“…just two guys in a box” – Really?

by Suzanne Gordon & Patrick Mendenhall

As we have gone around the country discussing our book Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety, we have been struck by the number of people who insist that healthcare has little to learn from aviation because the two enterprises are entirely different. Critics suggest that healthcare is far more complex than aviation. One physician in charge of simulation at a large medical school blithely opined that really “in aviation, it’s just two guys in a box.” Another physician insisted that “…flying a 747 is really no different than flying a Cessna.” On further inquiry, we learned that he had done neither. Even many who are somewhat sympathetic to our message believe that healthcare and aviation have little in common.

This idea has likely taken root because people do not understand the complexity of the global system of aviation safety in which each individual flight is embedded. People think of an airplane flight as an individual, discrete entity: Plane takes off, plane lands. Just two guys in the box get it off the ground and back on the ground, and with remarkably few glitches – this happens day in and day out. This idea is reinforced each time we look up at the sky and see this vast expanse of blue (or gray if you live in Seattle as Patrick does) with maybe the odd airplane skimming the horizon. What the individual standing on the ground does not see are the many, many airplanes that are up in the sky at 28,000 to 60,000 feet, all of which function in the same kind of interconnected system that patients in a hospital or other complex facility depend on.

For a little perspective on what is really going on “up there”, take a look at this YouTube video that shows you what is going on beyond your view in the so-called friendly skies:

Typical Airway Chart

Let’s say you are in San Francisco or Seattle, or New York or London. At any given time, there may be hundreds – even thousands – of aircraft above you beyond your view. At many major airports, for most of the day a flight departs or arrives nearly every minute. The sky is mapped out in interconnecting “airways” – highways in the sky – that pilots must navigate and monitor with extreme precision in three dimensions to avoid conflicts (two or more aircraft occupying the same space at the same time). To fly safely, requires continuous coordination and cooperation between other aircraft, air traffic controllers and internal resources that include cabin crew, ground support, company dispatch and maintenance.
Add to all of this complexity, the variables of weather – which can affect the entire air traffic control system in a particular region – or even an entire hemisphere as in the case of the Eyjafjallajökull volcano in Iceland in 2010.

Eyjafjallajökull Volcano Ash Cloud

In our book, we wrote that we think the kind of one-upmanship which pits healthcare and aviation against one another – insisting that one is potentially more lethal or more complex than the other — is ultimately unproductive and prevents people from learning needed lessons from each. As we put it in the introduction:

To focus only on the differences between the two endeavors, however, is to ignore the very important structural similarities that make the CRM model a useful and readily adaptable foundation for beneficial change in health care. No one can prove who experiences more job stress or complex responsibility, and in the end this is a spurious debate.

It’s a pretty safe bet that when Captain Sullenberger was landing his plane in the Hudson, he was not thinking, “Oh this could be so much worse: I could be a neurosurgeon!” Nor would we think that a physician rapidly managing all of the medications, actions, personnel, and supports needed to rally a “crashing” patient is thanking her lucky stars that she’s not an airline pilot. The pilot needs to deliver his or her passengers safely to their destination, and the surgeon must deliver his or her patient to wellness. If one industry can benefit from the experience of the other and reduce errors and thus enhance safety, why wouldn’t it try?

The real question is: How can the responsible parties in any industry or organization best function to protect those who depend on their skills and professional judgment for survival? We can learn from best practices and relevant models wherever and whenever they are developed and then adapt them to different set- tings in which they may be useful. What is paramount is how an institution—or, in the case of CRM, an entire global industry—learned to change for the better and for the safer and how it has sustained change over time. What did the airline industry do concretely to transform workplace relationships and create a different model of workplace hierarchy and teamwork? How did it confront power and status differentials and learn to help people speak up about safety without fear of reprisal? What strategies and tactics did it utilize, what obstacles did it confront and overcome, and what values and practices did it change—and how? We also believe that, in spite of the differences between healthcare and aviation, the principles of CRM—learning to communicate more effectively, learning to lead a team and work effectively on a team, as well as learning to manage stressful workloads and anticipate a variety of threats to safety, as well as to prevent, manage or contain error—are crucial in healthcare and can and should be taught to and learned by all who care for the sick and vulnerable.”

We think you’ll appreciate this argument even more if you consider the complexity of what happens up there while you are down here. Or what happens up there to get you back down here safely. Aviation, with all its system complexity managed to transform a toxic and dysfunctional culture over thirty years ago. We believe, as healthcare acknowledges its own similarities to where aviation was, those lessons can be similarly and very effectively applied.