What we can learn from the looming airline pilot shortage

As the Wall Street Journal reported, there’s a growing shortage of qualified pilots in the US, driven by both economic reality and federal policy.

Pilots typically start their professional careers at small, regional airlines — airlines that pay, approximately, fast-food wages. Less than that, really — for for the hours they work, many pilots make less than minimum wage.  After a few years, these pilots have enough flight time and experience to try to get jobs with the big carriers, for a substantial increase in salary. Once the promotion to captain of a commercial jet comes through, pilots can make $200,000 or more a year.

But the system is getting wobbly. The two-tiered payment system relies too heavily on a steady influx of new, fresh-faced pilots eager to fly at any income. And new federal regulations require that starting pilots have 1,500 hours of flying experience, up from 250 hours — meaning even more debt for young flyers.

In other words: Long training for an eventually good salary isn’t likely to continue to attract enough talent. Does this remind you of any other industry?

It’s expensive to train a pilot, and it’s expensive to train a doctor. We typically spend 4 years as undergrads, 4 years in medical school, then at least 3 years at a less-than-minimum wage job (residency) just to qualify as primary care providers in internal medicine, pediatrics, or family medicine. If we want to make the big bucks, that’s another several years for fellowship or surgical training.

Meanwhile, there’s a push to get more people insured — more people who will want to see a doctor. As with pilots, a doctor shortage looms.

Some people are suggesting an expanded role for non-doctors: nurse practitioners, physician’s assistants, pharmacists, and others to take a larger role, perhaps to “lead the health care team.” It’s unclear what the effect of such a change will be on the quality of health care delivery, but that hasn’t stopped many health care systems from relying more on these lower-cost providers. Most of the time, with most patients, that works out fine.

I suppose we could also rely more on low-cost “pilot assistants” or “flying practitioners” as well. Most of the time, that would work out fine, too. But I don’t think most people would be happy to ride a plane piloted by a non-pilot. When people fly, they expect a real pilot to be in charge: Someone with both the experience and the training not only to handle the routine stuff, but someone who can handle the rare emergencies or unexpected complications. Someone who can land any plane safely, even when things go wrong.

Physician extenders and other mid-levels can safely and effectively handle most medical questions. But the trick is knowing which patients really would do better with a physician. We don’t necessarily know ahead of time (just like we don’t know which flights will have emergencies.) Co-pilots and navigators and other assistants can be a valuable part of the cockpit team, but who will you turn to when something goes wrong?

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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    Hi Roy,
    Only problem with your repeat of the “pilot” analogy is that you have no proof of any of it. The whole post is a little snarky as well. I own a private practice NP clinic and serve thousands of patients a year. NPs have been doing this for 50 years. Is there a record for “pilot assistants” or “flying practitioners?” You apparently practice in a dark hole. NPs are everywhere – and practice everywhere without physicians. It’s one of the healthcare elephants in the room. Posts like this perpetuate fear and anxiety and the higher ups like it when we fight amongst ourselves. In my private clinic, I care for them straight out of mom’s womb. And the care is exceptional. And my profession DOES have a record. So three final things – 1) Warning – This article is not based in any fact and is written to perpetuate fear about NPs. We have a proven track record and that IS based in fact. 2) Dr. Pho – I wish you wouldn’t allow articles like this to be posted here. They bring out the crazies from the nursing forums and medical student forums and always end badly. 3) Roy – my patients turn to me when something goes wrong; and just like you – when it’s out of my league – and there is plenty out of your league too – they go to a specialist pilot; the same place you would send them.

    • ak123

      Keep in mind one simple fact NPPCP. This is the concept of intellectual property. An MD has invested more into their education than an NP. This is intellectual property and needs to be guarded. You should not have two different sets of training rules for the same rights and privileges.

    • Dr. Drake Ramoray

      I say we close down all the medical schools. The NPs do it just as well anyway and they cost far less to train. They even lobby the government and represent their own self interests better than doctors. In fact since they are just as good if not better than an MD without all that wasted time and money of getting an MD, I say we let them train to be specialists too (yes I know some already are, and yes I know your training isn’t as straightforward). If you don’t need to be a doctor to be a doctor, why do you need to be a doctor to be a specialist? We don’t need doctors anymore. So passé.

    • Arby

      Nothing against your practice, and I may have gotten the bad luck of the draw, yet I have not had good experiences with NPs or PAs. They were more empathic than the physicians I’ve visited, yet their medicine was not up to par. Now, I always ask for an appointment with an MD.

      I’ve also noticed that the urgent care clinics in my area advertise that you are always seen by a doctor. So, I don’t think I am the only patient to think this way.

    • Eric Goldberg

      The entire debate about whether NP’s should be allowed to practice independently with essentially the same practice rights as primary care physicians basically boils down to two possible scenarios: either NP training is equivalent in quality and depth to that of primary care physicians (in which case the entire medical school curriculum and training required to become a PCP is a complete racket and should be abolished immediately); or, the training of PCP’s is superior to non-physician practitioners, and in that case DNP’s shouldn’t be considered equivalent in terms of practice rights. So which is it?

