Normalization of Deviance in Veterinary Medicine

I'd like to mention a fascinating phenomenon called the Social Normalization of Deviance (NoD). The term was developed by Prof of Sociology Diane Vaughan:

"Social normalization of deviance means that people within the organization become so much accustomed to a deviant behaviour that they don't consider it as deviant, despite the fact that they far exceed their own rules for their elementary safety. But it is a complex process with some kind of organizational acceptance. The people outside see the situation as deviant whereas the people inside get accustomed to it and do not. The more they do it, the more they get accustomed."

My introduction to the concept was in a recent article by Bruce Scheiner, a highly-regarded expert in systems and network security. It connected how NoD - which led to the crash on takeoff of a Gulfstream IV business jet - is also a significant reason for lapses in information technology security.

I immediately realized how often I had encountered this effect in my current veterinary career as well as in engineering. Every professional I've talked to over time - veterinarians, MDs, RNs, engineers, lawyers, professors, etc - can recall at least one conversation they've had with another colleague where they went, "WTF?" inside when they learned about some process in use at their colleague's business. The deviant process had become normal to the speaker due to habituation, organizational acceptance, lack of consequences (often merely perceived and not the reality), and a culture where speaking out wasn't encouraged or heard. The recent VIN thread on frustrations with standard of care makes this concept especially apropos.

As a relief veterinarian I've encountered many such examples. I have to stress the word "encountered" - these are by no means common practices.

  • As a new graduate I was introduced to the "traction avulsion" method for feline neuters as acceptable.
  • A 13-yo GSD was dropped off for sedation and radiographs. Before I realized it, standard operating procedure at that clinic meant that the technicians gave dexmedetomidine/ketamine/butorphanol IV and then called the doctor to supervise the radiographs.
  • Surgery with no monitoring whatsoever beyond the surgeon watching the rebreather bag. Now and then.
  • Chromic gut used to close septic wounds.
  • Routinely boxing down all cats instead of premedicating.
  • A 4 line medical record for a newly diagnosed CHF patient. Medication orders were on a Post-It.
  • Polyflex, B vitamins, and dexamethasone injections given to every canine patient to increase ATF.

A first draft of this post among peers brought out *MANY* more examples (again "encountered" but not common):

  • Casting ACL tears.
  • Removing third eyelids despite known KCS risk.
  • Compounding chemo drugs without a hood or license to do so.
  • Injectable ivermectin passed off as oral heartworm prevention.
  • Exam gloves autoclaved then used for abdominal surgeries.
  • No cap or mask for surgery ever.
  • No scrubbing or hand prep for surgery, even major abdominal procedures.
  • No gloves for surgery.
  • No pain meds whatsoever for declaws (unless you count the ketamine IM induction).
  • No pain meds for any surgical procedure.
  • Refusing to write/sign prescriptions for outside pharmacies.
  • Refusing to release a patient's medical record because the client owes money.
  • "Anesthesia Free Dentistry" offered as the first choice option.
  • Technicians doing cat neuters, dental extractions, FNA cytology.
  • Receptionists authorizing controlled substance scripts/refills.
  • Lying for AAHA inspections (basically every AAHA practice I've been in).
  • Vaccination appointments by technicians without a doctor on site.
  • Anesthetized procedures happening without a doctor on site, sometimes without even a licensed tech on site.
  • Under-the-table paychecks for tax evasion.
  • Major after-hours surgeries done by a veterinarian alone (ie, no technician, no one to adjust anesthesia, etc) without offering the nearby e-clinic first.
  • Re-using the same surgical pack for multiple patients (I see this one a lot!).
  • Re-using the same laparoscopy instruments without sterilization between patients (she did squirt it with alcohol, so there's that).
  • Taking vaccine trays out of the fridge and leaving out all day so only they're only refrigerated at night.
  • In-house use and dispensing of expired drugs (super-common); use of expired suture.
  • Clean & re-autoclave syringes for injection, then store un-capped in a non-sterile cardboard box.
  • Prescribing of antibiotics by non-licensed staff without a written protocol (very common in shelters).
  • No written medical record whatsover, routinely - even to write down what controlled drugs were used for a surgery.
But wait, there's more. On the list of "I've actually seen this happen but none of the staff would consider it appropriate either":
  • Giving the incorrect drug by accident then not correcting it or telling the client (ie, giving cerenia instead of convenia).
  • One practitioner buying controlled drugs and giving to another practitioner (at another practice) so they don't have to buy a DEA license.
  • Photoshopping one veterinarian's face onto another veterinarian's body (from a competing clinic) for a plagiarized business card design (seriously, you can't make this stuff up).
My observation is that Normalization of Deviance in medicine is more significant in veterinary vs human medicine because we're both one of the last self-contained medical professions and our patients can't complain.

