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Sunday, May 27, 2012

Policing our own

The Secret Service is in the news. I am be fairly certain that the leadership of the Secret Service basically never wants its agency to be front and center in the news. It is hard to keep it "secret" when what it is up to is not so secret.

The gist of the story is that agents in Columbia, who were acting as an advance team for President Obama, were caught with prostitutes in their hotel rooms. This was not the product of a specific sting effort but actually was the consequence of one particular agent trying to stiff (no pun intended) a prostitute who had spent the night with him. She was not awed by the vaunted Secret Service and went through her usual channels to expose a customer who failed to live up to their end of the bargain. Thus, this particular episode ended up with a Congressional hearing. Who would have figured.

As a consequence of all this, all sorts of interesting tidbits of information have become public, relating to less than desirable behaviors of Secret Service agents through the ages. The famous stories about the Secret Service leading up to the assassination of President Kennedy have been rehashed. On top of this, numerous other anecdotes regarding isolated misbehaviors of  agents have been described. We have no idea of how prevalent these behaviors are but two things are obvious. First, the Secret Service is made up of young people, primarily young men and these people, particularly young men, have urges..frequent ones. Second, if the local culture does not provide them with prompt feedback not to succumb to urges, they will succumb to those urges. The most important part of the local culture are their immediate peers and local supervisors. In the case of the Secret Service, this local culture was not inclined to act when they observed their peers engaging in activity which we could characterize as not desirable.

I read Maureen Dowd's piece in the New York Times this morning and perhaps the most intriguing port were the comments. What I took away from the comments was that the specific behaviors which the agents engaged in are view is many different lights by the public at large. I suspect that there is also a similar spectrum of belief held by  their fellow agents. From the perspective of the Secret Service, there is no question that hiring prostitutes, while technically not illegal in Columbia, places the agency and their charges at some additional risk and is therefore unwise. However, the magnitude of the risk is undefined and from the perspective of the agents involved, it may appear to be very small since it is highly likely that they have been watching behaviors like this for years and nothing has happened.  They likely view this in the same light we view coming to a rolling stop at a stop sign or having a few glasses of wine with dinner and driving home. Probably not the smartest thing to do but everyone does it.

While the Secret Service story holds the public because of the obvious titillation factor; sex, powerful men and wasteful and inept government, there is a broader message here. Congress is now up in arms because the Secret Service appears to be incapable of policing itself. This is not surprising but what should also not be surprising is that the inability to self police is not unique to the Secret Service. Look elsewhere and what you will see is the same phenomena, in financial markets, in education, in biomedical research, in health care, the Catholic Church, and the Penn State athletic programs to name but a few in the news recently.

What all of these have in common is that these entities are made of communities of people who have a wide range of views as to acceptable and not acceptable behaviors. Furthermore, most people are inclined to leave other people alone and not challenging their peers, short of the most egregious activities. I can attest to situations within health care and biomedical research where I have observed varying degrees of  compulsiveness in adhering to particular norms.

In the health care practice realm, we are constantly faced with scenarios where we are in a position to second guess someone else's judgment, almost always without a complete story. When does a particular behavior reach the threshold for a response? Was that informed consent really adequate? Was that really the indicated procedure? Did that patient warrant treatment with that drug and were they really aware of the risks involved?  The default mode is to take care of what you can take care of and ignore the rest. Periodically we face situations where particularly egregious examples of behavior hit the press where physicians have been committing outlandish acts and it appears that no one appears to care or they may even be viewed in very positive lights until the OIG or other oversight body brings the hammer down.

In the case of biomedical research, the recent observations that much published high impact basic and clinical trials cannot be repeated would imply that a similar dynamic exists in this realm. We have peer review but the recent revelations point to limits of the peer review system in dealing with issues like these. Within our own research programs we grapple with the tension between publishing good vs. perfect data. Waiting for perfect results means that you will never publish anything. However, within the scientific community there exists a range of standards for what constitutes good enough and a potential for a funding advantage to redefine that good enough standard to a more minimal threshold. Does something constitute sloppiness if actual dishonesty? Where does that stop and how do we police this?

I have no pat answers. Self policing has its real limits. These types of quandaries are reflective of a broader range of behaviors both within and outside of medicine and research which can best be characterized as gaming behaviors. Wherever we find ourselves, we find that there are people who are very comfortable pushing to find where the boundaries are for acceptable behavior and actions. All of us are likely to be called upon the judge and blow the whistle on others are likely guilty of at least some gaming behavior and likely worse. We will be hesitant to hold their peers accountable when  we are aware of their own actions which fall short of perfection.  We remember when we looked for that particular angle to maximize our own gains.

However, before we call for creating  of in increasingly complex regulatory environment, we need to recall that this does not appear to work so well either. Those regulated and those who do the regulation often become partners in what has been termed regulatory capture.  Human nature being what it is means that we are not to be trusted and not amount of third party oversight can domesticate the risks of dealing with people. The world works on trust but the truth is no one or things made up of people can be completely trusted. Good institutions are compatible with bad outcomes and our quest to perfect them and perfect people may result in unintended and less desirable results.

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