If pilots worked like doctors, the sky would rain planes

“This note was produced using [mega-brand] medical dictation software. While every effort has been made to insure accuracy, errors may still exist.”

Really? What kind of doctor would admit in a medical chart to being too lazy or incompetent to produce an accurate record?

A lot of them.  Dictations are easy to read if you are willing to confound legibility and accuracy.  Dictation software is relatively cheap, and with the continued profusion of electronic health records (EHRs), dictation software allows the doctor’s words to become immediately a part of the patient’s chart, analogous to writing in a paper chart.  In a paper chart, though, I’ve never written a disclaimer warning of my own potential inaccuracy.

Doctors work in a safety-conscious environment on par with the best 19th century practices. If pilots worked like doctors, the sky would rain planes. Because as Americans we’ve chosen to maintain a medical culture reminiscent of pre-industrial guilds, with apprentices, journeymen, and masters craftsmen, medical quality is subject to the whims of individual patients and professionals. EHR’s are a tool that can be used to improve ourselves.  Health care  information entered into EHRs become potentially useful data. If I have 200 diabetic patients with paper charts, I have no easy way of seeing who is getting their yearly eye exams. If the data were entered into an EHR, I could easily produce a report that shows me the information—if I chose to.

Without agreed-upon ways to measure quality and share data, the EHR becomes a fancy toy, with amusing dictation errors. Many physicians have chosen to hold off on EHRs until their role in the system is more clear. The government and private insurers have stepped in to encourage EHR use.  Medicare started by offering incentive payments which are being phased into penalties. Private insurers are demanding physicians provide them with reams of data, each company using its own data collection method. What each method has in common is the reliance on doctors to extract and report the data.

Here’s the basic conflict: medical practice needs safety, accountability, and cost-effectiveness. We also need doctors and other providers to focus on patient care. Another lesson from the airline industry is that distraction kills.  The role of doctors has until now been to take care of patients, spending time with them, listening, examining, following up on tests.  When I look at my desk and see piles of (different) forms from each insurance company asking me to gather and submit data on all of their patients, data which as the payor they already have access to, I may just give up, allow my self to miss out on pay incentives (i.e. pay a penalty), and miss out on an opportunity to improve the quality of care I give.

The private sector has moved in to help fill this gap with companies such as WellCentive, which offers to help doctors to gather and report data. The general idea is that to improve the quality of medical care and to hold costs down for insurance companies, doctors will purchase EHRs, pay for their upkeep and the extra personnel and hardware, and for third parties such as WellCentive to gather and report the data, all to avoid the penalty of reduced payements, penalties that for many of us aren’t nearly as onerous as the process of avoiding them.

We need to use information technology to help improve safety, costs, and quality of care. But to put the burden directly on the shoulders of doctors, distracting them from patient care, is insane. If we are serious about this, the market, red in tooth in claw, is not the only solution. Until we take a systemic, serious approach to safety, cost, and quality, we will continue to have non-sensical medical practices designed around forms and incentives rather than efficient, data-driven care.

“PalMD” is an internal medicine physician who blogs at White Coat Underground.

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  • Peter Elias

    Yes, we (the culture and business of medicine) have been practicing the ‘normalization of deviance’ for a long time, tolerating multiple incremental decreases in our ability to focus on what Berwick calls The Compass that always points to True North: the patient. The usual outcome at the end of a long period of normalized deviances is catastrophe. Think of the Challenger.

    Sadly, if one points out the shortcomings of the system and the myriad of errors awaiting their opportunity, one is often criticized for not being a team player, for harping on the negative, and for being a PITA. But, the damn Emperor is Naked.

    Peter Elias, MD

  • rswmd

    Require all pilots to produce a minute-by-minute summary of what they do while flying a plane, meeting all ICD/CPT/MU/JCAH standards, and have it completed by the time the flight lands, and lets see what kind of crap results.

    And how many crashes result.

    • Ed

      Cockpit voice and flight data recorders record a second by second summary in real time. Anything goes wrong and the NTSB will have every word spoken and control input recorded to the second. If we make a mistake there is no hiding from the truth; the flying public deserves no
      less. Physicians would never agree to that level of intrusiveness in their professional lives because your patients would soon realize you’re not the omniscient gods you portray yourselves to be. Medicine could learn a lot from professional aviation; your patients deserve no less!

