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….

Making Connections for Change at #TPSER9

One of the most significant takeaways from the Telluride Patient Safety Educational Roundtables & Student/Resident Summer Camps has always been the new connections made with some truly amazing people from around the world. This year, we all were so very fortunate to meet Dr. Sarah Dalton, a pediatric emergency physician from Australia, visiting the U.S. on a Fulbright Scholarship. Sarah lives patient centered care in her daily work, and is here to study Clinical Leadership Development Programs.

As many following ETY and Transparent Health blogs may know, Paul Levy (Not Running A Hospital) has been on the TPSER faculty the past two years, and is also one of those amazing people working in the best interest of patients. Following is a link to his recent post, Monkeys and Bananas, which includes the following short video our new TPSER connection, Sarah, shared with him  — highlighting why “we’ve-always-done-it-this-way-thinking” is for monkeys — not the new leaders of healthcare!

Needed: A Greater Sense of Urgency Around Patient Safety & Culture Change in Healthcare

TSPRE9_Resident_Wk_2013_Grp_PhotoAfter spending a week with some amazing resident physicians at the Telluride Patient Safety Educational Roundtable & Student/Resident Summer Camp, I feel an even stronger need to create a greater sense of urgency around patient safety–as well as building patient centered care environments with a just culture as the foundation. The stories this passionate group carried with them to Telluride and shared with the group were the muse for this post.

For example, one physician, fighting back emotion, courageously told the group how she recently had to push a senior level care provider to finally acknowledge her concerns about an infant who later died. The physician sitting next to her, with emotional intelligence off the charts, not only acknowledged her pain, but that he also knew she had done everything she could in the best interest of her young patient. In a reflective blog piece, another Telluride alum expressed concerns about just how dangerous the academic medical environment is for patients. And more than one physician shared how coming together in Telluride, having an opportunity to compare similar experiences in an environment where open, honest communication was revered, was a reminder of why they went into medicine in the first place. But I wonder, how long can the Telluride influence last if the culture of our care environments these amazing, but human, care providers return to, does not change to embrace rather than ostracize those who truly put patient centered care before all other agendas?

Paul Levy, (Not Running A Hospital, and more), Telluride faculty for a second year, was equally as awed by the residents who attended. In a parting post on his blog, Not Like Too Many Hospitals, he also expressed the understanding that while this patient safety journey takes time, that time includes costs. Those costs are the lives and well-being of patients across the country. Here is an excerpt from his post:

As I have said before: Sometimes, I remind myself to be patient.  It is hard to change the medical system quickly.  But, more often,  I find myself agreeing with the words of Captain Sullenberger: “I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country. We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety.”

I hope and trust that our attendees these last few days in Telluride will have the commitment and courage to make a difference during their careers.

I came across an old post on the Transparent Health blog, Stand Up-Stand Out, as I was reading resident and student reflections from this year and last. In this post, I had referenced Dr. Don Berwick’s essay in JAMA, To Isiah. Following is an excerpt I shared with Telluride 2012 alumni to carry with them as they returned to those who have yet to learn what they have, or worse, those who create barriers to progress. It remains true — even more so today.

…There is a way to get our bearings. When you’re in a fog, get a compass. I have one—and you do too. We got our compass the day we decided to be healers. Our compass is a question, and it will point us true north: How will it help the patient?

TPSER9_Residents_Jump_for_JoyThe faces of this year’s Telluride 2013 Class are reflective of all the good that the healing profession has to offer. Anyone reading this post who is in a position to Stand Up and Stand Out–to clear the way and allow their passion to expand and elevate, not only patients, but the spirit of colleagues as well, please help. Today —

Meanwhile, the Telluride alumni network continues to grow, building a critical mass of voices who believe patient centered care comes first, above all else. We are here for you–reach out, continue to share your stories — they can move mountains!

Follow Telluride 2013 Resident Summer Camp Reflections at Transparent Health Blog

IMG_0188Please join us in Telluride this week!

We are well into day two with our resident scholars in Telluride, where the topic for 2013 is Change Agents: Teaching Caregivers Effective Communication Skills to Overcome Patient Safety Barriers in Healthcare.

This amazing group is engaging in some truly moving conversations around patient centered care, shared decision-making, personal experiences with near misses and the dangers that exist within medical education. Their bravery, knowledge and commitment to their patient is so very evident — it is inspiring, and gives hope of a very bright future for healthcare.

We will be posting summaries of the days events for the next two weeks here on ETY, but please also join us this week at our Transparent Health blog, (found here). Today’s post on the TH blog shares a number of resident reflections and can be linked to here.

Paul Levy, Not Running A Hospital, has joined us in Telluride to teach negotiation skills to our resident physicians and is also blogging about the experience. You can find his reflections here.