#113: Normative errors—a conversation with my daughter about current events

Hey, folks, welcome to a special episode that deals with kind of the aftermath and some of the questions that are surrounding us. In the wake of the brutal death of George Floyd, a lot of people have been speaking about this in their own way, choosing to post various things on social media. I've never really thought I had much to offer with respect to doing stuff like that. For me, it's been a very difficult couple of days, kind of just thinking about this stuff and not really knowing how to explain it to my daughter, who has been asking a lot of questions about it. And I kind of wrestled with this idea of doing a podcast or not. And in the end, I sort of decided this evening after dinner that, you know, I was going to do this. So Olivia and I sat down for maybe 20 minutes or something to talk about stuff that we have been talking about all week. And I really wanted to talk more in terms of something that I had some knowledge of. I don't consider myself an expert in law enforcement, racism, the history of police brutality, all of the things that might factor into this, but there is one area that I do think I have some knowledge in that I can speak to, and it has to do with the training of physicians. And there's something I've thought a lot about. So I approach this conversation with Olivia as I often approach conversations with her, which is sort of touching on a framework and an understanding, then maybe that's broader than this problem. As with all podcasts, of course I can't address all things, and that's more true in this podcast than probably any podcast I'll ever produce. But. But I do talk about one very particular way that I think about what's going on and perhaps more importantly, how we can start to get a handle on it. This podcast might not be for you. If it doesn't resonate with you, I apologize. But I think that for some folks, especially folks with kids who are struggling to kind of explain to them what's going on, perhaps you'll find this helpful. Hi, Olivia. Thanks for sitting down to talk for a few minutes tonight. Yeah, so there's been a lot going on for the last few days, and I know you're in the middle of finals, and I know that if that weren't enough, you've got a quarantine going on that you're probably kind of at your wit's end with, but tell me a little bit about how you feel about the last few days and how you've heard about it and what you and your friends are talking about at.

First, I was seeing it on everyone's Instagram justice for George. And I was confused. I was like, what is that? And then I started looking it up, and I was like, whoa, this just happened. And then I started reading articles about it to see what happened. And this is the first time that I've actually heard about something like this that's happened recently. Because the only ever times I've heard about it is when I was younger, and I don't remember it, but everyone that I text is sending, like, Black Lives Matter, and they're all doing different color fists. And I think that's great that they're noticing what's happening. And I just don't understand how this could happen, because, like, would people judge you about the color of your eyes? Like, what's the difference with skin color?

I mean, that's a very complicated question, Olivia. And it goes back hundreds of years. And you know how the other day we were talking about all the different things in school that I'm really looking forward to you learning in greater detail? Well, one of those things is history. And I don't think you've yet really fully understood the history of how black people came to this country and what terms that was under and what conditions of racism produced it and allowed it to continue for literally hundreds of years. And I hope that when you get to studying history, you will understand that it's not just about taking tests and passing tests and getting answers or writing essays, but it's about really understanding the systemic nature of racism. I want to tell you an interesting story that I've never told you before. I don't think I've ever told mom this story either. So I kind of have slightly different skin color, right? Like, if you look at me, you know, I'm not perfectly white. I'm not black. I mean, I kind of look like. I look like I'm something, right? You also have slightly darker skin than you.

I don't know what I am as.

