I was recently watching a documentary about the Space Shuttle Challenger disaster. In the third episode of the four-part series there is a point at which the engineering experts tell NASA that it would not be safe to launch at a temperature below 53°F. The temperature on the morning of the launch was 28°F. Initially, the engineers based at Morton Thiokol, along with their administrators, recommended against launching. Questions from NASA’s rocket booster leaders ensued, the Morton Thiokol team then went offline for a short caucus to further discuss the situation. Unbeknownst to those at NASA, the senior management officials at Morton Thiokol took a poll and decided to reverse the initial recommendations without the agreement of the engineers. One vice president was infamously told: “take off your engineering hat and put on your management hat.”
We all know the outcome of that decision. This tragic disaster also serves as a potent case study.
This defining and tragic disaster changed NASA. It is also eerily similar to what is occurring in medicine today.
Research completed by Diane Vaughan1 shows that the following factors led to the Space Shuttle Challenger tragedy, and we see each of them today in medicine:
How many times have physicians, the experts in medicine, been asked to step aside or been excluded from a vote while those less qualified made the decisions?
- Normalization of Deviance: defining and redefining risk, rationalizing new standards via a changing group culture. It’s clear how the normalization of deviance led to the Space Shuttle disaster. In medicine, the same phenomenon is breaking down the team in team-based care. For example, in a lecture given by Mary Mundinger, architect of nurse practitioner independent practice and United HealthCare board member, she states there is not enough prestige in being a family physician therefore physicians should be relegated to the role of specialists. She says Nurse Practitioners should work in primary care INSTEAD of physicians.
- Structural Secrecy: The way that information patterns and their details systematically undermine “the attempt to know”. Information is, in effect, siloed and obscured. We see this in the replacement of physicians with what corporations perceive to be “cheaper” NPs/PAs, while patients are kept in the dark about the differences in credentials, education, and training.
- A Culture of Production: Budgetary constraints and the pressure to maintain the launch schedule both compelled and limited activity in the Shuttle launch. Vaughan says, “Within the culture of production, cost/schedule/safety compromises were normal and non-deviant for managers and engineers alike.” Again, the corporatization of medicine has led to a productivity mentality, including replacing physicians with algorithm-following non-physician practitioners.
The healthcare system must learn from the errors that led to the Challenger tragedy. Multiple problems preceding the shuttle launch were recognized.
Those problems were then rationalized, and then normalized when they didn’t actually cause any disaster–until they finally did cause a horrific disaster.
Physicians and not administrators must be the final decision-maker in policy that affects patient care. But to do this, doctors must speak out and advocate for changes to our system that put patient safety first.
Vaughan, D. The Challenger launch decision: Risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press. 1996.