It’s Not Automatically OK
It’s complicated. Changes are flying at us at an accelerating rate, clashing and clanging against what we thought was certain. Legislative measures that may or may not prevail, changes in how performance is evaluated, changes in reimbursement, changes in the roles of all involved – seemingly the only thing for certain is change. What will be the opposite and equal reaction?
Let’s take stock of the current situation. The anticipated shortfall of primary care physicians if the Affordable Care Act (ACA) remains in force is estimated to balloon to more than 60,000 by 2025. Whether or not the ACA remains in force, the active patient population will continue to grow as baby boomers age. This burgeoning patient population is adding to the strain caused by increasing multimorbidities and chronic conditions. Medicine, like aviation, is going to face greater demands and an increasing need for more experts.
This change in the environment will require changes in behavior. Parts 1 and 2 of this series explored how medicine learned from aviation’s work on changing behavior. It started with the checklist, moved into Cockpit Resource Management, and then evolved into Crew Resource Management. Aviation had made huge strides in recognizing that, in order to optimize resources in the work environment, it was essential for all crew members to be actively involved. With Crew Resource Management’s team approach widely implemented and on its way to being mastered, the fiercely competitive aviation industry (manufacturers and airlines) scanned the environment for a concept to leverage to lower training costs, improve safety and deal with the shrinking pool of already trained pilots from the military. And so they were seduced by the siren song of automation.
While automation has improved costs and safety, commercial aviation is now in the midst of the painful process of recognizing and adjusting to the unintended pitfalls of automation reliance. In a fascinating recording of an American Airlines pilot training session, Children of the Magenta, over-reliance on automation is the key concept. The trainer repeatedly demonstrates how pilots rely on automation even when they can clearly use manual controls. He cautions that “in 68% of accidents, automation dependency plays a critical part in leading crews… to allow their aircraft to get much closer to the [edge of the envelope] than they should have.” In other words, their reliance on automation has caused them to neglect their critical thinking.
Understanding why automation can lead to failure is important. One interesting study of automation’s surprises contained in Handbook of Human Factors & Ergonomics points out that the implicit promise of automation technology is that it increases precision and efficiencies while reducing the potential for human error. However, that promise can come up short because the human-machine interaction cannot replicate the “basic competencies” of human-human interaction. Humans have difficulty remaining actively engaged while monitoring – the place automation puts us. We disengage and lose situational awareness.
Moreover, automated systems tend to “switch off” in complex situations where they may be needed most. The person monitoring may not be sufficiently oriented to the situation to handle it effectively. Even worse, key bits of information can be masked by well meaning efforts to simplify matters for the human monitoring the process. One widely studied accident occurred in part because key information needed by the crew was masked.
Similarly, in medicine, technological advances have created opportunities to reduce the likelihood of error through systems design and processes. As the number and variety of ways to automate performance increases, so does the reliance on those mechanisms. Physician shortages and finite resources coupled with increasing demand create a pressure to do more with less. Automation may again seem to be the silver bullet. Aviation has learned that automation can help but it comes with its own pitfalls. Health care can avoid these potential pitfalls by learning from aviation’s experience.
So how are we in health care being seduced by automation? It’s easy to see how enticing high-tech diagnostic imaging and robotic surgery can be. Here are some more discrete real-life examples:
- Physicians increasingly request decision support to help them with clinical implementation. An example of this is clinical indicators by condition.
- Electronic medical records (EMR) are being designed so that the physician cannot digress from the protocol embedded in the EMR without documenting the reason.
- Workstations are being set up and work flows designed so that the clinician has a limited set of options for actions and activities.
Again, automation in itself is not inherently bad. It is when it is used so widely and extensively that critical thinking falls to the wayside that issues start to arise. Here are some examples of automation’s unintended consequences:
- Electronic dosing schedules that do not include maximum dosages can result in overdosing if there is an over-reliance on the system.
- When processes are developed to reduce error and ensure the clinician “does the right thing,” opportunities for critical thinking are being designed out of the process.
- Over-focus on the processes may cause the obvious to be missed. One patient shared her recent experience with a hospital room not being tended as it should. It escaped the floor nurse’s attention although the nurse’s station was in close proximity to the room because there was no “check room cleanliness” prompt on her computer screen.
Aviation and health care’s shared draw to automation and the potential for negative unintended consequences has not escaped notice of those straddling both industries. One such individual, a clinician from Sydney, pointed this out on a pilot’s forum. He commented, “You know, this is a broader cultural issue. We are seeing the exact same paradox in medicine. Everything is being reduced to autopilot with clinical pathways and guidelines. This approach inevitably de-emphasizes critical thinking, and clinical decision making skills are being lost as a result.”
The impact of a loss of focus on critical decision-making skills now may have a large impact in the future. The commenter continues by pointing out that medicine is like an apprentice system where students and junior physicians model their future practices after what they observe. They are likely to practice what they learn.
He points out that while the benefits of automation may be immediate, the true cost may not be realized for years, and cautions, “This is like aviation. All the airlines have followed this path for years – in part due to regulatory requirements, but also due to significant economic benefits. But people are now starting to question the consequences.”
The risk for error in both health care and aviation increases when the automation is highly complex or inconsistent. Additionally, the visual and tactile cues that can increase situational awareness are often casualties of automation design process. For example, debates have continued to wage for years about the value of a flight yoke versus a side stick because of the related loss of visual and tactile clues provided by the yoke to all the crew in the cockpit. Similarly, there are scores of unintended consequences from each design choice and philosophy. Perhaps one salient lesson is to design these cues in to the process instead of out.
Health care has benefited from incorporating aviation’s quality and safety improvement tactics into our industry, but often only after the long passage of time, many lost lives and wasted resources. We have an opportunity to head off the worst of automation’s unintended consequences by designing automation in a way that fosters critical thinking skills.
