As a resident in the 1970s, I used to receive the AMA weekly newsletter. A squib of a few paragraphs noted that the Alabama Medical Board had issued a reprimand to a surgeon for suturing the hand of a young African-American man, then removing the sutures when the fellow did not have $25 on him to cover the fee. The surgeon contested, indicating that a patient should have the expectation of having to pay the surgeon. However, there was ample evidence of that surgeon not demanding immediate cash on other patients, and deferring or reducing the fees on the people who looked and voted more like the surgeon. Even in a place and time where unabashed segregationists comprised their Congressional delegation, there were limits to overtly egregious conduct that the surgeon’s medical peers would accept. Moving to our current times, Civil Rights enactments may not have changed how people think but has changed how most of us behave, or at least the expectations of how we should conduct ourselves amid a diverse public. Restaurants, hotels, and hospitals accept people without ethnic or religious exclusion, transforming an established norm abruptly with little overt opposition.
Our medical institutions, including my hospital from which I recently retired, having served an inner-city and African/Asian immigrant population, insisted on equity for our patients and for our staff. Among American mega-corporations, acceptance of ethnic dignity is invariably explicit corporate policy, though with varying success on corporate culture, reality, or enforcement. By any measure, medical institutions have not been left holding the bag for lurid exposures of any systemic misconduct other than financial. We have a few individual rogues who bring public discredit more to themselves than to our profession. No constable of any place I have worked would abuse a patient, nor would the city or county police who bring patients to our ER. Even prison guards assigned to sit with patients shackled to their beds always seem courteous and helpful, at least when I rounded in those rooms. Yes, there is often tacet stereotyping from senior Jewish doctors who not only own psychiatry, but the furniture stores that supply the couches perceived ethnic imbalances of those seeking treatment of DT’s, suspicion of physicians of foreign or minority origin, or irreverent quips about grandiose surgeons with big cars who always send a surrogate as they are too important to see you personally. Our pageant of medical care includes the entire public with all its imprints. While folk tales that accrue from interacting with nearly the full spectrum of humanity will continue, there are very clear behavioral standards. We physicians have our unfulfilled challenges. Ethnic disparities in outcome remain distressingly difficult to remedy despite specialty organizations and medical systems devoting attention and resources. Some of the postings, particularly from the younger physicians suggest something systemically racist or sinister, though at the level of one physician or one team acting on behalf of one patient or a defined group of patients, the behavior remains among the most consistently benevolent of any noble profession.
Police generate public scorn when unwarranted sentinel events reflect racial inequities; hospitals generally don’t create such public outrages. Many have officers as patients or appreciate their interventions in times of crisis. We also acknowledge that as individuals or as a group, they are not mighty hunters going out into urban jungles to kill wrongdoers for food. I think many of the medical processes that have evolved over my forty-year professional lifetime have applicability to reversing some of the professional lapses in policing. One big change from the 1970s in medicine was to switch focus from seeking punitive consequences for poor outcomes to looking at the enhancement of patient and public safety goals, which are often deterred by a culture of reprisal. We now have expert panels issuing mostly clear guidance on best practices for different conditions that we encounter. Compliance by physicians in the exam rooms has been highly effective, in large part because the guidelines are never arbitrary and contain a certain amount of humility on the part of the committees that issue them, recognizing that some aspects of a condition remain unsettled or demand the practitioners’ individual judgment. We have peer review with protected confidentiality. Our state licensing agencies require us to devote a specified fraction of our CME to patient safety enhancement. Morbidity and Mortality conferences occur at scheduled intervals to assess what we might have done better, always in a non-threatening forum over coffee or lunch. As much as we often object to intrusive but anonymous Big Data, medicine has committed to this to tease out aggregate consequences of our common practices some exposed as favorable, some not but often remediable. Each institution has accountability standards to report infection rates, readmissions, and other undesired events with the intention of eliminating them by changing processes, not by threatening its clinicians. Even for our own somewhat scandalous opiate overprescription, as a profession, we looked to changing standards systemically.
All these upgrades in medical safety occurred in my professional life. The common theme that contributed to their success was to evaluate processes, not to find cause for punishment. Massive marches affirm that sentinel events promote a mandate for public safety and for professionalism. Law enforcement has already shown its own commitment to advancing its professional capacity. The same modern molecular science that we utilize for patients has been adapted to forensics and to crime detection on a very large scale. “Nearly all men can stand adversity, but if you want to test a man’s character, give him power” misattributed to Honest Abe. Policing misadventures seem to reflect this. Changing imprinted character rarely happens. Putting restraints on power and its behavioral expression succeeds more often than not. Policing looks to be where medicine was when I arrived. Applications of accountability, peer review, evidence-based guidelines, and a non-punitive culture await a more meaningful transfer from our successful medical environment to that of law enforcement, with public safety and enhanced public respect as measurable endpoints.
Richard Plotzker is an endocrinologist who blogs at Consult Maven.
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