A result of that. So when I was in college, which was in an area that was pretty much exclusively white people, one day, it was 1995, I remember this very well. I was riding my bike to the gym. I used to go to this gym a couple miles from my house, and I'm riding my bike, and you're supposed to ride your bike on the right side of the road. But, like, I don't know. I forget. I think there was, like, a lot of water and snow in the ground. So I rode up on the sidewalk, and a police officer pulled his car right in front of me and yanked me off my bike and threw me onto the grass right in front of where I went to the gym. This all took place right in front of the gym that I went to. And I basically stood up and said, what the f, man? And he said, were you in such and such a place at such and such a time? And I'm like, what are you talking about? He goes, you can't ride your bike here. And I was, like, totally confused by what was going on. He kept going back and forth between, I'm not allowed to ride my bike on the sidewalk, and then sort of making these accusations. And he said an older woman was mugged near here, like, yesterday or something like that. And it was really clear at that point what he was basically saying, which was, you did this, And I can't prove it, but that's my suspicion. I don't like the way you look and the fact that you're riding your bike on a sidewalk where you shouldn't be riding it is my chance to make that case. Eventually, a whole bunch of people came out from the gym, apparently including somebody who was kind of related to him. It was a small town that I went to college in, and he basically let me walk away. And I was pretty shaken up about that. That was super upsetting to me. And of course, to put that in the perspective of what we're talking about today, that's like one. One millionth of the type of racial profiling and racial discrimination that is experienced by black people in the United States and elsewhere, but certainly in the United States on a daily basis. Something that, I mean, you just won't understand and nor will I.

Why do you think he did that?

I think it's a combination of factors. In my example, I think certainly racism played a role. I don't believe that he would have done that to anybody else necessarily. But I also think in that case, there was some indication that he legitimately felt like, hey, this is a guy. There's a kid who's riding on the wrong side of the road or up on the sidewalk, and, you know, he shouldn't be. And, oh, by the way, I have a reason of suspicion that there's some bad apple somewhere out here, and this is what I'm going to do. And that's. It's hard to imagine that times a thousand. And that's what's going on in the case of someone like George Floyd or any one of the other people whose names we don't know. Remember, the reason we know about this, Olivia, is it's caught on video.

Yeah. There can be so many other people just like this that we don't know about.

Well, that's exactly right. And you have to think about. Imagine an era when you didn't have cell phones that we could capture anything and everything by video. How many times do you think this has already happened?

Probably more than we can count.

Yeah, you would need scientific notation to count the number of times this has happened.

So when I was reading the article where I started to learn about this, I saw. So when George Floyd was in the deli and he gave a check that people thought was fake, I saw a comment in the article that said, one time I went to Home Depot and I used a fake 20 bill and they knew it was fake and they gave it back to me and let me just walk out because I was white.

Yeah. There's absolutely no question that a white person and a black person has a completely different interaction with, frankly, law enforcement, the criminal justice system, all of these things. I'm glad to see how much this is upsetting you. It's good to see that this is upsetting to you. As much as I hate to see a kid upset, it should upset you. It should upset you greatly.

Well, why do you think that police officers do this? I mean, the only difference is that some people of darker skin, some people of lighter skin, why. Why does that make them more likely to get killed or hurt?

I mean, it comes down to racism. This is what we call systemic racism. And so the real question is, why is it tolerated in the police force?

Yeah. Shouldn't there be some sort of. I don't know how to put this, but like a test to see if you're not racist before they let you on to be a police officer? Because it's not fair that innocent people are getting killed because of this.

Yeah. I mean, I've been thinking about this a lot, Olivia. I've seen some people who are very thoughtful make comments like, hey, look, there are very few protesters that are actually looting, and there are very few police officers that are going to do what this guy did. It's mostly good police officers and mostly good protesters, and we're focusing most of our attention on the worst of both groups. There may be some truth to that, but a counterargument to that is, isn't law enforcement a profession in which we can't tolerate any of this? Don't we need a zero tolerance policy for this? Would you want to fly on airplanes? I think Chris Rock used this analogy Would you want to fly on airplanes where 99% of the pilots were good and 1% were horrible?

No, you wouldn't. Because that 1% could make a difference, that they're horrible.

Yeah, it's totally unacceptable paradigm. So I've been thinking about this a little bit, and I actually realized that I don't know what the analogy is, and I don't know if that, you know, airlines are the right analogy, but I think a good analogy is actually doctors. Comparing doctors to police officers is better than trying to compare police officers to pilots.

Why is that?