The effect is strongest in the solo practices, but multi-doctor practices are not immune. Even in a solo practice the doctor is usually a participant in the larger profession through societies, journals, CE meetings, VIN, etc. They are aware that their deviant behavior isn't normal at some level. It persists from lack of direct feedback from other doctors, justified because of economics, perceived lack of consequences to the behavior (both from peers, licensing boards, and effects on the patient), and habituation (it's always been done this way).

NoD in multi-doctor practices is especially problematic for new graduates. They're very vulnerable in their level of confidence and when the organization's price of acceptance (social and professional) encompasses deviant behaviors, they're likely to go along because their mentors do.

What I would like to see happen in the profession is instituting a system of peer visits similar to the practice of "Line Operation Observations" in aviation. Simply put, every two years a practice owner invites another doctor they trust to shadow them in clinics, converse with staff, look over medical records, and then provide a confidential review of what they've observed. Reports could be verbal and (ideally) exempt from subpoena and discovery. My opinion is that a biennial review should be something local veterinary medical societies promote as a recommended best practice. Recruiting a pool of doctors that have been reviewed to serve as volunteer reviewers is something for these organizations to consider. If it's allowed to become a "Bet Your License" event, everyone involved will put on their best act and nothing will be learned or accomplished.

Given the extreme examples above, a reader will naturally picture the most problematic veterinarian they've ever known, the ones that continue to live in the profession of thirty years ago or that cynically and knowingly practice to maximize their ATF rather than patient well-being. They are the lost causes insofar as this proposal goes. On the other hand there are far more veterinarians that have just one or two odd behaviors that feedback from a colleague could help them re-examine.

As a pilot I can tell you that a once-a-year shared trip with a colleague is a strong counter-measure to complacency and procedural shortcuts. A similar program for veterinarians won't touch the ones living in the past. However I know there are far more veterinarians that believe that there's always room to learn and improve.

Addenda

In the case of the Gulfstream IV crash, two highly experienced pilots attempted takeoff with the controls for the flight surfaces (ailerons, elevator, and rudder) locked. It was not an accident. The pilots failed to go through *four* checklists that must be done before takeoff. Data from the flight data recorder showed that the "controls free" check - done by moving the control yoke end-to-end forward, back, and side to side - was omitted in 98% of the previous 175 flights. Ron Rapp has an excellent analyses of the damning NTSB report on N121JM.

Despite the control lock, the accident would have remained an incident - with no damages or loss of life - if the pilots had adhered to their training and aborted the takeoff while they still had plenty of runway. Instead they attempted an unapproved and fruitless measure to release the control lock for another 11 seconds while accelerating down the runway. By the time they first started to brake they were rolling at 160 MPH with less than 1400' of runway remaining. The aircraft ran through the airport perimeter fence and impacted into a ravine at 97 MPH. All aboard died in the subsequent fire.

As an example of how prevalent NoD is in other fields, consider this essay by Dan Wuu, now a Microsoft engineer. One quote in particular stands out:

People don't automatically know what should be normal, and when new people are onboarded, they can just as easily learn deviant processes that have become normalized as reasonable processes.

Julia Evans described to me how this happens:

new person joins
new person: WTF WTF WTF WTF WTF
old hands: yeah we know we're concerned about it
new person: WTF WTF wTF wtf wtf w...
new person gets used to it
new person #2 joins
new person #2: WTF WTF WTF WTF
new person: yeah we know. we're concerned about it.

Comments