Continued from Part 1 – Aviation Beyond Checklists
Part 1 of this blog detailed how integrating knowledge and experience from aviation into medicine was straightforward in the case of checklists. This installment explores why now is the time to move beyond checklists to a more comprehensive approach – Care Resource Mobilization.
Care Resource Mobilization (CRM) is the optimal mobilization of available resources to engage clinicians and patients for better health, better care, and lower health care costs. There are existing resources that we can use, right now, to help that happen. Many of these resources may be unconventional, and many are available at no added cost to the health care system and are currently underutilized.
Discovering and leveraging these underutilized resources is the key to CRM. Overlooked resources can include communities, peers, families, friends. It often requires expanding the focus from just the patient to the circle of influence within which this individual dwells. Folks may be waiting in the wings ready and willing to help. They offer a resource base for everything from moral support to help with rehabilitative exercise.
Harnessing these additional resources is the reasonable and responsible thing to do. This may require changes in both clinician and patient behavior as we increasingly recognize there are areas of expertise on both sides of the exam table. Moving from the familiar paternalistic model may feel uncomfortable to all involved. Yet the complexity of medicine and the prevalence of co-morbidities has created a situation too big for clinicians to handle alone. Following the trail already blazed by aviation, we can leverage CRM in medicine to mobilize all our available resources.
The first installment of this blog explained how checklists have been readily adopted in both aviation and medicine. Adopting CRM will require broader changes in behaviors to develop a highly functioning team. This is made even more complex in medicine because we are dealing with two sets of CRM: intra-care team and care team + patient.
Whether in aviation or medicine, the focus of CRM is less on technical knowledge and skills than “cognitive and interpersonal skills needed to manage resources within an organized system. In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, for solving problems and for making decisions. Interpersonal skills are regarded as communications and a range of behavioral activities associated with teamwork.”
As mentioned, integrating CRM into medicine is going to be more challenging than it was in aviation. On the one hand, intra-care teams, like flight crews, have the advantage of common work space, training, jargon and knowledge base.
On the other hand, care team + patient does not have a common lexicon nor a common experience to build upon. They will need to “train” each other to achieve common expectations of their roles in this partnership. As is often the case, the hardest part will be getting started.
Permission and a Path
The ultimate goal of CRM in medicine, like aviation, is to have fully functional partners bringing their expertise to the situation. The realization of that goal in medicine is the Self-Mobilized Patient. A Self-Mobilized Patient feels confident they can be an active partner in making decisions about their health, carrying out those choices, and taking responsibility for their decisions.
Today, however, even if patients and physicians want to begin to work toward this goal, they may be reluctant or uncertain how to honestly and safely share their perspectives and information.
I’ve seen this in action myself. One of my work groups for a palliative care initiative included a cancer survivor and oncologist who had not previously met. When asked about their experience with palliative care discussions, the patient piped up with, “I could never ask my doctor about palliative care. I don’t want to disappoint him.” To which the oncologist remarked, “I could never talk to my patient about palliative care. They’d think I gave up.” Both of them needed permission and a path to honestly exchange information that they knew best.
Thus, the first and foremost means to access the resources available through patient self-mobilization is communication. The challenges associated with improving communication can seem immense, but so are the benefits. Aviation’s move from checklists to cockpit resource management to crew resource management was in response to the recognized need to improve flight crew communication. Changes in behavior were required by all crew members, regardless of their place in the hierarchy. This necessitated more than an intuitive leap and training was created to address the needed changes in behavior and culture. Fortunately, medicine’s Collaborative Conversation™ can play the same role.
There are many established approaches available to facilitate the other cultural and behavioral changes required for clinicians and patients. However, to maximize their effectiveness, the clinician must understand the patient’s level of engagement.
One tool that can be used to do this is the Patient Activation Measure (PAM) developed by Dr. Judith Hibbard. This tool helps clinicians understand where the patient feels they are on the continuum between needing to be passive to wanting to be an active participant in their health care. Modifying the interaction to the patient’s specific needs and abilities helps jumpstart the patient on their journey towards self-mobilization.
Once the initial level is understood, there are three broad categories of approach that make effective care resource mobilization: Patient Mobilization, Provider Mobilization, and Co-Creation. These approaches can work by themselves or in combination and vary in effectiveness depending on the patient’s level of engagement and activation.
Patient Mobilization methods include Motivational Interviewing, Shared Decision-Making and the Collaborative Conversation™ (for more details, follow the link to Collaborative Conversation™).
Provider Mobilization techniques include Practice Coaching, which helps practices improve in a variety of areas such as patient access, care coordination, team building and patient centeredness. These are areas of focus because improvement in these areas is proven to improve patient experience and outcomes. Another approach is Adaptive Leadership training, which can help clinicians recognize and take advantage of the opportunities embedded within changes in culture that occur as patients are increasingly self-mobilized.
Co-Creation melds the activation of patients into creating enhanced patient involvement. Peer coaching for chronic disease patients is one example.
At the core, all of these components need explicit permission from the experts to be part of the process. Remember there are two sets of experts involved here – clinicians and patients.
Whether it’s Crew Resource Management in aviation or Care Resource Mobilization in medicine, using all available resources on the team is a path to better outcomes. As medicine adopts this approach, it gets closer to its destination of better patient experience and population health at an affordable cost. Expediency is needed for the sake of our nation’s health and financial well-being.
But remember, CRM in aviation was introduced 30 years ago. What is aviation dealing with today and how can its failures and lessons help us face tomorrow (or should I say later today) in medicine? Part 3 will explore the next great challenge.
Read about the next great challenge in Part 3 – It’s Not Automatically OK.
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.