Pilots and Physicians…”Skin In the Game”

Over the past few years, I have really come to enjoy reading Paul Levy’s blog, Not Running A Hospital, especially when the focus is on quality and safety. I have found it educational, thought provoking, and timely. Paul’s post last Sunday, Kill this monster, was no exception, as he starts off by saying, “The time has come to drive a stake through the heart of an oft-repeated assertion. How often have you heard something like the following when those of us in healthcare who want to stimulate quality and safety improvements draw analogies to the airline industry?”

“Well, in an airplane, the pilot has an extra incentive to be safe, because he will go down with the ship. In contrast, when a doctor hurts a patient, he gets to go home safe and sound.”

Why Hospitals Should FlyHis story took me back in time, as I remembered first hearing that comment many years ago. A pilot remarked similarly to me as we walked off a stage together, having just concluded an “Ask the Experts” patient safety panel at a national medical meeting. To be honest, I was a little offended, feeling as though I had just been insulted for being a physician. He had challenged the essence of why the great majority of us enter the medical field, which is to help others and always put our patients above our own self-interests. Before I could respond and defend my chosen profession, he was off…running to catch his plane. But his comment stuck with me and forced me to think deeper into why it bothered me. While it is true that similar complexities exist in both professions–high stress, high risk, varying conditions forcing both pilots and physicians to adapt–why do we, as healthcare professionals, struggle to grasp simple elements–those repeatedly passed on by human factors engineers–that aviation seems to easily adopt and follow without push-back?

I first thought about my specialty – anesthesiology. Why is it that many surgeons will tell anyone who is willing to listen that anesthesiologists are overpaid. They complain that many of us read newspapers, answer emails on our handhelds, or talk on our cell phones with friends while a case is in progress. Would an airline pilot ever consider reading the newspaper, answering emails or using their personal cell phone while working in the cockpit?

How about the accepted practice of running our anesthesia machines through a set of safety checks before using them each morning for surgery? While the manufacturers have added many self-check features through the years, there are still a few things we as anesthesiologists are asked to do each morning. Unless things have drastically changed in recent years, this “recommended safety practice” is not being followed regularly, the assumption being the machine worked fine yesterday so it should be ok today. Would an airline pilot ever think of not doing a pre-flight, airplane walk-around, checking the plane he or she is about to fly, and instead say, “Lets skip the pre-flight walk-around this afternoon…the plane was flown earlier today and I am sure nothing happened during the previous flight”.

Wrong-sided anesthesia blocks have seen significant increases in the past few years as regional anesthesia has become an important element for pain management supplementation in the post-operative recovery period. With the Joint Commission mandating the use of human factor tools like pre-procedure site markings, time-outs, and the use of checklists designed to help eliminate the “humans will be humans and forget at times” factor, we still see over 90% of these wrong-sided, wrong-site, wrong patient procedures attributed to a lack of following Universal Protocol and the use of a checklist. Would a pilot ever think of saying “Let’s not do the pre-flight checklist today. The extra two minutes it takes to do it just kills my day”?

The same figures hold true for surgeons. Many refuse to use timeouts and checklists. They will be quick to point out they have never had a wrong-sided surgery in their ‘fifteen or twenty years of practice’ and don’t need to use these safety tools. As John Nance says, those are the physicians that scare him the most. They believe they are, and will always be, better than the rest of us who will under the right circumstances make a mistake when the holes of James Reason’s Swiss cheese all line up. Having interviewed a number of surgeons and anesthesiologists who were involved in a wrong-sided procedure, every single one of them said the same two things right after the event: (a) They never thought this could happened to them, and (b) They are always so careful. But after the event, they realize we are all human. So why do some physicians still choose not to adopt the same mindset as pilots, before a patient gets harmed?

If you believe Paul’s premise–that it isn’t because pilots have more personal “skin in the game” than physicians do (see More Skin in the Game…)–maybe it could be one, or a combination of, three of the following reasons why we see differences in safety adoption between pilots and physicians: (1) Physician autonomy, (2) Financial incentives, and (3) A lack of accountability by leadership in the face of less than “reckless” behaviors.

To be continued….

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