Key sociological concepts for medicine: standardisation and medicine

This is the third of four articles discussing medical sociological concepts that might be of use for medicine

Standardisation is an essential aspect of both the contemporary world and modern medicine. Human life and health increasingly depend on the ‘creation, implementation and maintenance of medical standards’. ¹ Defined sociologically, a standard refers to any norm, convention or requirement that attempts to construct uniformity across time and space. ¹ Standardisation describes the process, or at least the attempt, to construct this uniformity. Medicine uses standards (such as guidelines, protocols and standard operating procedures) for a number of reasons, including to manage risk (see article two in this series), to regulate costs and increase profit (see article one in this series), to improve patient outcomes and to control care across a relevant territory; and standardisation within medicine is maintained via a number of specific processes, including statistical comparisons of variations in medical practice, peer-review and evidence-based medicine. ² Perhaps in a more general sense medical standards are often used to prevent horror from erupting into the world. Evidence-based medicine as a movement developed from an awareness that medical care often varied considerably from area to area even within the same society.

Standards such as guidelines and standard operating procedures are generally considered to be ‘good’ things in relation to healthcare. There is generally concern when healthcare standards slip, and enforcement of healthcare standards is usually enacted, or at least backed up, by external medical bodies. Timmermans and Epstein argue that standardisation, on the other hand, may sometimes be viewed more ambivalently. ¹ On the one hand, healthcare professionals and managers may wish to ensure that all of their patients have the same experience of care with as little variation as possible. This applies to diagnoses, interventions and investigations. Patients, while valuing consistent care, may react negatively if they perceive that they are being processed in an identical manner by a system that does not respect their individuality, or the uniqueness of their medical needs or illness experiences.

Medical standards are usually perceived to be clear-cut, authoritative documents that are based on the most up-to-date medical evidence and on which there is universal agreement. However, this is not necessarily the case. Standards can be artefacts that reflect the views of the strongest parties that were involved in their production. They can be compromises that all parties can agree upon. The creation of standards is therefore often connected to power. ¹ The views of certain individuals and groups may be recognised within healthcare standards but the views of others may be marginalised. Once the standard is agreed, however, it appears and attempts to be apolitical and neutral. It is what sociologists call ‘black-boxed’, closed off and no longer open for discussion. That is the theory anyway; however, the political nature of healthcare standard formation potentially leaves them open to contestation once they are released into the real world.

A good example of this happened in relation to the American Psychological Association’s (APA) attempts to govern healthcare involvement in torture during the War on Terror. At the time, knowledge was emerging that some psychologists might have engaged in activities that were effectively close to torture, or at least torture adjacent, such as waterboarding. The APA formed a task force called The Presidential Task Force on Psychological Ethics and National Security (PENS) to develop healthcare standards that would prevent health professional from becoming involved in torture in the future. ³ However, the PENS standard, rather than being seen as objective and universal, generated significant opposition. This ultimately prevented the standard from governing reality in the way that it was intended to, and it was eventually rescinded. ⁴

When healthcare standards are operating correctly, they become social infrastructure; taken-for-granted and invisible directors and containers of medical practice and healthcare. However, this sign of success can itself become problematic if the standard is seen as an immoveable, unchallengeable thing rather than a human creation. Once a standard is released into the world, it can acquire significant inertia and drive healthcare in a path dependent way. In a worst case scenario, it might become difficult to think about practice in a way that contravenes the standard. In the UK, the Grenfell tower inquiry (which stemmed from a skyscraper-type building – the Grenfell Tower – igniting like a torch and killing a substantial number of people, including children) noted that to protect human life from fires, considerable care needed to be exercised to ensure that buildings materials ‘meet the required standards’; however, it also noted that ‘these concerns extend to the adequacy of the regulations themselves, the quality of the official guidance currently available’. ⁵ In effect, the inquiry suggested a need for ongoing interrogation of standards, implying that the presence of a standard may not be sufficient to protect health and can sometimes lead to incuriosity and disregard about the true nature of danger. The sociologist C. Wright Mills once warned against professionals developing ‘trained incapacity’, ⁶ being led into a state of intellectual numbing by bureaucracies and their regulations. At the same time, the most successful standards are sometimes the most loosely defined, as this allows the standards to be more easily translated into different situations and settings. ¹

