Dev Lall

Please stop saying medicine is like flying a plane

As I was ripping out pages of an old edition of the BMJ to stuff my wet trainers with, a quotation caught my eye. It was made by Jerry Heneghan, the director of product development at Human Sim, who manufacture the medical equivalents of flight simulators.

‘When I was a pilot, I was evaluated every year on a flight simulator to check I was still good to fly. I don’t see why that shouldn’t be compulsory for surgeons as well.’ BMJ 2014;349:g5642

No, we know you don’t see.

It doesn’t happen often, but I sympathise with the surgeons at whom this is directed. For many years anaesthetists have been compared to pilots by everyone, apart from anaesthetists themselves. I do not know of one anaesthetist who agrees with the belief that a pilot flying a plane is in any way similar to anaesthetising a patient.

The uninformed talk about the excitement of take off and induction, the required attention to landing and emergence, and the ‘boring’ bit in between which I assume means when the patient is kept alive, asleep, analgesed and unaware on auto-anaesthetist, while we go for our compulsory meal break.

Let’s be clear. Patients cannot be compared to aircrafts. Patients start ill and have surgery and anaesthesia to get better. They come in a variety of shapes and compositions, with underlying chronic problems and an acute pathological process requiring intervention, to improve the clinical condition or allow survival. Their response to any intervention is variable; patients do not come with a manual and have not read the same books we have. An identical anaesthetic ‘recipe’ will kill some patients yet barely affect others.

The aircraft is standard. Regularly maintained, with any fault being immediately repaired before flying. When serious faults are discovered, the aircraft is withdrawn from service while it is investigated and all other planes are grounded and checked for the same problem. Air travel is not a life saving procedure. No pilot takes the faulty plane, full of passengers, low on fuel, into a storm without navigation, to investigate and fix the problem at 30,000 feet, do they? Of course not, but this is a much closer representation of the challenge of emergency surgery.

I would concede pilots must ‘first do no harm’, particularly  as their ‘patients’ are all well and off on their holidays, but there the similarity ends.

If pilots want to compare flying and medicine, I suggest they use anaesthetic machines for their analogy. They need to be switched on and started up, if you’re very lucky they will all be the same in your theatre suite, they are maintained and checked each day. We would not consider using a machine with a fault until it is fixed and undergone its safety checks successfully.

Despite the increasingly digitalised new machines, human beings are still more complex than any hard drive.

And please, do not ask me about my weekend on call which culminated in being stranded on a remote Hebridean Island, with a head injured, intubated and ventilated patient while the pilots checked into a B&B for a meal, a couple of drinks and a sleep until morning because they had reached the limit of their flying time that day and required a rest.

Waiting without so much as a toothbrush, the only flying I did was off the handle.

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6 Responses to “Please stop saying medicine is like flying a plane”

  1. Skepticalscalpel says:

    Great post. I could not agree more. I have blogged about this myself on 4 occasions.

  2. Patrick says:

    The problem is getting the balance between ridiculous comparisons between clinical activity and flying AND the need for some sort of scrutiny on what we do in our various work. In our – quite large – hospital, watching what actually happens in an operating room has been salutary. Who watches and how that is interpreted is another issue. But your point is well made. It’s clear the author of the quote that stimulated your comment had a vested commercial interest – just like the pilots!

  3. Jerry Heneghan says:

    Hi Caroline,

    I stand by what I said. Simulation… Is needed for professional education and training when the stakes are high, lives are at risk and failure is not an option… Do you agree?

    Factual Information:

    Leading causes of death in the United States: (in order)
    • Heart Disease
    • Cancer
    • Preventable Medical Errors

    The Journal of Patient Safety: Up to 440,000 Americans are dying annually from preventable medical errors…

    …‘We are burying a population the size of Miami every year from medical errors that can be prevented’…

    A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care James, John T. PhD Journal of Patient Safety, Sept. 2013, Volume 9- Issue 3, p 122-128,_Evidence_based_Estimate_of_Patient_Harms.2.aspx

    Clearly, the status quo is not working… Patients deserve much better… Incompetence, poor proficiency, ineffective team communication, and failure to follow established protocols may result in the same needless tragedy (death), whether in a cockpit or in a clinical setting…

    The skills which can be enhanced with the use of simulation include:
    – Technical and functional expertise training
    – Problem solving and decision-making skills
    – Interpersonal and communications skills or team based competencies

    …’Despite the increasingly digitalised new machines, human beings are still more complex than any hard drive’…

    Check out It’s free,open source software… a baby step in the direction of achieving a virtual physiological human for education, training and research. Big Data is coming to healthcare whether we like it or not.

    I’ll be at IMSH in New Orleans in January. I’d be happy to engage in a thorough discussion about this over a friendly beverage

    Hope to see you there!

  4. caroline says:

    Hi Jerry, thanks for commenting. I agree, healthy debate is good. Sadly my employer will not stretch to transatlantic travel for healthy beverages!

    I use simulation a lot in teaching undergraduates and post graduates. The major down fall of our most sophisticated wireless simman is that he never looks unwell. He never looks grey, red, blue, pale, sweaty, flushed, clammy, full and bounding or peripherally shut down. He never feels warm or cold. So while many of the non technical skills you mention can be practiced, training in clinical and diagnostic acumen is limited by this lack of realism. Sick patients look sick and simman does not.

    The main benefit we find is using simulation in situ, in various workplaces which uncovers many latent errors.

    Regarding your opinion, might I suggest you have a wee conflict of interest…

  5. Patrick says:

    We use simulation as well but as Caroline states it has limitations. I train surgeons in elective surgery and the process is – an assessment of prior knowledge, performance on a relatively inexpensive simulation model and then a supervised and staged instruction on a real patient. I think this little scenario describes the place of simulation quite well. I do not dismiss simulation but I support Caroline’s contention that management of a critically ill patient is in no way comparable to flying aircraft. In another life I was a pilot so I do appreciate the difference more readily. Would love to come to New Orleans in January but already booked for something. I am submitting an abstract for AMEE in Glasgow next year maybe we can all catch up then.

  6. TooMuchMethinks says:

    Surgeon Atul Gawawande presents a compelling argument that supports Jerry Heneghan’s assertion. Doctors often struggle with accountability to which others, by nature of their professional expectations, are willing to submit.

    See also, Normal Accidents, by Charles Perrow.

    Caroline’s argument can be viewed as “My job is harder than your job, therefore any simulation or simplification of the inherent complexities of my job is of little value.”

    If there are procedures and best practices in medicine, a simulation can be useful. To misquote Hugh Laurie – not a doctor, but he played one on TV – “If you hear hoofbeats think horses not zebras.”

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