Malcolm Gladwell’s new book, Outliers: The Story of Success (Little Brown), contains a very interesting discussion of the reasons for plane crashes. It turns out that very few plane crashes involve unsurmountable catastrophic mechanical failure. Rather, most plane crashes occur as the consequence of a chain of small human decision-making errors compounded by poor communication between pilots in the cockpit.
Up until a few years ago, Korean Air Lines was plagued by a much higher crash rate than other airlines. Analysis of cockpit voice recorder data from a number of Korean plane crashes revealed that the god-like status of captains and the relative subordination of their second officers frequently led to situations where the captain was fucking up, the second officer was clearly aware of the fuckup, but the second officer was either unwilling or unable to communicate to the captain the fact that he was fucking up.
In one horrifying case, the transcript reveals that just before their plane plowed into the side of a hill, the second officer was saying something to the captain like, “sometimes it is not so easy in bad weather at this airport to see the runway”, when it was clear that he knew they were headed for the hill and should have been shouting, “Dude! Pull up!!! We’re about to crash into the motherfucking hill!! PULL UP!!!”
Turns out that this is consistent with the strongly hierarchical nature of Korean culture, and that once Korean Airlines realized what was going on, they were able to train their Korean pilots to not behave hierarchically in the cockpit. Their crash rate immediately declined to typical industry-wide levels.
It was the middle of the night, and Laura Silverthorn, a nurse at a hospital in Washington, knew her patient was in danger.
The boy had a shunt in his brain to drain fluid, but he was vomiting and had an extreme headache, two signs that the shunt was blocked and fluid was building up. When she paged the on-call resident, who was asleep in the hospital, he told her not to worry.
After a second page, Ms. Silverthorn said, “he became arrogant and said, ‘You don’t know what to look for — you’re not a doctor.’ ”
He ignored her third page, and after another harrowing hour she called the attending physician at home. The child was rushed into surgery.
“He could have died or had serious brain injury,” Ms. Silverthorn said, “but I was treated like a pest for calling in the middle of the night.”
Just like the second officer in the plane heading for the hill, this nurse was in possession of absolutely critical information in a life-or-death situation. And just like in the Korean Airlines cockpit, a culture of strict hierarchy resulted in a failure of essential communication of that information.
Many features of the medical training system reinforce the status of physicians as not only different from the other participants in the medical care system–nurses, physician assistants, technicians, etc–but superior, and to be deferred to. This is bad for patient care.
The fact of the matter is that physicians are, on average, no more intelligent, perceptive, or experienced than nurses, PAs, technicians, etc. They are, of course, in possession of specialized information and skills that other participants in the medical care system are not.
These communication breakdowns appear not to just be isolated incidents, as the Times article notes:
[A] survey by the Institute for Safe Medication Practices, a nonprofit organization, found that 40 percent of hospital staff members reported having been so intimidated by a doctor that they did not share their concerns about orders for medication that appeared to be incorrect. As a result, 7 percent said they contributed to a medication error.
Just as Korean Airlines was able to train its pilots to overcome the naturally hierarchical nature of Korean society, we should be able to train medical care providers to overcome the naturally hierarchical nature of the medical care system. This will lead to improvements in treatment outcome, and reduce suffering and premature death.
UPDATE: Check out my colleague PalMD’s post on this topic.