central themes of clinical and ethical relevance in the program can influence health care practice
4. Explain at least one way in which micro-level clinical ethics questions intersect with broader macro-level policy questions in health care
0.25 Credit CME

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

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Audio Transcript

[mellow theme music]

Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff.

Health care organizations' functioning relies on thousands of workers who are paid dismal wages. The median wage of support, direct care, and service workers in health care was $13.48/hour in 2019, with home health and personal care workers earning a median hourly wage of only $11.57. In 2019, nearly 20 percent of these workers lived in poverty, and more than 40 percent were poor enough to qualify for public assistance. And despite widespread support for raising wages for workers earning low wages, clinicians of status often don't know how to use their own positions of influence.

Noelle Driver, MD: Higher-wage workers in these health care systems may genuinely care about their colleagues, but they don't have the vocabulary or tools or the awareness to really know how to advocate for these groups.

Hoff: That was Dr Noelle Driver, the editorial fellow who curated this issue with us on what we owe workers in health care who earn low wages.

Demand for long-term care workers in the U.S. is growing, and Dr Driver urges recognition of the key roles and sources of knowledge these and other underpaid workers bring to caregiving.

Driver: For example, home health aides may be one of the only consistent social supports to individuals aging at home. And because of this, there's often a real deep connection with their clients. They go above and beyond their job descriptions to provide companionship, and a lot of work happens off of the clock.

Hoff: In addition to improving working conditions for workers who earn low wages, clinicians of status are ethically obliged to become robustly aware of how these workers share duties to care for the same patients.

Driver: It's really interesting to me that a home health aide would be so disconnected from a primary care physician tending to the same patient. And the care that happens in each of those spaces has influence on that patient and matters to their care in the opposite space. So, what a primary care physician prescribes, whether it can be successfully accomplished at home matters to the home health aide's job, and likewise, the home health aide's insight into the home situation has tremendous impact on working with the patient in a primary care setting. And likewise, take that to the inpatient setting. So, all of us really should be on the same team, but I don't think that's happening currently to the extent that it should.

Hoff: Joining us now is Phoebe Cohen, a comic maker and illustrator whose work draws on, among other things, her past experience as a paramedic and a home health aide. She's here to discuss what her experience in low-wage health care work taught her about our perceptions of low-wage positions and the people who do them. Phoebe, thank you so much for being on the podcast with me today.

[music fades]

Phoebe Cohen: Thanks. Glad to be here.

Hoff: So, to begin with, could you introduce yourself and your work to our listeners?

Cohen: Absolutely. My name is Phoebe Cohen. I'm an illustrator for the American Medical Association Journal of Ethics and also The Nib. I'm an illustrator and a paramedic and a former home health aide. I became a home health aide around 2012, and then I later got my certification for EMT in 2015. And then at the beginning of 2016, I got my certification for EMT paramedic, and I have been practicing EMS emergency medicine for several years now, though I'm currently now going into nursing school. So, I'm on a bit of a hiatus.

Hoff: Oh, I didn't know that. Congratulations.

Cohen: Thank you. [chuckles]

Hoff: So, much of our theme issue this month considers workers who earn low wages from within large health systems that is on their relationship [sic] with other health professionals of status like physicians and with the large health care organizations that employ them. Much of your experience, however, found you working outside of the hospital, as you say, as a home health aide or as a paramedic. So, what have your experiences with the public taught you about how we regard health care workers who don't occupy the positions of status that people like physicians or surgeons do?

Cohen: Well, I think I was a little shocked, first, both as a home health aide and also as someone who has very elderly grandparents, that we desperately rely on home health aid.

Hoff: Mmhmm.

Cohen: And it's sort of bizarre that we don't value them more in society. Like, for example, I was a home health aide in Florida for several years. And during that time, there were several hurricanes that hit Florida, and the media was quite justifiably honoring first responders like fire fighters and paramedics and EMTs who were staying and helping the community through the sometimes weeks-long power outages that can happen in Florida when the temperature indoors can hit 100, 110 because there's literally no air conditioning. But nobody was talking about the home health aides who had to stay in the nursing facilities, the skilled nursing facilities, who had to stay in their nursing homes, who had to stay in the assisted living facilities to make sure those patients—our parents and our grandparents—stayed alive during the hurricane. Our society honors sort of more…the more male-dominated paramedic, paramedicine, like EMTs, paramedics, all that. But when it comes to substantially female-dominated, substantially women who are people of color, sort of who are disproportionately represented among home health aides, society takes them for granted.

