Tuesday, January 6, 2009

Flying the Plane

I wanted to share an email with you that I found very compelling. It was written by our Residency Director, Dr. Jeremy Fish. I asked him if I may share it with you as I think you will find it both interesting and heartwarming.

Dear Residents,

The days have grown shorter, many of you now arrive at work in the dark, and leave work in the dark. That's not always the most fun thing to do as we prepare for the Holidays.
It's not unusual in this season of Joy for some of us to feel the pull of sadness. Family get-togethers, travel, missing travel because you have to work, buying gifts or not having time to buy gifts because your on a tough rotation---these are the dynamics of the Holiday season. Medicine is an everyday, 24 x 7 career---illness knows no holiday. I am always amazed, however, at how some patients can hold out and enjoy a holiday before crumbling into the Emergency department the day after the holiday. So, sometimes right when others are recovering from the frenzy of the holidays, our workload rises in a paradoxical way.
There is much sacrifice in becoming a family physician---few boundaries protect us from the reality of our patients. Yet I have great gratitude every year for the sacrifice and dedication our residents bring to work every day. Despite being the lowest paid, often hardest worked physicians in our system---residents bring a great deal of hope and healthy energy into this system. In fact, the residents are the core to our mission here in my view.
Sometimes I hear someone express that they think having residents makes healthcare riskier---maybe less safe for patients. They want attendings to be everywhere and do everything. Yet when I read carefully about what makes things safe I am reassured again and again that our residents make the care here better AND safer than it would be without them. Here's are some little known facts from intensive aviation research on the role of expertise and communication in flight safety .
One would guess that the safest way to fly is to have the most experienced, most expert person flying the commercial jet. That was a standard view in aviation until someone got the crazy idea of studying that assumption. In doing so, guess what they discovered-- -the safest flight records came when the LEAST EXPERIENCED person in the cockpit was actually FLYING THE PLANE . That perplexed a lot of people for a while until they looked into communication patterns. Guess what, very few people have the willingness to question the MOST EXPERIENCED person in the cockpit---out of deference and fear of offending him or her co-pilots have allowed planes to run out of gas, pilots fly into mountains, fly into the ocean---when subordinates clearly knew it was happening and very meekly attempted to HINT that the experienced pilot was making mistakes.
Guess what, most experienced and weathered experts DON'T HEAR HINTS !! They have learned to trust their own judgement above all others .
Well, when the lesser experienced person is in the pilot seat---the experienced person tends to pay more attention to more than just the direction they are going. Think of it like when running a code---if you are intubating the patient while trying to lead the code---you are NOT leading the code....in fact no one is leading the code. In emergency and risky situations that run outside the norm it is best to have a lesser experienced person in the driver's seat and the experienced veteran navigating, guiding, and planning. It turns out that the leadership role is the most critical element of safety---and that the leader is observing, guiding, directing but not always actually flying---especially when unexpected events occur.
The other major finding of these studies was that HORIZONTAL hierarchies in the cockpit are SAFER---meaning the pilot and co-pilot speak to each other as peers, using first names. This environment encourages the subordinate to speak more frankly when an emergency happens.
So two essential elements of our training program are that our RESIDENTS are often FLYING THE PLANE while our attendings (especially our most experienced) are guiding them, are comfortable being called by their first name, and setting a tone of calm no matter how crazy things appear in the moment. It is very reassuring and encouraging to me to find that key human behavior safety research confirms that our Residency training structure is exactly what safety experts would put together to assure healthy and safe communication for our patients.
Thank you all for assuring the health and safety of our patients and for working so hard and complaining so little as you complete three of the most vital years of your careers !!
Happy Holidays,

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