Well, one, I think there are probably more interactions that are interpersonal, that are the ones that we're really talking about. I think that's probably the most different thing when you talk about a pilot being ethical or not ethical, moral or amoral. And of course, by the way, there are examples of pilots that have done very bad things. There are pilots that have crashed airplanes deliberately, but the frequency of that is so incredibly low. But in medicine, there really are some bad doctors out there. And I don't mean bad doctors that aren't smart. I mean doctors that do horrible things, that abuse patients. There's a very famous doctor. He was the doctor of the US Gymnastics team, and he abused many of the gymnasts. I mean, these are despicable doctors. And so I wonder if that's a better analogy. And in medicine, there are basically three types of mistakes you can make. And I think of this as a very important way to think about how you train people. There are technical mistakes, there are judgment mistakes, There are normative mistakes. Do any of those words mean anything to you?

Normative mistakes that can mean, like, mistakes that you don't mean to cause?

No, actually, that's not what normative is. So let me explain what these are. So a technical mistake is like, if you think about surgery, which is the easiest place to explain it, a technical error is you mean to do something, but you make a mistake. You cut too much, you cut too little, you poke too much, you poke too little. The patient is hurt as a result of a technical error that you make. I've made many technical errors in my residency when I was training. You know, I remember once doing an operation on a patient and I cut the bile duct by accident, you know, when I didn't mean to doing an operation. Do we forgive people who make those kinds of mistakes?

Yeah, because it wasn't. They didn't want to do that.

That's true. But there's a bigger and a more important point there. We forgive them, provided What? They have to own the mistake immediately. They can never try to cover it up.

They can't deny it. They have to own up to their mistake and not hide the fact that they made a mistake about that.

That's right. The other condition to that is you must learn from your mistakes and not make the same mistakes over and over again. So if I cut the bile duct every single week, well, that would be a problem, right? If I'm putting a central line in a patient, which is a special IV that goes into their neck and I constantly poke their lung, which causes a huge catastrophe of problems. And even if I admit to it every time but never get better, that is a problem.

That's also not helpful. Even if you do admit it, that's still not going to make.

Yeah, at some point, you just have to decide you're maybe you're not technically capable of doing this job. So that's a technical error. Then there's an error of judgment. Judgment errors are a little harder to understand. But it basically says, should I or should I not operate on this patient now? Should I or should I not change this medication now? Should I or should I not admit this patient to the hospital now or send this patient home or call in another doctor to help consult with this? Now, again, you can make lots of mistakes with respect to judgment. Are they forgivable?

They can be as long as you own up to what you did and.

You don't repeat them.

And you don't repeat them.

Okay, now enter normative errors. Normative errors are the third class of error in training physicians. These are errors of character. This is when you lie about something. Let me give you examples that I witnessed firsthand. You go in to see a patient in the emergency room who comes in with an infection, and you give them an antibiotic. You don't ask them if they're allergic to the antibiotic. They have an allergic reaction to the antibiotic. You go back and change the form where it says, what was their allergy to the antibiotic? And you write in, oh, they had a penicillin allergy, even though you didn't ask them. Seems like a little error, doesn't it? No. Why? Why isn't that just a little error?

Because when you lie about something that you did like that, that just makes it worse.

Well, what if, in that case the patient was fine? You gave them penicillin, they had an allergy to the penicillin, you gave them the appropriate Benadryl or epinephrine or whatever they needed to not die from it and they're totally fine. But you went back and you changed your form.

That's still not right.

Why is it not right?

Well, you have to live with the fact that you did that and you could have hurt them if you didn't know how to fix it.

That's true. And there's an even deeper issue, which is people who consistently make those kinds of mistakes, or frankly make those kinds of mistakes at all, will go on to make bigger and bigger. That's right. They make bigger and bigger versions of those mistakes. And so a good training system in medicine is one that fosters and encourages open and honest discussion of technical errors and judgment errors, but it immediately identifies normative errors and kicks those people out of programs. And not just kicks those people out of programs, kicks those people out of medicine. If a person commits a normative error and they are kicked out of one program only to be picked up by another program, that hasn't really solved the.

Problem, they can just still make more mistakes like that.

