Thursday, January 3, 2013


"When sages commend excess, desire is sick!"
I came across an erudite article from a very polished source the other day. His premise was that too much information could expose physicians to a higher chance of malpractice litigation risk. (Dr. Wes Fisher is an interventional cardiologist and blogs at “Dr. Wes”)

So I asked the question, why would more information enhance such a risk? Why indeed?

His arguments in the article, here are well balanced and true. He argues from the perspective of the Electronic Medical Records where “Clicking” and accepting someone else’s (a nurse, NP, PA, another physician’s and even the hospital’s) statements/recommendations get “auto-ordered,” much like the “pneumovax vaccine assuring the hospital excellent public reporting metrics.” He argues that given the time constraints in a “multidirectional electronic communication” medical environment and the “avalanche of items,” the doctor has to spend extraordinary amount of time, completing the medical record and in haste or another competing medical emergency, may click and accept responsibility of another’s action, that might expose him to liability. All that is self evident and true because the legal eagles love the retrospective review.

In the medical world where minutes are measured in hours and hours in days, compacting the flow of information and action in a non-discriminatory digital throughput has the physician on the wrong side of the microscope.

So what of this?

To further delve into this information overload conundrum, I turned to aviation. Why aviation, you might ask? Well if you have been following the quasi-medical chronicles by the medical and non-medical sages of today, there is an emotionally satisfying appeal in equating pilots to doctors. Some less informed but clever writers, even state bluntly, “If pilots worked like doctors, the sky would rain planes” can be found here:

The view from those eyes, fails to take into consideration a lot of issues inherent in medicine and for that matter in aviation skills. The skill set and knowledge base are fundamentally different as is the format of knowledge acquisition and the required training.  

Even though certain correlations do exist as they would in any scientific, engineering, electronic or mechanical discipline, where an epistemological rigor is present, but not the kind being bandied about recently. Human lives are at stake in medicine when disease manifests, unlike in aviation or for that matter in driving a bus or even a car, where mechanical standards apply. The desire to integrate such disparate disciplines harbors within the lack of real knowledge about the multiple co-morbid states in human beings. A mechanical aircraft cannot equate to the lub-dub of the beating human heart. A person undergoing surgery for a gall bladder may have issues related to stress-hyperglycemia, which might expose him or her to a higher risk of infection, a minimally weak heart that might go into heart failure from the surgical intervention, a weakened immunity from a undiagnosed viral agent, anesthetic stress or an allergic reaction to an anesthetic agent. These are contributing factors to unquantifiable risks that before hand cannot be mitigated a 100% (much as "experts" would claim they can and we should). Once the hazards are determined, the events are addressed by the physicians and mitigated accordingly. One can only be cognizant and alert to known hazards. Additionally, help is always nearby. In difficult medical cases, where other physicians are called in to impart their expertise and provide help.

In driving a car the driver is ignorant of a loose brake-pedal screw (unless he checks for it before each drive), a faulty torque tube or an electronic sensor that sends imperfect fuel information signals (slapping and kicking may cause it to flicker the right signal only some of the times). Unless the driver examines the car with X-Rays for every fatigued metal before each use, malfunctions can and do occur anytime with failures, leading to accidents. The driver’s skills might save the day in some circumstance but not all. And thus a roadside calamity would not be for the lack of experience, but chance. It is true that there is a 0.43 risk of fatality per 100,000 hours of flying while the risk in driving is 20.3 risk of death per 100,000 hours of driving, one cannot equate these events to those in medicine. Where the two have in common is the surplus of unwarranted information that can color the circumstance and prove hazardous. Where they diverge, well... Medicine like all others, is not a perfect science, but this provocative unorthodoxy of combining disparate disciplines of aviation recurrent training and medical re-certification to reduce risks is without merit and is done mostly to reap personal gains and polish a vanity that is in search of a mirror.

Let me explain further.

In aviation, the pilot peruses the checklist before each flight (A similar “time-out” is now an accepted format prior to surgery to prevent errant intervention). You might have seen the pilot walk around a Boeing or an Airbus; you are seated in, looking at the wings and the gear as he eyeballs information during his walk around. A similar evaluation is accomplished by the surgeon before surgery. He then spends several minutes in the cockpit reviewing his checklist. Even then there are circumstances of fuel contamination, metal fatigue, autopilot failure due to a faulty resistor, electrical fire due to shorting, loss of hydraulics, engine flameout, gear retraction or extension failure and a whole host of things that can cut a flight short. The pilot and his/her co-pilot address these issues during such a malfunction, additional help can be had for the pilot, from the Air Traffic Control by patching his call to his company’s service center with issues that may not be detailed in the Pilot Operating handbook (POH).

