BY JONATHAN D. MILLER, MD
The seat belt sign chimes again. Pinned between two strangers for hours, I silently wish for a brief reprieve—beverage service or a chance to hobble toward the back of the plane to stretch. But, no, the captain has turned on the seat belt sign again. She's the boss, and I trust her with my safety, regardless of how uncomfortable I might be.
Many analogies have been drawn between the seemingly different worlds of aviation and medicine over the years. Many have continued to look for similarities since Dr. Atul Gawande wrote The Checklist Manifesto. One of the best lectures I've heard was from fellow emergency physician Dr. Joe Novak who spoke at the ACEP Scientific Assembly about combat aviation paradigms" comparing our craft and our training to that of an Air Force fighter pilot. As a pilot and emergency physician, I think there are more comparisons yet to be made.
The aviation industry is plagued with bureaucracy. It makes sense to the lay passenger that the government ensures our safety. Colgan Air flight 3407 tragically crashed in Buffalo in 2009. This led Congress to raise the minimum number of hours required to fly as a co-pilot from 250 to 1,500 hours before being eligible for hire. The new requirements have led to a pilot shortage in our country, although this rule was developed with input from the Airline Pilots Association, a union with 52,000 members.
Medicine is no stranger to oversight. Joint Commission visits and an onslaught of quality metrics to report on is a never-ending plight for hospitals and physicians. Yet, unlike pilots, we have no voice. Sure, the American Medical Association and specialty colleges like the American College of Emergency Physicians exist to express concerns for physicians throughout our country, but the past decade of government turmoil brought down on physicians would suggest that having a few lobbyists looking out for us isn't enough.
Pilots would not follow a new operating procedure that made flying unsafe. Their union would speak up. The government dragged their feet when iPads became the new way to keep charts and airport information handy. The Federal Aviation Administration said they would need to do "more research" before agreeing that its use would be safe in flight. Pilots knew that this technology would save fuel and paper, reduce pilot workload, make flying safer, and save the pilot from dragging a 40-pound bag of charts through every airport. Many pilots still used the technology before given the official go-ahead. They are the experts, not the bureaucrats. They knew having charts readily accessible on an iPad when struggling to fly through difficult weather made the flight safer. So they did it. The FAA eventually saw the light, and now having an iPad in the cockpit is ubiquitous.
Pilots had work-hour restrictions long before medical residents did. Some experts doubt the ACGME requirements have resulted in increased safety at academic institutions, but aviation authorities certainly believe in their utility. The FAA (not the pilot experts) attempted to make the rules even more stringent in 1995, requiring increased periods of rest and less time in the cockpit each day. There can be too much of a good thing, and the pilots rang out! Union and industry pundits had a seat at the table. The increase in policymaking oversight was stifled. Every time it comes up again, it's a committee of pilots and doctors (experts in the physiology of flight) who have a voice. It is not a committee of congressmen on Capitol Hill.
Why don't physicians act in the same manner? Recently I was told by an administrator that nurses and providers (administrators never call us doctors anymore) couldn't have cell phones in patient care areas. I keep many resources on my phone. Paucis Verbis cards, Epocrates, Pedi-Stat, and other cell phone apps are integral to my practice of emergency medicine. The other option is to carry around a stack of outdated pocket cards, which would make a seasoned emergency physician look more like a third-year medical student with their overburdened white coats. I told her I would continue to use my phone. I am the expert in patient care. I know that having these resources helps me provide excellent, up-to-date care. Speak up! You are the expert.
North America is beginning to see a pilot shortage crisis. It is only expected to worsen. The experience required to be eligible for a co-pilot position increased sixfold in 2009. The typical debt incurred to become a pilot is well over $100,000 unless one joins the military. Once done with that, you suffer through endless low-paying jobs before you make it. Then, your first job at the regional airlines pays quite poorly, although slightly more per hour than you made during your residency. Eventually, you make a healthy salary after gaining experience and seniority. Sound familiar to the long road toward a career in medicine that you followed?
How are airlines fixing the pilot shortage? Many are beginning to create their own training programs. Train with them, and you are guaranteed a job—with less debt in the process. Remove financial barriers toward education, and more eligible pilots will come knocking. Airlines understand economics better than hospital systems and insurance companies. If you pay more, they will come. Bonuses and increased wages are also beginning to result in more aviators being willing to take on the financial burden of becoming an airline pilot.
