Complacent bureaucracies could not answer the call. Now is the time to make adjustments. The next shoe will drop.
Michael S. Victoroff, MD
It is necessary that society should look at these things, because it is itself which creates them. — Victor Hugo, Les Misérables
Two weeks after Hurricane Katrina, I am scanning thorough photos of post-diluvian Louisiana, where I have some family.
It was obvious that Katrina was going to teach us some important lessons about managing care. In coming months, officials, managers, and caregivers of all denominations will be sitting (some reluctantly) in Katrina's classroom, reviewing the game films. One thing that sure won't be on the curriculum is "intelligent design."
A defining canon of managed care is "Getting the right treatment to the right person at the right time." Katrina demonstrated how fragile this proposition is under conditions of extreme social disorganization. As commentators at every level deliver critiques of each other's pre- and post-disaster performance, the parameter I keep returning to is, "What did we expect to happen?"
Was anyone surprised?
When a 15-year-old collapses at a track meet, the issues are different than when it's a 60-year-old, obese, hypertensive, diabetic chain-smoker with a family history of heart disease. When Katrina arrived — foretold by decades of scientific prophecy — what did folks think would happen? The flood was a probability both in the long term and in the immediate hours before it arrived. How predictable were the events that subsequently unreeled?
When the mayor of New Orleans said, "Run for it!" what did he imagine would occur? Did he have a roster of people who were homebound, hospitalized, or handicapped? What was the plan for these and other tens of thousands who found this a problematic order? Casualties were foreseeable; such is life. How many were avoidable? Lessons from the Titanic: Which populations do your plans neglect? Do they require two working legs or a reading knowledge of English? Are there enough lifeboats?
Many verbal potshots (and some literal ones) have been taken at "looters," but I haven't seen much pragmatic guidance for how an abandoned population is supposed to conduct itself.
When grocery stores are deserted and mobs of people are short of supplies in 100-degree heat, what do you suppose might happen? When jewelry stores and pharmacies are unguarded? When jails are opened? Is it realistic to say, "Zero tolerance for looting?" Looting food is a sensible and morally appropriate action to take in the face of some emergencies; looting TV sets isn't. Breaking into a pharmacy for insulin is resourceful and praiseworthy; breaking in for narcotics isn't — unless you have a broken arm, in which case it is. With that clarified, what is your duty as a police officer stationed outside the store?
Rules? What rules?
How should authorities respond when rules are broken in a good cause? At times when some rules are properly ignored, which ones still need enforcement?
Disasters accentuate extremes. Good behavior becomes extraordinary. Mistakes are amplified. Human nature busts out all over.
One way you know you're in an emergency is that a lot of everyday rules and procedures are out the window. Both the best and worst human behaviors are reflected in a readiness to break rules when things go sour. It is problematic to know what actions we should praise and blame during emergencies, but it isn't unfathomable.
Part of the delay in responding to Katrina was because some public officials were so daunted by fear of being caught in a mistake, so cynical about being sacrificed by their superiors in the name of accountability, so conditioned to ask permission and draw up a CYA plan in triplicate before taking any action, that they became paralyzed. The name for this is intimidation, with the emphasis on "timid."
It's hard to measure hesitation in the face of ambiguous authority. Outside of a real catastrophe, it's hard to predict how an organization's culture might inhibit people from doing the right thing. A group in which rigid adherence to procedures is always seen as the safest choice exposes itself to a predictable kind of system failure, when the tempo and volume of incoming problems overwhelms capacity to process them by normal channels. The possible responses are to bog down — or ditch the rule book.
Too many formalities
Do you have a plan for when your disaster plan meets disaster?
We are used to cartoons of patients being body checked at the hospital door by officious clerks with clipboards. However, this tired HMO joke became reality during Katrina, when relief organizations and emergency services were impeded by gluey formalities. Many first responders were effective in the early hours of the disaster because they jettisoned routine procedures in favor of common sense.
Although management rhetoric often puts a nominal value on initiative, many who work in large organizations understand that this does not usually encompass stepping out of line. Yet, this is the leadership quality that is often called for in a disaster.
It's simplistic to define errors as "departures from the rules." This misses the point of why we have rules, which is to improve outcomes. Physicians sometimes voice aversion to guidelines based on a claim that they must frequently improvise in situations that don't match a set of preconceived conditions. This conceit is often exaggerated to the point of delusion. But that doesn't mean it's never true.
On the other hand, the truism that "rules are made to be broken" does not give us license to play Lord of the Flies whenever we can't get a dial tone.
Right and wrong
The moral definitions of right and wrong don't change during hard times. There are still standards of decency, honor, duty, and human rights. But, one thing that does need to be adjusted is the standard for asking permission, because of a complicated ethical principle called necessity. This is what makes pilfering a food store different from robbing a liquor store. In an emergency, proper actions are the ones a sensible authority would sensibly permit, if one were present to ask.
Over the next year, a couple of hundred thousand people are going to submit storm-related claims to insurers, and try to rebuild lives out of chaos. Few will be made whole. Many were not insured. Many insured will find their coverage excludes flood damage. Both the victims and the medical, insurance, law enforcement, and social agencies they will interact with are vulnerable to error, fraud, exploitation, identity theft, swindles, profiteering, perjury, fatigue, and a million other miseries.
I offer this plea to thousands of claims adjudicators whose jobs normally call upon them to follow protocols rigorously and to guard vigilantly against fraud. It's the advice I give physicians concerned about being suckered by fakers looking for narcotics prescriptions: The harm when you are taken in by a scam is more excusable than the harm of turning away one person in real need.
For those not directly affected by this event — but who may be in line for the next — let's jot down a few notes about how complacent bureaucracies can fail, why we can never be fully prepared for disaster, and how vulnerable we are when we have to rely on competencies that are in short supply in society. This Thanksgiving, I'm going to stash some things in a dry bag.
This is not a drill, but, it has been a test.
Michael S. Victoroff, MD, is a family practitioner and ethicist in Denver who has also been an HMO medical director. He reports no conflicts of interest in relation to his column in Managed Care.