Comparing airline industry & health care is fallacious, an oversimplification; apples to musk-melons



The issue of patient safety has been gaining increased traction year on year and the issue is in right direction.  Hospitals, doctors and administration need to vigorously address shortcomings and strive toward minimum errors and desired goals of safety.   Patient safety is of paramount importance; therefore it is an serious issue. It should be achieved by good ground work and not by sensationalizing and mischaracterizing the real basic issues, transparent safety culture, adequate number of staff and resources.

There is a recurrent old argument and temptation to ask about why healthcare can’t be as safe as airline travel.   There can be many apt comparisons that may be possible between aviation and health care especially taking into account the risk involved. But the doctors who treat critical emergencies,  have  insight looking at life and death situations directly,  know  that comparing both would be just an oversimplification of the real basic issues.

  At most of the points, the comparison is a complete fallacy; and like comparing apples to musk-melons.

It is beyond doubt that air-industry maintains truly an impressive system which is well-designed to achieve the safety results that it does.  But , the kind of  comparison  that  some health care safety leaders make in which they compare the  mortality data of acute hospital care and airline fatal accident rates is more of a word play and not so appropriate. This comparison is dangerous because it misses the key points for improvement. Such comparisons  merely present over-simplified and convenient tool for the health quality experts, who themselves have never been a front line health workers at any point of time, but still pretend to pioneer the  quality in health industry.  For the quality improvement the leaders need to be grounded in the reality of emergency front line medicine to be really effective.

  1. Aircrafts  are engineered to be in the best possible shape before they fly. Patients, on the other hand, patients  are in the worst shape when they enter the emergency of the hospital.

Medicine is by nature, a much more risky work than flying along with vulnerability to death always.

  1. The aircrafts are required to regularly demonstrate that the performance of their critical systems meets or exceeds strict standards. If systems are not operating well the plane will not be allowed to fly.

But all the patients, (aeroplane metaphor) are already sick; doctors are expected to fly such aeroplanes, who are in crashed condition universally. Doctors do not have the luxury to replace any part.  For example, when doctors treat an elderly with heart failure, chronic kidney failure and pneumonia, they try to keep them “flying” despite multiple sub optimally functioning critical systems.

  1.  In other words, doctors have to fly crashed planes always on every day basis, something that never happens even once in aviation industry.
  2. Has any Pilot ever tried to fly  a plane in which engine power is only 25 percent of normal with  other systems are functioning  sub optimally  and  the fuel tank is leaking?  What will be standard procedure (SOP)  for Pilot to fly this plane? But everyday doctors try to fly such planes and they have to fly it no matter how many systems are non-functional.  Moreover, doctors can be sued on some flimsy grounds in case they fail or an accident happens in an effort to keep this plane in the air.  Treating a critical illness is like an effort to keep such planes in air with suboptimal functioning systems.

Obviously the comparison is a bit overzealous.

  1.   What would be chances that a fully checked plane with a trained pilot will crash after flight takes off. Now compare the chances of patient who lands in emergency, and treatment is started.

By a simple common sense, are two situations comparable?

Former has no chance (almost Zero percent) of crash whereas in a critical emergency patient, the chances of crash are 100 % to start with.

  1. Communication of passengers to the pilot about what he should do and what he should not while flying the plane is nil. Whereas doctors are continuously bombarded with google knowledge of patients and interference by relatives and questioned about every action.
  2.   Doctors are expected to make future prediction about what can happen, how he will be able to keep the crashed plane in the air and take consent, based on few assumptions. Doctors can be harassed and dragged to courts if such predictions fail.
  3. Airlines will always have full staff to serve promptly during a flight. The pilot will be totally dedicated to flying the plane, and will not fly without the co-pilot and crew. On the other hand, front line healthcare workers know it well the fact that patient safety incidents and errors tend to occur when they are struggling with staffing levels and feel grossly overworked.

Fatigue and overwork is too common scenario among front line healthcare staff in clinical settings.

  1. A pilot is also only ever going to fly one plane at a time. It is not realistic for a doctor or nurse to be allocated to just one patient, but the workflow is very different, with healthcare tasks frequently interrupted with new clinical issues and emergency situations. Consequently, insufficient staffing can have an acute effect on outcomes and the ability to perform safely.
  2. Aviation industry is too predictable and on the contrary, health care is combination of uncountable unpredictable risk factors, be it allocation of staff or risk of death or resource prediction and complexity of communication.
  3. Aviation is more of mechanical milieu, whereas health care deals with emotion and compassion. The two industries are vastly heterogeneous, and to say that safety in medicine should follow in the path of flying airplanes, grossly oversimplifies a complex problem.
  4.    Last but not the least; health care involves lot of financial uncertainties and arrangements. Needless to say, doctors carry the blame for financial hardship of the patients, even if they are not responsible for costs. The mammoth industry remains hidden and doctors are blamed as they are the only front man visible.
  5. Basic difference lies in the fact that patients are real living people, whereas airplanes are simply machines, whose codes and protocols are well defined and limited to within human capabilities. The importance of human contact, empathy, compassion, interact and listen to concerns, and the ability to spend adequate time with patients,  should be  always be the first pillar of promoting a culture of safety.
  6.   Exhortations by armchair preachers to learn oversimplified improvement examples from aviation can provoke considerable frustration and skepticism among clinicians exposed to the unique challenges, difficult working conditions and everyday complexities.  Patients are not aeroplanes, and hospitals are not production lines.

Most unfortunate part is the assumption that every sick person who dies in a hospital from an adverse event is an example of a truly preventable death rather than clinicians trying their best to keep someone alive and eventually failing.

  1.  Checklists and documentation to improve systems are wonderful in mechanical areas like operative care and inserting central lines, but have limited role and can only go so far without the most important virtues of being a doctor or nurse. It means more than mechanically following protocols and doing paper work in real sense.

In health care merely providing check list and doing extra- paper work may be counterproductive for many reasons.  Increase in time for voluminous documentations will consume time and forces health care workers to focus on paper work and takes them away from patient’s real issues.

Completed paper work and excessive documentation provides a false assurance of quality work, which may or may not reflect true picture of patient care. Even after full documentation,  still  it will be required  to be carried out in a diligent manner, a  task which is different from mechanical  task of mere check list  of other  industries . Learning from other industries seems to offer a simple shortcut to anyone trying to improve healthcare, but its utility is limited only for documentation purposes and not real quality. Caring for patients is radically different from flying aeroplanes. Healthcare is unique in the intimacy, complexity, and sensitivity of the services it provides as well as the trust, compassion, and empathy that underpin it.

Merely completing protocols mechanically and excessive documentation will result in decline in quality actually.  Simply importing and applying a ready-made tool will lead to situation, where quality will exist only on papers and merely  reduced to a number to the satisfaction of so called ‘pioneers’ of quality.

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The  Myth  of  cost of  spending  on  medical  education needs to be made  transparent.

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