On vocationalism

I often hear it said that various professions, particularly medicine, nursing and teaching, are meant to be vocations, and that it is surprising that members of these professions are often found to be uncaring and even abusive given that they must have had entered them on the basis of some sort of vocation: they must have wanted to care for people, otherwise they could have chosen any number of other professions. This is often said in response to scandals in hospitals where nurses were found not to be empathetic or caring or where doctors abuse patients or (like Dr Fawaz al-Akhras, the father of Bashar al-Assad’s wife) are found to be collaborating with a brutal dictatorship as it tries to crush dissent. Sadly, this has never been true of a lot of members of these professions.

I believe the myth about nursing as a vocation has its roots in the time when many nurses were members of religious orders, and the process of joining one is meant to include the sense of a “vocation”, of being “called” to join the order. The problem is that, when religious orders were powerful and there were plenty of young applicants or ‘postulants’ (such as in Ireland until the 1960s), people joined them for many other reasons: the prospect of having security in life and of being trained in a profession, or of respectability when there was no prospect of finding a marriage; it was also easier to get out of a religious order in the early years than a marriage, which in the Catholic church is for life once entered into. For those who go into nursing or teaching independently of any religious order, it builds on a caring skill they may already have and is a skill that is transferable from place to place and could be offered independently.

Some do have a vocation and may have decided to embark on that career in search of “something more meaningful” than a boring office job even if it makes less money, particularly after a life-changing event such as a death or severe illness in the family. However, the job may appear much less meaningful once the daily grind, and low financial reward, of it become obvious, and dealing with numerous patients, many of whom they don’t particularly like, just because it’s a job, wear down the eagerness to care that once drove them into the profession. Their attitude towards particular types of patients may be influenced by the attitudes of their peers and teachers; I once saw a TV programme about the history of the UK mental health care system in which a nurse said that, on his first day working in an unnamed long-stay hospital, he had seen a colleague hit a patient over the head with a bed-pan, and explain himself thus: “if you live among shit, you become shit”. Someone I met whose sister had very severe ME said she could not tell them about her condition or that she believed it was genuine, because she would be labelled an “enabler”, i.e. someone who was encouraging a patient with a psychosomatic illness to believe they are ill. Such conditions may make it very difficult for a nurse (or teacher) who entered the profession with the best of intentions to behave as they had intended. After all, people join any profession at the bottom, and changing the attitudes of those who have been around for a long time and can rebut any objection from a newcomer with mere assertions of seniority, can be extremely difficult.

In the case of medicine, the reasons for entering it are even more complicated and may have nothing to do with a vocation for caring. It is a scientific profession that attracts driven young men with long lists of straight A’s (medical schools are over-subscribed and you have to get straight A’s at the first attempt to get in) and big egos with perhaps more of an interest in the human body than in caring, and many of those who enter are motivated possibly by the prospect of doing something important for mankind by being a great heart or brain surgeon or something like that rather than of everyday, hands-on care. There is much more prestige in being a doctor than in being a nurse, and many families (particularly of some immigrant backgrounds) are eager to have a doctor in the family, and often pressure their sons or daughters to enter medical school even if they would rather do something else. In some countries, including Syria, the highest-ranking students are automatically entered for medical school, and there is no choice except, perhaps, the army. It is not a matter of personal vocation, but of a perceived need for the brightest and best to be in the profession that most needs them, and has the most prestige; doctors ‘exported’ to other countries, like the aforementioned Dr Akhras, can also send substantial remittances home.

As with nurses, if someone does enter medical training with a sense of vocation, this may be compromised by the reality of working in a hospital: the long hours (especially at junior level), the arrogance of some consultants, the “old-boys’ clubs” that exist in some hospitals (and social circles that are difficult to break into if you won’t attend parties where there is alcohol or at times incompatible with religious observance), or even a personal or family medical crisis that is mishandled. It may mean someone decides to go into a branch of medicine they never really wanted to be in (such as general practice) or their early ideals are corrupted, or they leave medicine altogether.

So, we cannot really appeal to people’s sense of “vocation” when tackling poor care and abuse within hospitals or other care settings (and lectures about vocationalism from a bureaucrat or MP is quite unlikely to strike a chord with an audience of underpaid and overworked nurses). The number who really felt a vocation to pursue such a career which survived several years of training and then of ill-paid junior jobs is probably pretty small. What we can do is to make clear that there is a standard of care to which we expect them all to live up to, such that patients receive dignified and respectful care that does not make their condition worse or leave them afraid to come back for any further care they may need, and those unwilling or unable to do so should get out, or face being driven out.

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