DAILY MEMO: HEALTH:

How we come to accept wrong as the new right

‘Normalized deviance’ can lead to tragedy

Thursday, Aug. 14, 2008 | 2 a.m.

Space shuttle Challenger exploded in a split second two decades ago, but the disaster was years in the making.

The primary cause — an O-ring that failed in low temperatures — was only part of the story. Engineers knew the O-ring turned brittle in the cold, but their warnings were ignored because of what sociologist and author Diane Vaughn calls the “normalization of deviance.”

Politics and a culture of compliance led decision-makers to determine it was an acceptable risk. “They redefined evidence that deviated from an acceptable standard so that it became the standard,” Vaughn wrote.

Health care in Nevada also seems to suffer from a normalization of deviance. In two recent high-profile cases — the hepatitis C crisis and the widespread abuse of Nevada’s foreign doctors — trained professionals apparently ignored strong evidence of wrongdoing.

Fifty thousand people had to be tested for infectious diseases because of a hepatitis C outbreak caused by unsafe injection practices at Endoscopy Center of Southern Nevada. Nurse anesthetists infected patients with tainted blood by reusing syringes, possibly under the orders of their boss, investigators said.

The community asked: How could licensed professionals do such a thing? Why did those involved not speak out?

David Forman, assistant professor of philosophy at UNLV, compares the culture at the Endoscopy Center to the circumstances leading to the Challenger disaster. Groupthink takes over and pressure builds to conform, he said.

“People who go against the standard line of the organization feel like they’re not just expressing a difference of opinion, but that they’re traitors,” said Forman, who teaches a course on health care ethics.

Problems are compounded when people comply with the nonstandard procedure and don’t suffer consequences, Forman said. They begin to reason: Nothing bad happened, so maybe this is OK.

The same psychology might explain how people knew for years that doctors in Las Vegas were profiting by overworking foreign doctors, underpaying them, and ordering them away from the medically needy patients they were supposed to serve so they could bring in more revenue in hospitals.

The Sun’s 2007 investigation of the “J-1” visa waiver program prompted immediate reforms by the Nevada State Health Division. But the truth is, members of the medical community and officials from the state kept silent for years about the abuses.

“I knew what was going on before, but it wasn’t my part to blow any whistles or anything like that,” said a Las Vegas doctor who teaches at a local medical school.

The exploitation had become part of the status quo. Normalized deviance.

We like to think that people will stand up for what’s right, Forman said, but psychological research shows that people won’t take a stand if it might require sacrifice.

Which highlights the importance of regulation, he said. Ethical health care providers — and they are the majority — have long complained about inept regulation in Nevada. The problems are so egregious they fuel conspiracy theories about corruption on the Nevada Board of Medical Examiners and in the State Health Division.

Indeed, the state received a half-dozen letters between 2001 and 2004 from J-1 doctors who complained about the abuses by their employers — one of them was copied to the Nevada Board of Medical Examiners and the Nevada attorney general’s office.

Nothing was done. Worse, the same employers named in the complaints were allowed to hire five additional foreign doctors.

Critics of these Nevada regulators don’t use the term “normalized deviance” to describe the inept oversight, but they could.

Should it be allowed to continue?

NASA failed to correct its problems, and on Feb. 1, 2003, the space shuttle Columbia disintegrated while streaking through the Texas sky.

Discussion: 9 comments so far…

By esquared

8/14/08 at 8:37 a.m.

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It is unbelievable that in this bastion of Libertarianism, you speak to regulatory oversight and state boards to protect Nevada citizens from the overriding greed that controls your doctors, your hospitals and your health insurers. Unfortunately, the feeble and impotent State Boards and regulators are all that you have left, because you sold out to the doctors and the hospitals and the insurers when they whined about the evil trial lawyers and, with the petulence of a teenager, announced that they would just quit and go away if you didn't change the laws and give them all a free ride.And change them you did, in a campaign led by none other than your own Dr. Death, Mr. "You-don't-need-no-stinkin'-visual-evidence-of-my-stroke". Fancy that.

In a state that prides itself on self reliance, you killed the only means you have of protecting yourselves on an individual basis from your predatory medical community: the malpractice lawsuit. Today, a doctor in Nevada can cut your legs off by mistake because he or she was drunk on their butts and the tab would only be a mere pittance, less fees and expenses. You have no recourse against public or private or union based insurers who are in the business of collecting as much in premiums as possible and paying out as little in care as possible. These insurers would rather spend money on the easy, the cheap, and the appearance of care, rather than the reality of care. All that the people of Nevada are left with are your guns. Good job folks! Use them to take your temperatures.
By lemahj

8/14/08 at 10:31 a.m.

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M. Allen wrote: "but their warnings were ignored because of what sociologist and author Diane Vaughn calls the “normalization of deviance.”

So true . . . we are all subject to this flaw.

esquared wrote: "In a state that prides itself on self reliance, you killed the only means you have of protecting yourselves on an individual basis from your predatory medical community: the malpractice lawsuit."

You are right esquared . . . but only partly so.

This law was not the result of any Libertarian ideal, I claim that it was the Socialists view was that the state regulators would be able to protect the people from unscrupulous doctors and insurance companies, and hold health care down to a reasonable cost. This is was what was sold to the public, and what they got was an empty promise. I don’t think we should make the Libertarian movement a scapegoat, as they were not the cause of this effect. Those who thought that government would do all and protect all, got snookered . . . again.
By swan42

8/14/08 at 11:05 a.m.

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lemahj wrote "Those who thought that government would do all and protect all, got snookered . . . again"

Apparently lemhaj considers public policy to be an all or nothing situation. That is simply not so. As any well-read Libertarian should know, incentives are very powerful policy enforcement tools. However, not all people are equally influenced by economics or hold the same fear of malpractice lawsuits.