Standardisation is a feature of contemporary societies, and is reflective of a wider drive for rationalisation, for efficient control over life (see article one in this series); however, there may also be drives for destandardisation within a society. This might be on ideological grounds (i.e. deregulation is good in and of itself). There may also be strong financial motives to not follow certain standards. However, because there are also strong impression management reasons for actors and institutions to appear to be following ‘best practice’ (i.e. a standard), ironically actors who do not wish to follow a particular standard might go to considerable lengths to get themselves appointed to the bodies that set those standards. This is often so they can influence the design the standard in a way that will not constrain them. The health risks of their subversive activities must then be endured by end users and the wider public. Or, the people who design standards that govern health, such as building fire standards, may be limited in their knowledge, for example assuming that fires will start inside buildings rather than spread outside them before moving inside the building. Frequently, after a major disaster that was supposed to be prevented by a particular standard, individuals will use words such as ‘unprecedented’. However, at least in some situations, the disaster is often not truly unprecedented; it was just that the individuals who saw the disaster coming were excluded from the design of the standard that failed to prevent that disaster. In the terms of article two of this series, standards also have their Cassandras.

Implementing standards, and ensuring standardisation, is not easy. Standards can, as noted, collapse, and require support from both human and non-human entities. Each medical standard is released into a world that is already governed by and operating according to already existing standards ¹ ; fitting into and assuming dominance over that world takes time and effort. Even in the best of circumstances, individual and actors frequently subvert standards or alter them to more clearly suit their needs. This can result in the standard being implemented in a ‘kind of’ or idiosyncratic way; however, the alternative to adaptation may be the complete failure of the standard. There is a balance to be struck here. A degree of violation, basically a degree of non-compliance with a standard, may be necessary for the standard to be accepted. However, too much violation may increase risk uncontrollably. A type of uncertainty principle may be present. It is sometimes unclear to observers whether particular violations of a standard are an example of a necessary adaptation of the standard to local circumstances, or whether it is the beginning of a process of normalisation of deviance that could ultimately result in disaster.

As noted, healthcare workers often value standardisation, for example because they feel that it can help to regulate things, such as clinical uncertainty. ⁷ However, they can also sometimes resist standardisation because they feel that as a process it does not lead to the best care for their patients. They might see standards as optional guidelines rather than compulsory instructions. There might also simply be a lack of time and energy to change existing practice. Local units might be inundated with potentially thousands of new guidelines and standards a year. Some healthcare professionals who do not wish to challenge a standard outright, but who also do not believe in it, might use workarounds, ad hoc solutions and strategies that allow the circumvention of the standard while enabling the health professional to appear to follow it. ⁸ There is also the fact that doctors see medicine as both an art and a science, and might see standardised healthcare as tipping the profession much towards the epidemiology end of the spectrum at the expense of individual clinical judgement, which needs to be informed by standards but not controlled by them. ⁹ Doctors who work in bureaucracies might furthermore experience standards as a way of a bureaucracy attempting to control their professional practice (often for cost containment reasons). ¹⁰ Two visions of professionalism might be in competition. On the one hand, the doctor might ascribe to the traditional view of the professional as a self-regulating actor who uses standards to guide, but not determine, their clinical practice. On the other hand, the bureaucracy might see a professional as someone who will follow standards and then execute directions from those standards both effectively and consistently. Health professionals might furthermore violate standards unconsciously, for instance because they are tired or exhausted or because over time they have grown careless. Carelessness can even become an issue for health professionals who must work with deadly infectious diseases.

It might also be the case that some issues that health professionals face cannot be standardised. ¹¹ For instance, returning to the issue of U.S. health professional involvement in torture mentioned above. Considerable efforts went into standardising and regulating the activities of interrogating professionals who either administered or supervised activities such as waterboarding. However, while some health professionals and interrogators followed interrogation guidelines very closely, in other situations, other interrogators began to deviate quite widely from interrogation standards. This was despite the participation of multiple supervising health professionals and units, and the huge amounts of money (millions of dollars) and time (years of effort and refinement) that went into trying to standardise interrogators’ activities; since these standardisation efforts did not result in actual standardisation on the ground, it might well be that an activity such as torture simply cannot be medically standardised. There might be something about the practice that escapes rationalisation efforts. While at the same time, efforts to medically standardise it leads to the immediate undermining of fundamental medical ethical and professional standards.

Timmermans and Epstein ¹ argue that although we live in a world of standards, we do not live in a standard world. Rather than standardising the world wholesale, in some respects standards can result in islands of rationalisation that exist alongside areas that are more ungoverned and uncontrolled. Lovecraft, a man damaged by the standards of his own time, noted that ‘we live on a placid island of ignorance in the midst of black seas of infinity’. ¹² The promise of standards for medicine is that they lay the groundwork ‘to achieve a level of standardized care that will allow us to return to the art of medicine’. ¹³ The danger with standards is that they sometimes give the illusion of solid ground underneath when in fact they might be the equivalent of thin ice that can easily be broken through. And always under the ice, the cold water.