Health Care and Aviation: Zero Tolerance for Sub-Par Performance?

Some aviation-related events and conversations this week prompt this post.

Two pilots have their licenses revoked by the FAA for overflying the Minneapolis airport, being out of radio contact for more than an hour, and lacking situational awareness. No one was hurt. No alcohol or drugs were involved. By all accounts, the pilots are nice people without any previous disciplinary issues. Did the punishment fit the situation, where safety of passengers and flight crew was at risk? Yes. There’s no tolerance for certain behaviors in aviation.

Next week, our survey of disruptive behavior in health care will be published. Many of you contributed powerful anecdotes on the current state of our culture, and how we behave in stressful situations. What would be the response in the health care system to a physician throwing an object at a nurse, or operating on the wrong limb because a time-out wasn’t done? Do we have zero tolerance for certain behaviors in health care, or do we find a way to avoid confronting these dangerous situations?

In a discussion with a national leader of airline pilots last weekend, he pointed out that aviation realized about two decades ago that fatal accidents were occurring that were not equipment or technologic failures, but communication failures. In one incident, people died needlessly because a captain was not receptive to safety concerns of other pilots, flight attendants, or ground crew team members. He cited an example of a pilot who was “checklist driven” instead of listening to the more accurate analysis of his co-pilot and flight engineer regarding the relative risks in the situation they were dealing with. In the end, running out of fuel on approach was the risk that he wasn’t seeing on his checklist. In health care, checklists or “cookbook medicine” are valuable, but equally as important is the judgment and input of everyone on the health care team during the safety-critical events of patient care. We need both to be ultra safe.

My oldest son, a commercial pilot, says that the cockpit crew must verify altitude, airspeed, airport and runway at a certain point before landing. It’s a low risk situation, much like a timeout prior to a procedure, or two-person independent verification of a patient’s ID before administering blood or blood products. If something bad happens during the high risk situation (landing), the pilots can be forgiven if they carried out the pre-landing checklist diligently and seriously. But if they didn’t, there may not be any excuse for an adverse event on landing. In other words, the consequences for the professionals may not be related to the outcome.

Such is the case for the NWA pilots. It seems to me that we often tie the consequences to the outcomes in health care: “Yes, she called the nurse stupid, and threw a needle and syringe at her, but the patient wasn’t affected. We just have to understand that Dr. X is our biggest admitter.”

Finally, in a discussion with physicians at a medical executive committee/health system board retreat recently, one physician commented that it’s hard to see how what happens in the cockpit has any relationship to health care. He thought if a comparison was made to the entire aviation experience – ticketing, baggage handling, dealing with intoxicated, frail, or extremely obese passengers – it would be a better analogy to the variability we deal with in health care. I think that’s correct, but can’t stop thinking about how much better off we’d be in health care if the professionals highest in the hierarchy (physicians) encouraged questions from other professionals, and had zero tolerance for intimidating and threatening behaviors directed toward those lower in the hierarchy.

Celebrating the Passing of Time on a Train

When I was an oncology fellow many years ago, two other residents/fellows and their significant others joined my wife Janet and me for a ride on an old, narrow-gauge steam train that chugs up and down the Rockies on the Colorado-New Mexico border between Antonito, CO and Chama, NM. Every year since then, we’ve marked the passages of our professional and personal lives, and prepared for the transition from fall to winter, by renting a parlor car and caboose to enjoy the fall colors and catching up with friends and families. Moving at the pace of the century-old steam engine that pulls the train, conversations are unhurried.

Over the years, the group grew to include several more docs and their families. Children were born between each annual train trip. As they grew, the kids always grabbed seats in the cupola (the small windowed projection above the caboose). That made it easy for their parents to have adult conversations without having to keep a constant eye on the kids. My secret for getting to ride for awhile in the cupola with the youngsters was agreeing to tell stories featuring the Lone Ranger, Tonto -- and ghosts. I learned that saving the scariest part of a ghost story for the moment the train entered a tunnel was a surefire way to be invited back up to the cupola by the kids, year after year!

Now those kids are college students, just out of grad school, or starting their careers. They’re bringing their significant others to meet families and friends. Young physicians and their children have again become part of the annual fall ritual in the Rockies. It’s hard to get a seat in the cupola again.

The aspens were spectacular this year. The chill of early October at 10,000 feet, along with the autumnal light in the high country and the aroma of coal smoke, are familiar and memorable experiences every year. The appreciation of long-time friends, making new friends, sharing the stories of our lives – that’s what makes the train ride so special.

Dx: Sick health system; Rx: Physician leadership

Heated emotions in town hall meetings. Partisanship in Washington reaching new levels of acrimony. The stress, uncertainty and hunches in the health care industry about what reforms will take place has sparked a new concern: we need more – and more effective – physician leaders to get us through this crisis. This is like watching a sick patient arrive in the ER with worrisome vital signs, and then continue to deteriorate as delays in diagnosis, turf battles over accountability and delays in treatment make the situation downright dangerous!

There’s a real yearning for physicians to step up to the plate and help create a more responsive and reliable system of health care. Like the competent, calm, and compassionate physician that defines the clinician of our best memories, we need to abandon the learned helplessness that is so common among our ranks and ask ourselves what we can do to lend a hand to our non-clinical neighbors, friends and professional colleagues who are searching for answers and reassurance during this crisis.

