Avoiding medicine’s Boeing 737 Max

I’m sitting on a cross-country flight to California with utmost respect for the professionalism of the crew, especially considering my life will be in their hands for the next 6 hours. Despite understanding the physics, I am still amazed by flight, and even more so by the coordination required to manage the logistics of shuttling so many people and their luggage around the world.

As health care leaders apply a business mentality to medical care, these administrators are apt to make comparisons to complex fields like commercial airline travel. While we physicians may resent the idea that any field is comparable to the challenges of medical care, to be fair, in some ways drawing on these analogies can improve health care systems. For example, at my institution we have a new division devoted to the patient experience, with the intention to increase patient satisfaction and decrease lapses in communication. These initiatives require investments of limited resources, and ideally, health care administrators should welcome input from physicians before applying outside business models to hospital operations to prevent unforeseen negative consequences, such as burnout among staff, which can potentially comprise patient care.

On October 29, 2018, Lion Air Flight 610 plunged into the Java Sea 13 minutes after takeoff, killing all 189 souls aboard. An investigation highlighting the faulty software ensued, but no changes were immediately made. Five months later, another Boeing 737 Max 8 jet, Ethiopian Airlines Flight 302, similarly crashed 6 minutes after takeoff, killing all 157 passengers and crew. We are still learning the details of both flights, however, initial reports point to a flawed system on the 737 Max 8 that was created to adapt to changes in this new aircraft designed for cost savings, which would allow for more sales in a competitive market. As we learn more, a narrative is taking shape that the roll-out of the Max 8 was done hastily, with lapses in supervision of the industry leading to a focus on profit over safety. While we await more details to corroborate this, one thing is clear: Safety becomes compromised when volume and revenue are the top priorities in any field, especially in an industry intended to keep the public safe. While advocates of Boeing have lauded the company’s track record of safety, critics have lambasted Boeing’s competitive drive for profits as superseding safety measures. As I write this at 35,000 feet, I believe I share the sentiment of most of the public: Could these tragedies have been prevented in the first place and how can we prevent them from happening in the future?

The analogy here to medicine is obvious. What physicians are experiencing as more of us become employed by large health care systems is a tug-of-war between administrators who are well-intentioned to keep the hospital system profitable to achieve growth, our duty to patient well-being, and a health care system that places limitations on reimbursement due to insurers’ myriad cost-containment measures. The concern here is also whether financial drivers are superseding the limits of being able to provide safe, high-quality patient care.

For example, many physicians’ contracts are based on volume, such as the RVU model, intended to motivate physicians to see more patients and increase their compensation. The question is, at what point does the motivation to increase volume become unsafe due to a shift in priorities from public safety to profit, as appears to have been the case with the Boeing Max 8? Should we continue to be double-booking appointments? Is it safe to supervise anesthesia nurses in multiple operating suites? Should we allow for more time to follow up results and other time-consuming clinical issues by carving out more administrative time? And the list of potential questions like these goes on.

Residency programs often limit the amount of time trainees can moonlight, since they understand that the economics of earning additional income may drive residents to take even less time to rest, which can endanger patient safety. Why does the current system which focuses on volume then become the motivating factor for physicians when they transition to attendings? I’m not sure what the solution will be in the long run, but one thing is clear to me in the short run as I continue on my current flight: I really hope the crew are content, confident that their leadership welcomes their feedback, and certain that passenger safety is not at risk of being compromised for the sake of profits. Now there’s an analogy I would love to make to medicine.

Marc Braunstein is a hematology-oncology physician and can be reached on Twitter @docbraunstein.

Image credit: Shutterstock.com

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