‘Medical Security Theater': Ritual and Superstition in Medical Practice

While some superstitions in the wound clinic can be harmless, such as tying a knot in the bedsheet of a dying patient, some can risk harm to patients, such as providing unnecessary antimicrobial agents. This author examines how some of the practices performed in the wound clinic may be based more on superstition than evidence.

Many times in my career, I have witnessed instances of ritual practice and a propensity for superstition in healthcare workers. I chalked up many of these strange instances to a peculiar way that people were passing on their knowledge of best practices.

Some practices were overtly superstitious but entrenched in the culture. Woe be to any provider who waltzes into a nursing station and decries that it has been a "quiet day"! While in the intensive care unit, I was made aware of the practice of tying a knot in the bedsheet of an actively dying patient in order to keep them alive during the shift.¹ While this struck me as a futile, absurd practice upon hearing of it, I quickly tied that knot in the sheet when it was my patient who was dying. When that patient made it through the whole shift, I understood how such a silly gesture could endure in nursing culture.

These ritual acts were largely accepted and were rarely ever discussed. It wasn't until hearing about "security theater" as a concept that I started to look deeper into these activities.

Bruce Schneier, a computer security expert, presented a means of evaluating the utility of countermeasures against security breaches in his book Beyond Fear. "Security theater" was the term coined to describe the practice of investing in countermeasures that provoked feelings of improved security while actually providing little to no actual security.² The most prominent example of security theater is that of the Transport Security Administration's (TSA) implemented security measures that are famously farcical and ineffective.³

Security theater highlights a contradiction that occurs when there is an uninformed attempt made to establish safety and the ultimate resultant endangerment of those who believed they were protected and let their guard down.

What Is ‘Medical Security Theater’?

Through observation of certain common ritual practices in the medical field, I have found several cases which strike me as possibilities of "medical security theater."

When I started in wound care, I became more familiar with the operating room and I quickly found out that it was a wealth of mythical practice. I observed providers administer unnecessary, excessive antimicrobials or antiseptics intraoperatively in fashions bordering on "throwing salt over your shoulder to ward off evil spirits."⁴ I say this not to contest the practice of prophylactic antibiotics, but that "extra pinch" of antibiotic powder applied to surgical sites in excess to the recognized practice. Certain procedures or medications were also notably avoided not because of the evidence base but because of ritual practice passed down by the attending physician.⁵ In this era of antibiotic stewardship, the administration of antimicrobials based on purely ritual or defensive practice should be more heavily scrutinized.

A recent randomized controlled trial provided evidence that, contrary to common belief, antiseptic cleaning of the skin prior to injection may not be needed.⁶ A recent systematic review also showed that there was no significant difference in sterile versus nonsterile glove use in procedural dermatology.⁷ These studies highlight two specific, unquestioned practices that were based solely on untested, circumstantial experience due to a lack of evidence-based research.

Do I think that after hearing these results, medical professionals should start giving all injections without preemptive antisepsis or that all bedside procedures should be performed with only clean technique? Of course not. I merely highlight these findings in order to make a point that even the most entrenched practices that we perform in medicine may be more ritualistic than evidence-based.

Taking this into consideration, I urge scrutiny of ritual practice. Are your actions borne of superstition and fear or are they evidence-based? If your medical practice is primarily defensive, there is a risk that you are playing a part in medical security theater and unwittingly disseminating potential harms while hiding under a presumption of safety.

Richard Hill practices at Natchitoches Regional Medical Center in Natchitoches, LA.

References
1.    Phipps M. The little superstitions of nurses. American Journal of Nursing blog. 2010. Retrieved from: https://ajnoffthecharts.com/the-little-superstitions-of-nurses/
2.    Schneier B. Beyond Fear: Thinking Sensibly about Security in an Uncertain World. Copernicus Books, 2003.
3.    Kline CL. Security theater: and database-driven information markets: a case for an omnibus US data privacy statute. University of Toledo Law Review. 2007; 39: 443.
4.    Broom A, Kirby E, Gibson AF, Post JJ, Broom J. Myth, manners, and medical ritual: defensive medicine and the fetish of antibiotics. Qualitative Health Res. 2017; 27(13):1994–2005.
5.    Meza JP. Diagnosis Narratives and the Healing Ritual in Western Medicine. Routledge, 2018.
6.    Wong H, Moss C, Moss SM, Shah V, Halperin SA, Ito S, et al. Effect of alcohol skin cleansing on vaccination-associated infections and local skin reactions: a randomized controlled trial. Hum Vaccin Immunother. 2019; 15(4):995–1002.
7.    Brewer JD, Gonzalez AB, Baum CL, Arpey CJ, Roenigk RK, Otley CC, et al. Comparison of sterile vs nonsterile gloves in cutaneous surgery and common outpatient dental procedures: a systematic review and meta-analysis. JAMA Dermatol. 2016; 152(9):1008–14.