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'Deviant' care for premature son inspires scholarship

November 21, 2014

Eighteen years ago, Dr. Arvind Singhal's son, Anshuman, was born premature at 29 weeks. He weighed 678 grams, less than one and a half pounds. The first two years of Anshuman’s life were spent on life support at the Children’s Hospital in Columbus, Ohio, as he underwent multiple complex surgeries. That time in the hospital was a blur for Singhal and his wife, Anuja, but the practices of two medical professionals will always remain clear in Singhal’s mind, and close to his heart and soul.

“Pre-op with a preemie baby,” Singhal takes a deep breath at the memory. “Stressful.”

Why? Because babies are typically pinned down while they’re poked, he says. Wiggling. Screaming. It’s not easy to find a vein on such a tiny arm.

“They fight it with every ounce of strength in their body and with every ounce of oxygen that they can muster,” says Singhal, a prominent U.S.-based scholar and associate faculty member at Royal Roads University.

But one pediatric anesthesiologist, he recalls, had a different approach. Singhal didn’t know it at the time, but what she was practising was positive deviance. Her pre-op strategy was to ask for permission to hold the baby, which comforted and calmed him – and his parents. Next her team administered what Singhal calls “verbal anesthesia,” a.k.a. “peek-a-boo.”

“And while the child is happy and calm and playful,” Singhal recalls, “one of (the anesthesiologist’s) assistants has found the exact spot, the needle goes in the first try, the child doesn’t even realize it and when they do, there’s Dr. Mommy to comfort you.”

The anesthesiologist then asked if she could carry Anshuman to the operating room when the standard normative practice is to wheel babies in. As she was carrying him, Singhal recalls her looking back at him and his wife and whispering, “Mr. and Mrs. Singhal. I know you’re worried. He will be okay with me. He’ll be fine.”

And he was.

A neonatologist, among the dozens who attended to Anshuman, also made an impact on Singhal. When doing morning rounds in the neonatal intensive care unit, doctors and their teams would typically crowd around the incubator looking down. However, this neonatologist had a non-normative practice that brought him down to his tiny patients’ level: he and his team carted around stools and sat down when checking on a child. He would also invite in parents, who typically waited anxiously outside the crowded circle, to join the conversation about the care of their child. He would even ask moms and dads how they thought their baby was doing instead of launching into the usual "reading of charts." This approach didn’t take any additional time, Singhal says, but it offered many benefits.

The approaches of the anesthesiologist and the neonatologist, Singhal says, exemplify positive deviance, now his area of expertise. They are deviant because their actions are not the norm and they lead to positive outcomes, clinically and relationally.

“I want to stress that (my son) had a wonderful team of neonatologists – all of them,” Singhal says. “This one doctor made it sweeter. He had a wonderful team of pediatric anesthesiologists. All of them, technically, role wise, they were experts. The soul came from a few others. And that soul was what made for better outcomes and, believe it or not, that soul costs nothing.”

On Wednesday, two days after World Prematurity Day, Singhal shared his family’s story at Royal Roads University. The presentation can be viewed here.

While Singhal and his wife had an intimate experience with positive deviance 18 years ago, it wasn’t until 2004 that Singhal decided to dedicate his work to the approach. He met Jerry Sternin, founder of the positive deviance approach, at a Harvard-sponsored health symposium, and his “world was flipped.” He walked up to Sternin after the presentation and asked to be his apprentice. Sternin and his wife, Monique, invited Singhal to Tufts University, where they had founded the Positive Deviance Initiative, beginning a friendship and launching an ongoing apprenticeship.

Soon thereafter, the Robert Wood Johnson Foundation funded the first positive deviance project in the United States, which aimed to reduce hospital-acquired infections. The Sternins, in collaboration with the Plexus Institute, led this project, and Singhal participated as learner, sense-maker and scribe, penning three books and several articles on these early positive deviance experiences in the U.S. The team sought to answer the question of what enabled some healthcare workers, patients and hospitals to better prevent the spread of hospital-acquired infections than their peers. They found, for example, a patient who would nod in the direction of the sink if he didn’t hear the water running when a healthcare worker entered his room. Inspired by this individual, the hospital created a sign saying patients have a right to clean hands and they should remind healthcare workers to wash up. There were hundreds of other hidden “positively deviant” insights that were unearthed, shared and amplified. 

Positive deviance is the “special sauce,” Singhal explains. It’s the small things people do (that most others do not do) that make a big difference. It comes from ordinary people (and institutions) who have found better solutions to existing problems without access to any additional resources, he says. How do you find these solutions? Ask a question that’s never asked.  

Singhal’s presentation was hosted in collaboration between Royal Roads and Island Health. It was part of Island Health’s Knowledge-to-Action Month. Island Health and RRU’s Centre for Health Leadership and Research recently signed a MOU, through which the organizations have committed to a collaborative pursuit of enhanced health leadership development and educational programming.