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Healthcare, aviation and the clinicians’ revolution

Martin Bromiley
Martin Bromiley
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Many of you will have seen the recent BMJ article asking if there were any further lessons to be learnt from aviation for healthcare. My immediate response was that the question is less relevant than it first appears: the real issue is whether healthcare is ready to learn lessons from any safety critical industry, especially about safety and human factors.

Last year I spoke at a workshop with the Medical Protection Society. One of my fellow speakers, a softly spoken Australian doctor with an Irish family background made this observation: ‘In the old days in Ireland if you wanted to be closer to God there were three professions: a priest, a teacher or a doctor. And the healthcare system still thinks of itself as one of those ‘institutions’. It needs to shift its thinking… to think like nuclear, rail, aviation or other such safety critical industries.’ 

Pilots can offer a unique perspective on the development of safer systems. I believe this is currently especially valuable and relevant to areas such as revalidation and the increasing use of simulation (where the training of skilled ‘notechs’ – non technical skills – observers is particularly crucial to get the most from the simulation or any feedback opportunity). But I also think the time has come for the modern, safety and human factor aware clinician to take the lead.

Let me explain. It seems true that clinicians love hearing flying stories – they like the tales of disasters and how we’ve made flying safer. However, last year I met a pilot who strongly disagreed with this. He’d done a lot of work with clinicians in the US and his experience was opposite to mine.

It got me thinking and then I reached one of those eureka moments: the reason clinicians like hearing pilots speak is that while many can identify strong lessons with their work, it doesn’t threaten them. Pilots can inspire, but if they say ‘This is how you should do it’ then the audience can walk away at the end saying ‘Of course, it doesn’t work like that in my hospital!’

But if a fellow clinician stands up and says ‘This is how I’ve made my practice safer for me and my team’ then it’s very different. Suddenly some of the audience feel excited (if not a little concerned) and others feel threatened because it questions basic assumptions, training and practice. Often the more observant can sense a new way of doing things, but if only the old school would listen!   

A nurse colleague of mine was teaching a group of Foundation stage doctors last week. She commented that they were really demoralised when she met them, because they’d learnt all about safer systems such as the WHO Safer Surgery Checklist (which, as we know, is used properly and consistently in every hospital in the land – yeah right!) and then, when they got into their work placements, they faced comments such as ‘We don’t do that here’. 

So much for evidence-based medicine then.

When I first got involved in patient safety I massively underestimated the complexity of healthcare – I too thought it was just like aviation. If you want to make a change you just ‘regulate’ it and everybody, after a while, does it because life’s much easier with a job!

But I learnt there is one massive difference between healthcare in the UK and aviation. Pilots have grown up with a military-style command and control ethos. However, the inertia and complexity of healthcare have created an autonomy that makes it hard for simple policies and regulation to influence. I realised a while back that to make real, lasting change in healthcare requires the clinicians to want it, while at the same time the organisation creates regulations that target the managers to provide the fertile ground for safe practice to flourish.

I recently spoke at Whittington Hospital in London in a joint session with Mark, an orthopaedic surgeon from Leeds. He’s an example of what healthcare needs more than ever, someone who has learnt how to integrate safer practice and systems thinking into his lists – and it works.

I spoke first, about my late wife’s story and some lessons from aviation, and Mark followed straight on talking about his practice, the evidence, and challenging the audience to think about what professionalism really means in this age where we now understand what can make healthcare safer.

Normally, on any panel, the bulk of the questions at the end of the session come to me, but everyone wanted to ask Mark about what he’d said. And it felt good, really good, because at last here was an audience who felt someone who spoke their language had found a way to ‘do it better’ and they could learn from it. This was the best example I’ve ever witnessed of clinical engagement or clinical leadership in action.

You’re entering a new age of clinical practice, one in which safety is built into systems and ways of working that take account of human performance variability and human error. It’s probably going to be the best time in history to be a clinician because you’ll be making history. 

Maybe the light at the end of the tunnel is you?

Martin is the founder and current Chair of the Clinical Human Factors Group.





 
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Comments
There is an important distiction between aviation and medicine: as a pilot, if I screw up I am the one that dies. That does focus the mind!
Whilst this is an important distinction, we should not underestimate the very significant impact of serious error and harm on the professionals involved.

Over the past two years I have had many honest and direct conversations with clinicians and practitioners about their involvement in "harm events" (either directly or as part of teams) which has left me in no doubt whatsoever about the longer term effects.

This is a rarely discussed issue which in my view, is often avoided. Discussing error is a complex issue which touches on issues associated with the management of "face", professional confidence and identity (as Martin Bromiley clearly describes above) and most healthcare organisations are ill-equipped to deal with the implications of having those discussions.

I strongly feel that it is time for every hospital to engage in teaching human factors to improve patient safety and intergrate regular simulation based training to practice difficult airway management.
We have certainly commenced this at the Lister hospital, since learning about Elaine in in 2006 and the health care should greatly benefit from Martin Bromley's useful initiatives.
just a note on Martin Grundy's comment... I am a pilot and if I screw up 385 other people also die.....

The big issue for me is one of human nature, it will probably take a few generations of wise and unwise clinicians to pass by before the generation following take Human factors at its real face value....its one of control, discipline and common sense and undertsanding why people fail to perform fully. Its the teaching today at teaching hospitals that needs to work to ensure the future surgeons address this subject properly without second thought. That doesnt mean we have to stop pushing forward today...if some surgeons change then lives will be saved and near misses avoided.
Dear Martin,
I would just like to share with you the work that we have been doing in our Trust with community midwives, independent midwives and paramedics. We facilitate obstetric emergencies skills training outside of hospital, usually in one of the faciltators homes. Our focus is on team working, communication and leadership and inter-professional roles in dealing with such obstetric emergencies. We recently attended a training session delivered by one of the anaesthetists at the Montagu simulation centre at Doncaster and Bassettlaw and were shown the video on human factors that you developed. Since then we have included your video in our training sessions and discuss aspects of human factors and situational awareness with participants. Yesterday we presented our training initiative to attendees at the Primary Care conference at the NEC in Birmingham and included your video. There was stunned silence in the conference hall followed by a round of applause. A crowd approached us afterwards asking where they could access more information about human factors and access to the video. We signposted them to the website for more information. What I would like you to know is that although we recognise your profound loss of Elaine due to this enormously tragic event, your wish that healthcare professionals learn lessons from this is starting to materialise and be recognised as an area for immediate attention.
With kindest regards and best wishes to your family
Caroline Booth, Helen Hall & Tina Mori - Midwives at Bradford Teaching Hospitals NHS Foundation Trust
Martin. Your moving story is used by our team at Northumbria University to enhance our message about the importance of patient safety. It never fails to move students and the message is powerful because it helps put into context the factual information and evidence we present. Your message is being heard and disseminated. Best wishes.
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