Human connection in health care is under threat

Allison Pugh, PhD, speaks at a conference of the American Sociological Association.

Credit: American Sociological Association

Many people see the automated checkout line at the grocery store as yet another tech innovation that lets us whisk through dull tasks efficiently. Sociologist Allison Pugh, PhD, sees a "cautionary parable" for medical practice.

"It's an example of where we are headed" in medicine, says Pugh, author of a recent book, The Last Human Job: The Work of Connecting in a Disconnected World. Where the grocery cashier once connected with customers on a personal level, pressures to be more efficient turned them into assembly line robots moving as much product as possible as quickly as possible.

"There's no relationship" with the customer, and that has eased the way to automation replacing many of those jobs, she says.

"Professionals - teachers, therapists, doctors - look at that and go, 'Well, that's not me. That's an automatable job, because it's routinized, it's standardized,'" says Pugh, a sociologist at Johns Hopkins University, in Baltimore. "The more you allow efficiency pressures to dictate standardization [of your job], the more you are walking on that path" toward reducing the importance of human connection in your work.

The Last Human Job stresses the irreplaceable value of "connective labor," arguing that work centered on human interaction - as in health care, education, and social work - is increasingly threatened by efficiency pressures, standardization, and automation, including artificial intelligence. Pugh calls for a movement in medicine to prioritize human connection over efficiency.

Pugh - who for her book interviewed more than 100 doctors, nurses, social workers, teachers, managers, therapists, and other care workers whose jobs rely on human connection, as well as administrators and artificial intelligence (AI) engineers - will discuss her observations in a session at Learn Serve Lead 2025: The AAMC Annual Meeting, on Sunday, Nov. 2, in San Antonio, Texas. Pugh talked about this challenge for medical professionals in a recent interview with AAMCNews.

This interview has been edited for brevity and clarity.

What is connective labor in health care, and why is it important?

Connective labor is the practice of seeing the other [person], so that the other feels seen. It's important for health care in a couple of important ways.

First, diagnostics rely on getting good information. If your patient is not telling you the truth because they don't trust you, or they don't think you see them, or they feel misrecognized in some way, then you're not going to have what you need to make a good diagnosis.

Also, a lot of health care relies on patient compliance, which is all about relationships. Primary care physicians know this well.

Finally, it's really important for workers. I heard time and again that it [human connection] is what makes the work really meaningful and sustaining for them.

You write, "Connective labor is a valuable human practice under siege by systems that to some degree enable but often impede it." What are those systems and how do they enable or impede collective labor?

In medicine, the systems are those that are about endlessly counting what people are doing. Too often the people who are charged with connecting are also charged with collecting the data on those relationships, on those interactions [with patients]. Many doctors that I interviewed were proud of how they learned how to look you in the eye and type [notes into an electronic records system]. That's an impediment. The relentless requirement to account for everything you're doing and what you're not doing.

You see scripts - the sequences of questions that doctors are expected to ask - and standardization - that is, certain protocols and procedures - as contributing to this dehumanizing process. How?

The [potential] harm is the dehumanizing of the person. Because the engine behind the scripts is the drive for efficiency. If deadlines and efficiency pressures drive the system, then the temptation is great to minimize or dehumanize the other along the way.

There is a balance. Too often we are off balance. The problem with scripts and standardization is that they lead to degradation of connective labor. And as soon as you go down that slippery slope, you get people saying, "AI can do better than that." It leads to the automation of these vital human tasks. It's contributing to mechanization.

You write: "The biggest impediment to warm, empathetic, connective labor is sheer overload. Sometimes workers have too many clients with too much need while they face too many tasks."

AI advocates contend that the technology lessens that overload. Like apps that record the discussion in a physician-patient visit so the doctor doesn't have to type while they are listening. Or chatbots with my health care system that give me answers about certain conditions. The idea is that we free up doctors from the laptop during visits and from online messages so that they can connect in a more focused, personal way when we meet. But you write that "the free-up language seems strikingly optimistic."

The first problem is that these people are very optimistic about modern capitalism. But if a machine can do your job, then you're going to lose it. In the case of physicians, they're going to get piled on with different work. There has never been a case in which our medical system has eased up on what we demand of physicians.

Point number two: These free-up claims are unrealistic about what AI can do well. I've spoken to physicians who have been asked to rely on AI scribes. I'm thinking of a physician [treating] diabetes. He said [regarding a patient meeting] AI ignored all the connective labor and started taking notes after some 20 minutes had gone by. The connective labor [that AI ignored] was along the lines of, "Are you still living with your sister? Is she bringing you to the grocery store?" That's relevant information for a physician. It [the AI tool] was ignoring what it didn't think was medicine, but what is actually medicine for some physicians.

When I go to see my doctor now, he does spend less time typing and more time looking at me because an AI tool is listening and transcribing the conversation into his notes.

Which is a positive!

So can AI contribute to connective labor?

I want to say yes. I'm not immune to this transformation. I've heard some technologists advocate [for AI] as a way to practice hard conversations. That's not a terrible idea, and it is probably good for students or trainees to practice how to say something that's difficult.

I appreciate that you write about grocery stores and self-checkout - about how checkout clerks used to talk with you about what you need.

Grocery clerks, a hundred years ago, used to do connective labor. They would talk to you, they knew who you were buying for.

I love going to self-checkout at grocery stores. You made me feel bad about that.

Good! I wrote this book to highlight what road we're on and what the choices we're making today are going to lead to if we're not careful. I reject that [the choices] are inevitable.

You call for "a new awareness of connective labor and a social movement to protect it." What does such a social movement look like in medicine?

Administrators have the power to make change happen. That ranges from paying close attention to time, space, and money, but also to the norms and values that you are propagating.

The organizations that I found were doing it right were careful about giving people who do connective labor chances to talk to others about it. That's hard. It's another meeting. It's another thing that doctors have to give time to.

Organizations that do it well, they take attention seriously. It means limiting how much a worker has to attend to, not overloading them with appointments or tasks. Treating that attention as if it's precious.

I'm not saying they have to eschew all technology or systems. Just subordinate them to the real priority of connection, not the priority of efficiency. We're out of whack.

If I'm a health care provider, I've still got metrics to meet. How do I measure the value of what you've just asked me to do?

The domination of metrics is a symptom of our pathology. We are letting the metrics and the insistence upon data analysis drive the bus. The human interactions should drive the bus. We should fit the other stuff in as it helps that bus go in the right direction.