The concept of norms has gained prominence in both my professional life as a physician and in the American political landscape. As Yale political historian Joanne Freeman observes, the constitutional framework for our government is just that: a framework. The actual practice and outworking of government is saturated with norms.

Freeman 1

Freeman 2

When a person who thinks about government for a living describes her experience in such vivid terms, that’s a lesson to those of us whose formal civic education comprises a one-semester high school course. It’s not about a mere difference in style. Take, for instance, the embrace of an authoritarian leader who practices extrajudicial killings. It’s shattering to realize that a norm that at one time seemed immutable is actually quite fragile.

Social norms are real

Social norms are developed over time within a community or society, and they impact both exhibited behavior as well as responses to observed behavior. Their formation is affected by values, culture, and religion. One example is amount of alcohol intake: a glass of wine daily is desirable in some societies, but frowned upon in others. Voter turnout is another commonly cited example: staying home on election day is shameful in some countries, and a common practice in others. In New York City, the impetus to recycle everything* that possibly can be recycled is driven more by norms than by law. And in New York City–compared with my experience in Texas–it’s much more acceptable to be blunt when interacting with others.

Norms represent collective wisdom, gradually defined by the accumulation of shared experiences. They are neither spoken into being nor codified by law, and part of their value may rest in their informal, flexible nature. Although norms have an abstract quality to those of us not used to thinking in these terms, norms have real and tangible impact. They tell us how things should work and what people should do. This shared understanding is critical to the normal functioning of institutions and society.

Freeman 3

This analogy seems apt: if a constitutional framework gives overall structure, and if elaborated laws (as muscles) both are defined by this framework and constrain how structural components move and interact, then norms are the flesh, giving contours and texture to a body. The first contact we have with an institution is influenced by norms, and the underlying structure becomes apparent only with increasing familiarity.

Medicine has norms

The description of changing political norms is better left to political scientists and journalists rather than to this ordinary citizen. However, norms and their role in society are worth considering. A few examples from my professional world, the hospital, are described here:

  • When–as an anesthesiologist–I meet a patient, I usually have just a few minutes to convey professional competence, to express compassion, and to build an alliance of trust. A smile with my greeting, a moment’s pause, and a look into my patient’s eyes are a good start in the first few seconds. In the next ten seconds, we establish how we will communicate with one another (names, level of formality, amount of personal space and physical contact), and I meet everyone in the room with the patient. These actions establish the importance of the patient as a person with values, perspectives, and loved ones. At the end of the interview, confirming understanding of the plan and providing an opportunity for questions demonstrate respect for the patient’s autonomy–his ability to make decisions on his behalf.
  • As a critical care physician, when I see a consultant or surgeon enter the intensive care unit, I make an effort to pause what I’m doing, approach her, and discuss her patient’s status and our respective concerns. This is intended to convey collaboration and respect.
  • When I perform endotracheal intubation, some surgeons make a notable effort to stand immediately by for what they recognize to be a critical part of the delivery of anesthesia. Their action communicates to me teamwork and support.
  • When we have rounds in the ICU, we make an effort to form a circle, such that no one’s back is to another. Because the ICU nurse is on the front lines of the delivery of care, the ICU nurse should be on the inner circle, not behind the back of the presenting physician.

Not one of these examples is codified in hospital or professional policy, nor were any explicitly taught to me. But these examples are built on culture, professional values, and interpersonal dynamics. And each one has value, meaning, and impact on everyday work.

* It is worth noting that the excessive use of cardboard necessary for home delivery of groceries fits within NYC social norms.

Photo credit (featured image) McMansion in Rockwall, Texas. A clear affront to social norms.

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