In medicine most physicians review new information about complicated cases and are adept at regaling themselves with the newer fund of knowledge to better care for their patients. After all, a requirement of 50 hours Continuing Medical Education is a prerequisite for maintenance of license to practice across the United States! Whereas in aviation it is the eye-hand coordination in flight review and responses to simulated emergencies, in medicine a re-certification examination is a learning by rote of esoteric conditions that one rarely encounters. Speaking of conditions, I have as yet to see a case of "Acinic Cell Carcinoma" that had a total of 5 questions in the last re-certifying board examination in Medical Oncology. If I was confronted with such a diagnosis, there is plenty of literature to educate me. Having answered those questions correctly, I do not recall the answers today, since the "rut" in brain is formed by the daily adventures. The kind of information requested in these Certification examination is mostly unusable trivia that takes hours of study with no benefit to the patient. 

While medicine deals with the anatomy, physiology and pathology of another human, aviation is a human determining the functionality of a mechanical airplane, thus medicine is not and cannot be reduced to a context-independent, deterministic set of mathematical terms. This disputatious relationship that many are eager to combine in their theoretical soup, fails to undergo the rigors of reason. Ilya Prigogine’s “End of Certainty” suggested that the human rationale exists in the spectrum from “Becoming to Being” through the acts of reason. Unfortunately reason is the least common denominator in the current day of “being!” We marvel at a process and then try to merge diverse and opposing concepts under the conceit of intellectual bias. After all John Dryden’s “noble savage” that later became Rousseau’s “natural man” was gifted with an innate goodness that with “reason” transformed society into the “Social Contract” for humanity's civil existence. The Social Contract was not one designed by the selfish desires of self-aggrandizement. But by logic, reason and intuit.

However much we are enamored by the glitz and glamour of aviation safety, there exist significant problems in this glorified discipline also, even though they might be hidden from the non-discerning eyes that proclaim its grand vision. For instance, getting back to the original premise, information overload is one of them. Too much information is a calamity for both physicians and for pilots. Unnecessary data fed to pilots confuses the mind. (The taoists wisely suggest that one cannot fill a glass that is already full). During an emergency, a pilot is trained to feed his brain with the following: “Aviate, Navigate and Communicate” in that order. In the aviate portion, a pilot has to discern the flaw that has culminated in the system malfunction and try to eliminate it and if not, then find alternate methods to circumvent the occurrence. Early recognition leads to early elimination and possible prevention of a catastrophe. Early recognition comes from experience and knowledge. Only after the “aviate” portion has been accomplished, that is to say the plane is not allowed to depart the flight envelope, should the pilot “navigate” and consider looking for a place to land and once that is accomplished then “Communicate” with the Air Traffic Controller, declare an emergency and seek additional help, if needed. These three words have saved countless lives! A simplified directive!

Too much information at the wrong phase of flight can lead to disaster. On takeoff or in the landing phase for instance distractions can have bad consequences. The current Glass Cockpit displays reveal reams of information on a single screen for the pilot and have lead to compromised safety.

“The US National Transportation Safety Board (NTSB) sent out a press release yesterday (2010) saying that it had "adopted a study concluding that single engine airplanes equipped with glass cockpits had no better overall safety record than airplanes with conventional instrumentation."
“The study, which looked at the accident rates of over 8,000 small piston-powered airplanes manufactured between 2002 and 2006, found that those equipped with glass cockpits had a higher fatal accident rate then similar aircraft with conventional instruments.”

It is in the essence of the needed information vs. a plethora of meaningless data, where safety exists, both in medicine and in aviation. It is and would be a meaningless, albeit a wonderful newsworthy splash, by equating aviators with physicians in outcome studies.

Consider this: Pilots undergo recurrent training to verify their abilities in understanding and mitigating emergency situations. They learn about what happens if the aircraft loses hydraulics, or electrical failure, or engine flameouts or avionics malfunction? It is hands on manipulation of the controls in the simulators in aviation training. The pilots have to review and understand their pilot operating handbooks (POH) "specific for each type of aircraft" during the recurrent training and have hands-on experience in the comfort of a simulator where crashes have no consequences but a bruised ego. There are no punitive pass/fail, just time and more time in the simulator. This sharpens their skills in case of an emergency during actual flights. Physicians do the same with daily experience, CMEs and annual seminars and meetings and to boot they have to be cognizant of the many ailments of each organ!

