PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Imagine, you are the pilot of a 747, getting ready to land the plane at LAX (pilot speak for Los Angeles International Airport), your ear phones are strapped on, you are talking to the tower, verifying your landing instructions, going through the check list, lowering the landing gear, adjusting the fuel mixture, and just as you throttle back–

“Excuse me, captain, but the passenger in 12B really needs to go to the bathroom even though the no smoking sign is on.  Is that okay?” 

Pilots have the sterile cockpit–a situation in which, if the plane is below 10,000 feet, only conversation directly relevant to flying is allowed.  The rule was developed because take offs and landings are the most likely time a crash will occur, and take offs and landings occur below 10,000 feet. Simple enough, and it saves lives.

Physicians need a sterile cock pit.  I speak as a hospitalist, but I imagine many specialties would benefit as well.  What are mission critical times during my day? For admissions, I would say writing (or typing!) the H&P is the most critical time, followed by order entry (or order writing.)  For discharges I would say medical reconciliation is the most critical time.  For rounding, I would again say order making followed by the “plan” part of the SOAP note.

Wouldn’t it be nice if we could have a “cone of silence” or sterile cockpit in which we could think and perform these critical functions? Wouldn’t it be nice to have all pages delayed for a set amount of time (say, 20 minutes) until we are through with our critical tasks? (Does such a pager exist?) I’d still be willing to get Code Blue pages, but can’t the other stuff wait?  (Mr. Smith’s constipation for example.)  Nurses at my institution have a “no talk zone” around the pyxis to help decrease medical errors, so why are physicians any different than pilots and nurses?

They aren’t.  It’s a cultural issue.  Page early and often needs to be replaced with “page urgently when appropriate,” and an understanding that physicians need to be able to think uninterrupted to make good decisions and give good patient care.

The November Mayo Clinic Proceedings has a feature article on “Armodafinil for Treatment of Excessive Sleepiness Associated with Shift Work Disorder: A Randomized, Controlled Study.”  The cliff note version: taking armodafinil makes the user more awaken and less likely to fall asleep during shift work, along with improving memory and attention.  (For details go read the article!)  In an accompanying editorial, Dr. Steven Rose wonders if such drugs should be used by resident physicians  He sites a push from the Institute of Medicine to further limit resident work hours, and examines the usefulness of a drug like armodafinil in residents.

Yuck.

Health care workers and “social service” workers represent the largest percentage of night shift workers in the United States.  They have higher rates of car crashes, depression and cardiovascular events than their day time counterparts.  What does the American pharmaceutical market, and by extension, the health care industry do?

Tell it’s workers to take drugs to “enhance performance”!  Mark McGuire are you listening?  You should have been a physician, where you would have been lauded as a test subject extraordinaire!

I’m going to be blunt here–this is totally screwed up!  Instead of figuring out ways to help residents, and all of us that work grave yard shifts,get more rest, and decrease the AMOUNT of shift workers needed, we are told to take drugs so we can stay awake longer on the job, and not crash our cars on the way home!  Dr. Rose points to the example of fighter pilots who are rigorously counselled and examined when they use armodafinil on long missions.  Do you think residents, and “nocturnists” will be counselled and followed clinically if they take armodafinil?  Heck no!

What example does this set? Just go ahead and take a pill to stay awake, another pill to sleep, another pill not to be depressed, another pill to have sex!

Pathetic! Let’s look for ways to use fewer night time workers, such as 4 hour shifts, automation, etc.  Let’s not create a bunch of pill popping physicians forced to do so because they are residents, or hospitalists, or ED MDs.  The last thing we need is a bunch of pill popping docs!

Note: at the time of this posting the online version of the Proceedings didn’t include the November issue.  Look for it in your mail.

Readers who follow this blog probably know that my husband is a pilot, and that we fly around in his small plane.  He avidly follows up on plane crashes, near misses and other hazards of general aviation.  Along the way I have learned a lot about aviation that can be applied to medicine.  Hubby tore out an article from the June AOPA (Aircraft Owners and Pilots Association) magazine and insisted I read it.  It was titled, “The Aviation Safety Reporting Program.”

His point: physicians need an agency to which we can report “near misses.”  General Aviation has the Aviation Safety Reporting Program, which allows pilots to anonymously report flying “incidents.”  The pilot is then granted immunity from loss of pilot’s certificate provided the violation was inadvertent, not deliberate, and didn’t result in an accident.  The FAA investigates the incidents and looks for systems problems. After analysis, the FAA issues ‘alerts’ and guidelines in attempt to correct the problem.

Heath care would benefit. If physicians could report freely, with out penalty, the mishaps that occur through the day, and report them in a standardized fashion, much progress could be made.  Systems errors could be analyzed and corrected.  This would require lots of reporting to make a robust data base, but having an unbiased investigator and the “no penalty” aspect would encourage reporting.  From that data base much would be gleaned about recognizing and preventing mistakes that occur from systems errors.

We have learned a lot from aviation–read backs and checklists are great examples.  We should also learn how to meticulously analyze our own near misses and crashes so they don’t happen again.  We need an entity similar to the Aviation Safety Reporting Program.  Perhaps the “Medical Safety Reporting Program?”

For interest, check out the safety blog, which details  JFK Junior’s fatal crash in to the waters of Cape Cod.