Policing Can Take a Lesson from Health Care

The grief is indescribable. George Floyd, Breonna Taylor and other unarmed Black Americans dying at the hands of police is unacceptable. It is happening repeatedly, and we are fed up.

I will be forever haunted by the images of a police officer’s knee being used, not in protest, but to asphyxiate a fellow American. While I had to watch parts of it on mute to keep from hearing the calls of Mr. Floyd asking for water, begging for his deceased mother and pleading for his life over and over again, I keep thinking of the details of how he died—how his carotid arteries were compressed, leaving it impossible for his brain to get oxygen; how the vagal, or relaxation, centers in his neck were overstimulated by the pressure, likely slowing or stopping his heart; how his trachea, as rigid and firm as it is, may have also been collapsing from all the external pressure; and how pinning him down kept him from expanding his chest cavity to take in enough air and compensate for his already oxygen-deprived organs.

For days, I avoided watching the entire video, but reminded myself that this was not an experience Floyd asked for or deserved. As much as I wanted to protect my mental health, it paled in comparison to the horror of being killed slowly and unjustly. After watching the video, and seeing that the officers knew that they were being videotaped, I realized that what the public sees as solely an accountability tool may in fact be a stage for some police officers to amplify and assert to the world who is in charge

What we attempt to sweep under the rug as isolated instances, bad apples that should not spoil the bunch, is increasingly becoming a pattern. The bunch is unmistakably being spoiled, and the American public is watching. We are watching for the true acknowledgement of ills in policing by the police themselves, for the recognition that all parties involved, including those setting the stage for murder, those ignoring or mocking the cries of screaming bystanders and those using a person’s past or current misfortune as justification for murder, are all complicit.  

It is incredibly tough to be yelled at, assaulted and chastised while being a public servant. I am an emergency medicine physician, and I have had bodily fluids thrown at me, been assaulted by patients and been accused of withholding resources and care. I recognize the stark differences between the natural hazards I am responsible for trying to fix and the human-to-human hazard that police respond to. My job does not require me to interface with a potentially armed public. Nonetheless, the decisions we make every day, in either circumstance, can result in life or death. Even on my worst day, I could only hope that those who have also made the pledge to “Do No Harm” would not let me get away with hurting anyone. To be responsible for a life is to be held accountable for life. To be a teammate to another public servant means encouraging the best behavior possible.

So, if our police force says these murderers among them are bad actors, how do we better screen for them before they are hired? How do we remove and punish them for egregious acts against weaponless Americans? How do we best account for and address implicit and explicit bias and Chauvin-ism in policing?

Health care may be able to provide a model for improvement. Health care in America is far from perfect and needs its own serious introspection. To be a physician or nurse in the U.S. and not recognize that mistrust, bias and inefficiency in medicine is real would be willful ignorance. Nevertheless, our health care system recognizes that even the best and brightest trained and most well-intentioned among us are imperfect people functioning in an imperfect system. Our job requires a constant mental exercise of risk versus benefit, checking bias, examining power dynamics and staying current on the best practices for patients.

In risk management, analysis and prevention, an accident causation model called the Swiss cheese model, proposed by James Reason, author of Human Error, is used to help avoid unacceptable events in an organization. It is a model commonly used in health care as well as in aviation and engineering. Each component of an organization is considered a slice of cheese. If there are any deficiencies in the slices of your organization, you will have a hole in that slice, hence Swiss cheese.

If a hole, or an area of failed or absent defenses in several slices of an agency line up, it can create a continuous hole, thereby resulting in an adverse outcome. Factors that contribute to failure of a system or a bad outcome result from problems in organizational structure, supervision, preconditions and unsafe individual acts. For example, a hospital purchases an electronic health record that does not record allergies upon patient arrival. The supervising physician unknowingly orders a medication that a patient is allergic to. The pharmacist is not prompted to check for allergies prior to filling and delivering the medication. The nurse then administers the medication to which the patient is severely allergic; the patient is then unable to breath and dies. 

The layers of cheese are aligning quite strikingly in American policing.