      Based on the percentage of DNP’s who were able to pass a watered down version of the USMLE step 3 exam (an abysmal 50%), which doesn’t even approach the same level of difficulty or scope of knowledge tested in the real step 3, I’m gonna go with scenario number two. FYI the first time step 3 pass rate for American medical students is about 97%.


  • Sherman Kensinga

    Pilot Assistants or Flying Practitioners are MPL pilots, minimally trained and lower paid pilots used internationally instead of fully-qualified pilots on multi-pilot crews. They have not yet been accepted by the FAA, but we are headed there. They now carry the responsibility for hundreds of lives and over a billion-dollars in liability every flight, for a few dollars less than a fully qualified pilot.

    Your comment about $200k/yr is true, they CAN make that much, and that is what still draws young pilots to spend over $200k and 8+ years getting licensed and qualified for the profession. But in reality, only a very few major airline pilots ever make that much, and only for their last few years. Most major airline pilots will top out at around $160k/yr for their last few years, regional pilots top out closer to $100k. Average career earnings are in line with most bachelor degree grads.

    Starting pay of $15k/yr, longer hours, more days away from home, the growing threat of automation, and the general decline of the industry and profession, led to very few young Americans entering flight school eight years ago. That loss is just now hitting the industry as they stop graduating, and it will not be fixed quickly or cheaply without significant compromises in safety.

    I appreciate the comparison to a career as a doctor, but it isn’t even close. You can pack up your stethoscope and walk across the street or across the country, and expect to resume your status and income. If Captain Sullenberger started over at a major airline today he would earn $21k/yr by contract as a first-officer on the smallest equipment flying the least desirable routes. A pilot’s career can be ended by relatively moderate illness or injury, legal problems, failed checkrides, or their current airline failing. The major airlines just re-hired thousands of pilots laid off over ten years ago, at beginning pay. American Eagle (Envoy) is in the process of shrinking out of business, because their pilots wouldn’t take another paycut, this happens often. Airlines expect their pilots to move to another city or commute when the airline shuts down a base.

    After 40 years in this business, I fear for the future of commercial aviation. It is going to get rough, and dangerous.

    • PCPMD

      I think the article is drawing comparison between the forces that have already adversely affected pilots, and have compromised the aviation industry, with the forces that are currently starting to do the same in medicine. I don’t think anyone is saying they’re at the same place, or that doctors experience the same difficulties as pilots do (as yet).

      At the same time, I think the there are striking similarities between the evolution of piloting and clinical practice, especially for primary care:

      MPL Pilots –> NP’s and PA’s

      The threat of replacing U.S. pilots with foreign-trained ones with less U.S. training or experience –> loosening of licensure/H1 Visa regulation to attract foreign physicians to replace U.S. PCP’s.

      Reorganization of airlines into a few large oligopolies with fewer flight options, poorer customer service, at higher cost –> Consolidation/buying up of small practices and hospitals, with lower patient satisfaction and higher cost

      Declining status of pilots (being seen as “glorified bus-drivers” rather than “the captain of the ship” ) –> declining status of physicians (being portrayed as “glorified mechanics/pill pushes” to be avoided, rather than highly skilled professionals, who’s insight should be valued and sought).

      • Allie

        Airplane fatalities are rare events. It takes a lot of careful study to get at the real differences. I could probably fly with minimal training at cruising altitude without crashing, but it doesn’t mean I should land the plane.

  • ninguem

    What’s cruising altitude for a Boeing 747?

    About 30-40,000 feet?


    Have the pilot-practitioners fly at 15-20,000 feet.

    You know.


    • NPPCP

      All these points are valid. No argument from me. Great comparison doc. I love it. Very creative. :)

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

    The way I see it, here is the problem: Medicare currently reimburses NP and PA services billed under the NP/PA NPI at 85% of physicians, while incident-to services are reimbursed at 100% physician fees.
    This is nowhere in the vicinity of nearly enough “savings” for CorpMed. So once we all accept that you don’t need doctors for these “regular” services, the payers/health systems/CorpMed are going to come down like a ton of bricks on NP/PA rates, and after that they will campaign for MAs to do these things (they already are, see below), because you really don’t need an NP/PA either. A “certified” MA with a nice set of standing orders can take care of sore throats, “supervised” by a “provider” of course, at least in the beginning…
    (Scroll down to the second to last paragraph if you’re in a hurry: http://onhealthtech.blogspot.com/2014/05/as-health-care-learns-and-grows.html )

    You guys need to stop this infighting and pay attention to the endgame. The average salary in 2013 for NPs/PAs was around $100k. You don’t seriously think that Walmart is planning on paying that kind of money to anybody for very long, do you?

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