      • khmd

        Ed, it’s people like you that make me practice defensive medicine.

      • southerndoc1

        And you’ve completely missed the point.
        No other profession, particularly one dealing with human lives, would accept the distractions from the important work to be done that are created by the EMR. The point of the post was to ask people to consider the chaos and death that would result if the pilot were required to spend as much of his mental energy doing real time data entry, instead of flying the plane, as physicians currently are.

        • Ed

          Strictly speaking, I concede your point. However, the author stated and I quote “Because as Americans we’ve chosen to maintain a medical culture reminiscent of pre-industrial guilds, with apprentices, journeymen, and masters craftsmen, medical quality is subject to the whims of individual patients and professionals.”

          Commercial aviation is federally regulated in the manner it is because if pilots screw up, passengers die in double or triple digits simultaneously, national news. In addition, arriving at the crash scene first lends a slightly different perspective vice a physicians’ on a successful outcome. Therefore, pilots and professional aviation associations actively and publicly advocate for safety enhancements.

          A patient death due to provider error doesn’t result in the same public clamor, hence 19th century practices. There is no mandated public mechanism for investigating, documenting, and sharing those errors, even anonymously, profession wide. No uniform national standards for simple things like OR checklist usage, currency requirements, random drug and alcohol screening, physician medical standards, and recurrent training requirements with teeth.

          We lag other industrialized nations in infant mortality and life expectancy. Short of the ER, we don’t even guarantee citizens access to healthcare. All while spending more as a percentage of GDP and per capita than any other nation.

          Practice “defensive medicine” all you want. We’re not getting our monies’ worth and you know it. Medicine could learn a lot from professional aviation; your choice is either proactive or reactive change.

          • southerndoc1

            Actually agree with a fair amount of what you say.
            My point is that increasing the distractions on physicians past the breaking point is not a good way to reduce errors. To continue the comparison, what we’ve got now is comparable to requiring the pilot to go back in the cabin during take-off and find out who ordered the fruit plate for lunch.
            And, not surprisingly, those who consider themselves at the forefront of the “medical error” battle are frequently the same people who want to ramp up the already intolerable number of distractions a doc must deal with.

          • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

            “Practice “defensive medicine” all you want. We’re not getting our monies’ worth and you know it. Medicine could learn a lot from professional aviation; your choice is either proactive or reactive change”

            You dont like our service, the answer is simple — DONT COME BACK!

            But like all the other weasles who constantly complain about doctors, we know you will always come back to us in the end. You cant help yourself. You need us and you know it.

      • WhiteCoatRants

        Ed,

        I’m probably not worthy enough to be addressing you
        directly, but I’ll take the chance since it has now been exposed that I
        and my ilk are not “omniscient gods”.

        Let me give you a better comparison of medicine and aviation.

        Walk
        into a hangar, be forced to fly a plane you’ve never seen or flown
        before when you don’t know the plane’s history or how well the plane has
        been maintained, make a perfect outcome with every flight regardless of
        the weather, and make sure that your passenger satisfaction scores are
        all perfect lest (at best) you get docked pay or (at worst) lose your
        job. If someone doesn’t reach their destination on time, then you can be
        sued for multiple millions of dollars while other pilots shake their
        heads and tell the jury what a bad pilot you were for letting that
        happen. Get sued a few times and none of the airlines will hire you.

        On
        emergency flights with heart passengers, if you don’t reach your
        destination within 90 minutes – regardless of the circumstances,
        weather, plane conditions, or crew status – you have government
        regulators and airline administrators picking through your rump hairs
        chastising you on what you should have done even though none of them
        have flown a plane since Amelia Earhart disappeared. This occurs even if
        the flight went fine and was on time.

        Oh, and don’t forget to
        use a byzantine computer program forced upon you by the airline to
        complete a comprehensive record of every flight, because if you miss
        only one data point out of the many dozens you are forced to record, the
        FAA will only pay you a fraction of your regular salary and if you
        document too many data points, the FAA will file criminal charges
        against you for fraud.

        Then fill out reams of paper documenting
        your full assessment of the plane after every flight. If you don’t fill
        out the paperwork properly, the airline doesn’t pay you. When you call
        them a month later inquiring about your paycheck, they tell you that you
        didn’t fill out the 9 digit zip code on the plane’s hangar and make you
        fill out all the paperwork all over again. You send them another ream
        of paper and call them a month later inquiring about your paycheck. They
        deny ever receiving the paperwork.