While we work to address the systemic issues of inequality and racism, as well as campaign finance reform, voter turnout and suppression—bearing in mind how such electoral conditions contribute to the employment of local officials such as district attorneys, prosecutors, sheriffs and medical examiners—I want to offer 10 solutions to support effective and unbiased maintenance of public safety in our communities.

1. Third party external review of deaths under police custody. There should be an external, nonpartisan body that reviews every death under police custody for police departments nationwide. This would allow for an impartial assessment of pattern and practice in the review of deaths in custody and would be made of a panel of law enforcement leadership, legal officials and civilian participants. Cases that may present potential conflict of interest would be escalated to the state governor or federal Department of Justice. An unbiased, third-party medical examiner should also be selected to conduct autopsies in these cases as local medical examiners are often appointed officials with political relationships that could pose conflicts of interest.  

2. Anonymous reporting with no retribution. Police should be encouraged to securely report activities of misconduct without the concern of punishment from police stations or colleagues. To facilitate this safely, I recommend reporting through an anonymous external reporting system or hotline.

3. Internal reviews for quality and safety. All police departments should be required to engage in routine quality audits of their activities for continued improvement of policing practices. Quality audits would include reports from the anonymous reporting system, as well as frequent review and audit of police reports, dash and body camera footage, radio exchanges with both peer and community review. This would also encourage preferential use of alternative nonlethal agents when a citizen is posing a possible nonlethal threat to the officers. A system for remediation, probation and termination should be enforced for officers with repeated offenses and not meeting requirements of their corrective action plan. Special attention will also be paid to precincts with disproportionate disciplinary action of officers based on their race or gender.

4. Evaluation for racism and socioeconomic bias in the recruitment and hiring process. Screening through entry questionnaires, interviews and scenario-based evaluation with mental health professionals and character assessments via diverse job references should be conducted with all entering police officers. Longitudinal training in implicit bias and systemic inequality would also be required.

5. Routine psychological evaluation and mental health care for all police officers. Repeated trauma of frontline professionals, particularly those at risk of physical harm and death, should be acknowledged. Those at higher risk of post-traumatic stress disorder, including officers with backgrounds in wartime conflict and high-risk adverse childhood experiences such as significant bullying, violence, physical or sexual abuse, should be identified and supported. Partnerships with mental health professionals, consistent participation in activities promoting mental health and wellness, and routine sabbatical opportunities and respite from policing activities may also prove useful.

6. Training, in-service and continued policing education. In addition to routine training and in-service activities, police officers should be required to complete a set amount of continuing education units (CEUs) annually or at minimum every two years. This would include conflict resolution and basic first aid as well as cultural competency training involving members of the community that addresses the unique needs of the communities they serve.

7. Unarmed public safety teams. These teams can function as enhancements of or alternatives to armed police officers particularly for patrolling and nonviolent 911 calls. This public safety option would include locally recruited public safety workers trained in de-escalation and mental health emergencies.

8. Enhancing education and entry requirements. Journalist Sara Llana, in an article titled “Why Police Don’t Pull Guns in Many Countries,” describes a police training process in Germany wherein “rigorous education standards help to widen an officer’s vision when stress narrows it.” Currently, in the U.S., police training lasts on average 19 weeks. This may or may not include a field experience and probation period. In addition to academy training, local governments would require, at minimum, bachelor’s level liberal arts education focused on courses such as ethics, communication, history, psychology, domestic and international relations, foreign language and ethnic studies.

9. Performance review–based compensation. Compensation of officers would be increased based on fulfillment of the above requirements with incentives for strong peer, community and performance reviews, and avoidance of adverse events.  

10. External review for accreditation. By fulfilling the above requirements, a police department would be accredited by a third party for continued operation, potential increases in budget or fines if requirements are not fulfilled.  

When an apple is rotten and a slice of cheese riddled with holes, a typically delectable combination, is now difficult to eat. I hope these points can contribute to the dialogue and provide potential action items for change. Our nation should never have to witness an unnecessary, gruesome death at the hands of police. As a fellow public servant, we are the people that the public calls upon in times of distress, fear and concern. We are layers of protection and should function as such. We should prioritize trust and comfort over fear and terror and call out our colleagues who prioritize the latter.