As such, I do not and have not been snookered by the expectation that the government solves all problems. I do recognize that laws and regulations are capable of playing a part in protecting the public.
By esquared

8/14/08 at 1 p.m.

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But the Libertarians joined the fray against malpractice, casting the malpractice lawyers as mere profiteers and not what could arguably be called the ultimate entrepreneurs, staking their money and reputation on a cause or position risking earning nothing if they lose. And at trial, more than 60% of the cases are won by the physician or health care provider. And in return for granting these medical profiteers carte blanche, you didn't demand a higher standard of accountability, or even more transparency. The end result is medical mediocrity.

The only 'people' who feared malpractice suits were, and are, malpractice insurers. Quality physicians regard malpractice cases as vetting the wheat from the dangerous chaff. Unfortunately, the vast majority of Nevada medical professionals bought the bill of goods sold by the major insurers and just failed to ask for some proof of the claim that the cases were unjust, unfair and weighted against the practitioner. I hope they are better at asking questions as diagnosticians. The only hope for bringing Nevada health care out of the Dark Ages is a repeal of the malpractice 'reform,' a better funded and more disciplinary oriented licensing board, absolute transparency in both pricing and claims against individual practitioners, clinics and hospitals, a joint public and private funding push to pure electronic charting, orders and prescriptions, and a federally administered single-payer system that streamlines the enormous waste of effort required to submit multiple claim forms to multiple payers.

Discussing the mind-set of the regulators in an environment skewed and perverted toward the professional is an exercise in futility. Take back control.
By Sjohnson

8/14/08 at 2:03 p.m.

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The Name of the Game in Las Vegas is GREED, greed for money, greed for power

One ethnic group is forefront in corrupting the medical practice in Las Vegas. Almost all doctors named in recent Las Vegas Sun reporting regarding abuse of J1 doctors and Hepatitis scare, are prominent members of Las Vegas community of Indian origin

All blame must not be directed towards this ethnic group, as without the nod of state monitoring agencies, these doctors could not corrupt the practice of medicine in Las Vegas. There coming to prominence is favored by powerful members of our community, who knowingly or unknowingly fulfilled the ambition of these doctors, greed for money, greed for power. When talking with employees and others in social circles, very often these greedy doctors drop names of politicians, as their friends, so as to show power and gain prestige, which they then use to abuse, people and medical practice, fulfilling their innate desire and fervour for money and power.

Normal deviance, yes, this is true. Example, in India to get a telephone line, one bribes, to get a child entered to school, one bribes, in fact many aspects of life in India is fraught with corruption and bribery. People have no choice but to bribe. This is considered normal in India, a normal deviation.

When people leave India, they bring the good and the not good of India with them, as commonly quoted in Asian television programs and I quote, ‘You can take a person out of India, but you cannot take India out of a person’, unquote. True. Corruption is norm for these greedy Indian doctors.

Corruption exists in many countries, but doctors coming from these countries are not corrupt. Education teaches one to stay within rules and regulations, even when one is greedy for money and power. Education stops one from breaking laws and rules.

Question for David Forman, assistant professor of philosophy, at UNLV. Why education has not taught doctors of Indian origin to stay within the norms of rules and regulations?

I guess greed is much more basic and stronger force in the inside of these doctors, supplemented by their intelligent ability to get powerful people behind them, allowed these doctors to fulfil their greedy ambitions of acquiring wealth by hook or by crook, at the expense of patients, Hepatitis, at the expense of colleagues, abuse of J1 doctors.
By neiman1

8/14/08 at 3 p.m.

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When I read the headline about Wrong being the new Right I thought is was wondering why anyone was supporting Obama and Reid
By esquared

8/14/08 at 6:55 p.m.

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The way i understand the Sun's rules for comments is that it would be wrong to suggest that neiman1 up there is inappropriately off-topic in a rather typical, utterly myopic, and demonstrably teutonic sort of way, so I won't. But witness the mindless, robotic manner in which he interjects his kneejerk Nazi-esque, foaming at the mouth conservativism. If he were a dog, it would be an act of kindness to put it out of its painful lunacy.
By lemahj

8/15/08 at 8:32 a.m.

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Swan42 wrote: “Apparently lemhaj considers public policy to be an all or nothing situation. That is simply not so.”

Swan42, you claim that I am taking a ridiculous position of all or nothing government, then attack the position that I never made in an effort to nullify by arguments. In debating circles that is called a straw man argument. I think the Sun readers are smart enough not to fall for that old debating-101 level method.

esquared wrote: “But the Libertarians joined the fray against malpractice, casting the malpractice lawyers as mere profiteers and not what could arguably be called the ultimate entrepreneurs”

esquared, It may be true that some persons who claim to be Libertarians, joined the Collectivists to pass these laws to protect doctors who do wrong. My point is that the subject law is contrary to Libertarian thought, Libertarians believes in limited Constitutional government and the Rule of Law, Libertarians in another word are Classic Liberals. Libertarians believe in Individual Freedoms, not the collective state. However, this does not mean that a Libertarians reject extended multi-generational family units, what they reject is the Idea that Government becomes the extended multi-generational family unit. Libertarians do believe in Civil courts are a needed and essential role of government, a true Libertarian would never, support the subject law. For the record I did not support this law.
By fremmasmind

8/24/08 at 6:55 a.m.

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Why should we be giving good paying American jobs to foreigners with cards? The times they are a changing. It is time to put the American Citizen first. Duh,its not like we have an overwhelming amount of good paying jobs waiting to be taken. Yet they give these jobs away to card holders, illegals, etc. and then with an economic slowdown, our elected leaders cannot understand why our unemployment is so high.

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