That's right. They're still gonna make their way into the field and the practice of medicine. And so as I think about these awful things that have happened and I start to think about what can I do about it? Well, the short answer is I have no clue. I know what to do in terms of voting, and I know what to do in terms of protesting, and I know what to do with those things. But the thing that I think a lot about is how do you change the training? How do you identify systemic racism in training? And to me, it comes down to basically identifying traits that. That are prevalent in a way that are going to be amplified this way later on. Does that make sense? In other words, we should be treating racism as a normative error, and when it shows up in even the smallest ways, it has to be tolerated. Zero. Just as we wouldn't tolerate a doctor who says, oh, yeah, yeah, yeah. I did ask that patient if they had an allergy, and they said nothing. I don't know what they're talking about. I can't believe they had a penicillin allergy. You have to be very careful. And I know it sounds like a silly example, but, Olivia, I've seen lots of people make those normative errors where they lie about things. They put their own interests ahead of a patient's interest. Another example I've seen doctors do it financially. For example, there are two drugs that you could give a patient, and the doctor has a financial interest to use one instead of the other, and they use the more expensive one. Because they have a financial interest in that. Again, it's another example of a normative error. So I don't know if I answered some of your questions because you've been asking me so many great questions in the last couple of days, but I think that somewhere down the line, people a lot smarter than me have to understand what the normative equivalent looks like to the type of racism that can lead to. To a police officer putting his knee on the neck of a black man for nearly nine minutes for no apparent reason because that can't be hit the first time he has acted in a racist way. That guy's been a racist for a long time. Why didn't we figure that out? Yeah, what's the norm? That's the guy who is so far down the road that he's cutting off the patient's wrong leg out of sheer sloppiness.

Then he should be more than just fired for doing that. Because if this is repetitive, that's not right.

Yeah, and that's my point.

It's not even right to do it one time, but multiple times.

Well, my point is, how do we know what was seen the first time? I mean, at some point, I mean, not to get too far down this path, you have to have a self policing system. And this is not true in most systems. So I'm not singling out police officers here because I don't think doctors like to police other doctors any more than police officers like to police other, you know, police themselves. Or teachers want to police teachers. But remember, racism exists in a lot of professions. It exists in medicine, it exists in justice, it exists in education, it exists everywhere. It certainly exists in the military. It's just the stakes are so high in law enforcement that that's why we're seeing it the way we're seeing it here. And I think the point I want to make tonight as we sit here and try to make sense of this is I hope that there's a way that we can take this idea of normative errors as a tool that we can use to identify people who are making mistakes that are acceptable because they can be learned from and improved upon versus unacceptable mistakes and quickly getting those people out of the system. It's one thing to say we may never completely eradicate racism. It's quite another thing to say we're gonna tolerate racist police officers. You see the difference? The stakes are much higher.

The biggest question is, what can we even do about this?

There is probably one of the best videos I've seen going around on this I'm gonna show it to you later today. It's by this rapper and activist, Killer Mike. And he was at a press conference and he gave a very eloquent, passionate speech about what exactly you can and can't do. And it was like, hey, rioting, looting. That's not the thing to do. Yes, I know you're angry. Yes, you know you have every reason to be upset, but that's not the productive thing to do. The productive thing to do is not just march and not just send your fisted emoji to your friend. It's actually do something political. It's changed the system. Right. It's vote out the people who allow this type of racism to proliferate. That's one example. I thought that was a very elegant example. Have you guys talked about this in school? Like actually formally in any of your classes?

For some reason, teachers don't talk about politics like this in school, but I wish they did because I want to know more about it.

That's so crazy to me. Your teachers have not said anything about this.

No.

What do you guys think about that as students? Do you talk about it amongst yourselves and say, why are they not saying anything?

Yeah, all these group chats in my grade are blowing up right now, but the teachers don't really do anything.

I don't know what to say about that, but I'm glad that you and I get to talk about it.

Yeah. Thank you.

All right, well, thanks for making time to sit down tonight. I know you gotta get back to studying.

Bye.

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Sam.