A recent medical error of a wrong-site surgery that occurred in one of the country’s best hospitals, Massachusetts General, reminded me why doctors need to be less like Chuck Yeager and more like Captain Sullenberger.
Growing up, I always wanted to be a fighter pilot, years before the movie “Top Gun” became a part of the American lexicon. My hero was World War II pilot Chuck Yeager, who later became one of the country’s premier test pilots flying experimental jet and rocket propelled planes in a time when they were dangerous, unpredictable, and unreliable.
Much like the astronauts in the movie “The Right Stuff,” Yeager and his colleagues literally flew by the seat of their pants, made it up as they went along, and never really knew if their maiden flight in a new aircraft might be their last. They were cowboys in the sky wrangling and taming the heavens.
Fast forward to January 2009, when shortly after takeoff, a one-in-a-million chance, a double-bird strike completely disabled a US Airways jetliner. Captain Chesley Sullenberger, with the help of his co-pilot Jeff Skiles, ditches the aircraft in the Hudson River in under four minutes even as the nation surely expected a tragedy. But not on that day. Not with that pilot.
Though Sullenberger, an already-accomplished pilot from being the top cadet at the U.S. Air Force Academy, an aviation safety expert with his experience as a crash site investigator for both the military and civilian sector, as well as an instructor for US Airways pilots, he credited much of the success to his training and his experience.
Sullenberger had studied why pilots and crews often failed in critical emergency situations. He also mastered and understood the physics and performance aspects of the aircraft he flies (his wife calls him “a pilot’s pilot.”) He also believes strongly and instinctively the need to follow checklists and protocols to ensure the right thing is done every time. This was drilled in him in the military, where the difference between life and death in a fighter plane could be simply a matter of feet and seconds.
Though the media dubbed the landing as the “Miracle of the Hudson” and named him America’s hero, Sullenberger modestly noted he was simply doing his job, which only endeared him even more to a country looking for positive stories in a time of a new president, an unprecedented financial crisis, two wars, and an uncertain future. Ask Captain Sullenberger, review the cockpit recordings, and you’ll discover that he wasn’t really flying by the seat of his pants, but was very methodical, rational, and logical as he quickly evaluated his three options: Return the plane back to LaGuardia, go to Teterboro, New Jersey, or ditch in the Hudson River.
While planning for a landing after the unthinkable, his co-pilot automatically did his job attempting an engine restart by cycling through the checklist seven times. They landed the plane successfully with a little luck, a lot of skill, and a full understanding of how humans make mistakes in particularly stressful times and what mechanisms when put into place, checklists, protocols, and training, can decrease these to a minimum. Frankly, no one else could have landed that plane except Sullenberger.
Which brings me back to the medical error noted in the New England Journal of Medicine. Dr. David Ring, after a day of many carpal tunnel surgery releases, erroneously performed the surgery on a woman who was supposed to get a trigger finger release. Though he has been praised by many to be courageous to publicly acknowledge the error, what was quite disturbing was his one comment:
“I no longer see these protocols as a burden. That is the lesson.”
His insightful comment should not be seen as an anomaly. Dr. Ring should also not be ostracized. He speaks the truth. Doctors today still see themselves as cowboys, the heroic individual who despite whatever obstacle or hardship can just get the job done. Somehow, we are too smart to rely on surgical timeouts, checklists and protocols. Instead, we refer to the entire process as ”cookbook” medicine and go through the motions just to appease regulators and administrators.
It is this arrogance and hubris that pervades our profession that is quite disturbing and equally disappointing. A March 2010 report found that medical schools are not doing enough to prepare future doctors on how to develop the mindset for patient safety. Yet for much of medicine, we understand the precisely the science of how to do things better.
No central line infections occur when all doctors abide by a simple 5-point checklist developed by John Hopkins intensivist Peter Pronovost. Merely having every surgical team member introduce himself before surgery as noted by New Yorker writer and general surgeon Dr. Atul Gawande improves communications so that the team is more likely to function better in times of crisis. Even a singular phone call by Dr. Gawande to the blood bank to hold blood on standby for a “routine” surgical procedure, which he had done many times before and never needed the blood, ended up being critically important. On that day with that routine surgery, his patient had a tear which required 30 units of blood. If Dr. Gawande hasn’t called for blood on standby before the operation started, his patient would have died.
We know much more about medicine since the development of antibiotics, antiseptics, and best practices, yet we act no differently than 150 years ago:
“In 1852, the Massachusetts General Hospital was featured in a New York Times article detailing a series of events that led to the death of a young patient. Under the care of the surgeon, Dr. John Collins Warren, the patient had received chloroform instead of the usual chloric ether anesthesia. The event that we describe here, more than 150 years later, is a sad reminder that despite expert and well-intentioned providers, our patients continue to face risks caused by human fallibility and systems that do not fully support our efforts to provide safe care.”
It’s time doctors stop acting like the cowboy test pilots of Chuck Yeager’s era and adopt the mindset of Captain Chesley Sullenberger and Drs. Pronovost and Gawande. Protocols and checklists exist for the safety of our patients and to ensure highly-reliable outcomes everytime. Until all doctors adopt this mindset, medical errors will continue to happen despite policies and regulations — because somehow our profession still believes we are infallable.
*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*