Women cannot afford “nice”: The unpaid labor of gendered caregiving

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Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Karen Kelly-Blake, PhD

Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.” -Audre Lorde

Much has been written about finding meaning in illness. Others have written about finding meaning in caregiving. But taking care of someone else’s s!#t has its own intrinsic meaning, and for much of the time, it’s not all good.

For some, doing this work may allow them redemption—to repent for past wrongs, or it might allow them to display their humanity in ways they have not done before. Some may experience joy with self-sacrifice. I wish you well. Amid the crucible, women are performing all sorts of gendered work, and especially gendered care work. What do I mean by that? Women perform the majority of caregiving work to family and friends, i.e. women are the ones taking care of someone else’s s!#t. This work is unpaid, labor intensive, and career limiting if not career destroying.

Multitasking woman with six arms illustration
Image description: An illustration of a faceless woman with six arms, each arm holding objects that represent a particular set of tasks: correspondence, computer work, food, entertainment, cleaning, and childcare. Image source: Multitasking Vectors by Vecteezy.

Care work offers few rewards, but it is necessary, and it is often silently expected of women. Unpaid labor that diminishes or denies opportunity for growth and sustenance is unfair, unjust, unsustainable, and wrong. Caregiver resilience may be a thing but is most likely a statement of privilege. Women do the work to the detriment of self-care, careers, outside friendships and interests, and other family relationships. Un- and under-paid gendered care work is a real and present danger to the overall wellbeing of women. As a society, we cannot keep telling women that this kind of gender discrimination in care work, especially for their family, is okay. It is not okay. Women must acknowledge all the ugliness that comes with taking care of someone else’s s!#t—the resentment, anger, frustration, disappointment, loss, fear, disgust, exhaustion, defeat.

So, who will do this work?

Dare I say, salaried home health assistants with all the benefits afforded fully employed persons—health insurance, retirement, educational assistance, PTO, etc. BUT then, who will do that work? Women, and more specifically women of color and immigrants. Whether women do it as unpaid family labor or as salaried health aides, women do care work. It may be reasonable to assume that the salaried worker may be better able to handle the emotional demands of the work. The unpaid family care worker is burdened with history, regrets, slights, insults, lies, disappointments, unforgiven and unforgivable acts, whereas the salaried care worker is not burdened with that baggage, and thus, may be a better and perhaps even a more caring caregiver. Absent the burden and weight of historical relationship bonds, women—as daughters, sisters, spouses, and mothers—may be able to find meaning in just being themselves.

Although the inequity of gendered work has always been there, the COVID-19 pandemic has shed revealing light on this inequity, just as it has on racism. Women are performing job duties remotely from home, becoming teachers, chefs, activity directors, housekeeping staff, laundry workers, and of course the calm in the storm, etc. Working the second shift does not go far enough in describing that reality—women hold on average about 100 jobs that are unpaid! These jobs historically have been the purview of women, but gendered work in the home is the cause of much friction in marriages. Moreover, women are balancing care of children with the care of parents, at times both their own and those of their spouse. Those women fortunate enough to retain their jobs and work remotely were immediately immersed in work that was unfamiliar and, in many cases, unwanted—24/7 care and attention to children, spouses, and others. For those caring for the ill, the disabled (mentally, physically, or cognitively), or the aged, or any individual with any range of functional and psychological limitation, the pandemic significantly increased the workload. Many people do this care work because they want to, out of whatever love and obligation they have for the care receiver. For others, there is no one else to do the work and it may feel, and indeed be, life limiting. Engaging in this work during a pandemic is especially challenging.

Oftentimes, a crash course in highly technical aspects of care (flushing ports, inserting feeding tubes, cleaning wounds, managing LVADs, etc.) leaves one completely bewildered. This disjuncture between necessary specialized care exposes the schism in care work that overwhelms and burdens.

Photo of woman on the floor with hands over her face
Image description: Image description: A woman sits on the floor leaning against the back of a couch. Her elbows are resting on her knees with her hands clasped together over her face, eyes closed. Image source: Pixabay.