Hoff: Mmhmm.

Cohen: It's like, whoa, yeah. Yeah, yeah, they're doing a good job, too. We're very glad that they're staying in the nursing homes. Now, let's honor our heroes out there in the ambulances and fire trucks, which we should!

Hoff: Mmhmm, mmhmm.

Cohen: But we need to include home health aides, too.

Hoff: Right.

Cohen: We absolutely do.

Hoff: Right. Yeah, it's an issue of also, not instead.

Cohen: Exactly.

Hoff: Can you talk a little bit about… more about the breakdown, sort of the gender breakdown that you see? You wrote that piece for I think it was HuffPost about the way that certain patients interact with you as a paramedic. And they maybe question your ability or qualifications or just strength, things like that. Can you talk a little bit about that experience?

Cohen: Yeah, absolutely. So, I will say during the years that I worked as a home health aide, I met many other home health aides. I also worked in an older adult day program where older adults could spend the day while maybe their adult children were at work. And during that entire time, I think I only met one man who was a home health aide.

Hoff: Hmm.

Cohen: It's almost entirely female dominated as a home health aide profession. Disproportionately, the women tend to be women of color.

Hoff: Mmhmm.

Cohen: And okay, and just, I am not a woman of color. I am white.

Hoff: Mmhmm.

Cohen: And I do remember this one time when I was visiting the home of an elderly woman who, you know, it had gotten to the point where she was basically okay living by herself, but she needed some help cleaning her house. She was almost completely blind, and she had someone to help her clean the kitchen, clean the bathroom, make sure that her meds were in the right containers, all that stuff.

Hoff: Sure.

Cohen: And she also was visited once a week by an RN, a registered nurse. And registered nurses are very, very highly trained professionals. The RNs are sort of, they're considered far higher in terms of the social status as a medical professional than a home health aide.

Hoff: Mmhmm.

Cohen: And I remember the RN was scheduled to be there at the time I was working at her house, and I was in her bathroom scrubbing the toilet. And her daughter comes in, and she knows that the RN is scheduled to see her mother. So, she comes in, and she sees me in my scrubs, scrubbing a toilet.

Hoff: Right.

Cohen: And she looks at me, and she says, “Are you the RN?”

Hoff: Hmm.

Cohen: Which is odd. I'm like, why would she think that? And then I suddenly realize she is used to seeing women of color do the job that I'm doing. She's not used to seeing a white woman do that job. So, the fact that, you know, the fact that people are sort of assuming essentially, like when people are saying that this utterly necessary branch of the medicine, which is home health aides, they're just not getting recognized, and they also happen to be a branch of the profession that is disproportionately represented by women or disproportionately represented by women of color, I mean, it's hard not to read a sort of institutionalized racism that might be contributing to why we don't recognize home health aides as the absolute essential part of medicine that they are.

Hoff: Hmm. Yeah. Thank you for highlighting that angle of this conversation. In addition to the various health care positions that you've held that we've mentioned in the introduction, you're also a comic maker and an illustrator. And obviously, regular readers of the Journal will be familiar with some of your work in the October 2019 issue, I think it was, for example, as well as a number of illustrations throughout since then. How do comics and other illustrations help illuminate the key ethical concepts that are relevant in low-wage positions and for those who do them?

Cohen: People just, you know, the old saying, “A picture is worth a thousand words.”

Hoff: Mmhmm.

Cohen: I've noticed when I put in a picture, when I even look at a photograph—and this is just me. I'm not talking about society at large, but this is just me. And I think it can be expanded to society at large—I am far more…my attention is far more caught when I see a picture that is, you know, that really portrays a story. We don't really read as much as a society the way we used to. So, if somebody has a large article about, “Listen, this is why home health aides aren't really being recognized the way they should,” not a lot of people are going to read it, you know. Not a lot of people have the free time to read it. But if I put it in a cartoon format, it sort of allows people to read it in a much quicker fashion, digest the knowledge in a much quicker fashion, and sort of understand in a much quicker fashion.

Hoff: Hmm.

Cohen: Like, even if you're a teacher, if you say something along the lines of, “Oh, this is how gravity works,” and you just give them a verbal description or give them just a page of text, the student doesn't understand.

Hoff: Mmhmm.

