I Disagreed With a Medical Student

By Eric Warm

Last week I presented a conference on Normalized Deviance in Healthcare to a group of medical students.

Normalized Deviance, a termed coined by Diane Vaughan after she investigated the Space Shuttle Challenger disaster, is organizational behavior that deviates from normative standards or professional expectations. Outside people see the situation as deviant whereas inside people get accustomed to it, seeing it as ‘routine, rational, and entirely acceptable’

Examples of normalized deviance in healthcare include:

1.       When healthcare teams rush through their morning and leave patient rooms without checking for understanding, often leaving patients with confusion and unanswered questions. Third year medical students notice this (‘relative outsiders’), but third year residents don’t (normalized deviance).

2.       When medical schools provide perverse incentives to students and emphasize grades over growth. To get honors, medical students emphasize strengths and hide weaknesses. Imagine if flight school was like this:

Student: “Hey, I’m really good a takeoffs!”

Teacher: “What about landings?”

Student: “Hey, I’m really good at takeoffs.”

Teacher: “OK. You get Honors.”

My goal in having this discussion with the medical students is to get them to recognize the Normalized Deviance in their own lives before they lose the power to do so, and to activate them for change when change is needed.

After discussions like this, the students provide anonymous written feedback. Here is what one student wrote: The System Can’t Be Fixed.

Since this came after the class, I was unable to respond. But if I could, here is what I would say:

I’m sorry that you did not express this thought during class. I would have liked a chance to discuss it. I believe we are the system. You become the system when you join it. Systems change (for good or bad), and we are the ones who change it (for good or bad). However, if you believe the system can’t be fixed your statement will likely come true for you: you will not fix it.

To your classmates I say:  Creating positive change in the systems you join starts with being able to recognize the system for what it is.  You should also recognize that you will always encounter people who don’t believe it can be fixed or changed. It’s a principle as old as physics: a body at rest wants to stay at rest. Try to understand why someone thinks this way, but ultimately, don’t let them stop you from making positive change. You can do it.

A quote from Margaret Mead is apropos here: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has."