Like the airlines, we are facing a physician shortage in our country. The debt incurred by undergraduate and medical education is staggering. Much like a pilot, one has the option of joining the military to decrease the burden of debt. Doctors who don't join the military must endure a decade of training with hundreds of thousands of dollars in debt. We accept this despite an ever-decreasing salary. In fact, it's difficult to imagine another profession where you get paid less the longer you work.
Perhaps we should follow the airlines' lead. What if hospital systems paid for residencies instead of Medicare and Medicaid funding them? What if I train with Kaiser, and then Kaiser pays my medical school costs and pays my salary during residency? I become a well-oiled Kaiser machine in the process who then signs a contract to work for a given number of years. Money talks. Paying board-certified physicians what they deserve and what they've previously made makes sense. No doctor should have to spend two decades paying off their loans.
Pilots don't have at-risk funds. What if 15 percent of a pilot's paycheck was held at ransom, given to them only if their passengers' satisfaction was in the 90th percentile and if they had on-time arrivals 95 percent of the time. That will not happen. Do you think that would lead to safe decision-making? No, it would result in airline accidents. It would result in death.
Pilots don't control the weather. They can't control the fact that the airlines they work for took away meals, peanuts, and that extra inch of leg room. The pilot instead focuses his energy on being a consummate professional and getting people safely to their destinations. Why aren't physicians more like pilots? We too cannot control the climate in our workplace. Sometimes, the ED gets busy. Wait times will rise when several critical patients arrive at once. That's OK. Period.
When saving a life, the patient with an ankle sprain can wait. Unfortunately, all too commonly contracts are being written with the premise that physicians must do X, Y, and Z to get the reimbursement that was, at one time, rightfully theirs.
It's time to take control of our aircraft. Thinking back to that uncomfortable flight, I had a lot to complain about. I was hungry. I was tired. I was bored. I got home three hours later than expected. But when I take a step back, I realize just how amazing it all was. I flew from coast to coast, over and around major thunderstorms, in a period of four hours. I just left my home in the Northwest, and this evening I'm having a family dinner in Alabama. I'm not using FaceTime to say hello to my mom; I'm using a hug. It's incredible. It's easy to be increasingly negative in a society that values speed, ease, and a burden-free world, but it's much easier to see just how good we have it when you look at the view from 40,000 feet. The emergency department is no different.
Why don't our colleagues, our government, and our administrators look at medicine in the same way? Yes, there was a delay in getting you to your room. Yes, the food is terrible or nonexistent. Yes, the gurney is less comfortable than a plush recliner. But at the end of the day, a trip to the emergency department is as incredible as a flight across the country, despite its inadequacies.
A patient is distressed. He has had pain for a week. A board-certified physician decreases his pain, listens to their worries, diagnoses his ailment, and advocates for his treatment. What might take weeks to work up in the outpatient world takes hours to work up in the ED. Where at people at one time died due to injury, now they arrive and have their lives saved in an immediate fashion by experts.
We are the captains of our ship. We know what is best for our patients and for health care. When a pilot decides to delay a flight due to dangerous lightning or a warning light in the cockpit, no passenger has the audacity to walk to the front of the plane to tell them to get going. The CEO of the airline doesn't patch into the radio to tell them to depart immediately because of the growing number of passengers sitting at the gate. Believe it or not, there is safety in paternalism! We trust the pilot to get us to our destination without harm. We acknowledge they have more experience than we do. If that means we must wait an extra hour or an extra day, we comply.
I believe it is time for us to act more like pilots. If you don't need an MRI scan of your head, I shouldn't order it just to make you happy. If I spend an hour in the critical care bay, I shouldn't get reprimanded by administration for decreased throughput. They should thank me for saving a life and for doing what I was trained to do. They shouldn't chastise me or lessen my pay because someone with a cold waited for three hours. My skill as an emergency physician should not be tethered to a wait time on a billboard. The government shouldn't judge me by how well I treat someone's pain. Increased workload and alert fatigue through our EMRs (our version of the cockpit) has become unsafe and overly complicated, and it has diminished the human aspect of medicine that many of us sought when we chose our profession. Why should I be forced to spend more time in front of a computer screen under the guise of meaningful use when it has never been proven to be meaningful?
Many people love to talk about physician burnout. This is simply a synonym for its true meaning: physician disempowerment. Let's call it what it is. It's time we speak up. It's time we take the controls of the craft we spent so many years learning. It's time we have a seat at the controls. It's time we unionize, just like pilots have.
Dr. Miller is a clinical instructor with the University of Washington and an attending emergency physician practicing in Boise, Idaho. He also works as a critical care air transport physician and EMS director with the Idaho Air National Guard.