Because of shelter-in-place orders, the pandemic has also heightened concerns about domestic violence, child abuse, elder abuse, and alcohol and substance use disorders. We consequently will need to ramp up behavioral health and trauma-informed care services. Sadly, history predicts how unlikely we are to effectively meet this challenge. Essential caregivers unable to work remotely have had to expose themselves and their children to increased risk of disease, because their children had to remain in daycare or in multigenerational spaces with no means to isolate.

Gendered care work can no longer hide under the auspices of family love and selflessness. Caregivers oftentimes die before the care receiver. There is nothing heroic or laudable about a preventable early death. Too much togetherness can breed resentment. There is always something needed, an ask or a want. There is little give in return. Even a sincerely offered “thank you” neither diminishes nor alleviates profound fatigue.

How do we mitigate the harmful effects of such inequitable gendered expectations?

  • Recognize the gender inequity of care work and the harm such blindness inflicts.
  • Pave the way for long-term care access, regulation, and insurance.
  • Pay care workers (both in institutional and home health settings) a salary with PTO, retirement, and benefits (educational and promotion opportunities).
  • Provide paid family leave for family and friend care workers, so that they can focus on the care work they want to do without worrying about economic self-harm.
  • Ensure enhanced respite care and family mental health support.

Taking care of someone else’s s!#t is hard, labor-intensive work, both physically and mentally, and it must be recognized as such. We can no longer silently accept the gender discrimination inherent in care work. We all must bear the burden and the weight, and take care of each other’s s!#t.

Disclaimers: The title is gendered caregiving, which, for the purposes of this blog, focuses on the traditional gender binary of women and men doing caregiving. While clearly in the minority, men do provide unpaid care work. I afford no special credit for doing this work because one is a man. It is akin to saying, “my husband is babysitting the kids”—um, no they are doing the hard work of parenting. My goal is to highlight the burden of care work that is performed primarily by women. Women do not get gold stars for work that they have historically been expected to do.

The author acknowledges her own lifelong role as a caregiver. I do not aim to speak to every person’s experience with doing this work. Instead, I seek to highlight that the continued gender inequity and unpaid labor of care work harms women. If we are to be a just society, it is imperative for us to take care of the caregivers.

Karen Kelly-Blake photoKaren Kelly-Blake, PhD, is an Associate Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine in the Michigan State University College of Human Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, July 30, 2020. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Kelly-Blake: The Burden of Serving: Who Benefits?; Patient dumping: why are patients disposable?Incarcerated AND Sick: At Risk for Pain, Injury, and DeathWhite Horse, White Faces: The Decriminalization of Heroin AddictionRacism and the Public’s Health: Whose Lives Matter?Concussion in the NFL: A Case for Shared Decision-Making?

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Brittany Ajegba presents at Diversity in Medicine Conference

In early March, College of Human Medicine student Brittany Ajegba presented at the second annual Diversity in Medicine Conference at the University of Michigan in Ann Arbor. Ajegba presented a poster titled “Rationales for expanding minority physician representation in the workforce: a scoping review.” The poster presented the work of a multi-institution research team comprised of Karen Kelly-Blake (MSU), Libby Bogdan-Lovis (MSU), Nanibaa’ Garrison (UCLA), Faith Fletcher (University of Alabama at Birmingham), Brittany Ajegba (MSU), Nichole Smith (University of Chicago), and Morgan Brafford (Walden University). The team’s scoping review of the same name was published in the September 2018 issue of Medical Education.

Ajegba shared her experience on attending: “I was so happy I was able to attend and present at the [conference]. While I got to present on our physician-patient racial/ethnic concordance research, it was great to see what researchers from around the country are doing to address underrepresentation in medicine. Being from the area, it was nice to reconnect with future colleagues and to see what work was being done around various topics of diversity in medicine that included but was not limited to: unconscious bias projects, pipeline programs, LGBTQ+ healthcare, and much more.”

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Image description: Brittany Ajegba smiles next to her poster that is pinned on a display board at the Diversity in Medicine Conference. Photo courtesy of Brittany Ajegba.

