Here’s something the pre-med student I reference in the first post in this series, The Standardization Tax: Not Every Tradeoff Is Worth It, hasn’t experienced yet.
As soon as you tell people you’re in med school, things change. Aunts introduce you differently at family gatherings. Neighbors want your opinion about their knees. People often assume you must be smart and good, just because you chose a profession many see as not just hard, but noble. Fewer people think it noble than before, but many still do. You end up on a pedestal, long before you’ve earned it.
It feels flattering, but it’s also risky. A pedestal is not the best place to learn humility. That is one reason that doctors resist even helpful standardization. That same pedestal leads to a quiet belief in the superiority of our judgment.
Before I discuss a type of standardization I disagree with later in this series, I want to explain where it actually works. Otherwise, it might sound like I’m against standardization in general.
I’m not against it. I just think we sometimes use standardization when we don’t need it, and when it harms us.
One real example shows how standardization saved thousands of lives.
The Checklist That Saved Lives
Every year, tens of thousands of patients in American intensive care units used to get bloodstream infections from something called a central line. This plastic tube is placed in a large vein so doctors can give medicine, draw blood, or monitor the heart. Before a particular standardization, enough patients developed bloodstream infections from their central lines that the complication cost nearly $3 billion annually to treat. Still, it was estimated that 30,000 to 60,000 of them died each year.
In the 2000s at Johns Hopkins, a critical care doctor named Peter Pronovost tried something surprisingly simple for a group of medical professionals. He created a checklist. Five steps, every time: wash your hands; clean the patient’s skin with the right antiseptic; cover the patient with sterile drapes and wear a mask, cap, gown, and gloves; avoid the groin if possible, since infection risk is higher there; and remove the line as soon as it is no longer needed.
The checklist allowed any nurse in the room to stop the procedure if a step was missed, even if the doctor had much more experience. Each team regularly received its own infection numbers, shared openly with everyone.
When Michigan used this checklist in over 100 ICUs, infection rates fell by 66 percent. The median rate stayed at zero for a year and a half, and was still at zero three years later. A follow-up study found hospital deaths dropped by another 10 percent. Hospitals saved about $1.1 million each year. You can read more about the results here.
Before the checklist, a tired or rushed doctor might have skipped one of those five steps. Not out of arrogance, but because they forgot or thought their experience meant the risk of infection was low there. That’s preventable variation. Standardizing the process removed that risk.
Under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgment, but judgment aided — and even enhanced — by procedure.
— Atul Gawande, The Checklist Manifesto (2009)
How I Learned to Appreciate Standardization
I attended medical school in India, where alcohol use among women was, and still is, much less common than in the U.S. So, asking a woman about it was unusual. It felt disrespectful, almost inappropriate. I was young, proud of my white coat, and sure that my judgment about what to ask was enough.
When I began psychiatric training in the US, I had to unlearn that habit. Asking about alcohol and drug use was expected in every interview. Reluctantly and awkwardly, I learned to ask everyone — men, women, teenagers, and grandparents — the same question, the same way. I realized that not asking wasn’t being sensitive. It was a gap, and patients were slipping through it.
Once asking the question became routine, like checking blood pressure, I started hearing things I had missed for years. I doubt I would have become interested in Addiction Medicine or specialized in it if I had kept relying on my own judgment about who ‘needed’ the substance use question and who didn’t.
That Blind Spot Shows Up Elsewhere
Years later, I did mock exams for psychiatrists preparing for their oral boards. Once I watched a doctor in that course interview a pretend patient from start to finish without ever asking about alcohol, smoking, or drug use, even though the opportunity was there. If it had been the real exam, she probably would have failed.
During feedback, I asked her about it. She explained that she mostly treated professionals or teenagers, and in her experience, substance use rarely came up. So she had stopped asking.
She was a qualified, experienced psychiatrist, and she knew that substance use affects every socioeconomic group and age group. Still, she skipped the question because, over time, it had become optional in her mind. She began to assume that patients from backgrounds like hers didn’t drink or use drugs.
It was the same mistake I had made years before, though for a different reason. Different training and culture, but the same problem: trusting personal judgment in the very place where it often fails.
We can be blind to the obvious, and we are also blind to our blindness.
— Daniel Kahneman, Thinking, Fast and Slow (2011)
The Variation That Must Be Prevented
This is what preventable variation looks like. It isn’t about stupidity or laziness. It happens when smart, well-trained people, people who have been told for years that they are smart and that their judgment is good, let that judgment become a risk instead of a safeguard.
My main point is simple. If care gets better and risk goes down when a task is done the same way every time, for every patient, no matter who the clinician is or how they feel that day, then standardize it. Make a checklist. Let someone else in the room stop you if you miss a step. This approach saved thousands of lives in Michigan.
This post is about preventable variation that is actually worth preventing. There’s no legitimate alternative to that variation. That sets the stage for the issue this series is about — what happens when we treat a completely different kind of variation the same way. The kind of variation that isn’t a missed step, but a value someone holds, or knowledge someone accumulated about a person. That’s what I call load-bearing variation, and it’s next.
For our pre-med student, here’s the first thing I’d want you to know. The more people put you on that pedestal, the more cautious — the more willing to question your judgment and your practice — you must become. Stay curious. Stay humble. It will save you more than once.
The One Practice
Think about a question or procedure in your own practice that you sometimes skip because you believe, “this patient probably won’t need it.”
Then ask yourself: is that really a judgment call, or is it a blind spot like the ones in today’s blog
Next, ask: what harm could come from leaving it out?
If you’re not sure, take time.
This is Part 2 of a four-part series in which I explore where standardization helps in medicine, where it costs us something important that cannot be measured, and how patients and doctors pay the price that I call the Standardization Tax. The next post in the series will be published in one week.