Cohen: If you show them a video or a little computer animation or even a cartoon that shows a visual depiction of how gravity works, they will remember it. So, I do think that talking about subjects that people don't usually see portrayed in graphic novel format, like medicine, like growing old— And I'm just going give a quick shoutout to Roz Chast here, you know, Can't We Talk About Something More Pleasant?

Hoff: Sure.

Cohen: Like, that was, I think, the first time I saw sort of the taboo subject of caring for aging parents or people who took care of you are now basically completely dependent and helpless on you and on the doorstep to dying, that's the first time I've seen that portrayed in a graphic novel. And I think she just busted down so many barriers there. I absolutely love that book. And it's really one way in which people can say, “Let's broach subjects that we don't often talk about,” like, say, the parts of the health profession that are not really glamorized in society. And let's do it in a way that's very visual and in a way that will make people see it and understand it very quickly.

Hoff: Mmhmm.

Cohen: And I think illustration really does it so much better in many ways than articles, sort of just simple text articles.

Hoff: So, in addition to sort of allowing space to talk about taboo subjects in a frank way, do you think there's a way in which illustrations and graphic novels and things like that also make people more comfortable with uncomfortable subjects? For example, if you're broaching the same subject through an article and through a comic, do you find that in addition to the comic potentially being more striking and more memorable, do you find that people are more willing to accept the premise if it's presented in, I guess, what might be seen as a less threatening way? Not that difficult subjects always need to be made less threatening to audiences, but do you think there's something there?

Cohen: Oh, yeah, absolutely. Absolutely. I think, yeah, I think just seeing something in a visual format just makes people understand a lot better. And when you understand something a lot better, you are, in my opinion, I think psychologically, you are more easier [sic] to feel more empathetic towards the person, towards the creator's position than if you don't quite understand it.

Hoff: Sure, sure.

Cohen: And yeah, in that case, you know, in that position, that's how I think people like, once again, going back to Roz Chast, people like Roz Chast, who's talking about unpleasant subjects or not—well, all right. I'll use the word “unpleasant,” but also subjects that we don't talk about. I'm going to use the word “unglamorous”—unglamorous subjects like eldercare and all that in a graphic novel format, that really did help bust open a lot of the way people were understanding, the way people were saying, “Oh my gosh, what I'm going through with my grandparents, with my parents, so many other people are going through as well.” Or people who are realizing, “I might be reaching that stage soon with my aging relatives,” they start considering certain measures and not just realize thinking, “Oh, we don't talk about that stuff.”

Hoff: Mmhmm.

Cohen: You know, like the title says, Can't We Talk About Something More Pleasant?

Hoff: So, to wrap up, what do you think that health professions students and trainees, and especially those training to be physicians and surgeons and health professionals of status, should know about their relationship to workers who earn low wages?

Cohen: Oh, please, please, please be empathetic and please value them, please. You have absolutely…you're seeing… if you're looking at an elderly patient, you're seeing that patient for five minutes, and they're living with that patient. They're preparing meals. They're having conversations with that patient. They're there for that patient when that patient may not have children or may not even have nieces and nephews taking care of them. And I mean, any physician knows that emotional health plays such a huge role in making sure physical health gets better and better. There are articles talking about patients who are depressed but have every other physical aspect in a healthier wavelength somehow get more heart attacks than patients who even may be physically not so great but have a better emotional state. Emotion so resonates with physical health, and the people who are taking care of the emotional state of more elderly patients or patients who need 24-hour care are the home health aides. [mellow music returns] Home health aides are so essential to our society, and they really need to be treasured more than they are.

Hoff: Phoebe, thank you so much for being on the podcast and sharing your experience and for obviously, the continued work that you do with the Journal.

Cohen: Yeah. Thank you so much for having me on. This has been really enjoyable.

Hoff: That's our episode for this month. Thanks to Dr Noelle Driver and Phoebe Cohen for joining us. Music was by the Blue Dot Sessions. To read the full issue, head to our site, JournalOfEthics.org. And for all of our latest news and updates, follow us on Twitter and Facebook @JournalOfEthics. Be sure to check out our latest podcast series, Ethics Teaching and Learning, where we talk with educators on how to teach complex ethics content to health professions students. New episodes of that series on the 15th of each month. Ethics Talk will be back at the first of next month with an episode on pricing in health care. Talk to you then.

Audio Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

CME Expiration Date: 09/01/2025

Credit Designation Statement:  The American Medical Association designates this Enduring Material activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to: 

  • 0.25 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
  • 0.25 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 0.25 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
  • 0.25 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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