The breakdown of the rule of law in medicine

The United States is a nation of laws, not of men’s dictates.  The rule of law is what keeps (most) drivers from routinely running red lights, police officers from demanding bribes, and our civil servants and elected officials largely honest.  There, of course, will be violators of this code, as there are in any society, but nonetheless compared to many other nations in the US most citizens and state officials believe the laws are legitimate, and by and large obey them.  One of the most bitter criticisms of President Trump and proximate cause for his impeachment proceedings is that he is breaking down a critical part of the rule of law.  By using tools of state commonly felt to be apolitical (foreign policy, the justice department) to go after his political opponents; issuing executive orders that seem to punish certain religious or ethnic groups, thereby legitimizing white supremacy; and attacking institutions respected by all such as the FBI, intelligence agencies, and the judicial branch, he is accused of slowly diminishes respect for those institutions and the sense that the institutions of the state serve all citizens fairly and equally.  This then threatens to breakdown the trust that all Americans have in our nation, which is critical to its continued existence.

This ongoing debate caused me to consider the rule of law in health care, and to realize that it has completely broken down as well. Have you ever seen someone in scrubs in the grocery store?  Technically that’s strictly prohibited by most hospitals’ regulations.  Eating food at the nursing station, drinking coffee while rounding on patients, wearing a cloth scrub cap in the ORs, grabbing a warm blanket for yourself from the patient warmer, grabbing a juice cup from the patients’ pantry food supply: all of it is technically banned, and yet almost all of those behaviors are commonplace in every hospital in the country.  Especially on the night shift — after all, few to no inspectors (from the Joint Commission which is the accreditation body with the power to punish hospitals for violations) or administrators work past 5 p.m. or before 9 a.m.

Most of these violations are harmless, no matter what the bureaucrats say.  But the lack of respect for such regulations and rules is not always confined to such relatively benign issues. Every day in most every hospital in America, a large percentage of health care workers do not wash their hands as they walk into patient’s rooms, despite many interventions to make it universal.   Another serious problem is low rates of use of medical translators.  Despite laws mandating that patients with limited English proficiency be provided independent and trained medical translators, doctors and other providers still commonly use their own partial language proficiency, draft family members (including children) as ad hoc translators, or worst of all just speak very slowly and loudly in English while gesticulating.  Needless to say, it doesn’t work, and critical details are sometimes lost with terrible results.  Many (particularly for-profit) hospitals don’t even provide translators.  There are multiple reasons for this: limited resources, emergencies, etc., but oftentimes there is no acceptable justification.

There are two sources for the breakdown of the rule of law in medicine.  One of them is immense time pressures and patient needs; when there are 15 patients left to see at 2 p.m., some already waiting 3 hours past their appointment time, doctors get a fairly powerful message from their administrators and powers that be to cut corners.  This is a very hard problem to fix.

But there is an easier target: the other, useless rules that no one respects.  Casually looking the other way or bemoaning to a fellow health care worker that you got caught by an administrator or the Joint Commission leads to tolerance of more serious violations that actually hurt patient care.  If every day, no one cares about a doctor scarfing down a sandwich while desperately finishing notes and putting in orders on a 20 patient list, they are less likely to care when someone runs into a patient room on the way to the OR and has a 10-year-old ask their mom about whether they have a headache or numbness and tingling after a neurosurgical procedure.

One answer then is to start reducing the rules that no one respects, and truly focus on enforcing the regulations that actually matter with appropriate exemptions for emergencies and other situations.  Some progress is being made, with the Association for periOperative Registered Nurses (AORN) recently retracting a rule banning cloth hair coverings after much criticism that it reduced morale, contributed to burnout, and did nothing to actually help patients.  But there is a long way to go.

Vamsi Aribindi is a surgery resident who blogs at the Medical Intellectual.

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