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

KEYPOINTS

• 01

  Attia speaks from what he knows: how doctors are trained

  Recorded after dinner in the days following George Floyd's death, this 20-minute conversation with his daughter Olivia, who was in the middle of finals and lockdown, is explicitly limited in scope. Attia says he is not an expert in law enforcement, racism or the history of police brutality. His one contribution is a framework from medical training, which he offers for parents struggling to explain events to their children.

• 02

  Racism is systemic and centuries deep, not just individual

  When Olivia asks why skin colour should matter more than eye colour, Attia says the answer goes back hundreds of years, to how Black people were brought to the country and the conditions of racism that kept it going. He hopes that when she studies history she'll see it as understanding the systemic nature of racism, not just passing tests or writing essays.

• 03

  Video has exposed what was always happening

  Olivia notes that this case is known only because it was filmed, and that there must be many others no one knows about. Attia agrees and imagines the era before phone cameras: 'you would need scientific notation to count the number of times this has happened'.

• 04

  White and Black people have completely different encounters with the law

  Olivia mentions an online comment: a white person who tried to use a fake $20 bill at Home Depot was handed it back and allowed to leave. Attia says there is no question that white and Black people have completely different interactions with law enforcement and the criminal justice system. He tells her he is glad it upsets her, because it should.

• 05

  'Mostly good' isn't good enough when the stakes are this high

  Attia acknowledges the argument that most protesters don't loot and most officers wouldn't do what this officer did. But he asks whether law enforcement should have zero tolerance. He cites Chris Rock's analogy: you wouldn't fly with airlines where 99% of pilots are good and 1% horrible. He then argues doctors are a better comparison than pilots, because both jobs involve constant face-to-face encounters and medicine has its own abusers, such as the former US gymnastics team doctor.

• 06

  Medicine recognises three kinds of error

  Technical errors are mistakes in carrying out a procedure, such as cutting too much or too little. Judgment errors are wrong calls about whether to operate, change a medication, admit a patient or bring in a consultant. Normative errors are errors of character: lying, covering up, or putting your own interests ahead of the patient's.

• 07

  Technical and judgment errors are forgivable, with two conditions

  You must own the mistake immediately, never covering it up or denying it, and you must learn from it. Attia admits he made many technical errors in residency, including cutting a bile duct by accident. A trainee who keeps making the same error, such as puncturing a lung when placing a central line, may simply not be capable of the job, even if they admit it every time.

• 08

  Normative errors should end a career in medicine

  A good training system encourages open discussion of technical and judgment errors but removes people who commit normative errors, not just from one programme but from medicine. Otherwise they are picked up elsewhere. Attia's reasoning is that people who commit these errors at all tend to commit bigger and bigger versions of them.