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Flying Physicians Part II

we left on the discussion last month trying to figure out why doctors, and other high achievers, took crazy and dangerous risks in their airplanes leading to a series of fatal accidents 

Thanks to all of you who have weighed in, and also to my flying doctor friends, for your thoughts. One thing you all agreed on is that the answer to the question is pretty complicated. I got a couple of responses from high achievers who said that their cockpit skills apply in a number of different professions and have made them better at what they do. A couple of my flying doctor friends said that being a pilot has made them better doctors and surgeons. I totally agree with that and have spent a major part of my academic surgery life teaching operating room and patient safety to my residents based on cockpit safety skills. Studies I’ve done have found real improvements in patient outcomes in a critical care environment utilizing patient safety skills with this cockpit-based curriculum. I’ve written and published these results in surgery textbooks and peer-reviewed literature.

I have also noticed that many flying docs, generally, have taken their pilot safety skills into medical practice and were early adopters of patient safety initiatives like pre-procedure time-outs and checklists. I would no sooner take off in my airplane than start a complex operation without “running the checklist.” Many pilot-docs believed from the start that the now mandatory pre-procedure time-out was no different from our standard pre-flight aircraft inspections. No safe pilot would consider taking off into the clouds without dipping into the fuel tanks any more than a safe surgeon would embark on an operation on the left knee without confirming it was the correct patient and the correct side. Neither would a safe pilot take a long flight through potential weather hazards without a plan B, C, and even a plan D. That’s no different from doing a complicated surgical procedure without planning for multiple options to see the patient through to a successful outcome. But the question remains, why do some high achievers and docs not take these lessons with them into the cockpit?

One factor kicked around in the discussions has to do with confidence, warranted or not, and its evil doppelganger, overconfidence and hubris. Certainly self-confidence is a necessary characteristic high-achieving individuals need to get to where they are and stay at the top of their game. But managing that confidence in the airplane is a huge safety issue that we’ve talked about in a previous post on this site. I quoted from a great article on the subject in one of the psychology journals about being overconfident but clueless and unaware of it. This article and the one I wrote here in the AOPA space are based on something psychologists call the “Dunning-Kruger effect.” Dunning and Kruger came up with a fascinating theory that the knowledge and intelligence required to be good at a task are often the same qualities needed to recognize the opposite, that you’re not good at that task. Therein lies the danger. Someone who lacks the knowledge, intelligence, and introspection to properly assess their own skills is totally ignorant that they’re just not good at that task. Dunning and Kruger’s data shows that this lack of insight leads operators in a number of high-risk occupations to take risks beyond their skill level. They directly addressed that evil doppelganger, overconfidence and blatant hubris, by explaining that the incompetent are “filled with inappropriate confidence that feels to them like knowledge.” Mistaking confidence for knowledge is one of the fatal judgment flaws that led to the series of accidents we talked about last month.

Expanding on this theory that I’ve heard in the feedback to the article is that these bad judgments and bad habits permeate everything someone does on the ground as well as up in the sky.  A good friend of mine who has worked incredibly hard to become a senior vice president in one of the nation’s leading banks told me that he has to guard against this same kind of overconfidence in investing skills that leads to questionable, even illegal, speculation in his staff of investment advisors. He related a story about one of his subordinates whom clients accused of misappropriating their investment funds and who eventually went to jail for his illegal financial schemes. He ultimately killed himself in a high-speed auto accident out of control in a track-racing car he was not qualified to drive. This guy made bad calls all around and ended his professional career and ultimately his life. The FAA appears to agree that bad decisions on the ground carry over to bad decisions in the cockpit. FAR 14 C.F.R. § 61.15(e) requires part 61 certificate holders to send a written report to the FAA within 60 days of any drug and/or alcohol-related motor vehicle accident or citation. In the politically correct language of the FAA, these are referred to as “notification letters.”

