These walls are funny. First you hate ’em, then you get used to ’em. Enough time passes, you get so you depend on them. That’s institutionalized. ~ “The Shawshank Redemption” (1994)

Editor-In-Chief, Chester "Trip" Buckenmaier III, MD, COL (ret.), MC, USA

Chester “Trip” Buckenmaier III, MD,
COL (ret.), MC, USA

Occasionally, there is a movie that just seems to resonate with many groups and situations. The 1994 movie “The Shawshank Redemption,” directed by Frank Darabout and starring Tim Robbins and Morgan Freeman, was certainly one of those movies. It was, and remains, common for myself and work colleagues to refer to being “Shawshanked” whenever we are confronted with laborious federal bureaucratic rules that are ubiquitously enforced with little apparent forethought or purpose.

In the movie, Red, an older, experienced inmate within a fictional Maine state prison, is describing how the unreasonable and harsh rules and routine conditions of prison life become comforting over time to the point that any change to those incarcerated circumstances is perceived as a threat rather than an improvement. Specifically, Red was trying to explain why long-term inmates of the facility would often fail to adjust to the unregimented freedoms and relief of regimented persecution commonly associated with life outside of prison. These “institutionalized” individuals would often commit petty crimes to return to incarceration or, in harsher situations, commit suicide because they could not adjust to life on the outside.

No, I am not suggesting that working in federal medicine is similar to being in prison. As I have related countless times in this column, I take great pride and honor in working within federal medicine and for the patients we serve. That said, I believe anyone who has worked for some time within the federal medicine system would agree that the bureaucratic machinations of the organization can, at times, exasperate and challenge rational explanation. The majority of things that are served up by the federal system for me to do or accomplish, I do so willingly and with no complaint, trusting that the task has some importance that I cannot understand from my small corner of the massive federal health juggernaut.

This approach seems to be the best for keeping me off the naughty physician lists and satiating some intrepid administrator with a list and a “box” to check. Indeed, I have learned during my years within the federal system that, regardless of how irrational or silly some task may seem, it is far easier to comply and chalk up the seemingly wasted time and effort to the static of working for federal medicine. I have, I fear, as Red so eloquently described it in the movie, become “institutionalized” to federal medicine in some respects.

As satisfying and comforting as my institutionalization may be for the clipboard-welding hoards (I salute you folks for doing a difficult and usually thankless job.) that keep our system running, despite the morass of regulation and laws at both the state and federal level, there is risk associated with my becoming too much of a proverbial lemming. From time to time, federal medicine, like any human system to include our democracy, needs to be shaken up by having its routines and processes challenged.

Perhaps the most recent and disturbing example of the dangers of accepting the status quo is the VA waiting-list scandal that has played out on the nation’s news outlets. Fortunately for the VA and many veterans on these waiting lists, there were whistleblowers within the system willing to speak up and expose this harmful activity. Granted this issue has given the VA a black eye, and, I assume, many within the VA system do not appreciate the focus that has occurred on this negative issue that tends to overwhelm, in the public eye, all of the incredibly good care that happens in the VA every day. Then again, what if those whistleblowers chose to remain silent out of a misplaced sense of organizational loyalty or the perceived administrative “good” of the institution? What if they were “Shawshanked” in their response, if you will accept the metaphor? How many more veterans would have been adversely affected? How much more damage would have been done to the vitally important VA system?

We all need to accept a considerable amount of conformity within the federal medicine system to ensure safety and consistency of care for patients and maintain training standards for staff. Adherence to policies and rules for the good of the organization does not relieve us of our responsibility as healthcare professionals to continue to think independently, however. I am of the opinion that part of being a good provider and member of a healthcare team includes a duty to point out inconsistencies in practice, procedures or administrative policies that I believe to be detrimental to patient care.

Pointing out system flaws and errors will not necessarily make you the most popular provider at the holiday ball, but they do lead to a more meaningful career and a sounder sleep at night. The key is finding the correct balance between getting the needed administrative task “boxes” checked and noting to supervisors where improvements to processes can and should be made.

Most importantly, we should all work to avoid becoming “Shawshanked” and falling into comfortable complacency as we move, dronelike, from patient to patient with the only goal being the next paycheck and nonchallenging anonymity at work. The patients we serve have given so much to our society and deserve far more than an institutionalized employee. This system, faults and all, is ours, and we are the only ones who can determine the difference between what is working and what needs to be changed. As federal medicine providers, we all must be engaged and proactive in improving the system and watching for flaws. We should all work to be agents of positive change, understanding this is the more difficult path, but recognizing our patients deserve no less from us.