The team’s poster presented findings of their scoping review of the 2000-2015 literature on strategies for and approaches to expanding underrepresented minority (URM) representation in medicine, “which reveals a repetitive, amplifying message of URM physician service commitment to vulnerable populations in medically underserved communities. Such message repetition reinforces policies and practices that might limit the full scope of URM practice, research and leadership opportunities in medicine. Cross-nationally, service commitment and patient-physician concordance benefits admittedly respond to recognized societal need, yet there is an associated risk for instrumentally singling out members of URMs to fulfill that need. Additionally, the proceedings of a 2001 US Institute of Medicine symposium warned against creating a deterministic expectation that URM physicians provide care to minority populations.”

Listen to Episode 6 of our podcast series No Easy Answers in Bioethics, featuring Libby Bogdan-Lovis and Dr. Karen Kelly-Blake, to learn more about this ongoing research.

The Burden of Serving: Who Benefits?

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Karen Kelly-Blake, PhD

“We overworked, underpaid, and we underprivileged
They love us, they love us (Why?)
Because we feed the village”

– Killer Mike of Run the Jewels
“Lie, Cheat, Steal,” Run the Jewels 2 (2014)

In the United States, persons of color suffer disproportionately from a host of health care disparities related to racism, discrimination, lack of access, and undertreatment. When considering this disproportionate suffering, it is relevant to note the impact of the current physician shortage. That shortage is especially acute for underrepresented in medicine (URiM) physicians. Moreover, it is equally salient to recognize that URiM physicians provide care for underserved populations at levels disproportionate to their professional representation. There is a powerful narrative that a diverse and representative medical workforce, one reflecting general population characteristics, can effectively address access issues, increase satisfaction, and ultimately improve health outcomes. It seems reasonable to surmise that shared concordant characteristics (e.g. race/ethnicity, language, gender, geographic location, etc.) between patients and physicians might lead to improved communication and satisfaction in the clinical setting. Alsan et al. found that black patients paired with black physicians were more likely to agree to preventive screening, leading the authors to conclude that the racial/ethnic concordance between patient and physician was a significant factor for the observed increase in screening adherence. Kelly-Blake et al. found that the most mentioned rationales for increasing patient-physician concordance were patient-physician relationship and service commitment to care for the underserved.

A 2001 IOM (now the National Academy of Medicine) report warned that “we must be vigilant against the potentially pernicious effects of creating the expectation that minority physicians are being trained solely to provide health care services to minority patients or to research minority health issues.” It is now 2019 – nearly 20 years on – and so it seems a good time to revisit that prudent caution. Have we heeded the IOM’s prescient warning? I invite you to join me for a brief thought experiment. Suppose we made the profession of medicine responsible for caring for our most vulnerable—the sickest sick and poorest poor? Imagine that all patient panels included a significant number of homeless, poor, mentally ill, and uninsured. Imagine an equal, fair, and just distribution of medical care service to the underserved. The described distribution would lighten the service expectation on URiM physicians. We know that URiM physicians bear a disproportionate burden of providing care for the most vulnerable patients in the most challenging resource poor environments. It’s not unreasonable to imagine how such a burden might substantially constrain their ability to meet quality care metrics for reimbursement. Moreover, as we move from volume to value for reimbursement, for those URiM physicians who carry comparably higher educational loan debt and work to a greater degree than their white counterparts in resource poor communities with the sickest sick, the challenge of achieving measurable improvements in quality care would seem untenable.

The individual altruistic motivations of URiMs to “give back,” “make a difference,” and “help the community” are powerful. And indeed, those motivations are likely influenced by “community” expectations that people will return “home” to practice. Certainly, URiMs have valuable insider experiential knowledge about navigating the challenging, socially-layered U.S. landscape. Those perspectives would undoubtedly bring an enhanced sociocultural perspective to the clinical encounter. Community expectations align with similar sentiments. Individuals coming from underserved communities who desire to become a physician are often supported, encouraged and, yes, expected to come back to serve in the community. The community understandably holds out hope that someone from the neighborhood will come back and do good work for the community. While understandable, is such a community expectation fair?

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Image description: an individual with angel wings wearing blue surgical scrubs, a face mask covering their mouth, a cap, and glasses is standing with their arms crossed in front of a neutral background. They have a stethoscope around their neck. Image source: Sathish Kumar Periyasamy from Pixabay.