A really good friend of mine is an ATP, CFII, and high time turbine pilot. In addition, he’s an awesome orthopedic surgeon who does really complex spine surgery with multiple steps and huge instrument trays and raised an interesting question. If high-risk-taking bad pilots are also high-risk-taking bad doctors, we might be able to confirm it by checking if high achievers who have had accidents or docs who crashed their airplanes have had their license revoked for bad outcomes or an inordinate number of malpractice cases against them. It’s a great idea but not something you can figure out from NTSB statistics. Pilot-doctor crashes seem to get a lot of publicity so there are plenty of anecdotal examples of both bad doctors and bad pilots who kill themselves in the air. A quick search comes up with a bunch of hits like this doc who died over the Gulf of Mexico and also had a litany of surgical deaths and bad clinical outcomes. It got so bad that his state medical licensing board banned him from the practice of medicine. Another social media sensation is this doc with an allegedly sordid personal background and multiple malpractice cases who died when the hand-built airplane he was flying fell apart mid-flight and crashed. Preliminary findings indicate, “The wings of the aircraft became detached from the fuselage and fell to the ground.” Again, not proof, but these kinds of incidents support my friend’s observations that there’s an overall behavior pattern that applies to everything some of these docs do. If a professional individual behaves with overconfidence and lack of insight, they can’t seem to leave that on the ground and it’s certain that the consequences are going to be more devastating in an airplane.

George Carlin had an old joke asking, “Why do doctors only get a license to practice medicine?” I guess somehow he thought this might be funny, but I don’t take it that way. It reminds me of an admonition from my old CFI who constantly gave me a humble reminder as a young student pilot: “Never forget, you’re always a student in the airplane.” To me Carlin’s quip is kind of a compliment and a constant reminder that, both in my airplane and in the operating room, I work in an information-rich, technically demanding profession and must always be humble, self-aware, and self-critical of my skills and limitations, and stay up to date on the latest advances in my field. The vocabulary and the technical skills are different but the safety mind-set to have good outcomes in the operating room and in the cockpit are identical. Physicians are always reminded that we “practice” the art of medicine and flight safety demands the same attitude in the aircraft.

One of my surgical mentors gave me a similar warning when I complained about how long it took to finish my training slogging through the 9 years I spent as a surgical resident. The standard instruction for general surgery residents is five years, and after that comes the sub-specialty years. He said that it took those first five years to learn how to operate, then it took five more years of experience to learn when to operate, but it was the next five years that were the most important since that’s when you learned when not to operate. That fits right in with another comment from one of my good pilot-doctor friends who recently took his CFI refresher training with the King School program. John King said, “Experience is a hard teacher, she gives the test first and the lesson later.” The failure to get the experience before taking the test is exactly what my mentor told me and how Mohler explained the early run of accidents in the late 1960s.

I have two basic takeaways from the discussions with colleagues and feedback from all of you out there. One is that high-achieving professionals who get into trouble in the cockpit have confused the confidence of the first years of training in the airplane with expertise. They got into trouble in the air because they missed the follow-up experience and failed to learn the lesson of my mentor about when, and when not, to fly. They mistake the confidence of mastering their early flight skills with an overall sense that they’re masters of all skills, and it just isn’t so. In addition, these high-achieving individuals have fallen victim to the Dunning-Kruger effect and carry sloppy habits with them into everything they do and don’t have the insight to know what they’re not good at. These are important safety lessons for all of us pilots, physicians, and professionals. Stay current on your skills, keep up with your sim time and hood time, stay up on the latest information, but above all, stay honest with your self-assessment of your strengths and weaknesses. Never forget that good safety habits affect everything you do on the ground and in the air. Avoid the temptation to confuse skills with hubris. Treat your pilot’s license like it’s a license to practice being a pilot, and above all—stay safe.

Kenneth Stahl, MD, FACS

Kenneth Stahl, MD, FACS is an expert in principles of aviation safety and has adapted those lessons to healthcare and industry for maximizing patient safety and minimizing human error. He also writes and teaches pilot and patient safety principles and error avoidance. He is triple board-certified in cardiac surgery, trauma surgery/surgical critical care and general surgery. Dr. Stahl holds an active ATP certification and a 25-year member of the AOPA with thousands of hours as pilot in command in multiple airframes. He serves on the AOPA Board of Aviation Medical Advisors and is a published author with numerous peer reviewed journal and medical textbook contributions. Dr. Stahl practices surgery and is active in writing and industry consulting. He can be reached at [email protected].

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