was struck by this headline earlier this year and have pondered how an industry that flew more than 37 million flights got to a "perfect" year in flight safety. Is it just a fluke or are there any replicable lessons to be learned? Full disclosure: there were 10 recorded crashes involving small propeller planes and cargo aircraft, killing 44 passengers and 35 people on the ground in 2017. The stats also did not include military airline fatalities.
As the chart indicates above, things have been getting over for the past 40 years for a variety of reasons and U.S. flights are only part of the overall picture here. Randomly flying turbine blades notwithstanding, equipment continues to get better, radar technology improves, and storms are easier to predict. But the human side of flight safety will always remain a wildcard and so it was very encouraging to see a major change in the FAA pilot rest rules adopted in 2014, hoping that they promote a high standard in the industry as a whole:
Interestingly enough, cargo carriers — which do much of their flying overnight — are exempt from the new rules. The FAA said forcing them to "reduce the number of hours their pilots can fly would be too costly (emphasis added) when compared with the safety benefits." Perhaps it is time to look at those statistics and reconsider. It is also notable to point out that sleep deprivation was identified as a major factor in disasters such as the Exxon Valdez, Bhopal India gas leak, Three Mile Island, and Chernobyl. Occupational health studies have shown that even 17 hours without sleep is like having a BAC of 5% and 24 sleepless hours has the same effect as being legally drunk.
You can see where I am going with all of this.
Physicians and medical staff are unquestionably exhausted. A 2008 survey of U.S. physicians (N=581) had them self-reporting an average of 6.5 hours of sleep per night, and this was done at the outset of major health care reforms. A cursory search on-line for more up-to-date statistics shows nobody is even bothering to measure physician sleep because it is such an accepted part of the medical culture. ("Of course you're not going to get any sleep. Didn't you learn that in medical school and residency.") Besides mere physical exhaustion, there is also the cumulative emotional fatigue that comes from caring for sick and dying patients, as well as the mental fatigue of working in an industry with sustained, significant, and rapid change.
A friend of mine whose husband is an airline pilot said it was only after two decades of effort on behalf of their unions that these changes took place. With increasing evidence between pilots' lack of sleep and mistakes that led to accidents, regulators eventually had to act. But individual patient deaths due to physician exhaustion do not involve big pieces of machinery colliding with the ground and garnering horrific news coverage. Plus, the uncertainty of medical interventions always clouds the picture of where the fault lies when patients die. Without huge public medical disasters, it is unlikely that regulators will ever step into demand change for physicians.
Ultimately, a revolution towards better rested physicians will only happen group by group, hospital by hospital, system by system when they understand the link between physician wellness and patient safety. For all those seeking to become high-reliability organizations (HRO's), perhaps one of the things they should add to their daily safety huddle is to start tracking how much their medical staff isn't sleeping and why.
Until we decide we have to make physician (and resident) rest and rejuvenation more of a priority, that we have to get our physicians off their EHR's in the hours before bed, that we have to stop punishing physicians who show up reporting that they are not fit for duty today – I'm afraid the U.S. medical industry won't be following the commercial airline safety record anytime soon.
For the most part, gone are the days when solo practitioners put patient notes on paper, rounded on their patients in the hospital, dropped in to the physician lounge, and received the unmitigated respect and adulation of the community. While, there are still some specialties like dermatology and cosmetic surgery and direct primary care models that operate independently and have more freedom, the majority of physicians are part of a team, network or system to try to integrate care with one another. And as much as I admire and encourage those remain independent, I sometimes I wonder if we do physicians a disservice by idolizing the solo practice and paper chart "golden days" as a standard that health care should return to.
This is a question I think about a lot: how does ACMS best support and equip our members to thrive and grow in volatile, uncertain, complex and ambiguous times? I'm reading a book on organizational leadership which centers on the example of Lewis and Clark. Our heroic explorers climb to the source of the Missouri River thinking the West side of their trek to the Pacific Ocean would be the discovery of a cross-continental waterway sloping gently down to the ocean. What they see terrifies them: a range of the "most terrible mountains ever beheld," as wide and deep as the eye can see. Lewis and Clark suddenly realize canoes aren't going to cut it anymore.
