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Commie musings from the bedside

A hospital worker’s reflections

D.A. Wood reflects on the ideology that underpins the hospital.

The intelligentsia opted to redeploy me as a commie spy to a New Orleans hospital during the ongoing pandemic. Or at least that’s how most days at work feel. In the movie version, however, I’m not the strapping Bond villain conjured from stale Cold War fears, but Mr. Bean. The slapstick involving bedside commodes would all be based on true events.

During the previous decade, I spent much of my time studying the works of Fanon and Foucault, often exploring their various methods in armchair-friendly settings. I admired the powerful effect of their work within hospitals on their subsequent theories and praxis, though I hadn’t yet had such experiences myself. In addition to adjuncting online, I’ve spent the last year and change working as a Patient Care Technician (PCT) on a Med/Surg floor of a private, inner-city hospital. When not running down the halls, I now sometimes find myself in new reflective chairs—listening to patients, answering call-lights, waiting for vastly improbable adverse vaccine reactions, monitoring cardiac telemetry, watching the same glucometer tutorial for the seventeenth time, and so forth. What follows are some thoughts from these new seats.

A typical day on the floor begins at 6:45 AM with a short meeting known as the ‘huddle,’ a typical, abbreviated version of which runs something like the following.

Scene: Bach’s Fugue in D Minor resounds from the dialysis room to the dissonant accompaniment of screechy Sirens—from the call bell to bed alarms to AvaSys cameras to completed IV infusions to DynaMaps to a host of their automated, attention-seeking kin.

“Good morning, Ladies and Dan. The Joint Commission has been cleared to come any day, any time. Clean, prepare, and reorganize accordingly by taking an ownership mentality rather than a renter’s mentality of our floor. Our rooms are full of COVID-19 patients and we’re short on nurses and PCTs. Everyone, including me (the charge nurse), will have to take one for the team, taking six patients. Ask for support from your designated buddy before coming to the charge nurse. Folks are still not charting enough on central lines and catheters! Remember: if you didn’t chart it, it didn’t happen. There were two falls last night. Make sure every bed alarm is on and consider setting up more AvaSys cameras. Please show empathy to each other and to your patients—remember why you chose to become healers and heroes in the first place. There’re lots of extra cookies and donuts in the breakroom, so please help yourselves. We’re going to have a great day, y’all.”

Like a carnival ride operator’s repetition of rules before entry, huddle prepares us for our twelve-plus-hour ride in the funhouse where laughing, screaming, crying, and emesis are typical, daily occurrences. But like the visual perceptions of those who wear upside-down goggles for a period, hospital workers spend so much time in the funhouse that we’ve adapted to its topsy-turvydom. We hardly notice, for example, how capitalist ideology suffuses even huddle, disfiguring our lives and livelihoods. Let’s inspect a few of the different carnival mirrors and the overlapping distortions they reflect.

First, modern hospitals oblige their workers to accept a peculiar first principle: “If you didn’t chart it, it didn’t happen.” Since this proposition does not itself get charted, but instead governs the very process of charting, let’s call it ‘the charting principle.’ The conditional, “If you didn’t chart it, it didn’t happen” is logically equivalent to “If it happened, then you charted it.” Upon a moment’s reflection, all staff members would admit that such claims are absurd. We cannot really believe this statement that is parroted with nauseating seriousness. (Cue Mr. Bean pulling out a Foley catheter balloon then bunglingly uncharting it to undo his mistake).

Mr. Bean looking for the catheter; Photo by By Metro Centric – Budapest

If the charting principle is ludicrous, why do we accept it? We comply with a statement we nonetheless know to be false because we intuit the threat it harbors: “Chart—or else you will face the consequences.” The succeeding drive to have workers chart on more and more—even on charting itself, which in some instances must, in turn, be charted on—demonstrates the degree to which the norm holds sway. While infinite regresses are problems for the logician, they’re solutions for the bureaucrat.

Yet the charting principle says more than it intends. It does not only express a simple ‘thou shalt’ or ‘thou shalt not.’ The statement also belies the role of workers as both the subjects and objects of data-fication. In hospitals, this process serves as a primary means of bureaucratic oversight—in the sense of ‘the surveillance of oneself and others’ as well as in the sense of ‘turning a blind eye to.’ In addition to security cameras, telemetry, chart audits, noise monitors, teleconsultation, and rollerblading AvaSys drones, charting serves to give hospitals the upper edge in matters of liability. Since hospital workers have been conditioned to recall that “If you didn’t chart it, it didn’t happen,” then ideally one need only peruse the online charting system to resolve some complaint of misconduct, and then to deny its occurrence or remove dysfunctional cogs from the proverbial wheel.

But bureaucratic oversight also guards hospitals against internal threats, such as groups of workers who might raise charges of unjust treatment. The majority of things that matter most to the well-being of hospital workers do not get recorded, computed, or spoken of in any official, durable manner. Such remnants include violent spikes in labor intensity, the real reasons for call-in regularities, patient acuity, the amount of capital stolen in having employees pick up others’ work without any remuneration, the frequency of suicidal ideations per worker per day, workload histories, the in-creep of work into dreamlife, the actual physical toll of hospital labor, etc. Since these things aren’t data-fied, they’re rendered impertinent, merely personal, unreal.