Speaking of critical thinking of a superior mind: the critical thought of Sullenberger in ditching the US Airways flight in the Hudson River was not taught at any recurrent training scenario but as a result of his experience and good decision-making skills. Logic would have made him turn back to LaGuardia Airport or try for Teterboro Airport both within sight, but his sharp skills realized the risks were much greater with loss of vertical component of lift in a turn back for the former and the risk of harm to the populated terrain below in the latter trajectory ~ both might have resulted in loss of life.

Similarly preventing the loss of 185 lives in the United 232  Sioux City Iowa crash in 1989 was the “out of the box” thinking by Captain Al Haynes and not because of any training scenarios in the simulator. He used vectored use of the remaining two engines to control direction of flight and altitude without control surfaces to reach Sioux City. In fact 55 test pilots attempted to do in a simulator what he did in reality given the same circumstances and failed with 100% catastrophe. 55 test pilots!

Meanwhile, the 1977 Tenerife Disaster was blamed on the arrogance of Captain Jacob Veldhuyzen van Zanten of KLM flight 4805 and the Pan Am flight 1736, both aircraft were Boeing 747. The problem here was the Chief Pilot Van Zanten, who had his face on the cover of Time Magazine, as the best-trained pilot who gave fight training and he became the object of arrogance and disobedience of flight rules. 583 people perished as a result. So not all beauty lies in this comparison.

Even though Dr. Wes and others have written about the shadows that linger over medicine with a certain precautionary veil guarding their sentiments, there needs to be an intellectual debate over the plagued blackness that some enshroud the field of medicine. Besides too much information, the wrong kind is being deemed expositive by academic physicians who have long since been out of practice of medicine.

Here, Dr. Wes does not mince any words, “The Punitive Evolution of Board Certification”

The latest salvo against physicians comes from the American Board of Medical Specialties (ABMS) that advocates the need for continuing Maintenance of Certification. Their surrogates use the aviation pretext and state that pilots need recurrent training every six months to maintain their abilities, why not the doctors. these surrogates citing that the six monthly recurrent aviation training leads to safety in aviation, the ABMS wishes to establish a biannual examination to maintain certification, which then can later be tied to maintenance of the license of a physician to practice medicine. This is an unfortunate series of unwarranted comparisons made for financial self-enrichment and self-aggrandizement. While there is no doubt that a pilot loses his or her proficiency when not flying frequently, just like a video game aficionado, it is recommended an airline pilot should undergo six-monthly recurrent training at the designated company’s test centers and a general aviation pilot have a biannual flight review (since the general aviation pilots do not fly for a living) by a certified flight instructor (CFI), equating these recommendations for pilots to that of physicians is equating “apples to oranges.” A surgeon for instance operates almost daily while not so for a pilot. In piloting, it is decision-making and “eye-hand-coordination,” mostly. In medical practice it is not! Surgeons by their very experience and various courses become experts in their expertise and maintain this rigor throughout their careers. Family physicians through current experience and knowledge and their annual CMEs reap the same harvest for their patients. Further adding to the burden on a physician with illogic and lack of evidence based esoteric knowledge, is tantamount to eroding the skills, critical thinking and rational decision-making. Besides as mentioned before, unrelated esoteric information cripples good decision-making.

How many surgeons, pediatricians, family physicians, oncologists, orthopedists and other specialties have saved millions if not billions of lives over the course of human history. One will never know. But most never see the good in anything.

It all comes down to the proper form and amount of information needed to process in any circumstance. And within the rigors of that processing lies the golden rule of “Reason!” The esoteric reveled by the ABMS in their MOC does not save lives, nor does it help improve patient care (All data supports this statement). Delivering excess information through electronic or any means disrupts good patient care and as evidenced by the FAA study mentioned above, good piloting. The implied and forced epistemological rote leveled at the layperson via the uninformed media creates the nuance of “Scientific Rigor,” where none exists! The kidnapping of good medical care continues...

It all boils down to the right information at the right time… And REASON. 

The current art of reductionism will soon have doctors being compared to dish washers and many will pipe in that it is the water, or the spray or the speed of the water flow that needs to be addressed to fix medical care. ~ Reductio Ad Absurdum!!!

Let me leave you with a thought expressed by  Mason Cooley:

"When sages commend excess, desire is sick!" 

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