Perhaps it is time in medicine to prepare ourselves for the days ahead rather than pining away for the past. This kind of leadership – corporate, team and individual leadership – is going to require a different skill set than most ever learned in residency or medical school. There may be some who decide to settle at the edge of the frontier out of exhaustion or stubbornness, a toe in the new world but close enough to the past to retreat to it. But those who decide to move ahead into the future will have to grieve that the skills that got them there won't take them much further – and then journey on.
There are a few different ways of dealing with industry change, each with increasing effort and labor required.
1) Ignore it and pretend it will go away - or just retire early.
2) Whine about it because you can't ignore it.
3) Look inward to see how you can reframe your attitude and response to it.
4) Pro-actively shape the future of healthcare for yourself and community by leaning into it.
Lewis and Clark could have turned tail and reported back to President Jefferson that in fact there was no water route and they would have been right. But their spirit of duty, adventure, tenacity, and vision foresaw that eventually Americans would be streaming this way towards Idaho and their trek could help create the map.
Health care will always be moving us past our comfort zones and as a medical society, we must provide help to our members to learn new skill sets and sharpen the ones they have. As IMA's past-president Dr. Bruce Belzer said last summer, "The future of medicine is uncertain, but I bet that's what they said about 125 years ago." I hope to be on your team of people to help you get there.
Having just wrapped up our 59th Annual Winter Clinics in McCall I am in post-mortem mode, evaluating what went right and what needs to be fixed. As I reflect on what made this year very successful – we blew through our capacity with 125 registered for on-site attendance – it seems the factors are really just a reflection of what ACMS stands for throughout the year: We Connect the Docs.
With the central them of Managing Obesity, we had a wide variety of perspectives represented that made for, shall we say, a "vigorous" conversation. Duke University's Dr. Eric Westman made a strong pitch for a no moderation high fat, low-carb diet while Dr. James Valentine shared about the safety of bariatric surgery. Drs. Jennifer Shalz and Amy Baruch pushed lifestyle as medicine, explored alternative medical therapies, and gave physicians more education on nutrition in one hour than most probably received in all of residency.
Local obesity medicine physician W. Allen Rader spoke on the psychology of weight loss and OB fellow Tom Wonderlich covered the care of obesity during pregnancy. We finished up on Sunday with an excellent presentation on the use of probiotics by Dr. Robert Martindale of OHSU. Thomas Jefferson University's Dr. Salvatore Mangione was a world-class presentation on the need to reintegrate right and left brain thinking in medicine and an Augenblick approach to gait analysis. We also learned from IMA's Teresa Cirelli how to correctly bill for obesity management.
We saw a similar dynamic of multiple perspectives unfold at a career readiness event for year two residents, our R2 Unit Training in January. Both Boise hospital systems had a turn to talk about occupational values, site visits, interviews, and CV's, followed a brief on employment contracts and RVU's. Then a panel of independent physicians from the three resident specialties represented sharing the joys and challenges of being a non-employed physician. Afterwards, Direct Primary Care "evangelist" Dr. Julie Gunther had a ring of residents pelting her with questions and studiously taking notes.
These experiences illustrate the high value ACMS places on being a "big round table" for the medical community to meet at. In an attempt to tear down the silos of healthcare - whether it is between specialties, independents and health systems – we strive to nurture a medical community that fosters professional and collegial relationships that can operate without unnecessary barriers.
Dr. Dike Drummond – the blog editor of thehappymd.com and an upcoming ACMS guest speaker on May 10 – often says that "physician burnout is not a problem to be solved, but a dilemma to be managed." Likewise, just as there is no one right way to manage obesity or a best place or way to practice medicine in Boise, it is in the civil exchange of ideas and information from which we believe the most good can come. Now if you're a resident, you might just want the "right answer" to pass your boards, but beyond that, most physicians really appreciate a healthy discussion with a variety of perspectives.
At the end of Winter Clinics, a husband-wife physician couple who are new to Boise approached me and related this: "We have been a part of multiple medical societies over the years and I can tell you we've never seen one like this. You truly have something special here." The beauty of that statement is that what they experienced at Winter Clinics is available to all members year-round through our programming and I hope more will join us at the table.