Last month a remarkable little weekend retreat occurred on Orcas Island, Washington. A small group of highly accomplished health system executives (only two physicians in the group) gathered at a small, remote home to grapple with how to motivate more physicians to see themselves as leaders - from the clinician at the bedside who can lead improvement in clinical care processes, to medical staff leaders, to the executive suites of health systems, insurance companies, and pharmaceutical firms. The pervasive theme was that health care is critically ill from decades of diagnostic and treatment delays and intra-industry turf battles. From our experiences in working with powerful and competent physician leaders in our careers, we believe that more physician leaders are needed to manage the healing process of this critically ill American health system.

We don’t know what message will resonate with physicians – if at all. For young physicians wondering what they can do to build on their medical degree, learning the competencies of leadership gives more career options. For physicians frustrated with the waste and inefficiency of clinical care, or wondering how to demonstrate competency in Part IV of Maintenance of Certification requirements, learning how to lead a clinical improvement project is an excellent way to create the change you want.

I don’t want to sit in the doctors’ lounge anymore and listen to how bad everything is. I want to hear, “This is what I’m doing to make a difference for my patients, for my nursing colleagues, and for myself.” Stay tuned over the next several months as we focus on key issues demanding physician leadership, and ask yourself how you can help.

Climbing Mt. Kilimanjaro

After leaving ACPE faculty member Eric Berkowitz and Charles Cudjoe and the other Guild of Medical Directors staff in Abuja, my African vacation began with a solo journey through Nairobi, Kenya. Next I crossed the border by “tourist bus” into Tanzania, where I finally met my wife and daughter in Arusha at the central bus station.

After a day of rest and preparation at Hotel Marangu, we began our climb at the Rongai Route trailhead after a two-hour drive by Land Cruiser. Starting at about 8,000-feet elevation, the three Silbaughs and Freddie, Onesmo, and Erik (our guides and porters) moved up the mountain each day for the next three and a half days. Camping in our tents each night, I learned to appreciate the nightly call of nature. When else would you deliberately leave the warmth of a sleeping bag to see the stars shining brilliantly in the cold night sky?

Moving higher and higher, reminders of the risks were frequent. From Freddie’s stories of accidents on Kilimanjaro over the years, to the wreckage of a fatal plane crash a few months earlier, to the physical challenges of altitude, it made me appreciate my mortality. Knowing our time on earth is limited puts my daily activities in proper perspective. Confronting my mortality many years ago on my first visit to the Himalaya was liberating, and a refreshing change from how I viewed death as a physician.

The highest camp (Kibu Hut) is about 16,000 feet elevation. Arriving at Kibu around 2 p.m. in the midst of a snow squall, we crawled inside our tent for a few hours rest before the planned midnight departure for the summit. Each of us was thinking our own private thoughts about our fitness for the last part of the climb – another 3,000+ feet to the summit. If one of us couldn’t make it, the other two could still continue with one guide. But if two of us couldn’t, we’d all have to come down with the two guides. Our goals and well-being were clearly tied to that of the other climbers – the ultimate in team dynamics!

Midnight. Clear skies. Cold. Four layers of winter clothes. Headlamps all working well. Despite the discomforts of altitude, we all committed to going up. Focusing on one step at a time, I decided to avoid looking at my watch until the top. And I promised myself not to ask Freddie how much farther we had. What good would it do? I found that concentrating on how to make each step more efficient and less clumsy was my goal. A periodic glance at the intense, star-filled night sky was exhilarating! After a stretch of scrambling up some large boulders with great difficulty, we suddenly saw a sign that told us we were at Gilman’s Point – the so-called “false summit” of Kilimanjaro. Still pitch black, we could see other parties’ headlamps higher on the mountain. Only another one and a half hours to the top! Personally, I was glad it was still dark because seeing the work ahead in daylight might have been discouraging.

We watched the sun rise over Africa on Uhuru Peak, which cast a gigantic shadow over the cloud-covered jungle below. At 19,344 feet, it is the highest point in Africa. Being there with my wife and daughter was an unforgettable experience. We’d managed to successfully face thechallenges of travel and climbing in an unfamiliar place, and help our daughter fulfill a four-year goal of hers – climbing Kilimanjaro before the glacier disappeared. The experience of doing something challenging and hard with good people – not just the exhilaration of reaching the summit – was worth the effort, and will provide memories for a lifetime.

Out of Africa

ABUJA, NIGERIA -- ACPE faculty member Eric Berkowitz and I have just finished a two-day course for physician leaders in collaboration with the Guild of Medical Directors (GMD) at the Protea Oakwood Park Hotel in Lagos. Tomorrow we do it here in the capital city of Abuja.

Charles Cudjoe, a member of the College for several years, is the force behind this first-ever OnSite on the African continent. In addition to being a surgeon and ordained Episcopal priest who preached at Trinity Church in Boston, Charles owns a hospital, and is the president of the Guild of Medical Directors.

Charles has identified a need for physician management and leadership education here as the economy grows. The last few days with Charles have been unforgettable. I’ve appreciated his business acumen, devotion to his patients, and the number of people who are his friends. His enthusiasm and optimism are irrepressible. When Charles sent personal messengers to knock on the doors of physicians in rural clinics to inform them of our planned session, we knew we were all committed to making this happen.

Physicians here are working for bank-owned HMOs, private and public hospitals, and private medical groups. The response has been exciting! In the audience were Nigeria’s only physician-health economist, a crown prince, and the medical director of the government’s central bank. We see that the country’s reputation and passion for education are real and palpable. Colin Powell was here last week. Michael Porter, who developed the Five Forces model of strategy while at Harvard Business School, is scheduled to be here July 23 to speak with business leaders.

I’m hoping that many of our members in the US and elsewhere will be willing to help some of our new members in Nigeria think about how to address the problems and frustrations of an emerging managed care model. The next post you read will be from Charles Cudjoe.