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.