There’s a particular red-white-n-blue refrain often intoned as if it were an original thought. Nearly everyone in the U.S. has heard it: “Communism is a good idea but doesn’t work”—the insinuation being that, while the idea of economic justice sounds nice, capitalism is the better and more practical alternative. Hospitals in the U.S. breathe life into and reinvigorate this ideological assumption, ironically, through primarily idealistic means. To provide themselves with a moral aura, they poach communist ideas while concealing the extent to which capital determines all aspects of hospital life.

The foregoing huddle monologue offers a brief glimpse into this broader marketing strategy. For example, superiors emphasize the need to “take an ownership mentality rather than a renter’s mentality” in caring for and cleaning up “our” wing. And slogans hound employees to provide mutual aid to co-workers as members of a team whose individuals are thought to share goals among each other and with the corporation as if they comprised an association of free members (buddies, if you will).

But the prior injunctions remain merely good ideas, not because of their resemblance to some of communism’s proposals, but because the realities of capital always immediately contradict and undermine them. When said injunctions ultimately serve the ends of corporations that seek to expand and thrive within a capitalist economy, they do and must put capital first to be effective, despite warm-and-fuzzy slogans to the contrary. What happens when the moralistic rubber hits the material road?

By charging workers to act ‘as if’ they truly owned their hospital wing rather than rented it, bosses attempt to motivate their staff by playing on a wish (“Imagine owning such property one day!”) while ignoring the balky facts (“Sorry, you neither own nor rent your means of production. You’re replaceable human resources loaned out to us. Also, we need you to pick up an extra night shift this weekend.”) To advise others to alienate their labor through an illusory idea of ownership, that is, by ‘taking on a different mentality,’ is idealism per se.

As staff turnover hits overdrive and hospitals rely more and more on agency and travel nurses, managerial team-talk has become even more important to cohere staff cooperation. Throughout our hurricane-punctuated pandemic and in a characteristic top-down fashion, higher-ups have forced pink-collar laborers ‘to take one for the team’ every shift, often at least tripling already-unbearable workloads and exacting more than workers’ last drops of goodwill and stamina. At least in baseball, taking one for the team every time up to bat would hurt psychologically (“Why has this become my role?”) and physically (“I’m happy to get beaned once or twice when we need a run, but surely not every time up to the plate”). Such a team could only succeed in the realm of mere ideas.

Finally, in adjusting to our funhouse, hospital employees under capitalism become alienated from themselves. In the U.S., we often identify ourselves with our jobs. “What do you do?” follows on the heels of exchanging names. Whether we love, hate, or merely tolerate our work, hospitals variously reinforce this broader cultural phenomenon for their own material aggrandizement.

For example, many pink-collar workers desire to care for others and enter healthcare to do so. Hospitals exploit such selflessness, however, by conflating the notions of ‘labor’ and ‘vocation.’ The more that work-activity and activity outside of work coincide—both temporally and in terms of self-image/self-worth—the more a hospital system stands to profit. Since vocations require self-sacrifice (so the thought goes), staying for numerous consecutive days and nights, answering emails off the clock, coming to work for mandatory meetings on off-days, remaining on-call, and shouldering others’ shifts without compensation begin to blur with one’s identity, life, and purpose, often taking them hostage. The lionizing notions of ‘healer’ and ‘hero’ are feeble attempts at cheerleading the empty shells of former selves to reimagine exploitation as martyrdom.

But since those who despise or put up with work might not produce excess value in response to such pressures, upper echelons must also resort to other strategies. As members of the service industry, we’re coached to graciously bear and dampen class conflicts, as when dealing with bourgeois demandingness, playing our best roles until “off stage.” Workers take and retake mandatory quizzes on the importance of self-care, mental health, and sleep all while capital demands that these goods be locked away in never-never land. And so that we can continue to instruct patients about diabetes and check blood sugar levels, admins refuel us with chips, candy, cookies, pizza, donuts, and Red Bull. You know. Carnival fare.

At least on Med/Surg floors, burnout is treated as nothing but a natural stage in the healthcare worker’s life cycle—complete mental and physical exhaustion being but two more forms of debt heaped onto other loans. For those healthcare workers who identify at least some of their work-activity with their life’s meaning and purpose, burnout can entail a sense of disappointment, frustration, anger, guilt, and utter futility. In such cases, encouragement, reminders of why one entered healthcare in the first place, and further calls for selfless empathizing with others only exponentially exacerbate alienation from oneself and others. Invariably, the more care is demanded of one, the less one can care.

Funhouses profit from distortions that are sometimes laughable, sometimes frightening, and always do so at the expense of those who pay for their entry. Like all other bureaucracies, ancient and new, hospitals make use of metaphysical absurdities (like the charting principle) to discipline and norm the lowest strata of a social hierarchy. The threats hidden within such absurdities acclimate one to abiding by false statements in general, preparing one not to blink before other common ideological slips like, “hospitals are the only businesses trying to put themselves out of business.” A quaint quote worthy of a daily desk calendar.

As one sort of corporation among others, and whether of the profiteering or non-for-profit stripe, contemporary hospitals abound with idealistic language games concerning teamwork, ownership, self-care, kinship, mutual aid, equality, vocation, and heroism. Hospital workers have come to expect such discourse no less than crying and shouting echoing down the halls. But when healthcare workers themselves begin to cry and shout for help, it’s time to examine whether it’s not from freely sought-out amusement but rather from genuine anger and fear for oneself and others.

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D.A. Wood View All

D.A. Wood is the author of Epistemic Decolonization and the editor/translator of Amílcar Cabral's Resistance and Decolonization. He teaches philosophy at Dillard and Xavier Universities.