Desire to serve and to give back are laudable and admirable virtues, but is the “narrative of service” subtext disproportionately and perhaps unfairly limiting URiM potential professional opportunities? In our desire to have URiMs serve the underserved as physicians, are we paradoxically denying them opportunities to serve the profession of medicine as Chairs of Departments, Deans of Medical Schools, Chief Executive Officers of Hospitals, or Heads of NIH? Are we saying, “welcome to the house of medicine, but we need you to work in the basement kitchen”? If URiM have become the workhorses of medicine, who then is provided the opportunity to become the stallions and thoroughbreds? White medical student and physician counterparts do not receive the same targeted messaging about service commitment.

Research has shown that higher numbers of primary care physicians lead to better health and decreased mortality. Despite the call and the need for more primary care physicians, medical students are not choosing primary care specialties. Mona Signer, CEO of The Match, suggests that income is a factor because choosing a non-primary care specialty means a higher paycheck. The highest paying specialties remain overwhelmingly white and male. Who then is allowed the unfettered freedom to make the non-primary care specialty choice? Who gets to have access to opportunities untied to community and societal expectations? The burden of serving exhausts URiM talent and expertise. So, who reaps the benefits? If the argument is that: 1) society benefits from more primary care physicians in underserved areas, especially critical in rural areas, 2) medical schools benefit by meeting more stringent LCME accreditation requirements for student diversity, and 3) patients benefit by having physicians in their community that look like and sound like them, then undertaking strategies to ensure a broadly representative medical workforce is indeed a national priority. But, if the argument is that URiM value is to “serve the underserved” then the IOM warning has indeed been ignored. Racial congruity alone is insufficient to address the disparities gap in U.S. health care, and like-to-like patient-physician matching may dangerously and perversely heighten discrimination against URiM physicians.

URiM should not be selectively steered, based solely on assumptions of their background, to pursue a particular medical career pathway. The healthcare workforce should reflect the nation’s population and equally, it is still fair and just to question why we are channeling URiMs to do work not expected of the entire medical workforce. How might we ensure equity of healthcare work practice? Ensuring such equity is a moral obligation and the right thing to do. Professional fairness and responsibility within medicine mandate that the medical workforce equitably and fairly assume shared responsibility for meeting the healthcare needs of the underserved. Continuing an expectation of burdening the already overburdened is not just health care.

Karen Kelly-Blake photoKaren Kelly-Blake, PhD, is an Associate Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine in the Michigan State University College of Human Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 1, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Kelly-Blake: Patient dumping: why are patients disposable?Incarcerated AND Sick: At Risk for Pain, Injury, and DeathWhite Horse, White Faces: The Decriminalization of Heroin AddictionRacism and the Public’s Health: Whose Lives Matter?Concussion in the NFL: A Case for Shared Decision-Making?

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Medical workforce diversity research published in ‘Medical Education’

Karen Kelly-Blake photoLibby Bogdan-Lovis photoAn article from a multi-institution research team led by Center Assistant Professor Dr. Karen Kelly-Blake and Assistant Director Libby Bogdan-Lovis has been published in the September 2018 issue of Medical Education.

In “Rationales for expanding minority physician representation in the workforce: a scoping review,” the authors discuss “rationales for and approaches to expanding under‐represented minority (URM) physician representation in the medical workforce” found in their scoping review of fifteen years of literature.

The full text is available online via Wiley Online Library (MSU Library or other institutional access may be required to view this article).

Dr. Kelly-Blake and Libby Bogdan-Lovis further discussed their article in an interview for the Medical Education podcast series.

Related items from the Center:

Episode 6: Medical Workforce Diversity and the Professional Entry Tax

No Easy Answers in Bioethics logoEpisode 6 of No Easy Answers in Bioethics is now available! This episode features guests Libby Bogdan-Lovis, Assistant Director of the Center for Ethics and Humanities in the Life Sciences, and Dr. Karen Kelly-Blake, Assistant Professor in the Center for Ethics and the Department of Medicine at the Michigan State University College of Human Medicine. As leaders of a multi-institutional research team, they were interested in examining strategies and associated rationales for expanding underrepresented minority presence in U.S. undergraduate medical education. In this episode, they provide insight on what their scoping review has revealed, focusing on the notion that underrepresented minorities in medicine are often expected to pursue a service track—an expectation not placed on their white majority peers.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

