Now Reading: "Nickel and Dimed: On (Not) Getting By in America" (Barbara Ehrenreich)

Last week, I was walking with one of my patient-centered mentors, David Sobel, MD, through one of my favorite museums in Washington, DC., The National Portrait Gallery. As I brought him to one of my favorite pieces, I asked him if he read this book, and he told me it was one of the most influential books he’s read. “Have you gotten to the Wal-Mart section yet?” he asked. I have, and I have to say I agree with his assessment.

This book preceded a more modern version of living among the corporate natives which I reviewed previously, Punching In, by Alex Frankel. Unlike Alex Frankel’s adventure, Barbara Ehrenrich goes completely native, adopting the lifestyle of a minimum wage worker, down to eating, living, and surviving (or attempting to) in several different American cities. Her jobs include being a server in several restaurants, a house cleaner for a large national franchise, and a stint in retail.

We learn some realities of these jobs – it’s never really okay to not always be doing something, even if there’s nothing to do. One of her places of employment calls this “time theft.” So there’s a constant flow to the work, some of it useful, some of it not. The profiles of her coworkers describes the conditions that the working poor must accept – not having first month’s rent and deposit may mean spending $60 a night in a motel, an irrational yet necessary way to survive. The quality of life that Ms. Ehrenrich accepts for her assignment is concerning bordering on dangerous – a single woman in an efficiency with no screen on the window on the ground floor.

As I read this with an interest in employer-based health, I also learned a lot.


The maid service she works for provides donuts and bagels for free in the morning; however, the workers are not allowed to drink any water at the homes they are cleaning, no matter how much they sweat. One of her colleagues must use the phone at every house they clean that day in an attempt to find a free dentist. It’s unimaginable that a person with a chronic illness could manage it well in this environment, and when her team lead injures her ankle on the way out one home, she goes to the next, cleaning on one leg.

The people she works with are relatively accepting of their fate. When she “comes out” to her housecleaning colleagues and asks how they feel about their predicament, one says:

I don’t mind, really, because I guess I’m a simple person, and I don’t want what they have. I mean, it’s nothing to me. But what I would like is to be able to take a day off now and then…if I had to…and still be able to buy groceries the next day.

The story ends with the recognition that we’ve lost the ability to respect those who are scraping by, that managers are seen as getting in the way of providing good service:

Waitresses chafed at managers’ stinginess toward the customers; housecleaners resented the time constraints that sometimes made them cut corners; retail workers wanted the floor to be beautiful, not clutter with excess stock as management required.

It’s also worth noting that the poverty level in this country is based on food prices, not housing prices, which prove to be the largest barrier to getting by by the author.

As I read through the stories, I started to feel that the challenges of these workplaces are challenges of respect as much as they are about being paid a fair wage. There are similar stories in some health care environments, and experiences I have had in health care organizations where the contribution of patients are respected. I am actually going to go out on a limb here and say that even well funded health systems have the potential to create the types of feelings experienced by the author and her colleagues in their minimum wage jobs if they do not pay attention to the respect component (look at some of the feelings experienced by physicians in this statewide survey). The best understand that respect is more than about compensation, and it’s easy to provide.

I think this book is excellent reading for those that want to improve the health of the communities they work in. There is huge potential for respecting patients and those who care for them (using systems like LEAN), and the place to start to learn is to go where the care happens (or doesn’t). It’s worth the effort, and actually in my experience, it’s less effort because we waste less when we start by observing what happens outside of our medical centers, where the overwhelming majority of care is provided.

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