Can Aviation Help Medicine Navigate Health Care Transformation?
Aviation Beyond Checklists
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Aviation is a high stakes game that depends on meticulous execution to ensure the safety of its customers. So is medicine. But unlike medicine, the high visibility, transparency and personal risk to the providers intensifies the motivation to learn from every mistake.
As a result, a worldwide network of investigators from manufacturers, airlines, aviators and governments has evolved to provide the best technical and human factors analysis of incidents and accidents. In the U.S., the National Transportation Safety Board (NTSB) is tasked with leading the investigations and creating reports of what happened and providing guidance on what to do to prevent reoccurrence.
Over the past century these public investigations into accidents have led to massive improvements in aviation, from both technical and human factor perspectives. And, just as importantly, they have highlighted procedures and processes that are applicable to all high stake, highly technical endeavors, including medicine.
One of the most well known of these aviation investigations and recommendations arose from the 1935 roll and crash of a mammoth military aircraft. As highlighted by Atul Gawande, this incident was the genesis of what evolved into the pilot’s checklist. More than 70 years later, he outlined how aviation checklists could be utilized effectively in health care.
Aviation checklists proliferated from the 1930s on, evolving as aircraft complexity grew at an exponential rate. By the late 1970s aviation checklists were ubiquitous. Hierarchal cockpits were equally ubiquitous. Members of the flight crew rarely questioned the captain’s authority.
Then, in 1978, an NTSB investigation of an accident on a United Airlines flight to Portland, Oregon revealed risks that flowed from this cockpit ethos which checklists could not mitigate.
On that flight, United 173 experienced trouble with its landing gear and continued to circle while troubleshooting the issue. While the plane’s fuel level continued to rapidly approach a catastrophically low level, the flight crew failed to raise the critical nature of the fuel supply to the captain. The plane crashed. Ten perished.
Accident report AAR79-07 issued by the NTSB states “the probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crew-member’s advisories regarding fuel state. This resulted in fuel exhaustion to all engines. His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency. Contributing to the accident was the failure of two other crew members either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain.” The report goes on to say that this incident “exemplifies a reoccurring problem – a breakdown in cockpit management and teamwork…To combat this problem, responsibilities must be divided among members of the flight crew.” Further, they believe that, “in training of all airline cockpit and cabin crew members assertiveness training should be part of the standard curricula including the need for individual initiative and effective expression of concern.”
In response, United Airlines led the industry by instituting the first training program based on Cockpit Resource Management (CRM).
The roots of this training go back to a NASA workshop held in 1979 titled Resource Management on the Flightdeck, according to The Evolution of Crew Resource Management Training in Commercial Aviation. Research presented at the conference listed the human error components contributing to accidents as “failures of interpersonal communication, decision-making, and leadership.” Then the CRM process was suggested as a method to reduce “pilot error” by training flight crew to use human resources better.
This revolutionary approach was refined over the years to focus on the group dynamics of teams. The name was changed from Cockpit to Crew Resource Management. A team orientation was emphasized and course modules included situational awareness, decision-making strategies, and breaking the chain of errors that contribute to accidents. Now in existence for 30 years, CRM has become an essential part of conducting safe commercial aviation operations.
Two Experts in the Cockpit
CRM was developed to address cultural issues in aviation as The Evolution of Crew Resource Management Training in Commercial Aviation points out. This complex and highly technical environment has its own language, processes and norms. Its hierarchal environment has traditionally hampered communication between flight crew members and creates a communication void that is hard to bridge, regardless of the flight crew’s native culture. If the flight crew is from a collective society with a high power distance culture, subordinates were reluctant to question decisions and actions of their superiors. At the other end of the spectrum, captains from an individualistic native culture feel they are expected to know all of the answers and thus are less receptive to input from the rest of the flight crew. Either way, the result is the same — a high likelihood that insufficient communication would prevent the best possible outcome.
Watch what happens when we apply this concept to medicine.
Medicine is a complex and highly technical environment with its own language, processes and norms. This hierarchal environment and its nomenclature has traditionally hampered communication between the clinician and the patient. The patient may feel s/he is subordinate and is reluctant to question decisions and actions of the clinician. At the other end of the spectrum, the clinician may feel expected to know all of the answers and be less receptive to input from others. Either way, the result is the same. There can be insufficient communication to provide the best possible outcome.
Two Experts on the Plane
Now picture the cockpit with a flight crew morphing into an exam room with a patient and clinician. The NIH King’s Fund Making Shared Decision-Making a Reality report points out that there are two experts in the room. The clinician has the medical expertise to understand the causality, prognosis and treatment options. The patient’s expertise lies in their experience with the condition, risk tolerance, values, and preferences. Each expert has a role to play. Each has a responsibility to play that role. We need to help the patient take on this responsibility by taking them out of seat 24C and placing them in the cockpit.
Many Experts on the Team
Aviation was deliberate in its move from the term “cockpit” to “crew.” With that change in terminology came the recognition that valuable contributions could be made by all of the flight team. Medicine can fast track this evolution by embracing the valuable role of the patient as partner while simultaneously recognizing the potential for valuable contributions from a much larger team. This larger care team could include all care team members, the patient’s loved ones, clergy, peers, and communities to name a few. Each one of this larger team has areas of expertise to contribute, potentially in previously unanticipated ways. These contributions could be in areas such as logistics, support or information and could come at little to no additional cost to the health care system.
Most of modern medicine underutilizes these additional experts, either intentionally or unintentionally. It will take widespread culture change on both sides of the patient-clinician equation to realize the potential of navigating through the efforts of many experts. Culture change requires behavior change. Aviation worked to achieve desired changes in behaviors and attitudes through its CRM approach 30 years ago.
If the time it took for medicine’s uptake of aviation’s checklists is any indication, it could be 2050 before we apply aviation’s 1980s CRM insights. Doesn’t the rising incidence of chronic conditions, co-morbidities, and an environment of increasing technological complexity make modern medicine too much for just the one expert to navigate alone? In fact, Gawande maintains that at any point in intensive care, “we are more apt to harm as to heal.” And like pilots, we are vested in the outcome, from a moral and increasingly financial standpoint as reimbursement changes. Clearly, medicine needs its own CRM – Care Resource Mobilization.
Coming soon – read more about Care Resource Mobilization in Part 2 of 3.