When is it time to break the rules?

Earlier in the week Dr. Acharya shared this short reading with me; it is a commencement speech from a medical school graduation, but I think its message can be applied not only to MDs but across the field of public health and maybe even more broadly to life.  Feel free to read it for yourself (not a long read) at this link, but I’ll provide my perspective.

http://pulsevoices.org/archive/stories/234-stepping-into-power-shedding-your-white-coat-donald-berwick-s-graduation-address

 Rules tend to exist for a reason.  In the hospital setting, these rules are made for safety and efficiency.  In the speech, the author reads a letter from a woman whose husband had passed away, spending his last few weeks in the intensive care unit.  She had very restricted visiting hours due to hospital policy and lost a lot of time she could’ve spent soaking up their last few moments together.  Why were these rules in place?  It surely wasn’t because some evil hospital administrator sat in his office and scoffed and decided to make things hard on her.  It probably had to do with the fact that people in the ICU are very sick and there is a lot of equipment and medication and other patients to be dealt with, and that if all their visitors were coming in and out all the time as they pleased it could become a hectic, dangerous, and infection-prone environment for the other patients.  Still, that does not make the rule just.  That does not make it fair.  That does not mean it is always best for those it was meant to protect, because the husband dying in his hospital bed surely would’ve preferred his wife by his side.  Whether it is as a doctor or a health care professional, a public health crusader, or as a parent or friend or fellow human being, we have to be able to see past the rules.  Sometimes they must be broken; sometimes it is possible to challenge them in an attempt to cause more lasting change.  We also must not vilify those who made the rules, or even those who enforce them.  What if the nurse, who told that wife that she could not visit her husband at that time, did so because she feared losing her job, as a single mom with two kids at home?  Breaking the rules wasn’t worth it to her.  But that doesn’t mean it can’t be to us.  Progress is made by challenging a problematic status quo.  In the medical setting and beyond, the “rules” must not be taken as an unquestionable dogma written in stone, but as what someone thought was best at the time they were developed.  That doesn’t mean they can’t be reevaluated, and we must recognize when this is necessary and take appropriate action.