        Welcome to our world. I could
        go on and on, but the smug conclusions in your comments show that you
        have no clue what is involved with the practice of medicine and that you
        are content to show the world how perfect that pilots are as compared
        to all us doctors who you have singlehandedly knocked off our ivory
        pedestals.

        With pilots there is “No hiding from the truth”? Give
        me a break. Recording flight data isn’t synonymous with “the truth.”
        Does the flying public know every pilot’s experience before the flight?
        Is there any way to even find out? Do they have the opportunity to ask
        before entrusting their lives to this person? Do they know the pilot’s
        training? Do they record when the pilot is sleeping and allows the
        co-pilot to fly the plane? Do they know the plane’s maintenance record?
        Do they know the bona fides of the people screening other passengers on
        the flight? Do flight data recorders detect whether airplane wings have
        been properly de-iced? When you look at the whole flying experience, the
        public actually knows very little about the process — until there’s a
        crash.

        Where is the public dissemination of information about
        pilots and how many errors they have made in their careers? Hell, I
        can’t even find out what pilot is going to be flying the flight I’m
        taking.

        The AMA has a “physician finder” where the public can
        look up every physician’s background. State medical boards publish
        actions taken against physicians. Where is all that information about
        pilots made publicly available?

        The article used the aviation
        example to illustrate how distractions can sometimes knock professionals
        off task with disastrous results. You then picked up on that comparison
        to create many additional ill-informed and misleading comparisons.

        Go back to your cockpit.

        • Ed

          To all, my sincere apologies if I’ve offended anyone; no excuses! You’re correct, I have no clue about practicing medicine and pilots certainly have no monopoly on “perfect” when compared to any other group of professionals. You raise valid questions and if interested, I’ll try to address your questions or leave quietly tail between my legs; your call?

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Perfection!!! Couldn’t have said it any better (although I did try may times :-))
          This should be the final response to all the aviation/race cars/cheesecakes/etc. righteous fables and their tortured morals

    • http://twitter.com/drsadaty Robert Sadaty

      Well said. We have the toughest job there is so please spare us the inane comparisons.

  • LBENT

    When people are as simple machines as are planes, and the number of variables is fewer to control, then we can reasonably compare ourselves to the aviation industry.

    It is impossible to live an error free life. This post begs the question as to what it is that patients want and what we, as physicians and surgeons, can realistically provide.

    • Homeless

      I would like honesty when an error is made…something I have never found a doctor to provide.

      • LBENT

        Most doctors are afraid to admit error for fear of litigation.

        • Homeless

          So it’s not realistic for doctors to be honest? Then I’ll take the checklist.

  • pj

    Another BIG reason why you cannot reasonably compare healthcare w/aviation is, an aircraft crash is always an unexpected event (other than sucide hijacking). Assignment of responsibility is inevitable since no aircraft goes down without human error, component/system failure or weather issues.
    Human death, OTOH, occurs. no. matter. what…..
    No person gets off this earth alive (though too many of us seem in denial about that). So it gets very tricky to determine if a death is malpractice or not. It may have been that person’s time to go.
    i too must point out how pilots do not have to deal w/one customer at a time, and are not expected to consider requests such as, “I know we’re supposed to land in Denver, but my son is in Seattle, so we need to divert.”

  • ninguem

    Same old.

    When pilots maintain their aircraft like this:

    http://oopslist.com/AirMaint.jpg

    Than we’ll talk about comparing pilots and physicians.

  • ninguem

    Since we all die, I would imagine comparing pilots to physicians means a 100% aircraft crash rate.

    Or we can scrap the humans after a certain age, like old aircraft.

    Let’s go to the air museum and pull out an old Spitfire and see if the pilot can make it fly again.

  • John Henry

    Aviation is a mass-production industry. Pilots are not flying an individually-customized aircraft for each and every passenger aboard, each with its own individual maintenance standards and operating envelopes; they are flying a standardized machine with which a pilot can become type qualified. The design is standardized. Maintenance is standardized.There isn’t a black box, never mind a requirement to manually document the preflight and inflight activity for each passenger aboard
    Comparing commercial aviation to medicine is absurdly inappropriate and useless.

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