Dr. Kelly-Blake presents at National Association of African American Studies and Affiliates Conference

Karen Kelly-Blake photoOn February 15-16, Center Assistant Professor Dr. Karen Kelly-Blake attended the National Association of African American Studies (NAAAS) and Affiliates 25th Joint National Conference held in Dallas, Texas. This conference marked the 25th gathering of scholars from across the U.S. and more than twenty countries. Dr. Kelly-Blake’s presentation was titled, ““Danger Talk”: The Covert Costs of Racial/Ethnic Concordance in the Medical Workforce.” The presentation reported preliminary results of a 2000-2015 scoping literature review that examined medical workforce policy strategies for increasing under-represented minorities in medicine. The research is a multi-institutional collaboration with Libby Bogdan-Lovis, MA (MSU), Nanibaa’ Garrison, PhD (University of Washington), Faith Fletcher, PhD, MA (University of Illinois at Chicago), Brittany Ajegba, MPH (MSU), Nichole Smith (Vanderbilt University), and Morgann Brafford, BS (MSU).

Dr. Kelly-Blake discussed the rationales and strategies that are employed to increase under-represented minority (URM) physician workforce capacity. She began by asking the audience to provide reasons for why it would be important to increase URMs in the medical workforce. The top three replies were: communication, cultural sensitivity, and the need to reflect general population demographics. Dr. Kelly-Blake agreed with the audience that these are often the primary justifications provided in the literature. Under-represented minorities (URMs) disproportionately shoulder the burden of care to the underserved, and most often in under-resourced communities. The problem, or the “danger talk” is that selectively placing service expectations not similarly placed on White physician colleagues along with unexamined assumptions of racial/ethnic concordance between patient and physician may place an unfair and unequal burden on URMs. Dr. Kelly-Blake further suggested that such service commitment rhetoric might unwittingly dissuade URM physicians from pursuing research and professional leadership opportunities. In short, welcoming URM physicians into the “house” of medicine, but then limiting their service to the kitchen. Dr. Kelly-Blake concluded that increasing URM physician presence in the medical workforce is indeed admirable and welcomed, but policy initiatives that influence URM’s futures in the medical workforce may have hidden, unanticipated and restrictive consequences.

To learn more about this research, watch the Bioethics Brownbag & Webinar Series talk from Dr. Kelly-Blake, “Covert Costs of Racial and Ethnic Concordance in the Medical Workforce,” recorded on January 18, 2017.

Covert Costs of Racial and Ethnic Concordance in the Medical Workforce

bbag-icon-decCovert Costs of Racial and Ethnic Concordance in the Medical Workforce

Event Flyer

Over the past century US medical workforce demographics have shifted. Moving away from a white male dominated profession, there is a welcomed push towards increasing gender, ethnic, racial and linguistic representation. Commonly, that push is linked to notions of desirable doctor/patient identity matching – described here as “concordance.” That demographic shift is accompanied by policy initiatives and rhetoric shaping the professional futures of Native American, African American, and Latino underrepresented minority (URM) physicians. Do these policy initiatives carry social costs that inadvertently influence URM’s futures in the medical workforce? This analysis considers the nature of medical workforce policy strategies. Findings suggest that selectively placing service expectations not similarly placed on their non-minority physician colleagues along with unexamined assumptions of racial/ethnic concordance between patient and physician may place an undue burden on URMs.

jan18-bbagJoin us for Ms. Bogdan-Lovis and Dr. Kelly-Blake’s lecture on Wednesday, January 18, 2017 from noon till 1 pm in person or online.

Dr. Kelly-Blake is an Assistant Professor in the Center for Ethics and the Department of Medicine. Ms. Bogdan-Lovis is the Assistant Director for the Center for Ethics. Bogdan-Lovis and Kelly-Blake are co-leading a multi-institutional research project on Doctor-patient Race/Ethnic Concordance in the Medical Workforce. They are interested in unpacking the complexities surrounding underrepresented minority service to the underserved and how that service may distract those physicians from pursuing other medical professional opportunities.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lectures. To receive reminders before each webinar, please subscribe to our mailing list.