I was invited to speak recently at a CME session at Community Medical Centers, a three-hospital system in Fresno, California, that commits a lot of resources to graduated medical education. In their large teaching hospital, close to 30 percent of patients are uninsured/charity care; CMC is the safety-net provider for the community. The organization has a very engaged community medical staff; nearly 120 attended the three-day CME session.
One of the first speakers was Robert “Hoot” Gibson, a NASA commander who flew into space five times. He was the commander for the first docking of the Atlantis at the Mir Space station. He had a long career, first as a fighter pilot and later as an astronaut.
During a break I asked Gibson about his training, following the logic that if we can teach a 25-year-old to land on an aircraft carrier at night, we can surely train physicians faster and better. He had an interesting answer. (By the way, he is married to a female physician who is also an astronaut; she has probably educated him well.)
- Fighter pilots and astronauts spend a tremendous amount of time in simulators and have to demonstrate competency in a very stepwise fashion before they get in a cockpit.
- They have a longer learning process than you would think. They are constantly being retrained, observed, and evaluated by others.
- They are encouraged to be self-reflective about their mistakes in simulation exercises: In real life, mistakes can lead to catastrophes.
- They do make errors, but they analyze them and try to create systems that make the errors impossible. If they do make a mistake, it is not a career-ender.
Gibson said that he thought that training physicians is harder because of the many of the dependent variables and unknowns. He told powerful stories about the three missions that had catastrophic outcomes.
For example, the cause of the Apollo 1 launch pad fire? The capsule was pressurized with 100 percent oxygen!
The Challenger disaster was caused by the O rings cracking. Gibson says that NASA personnel knew this flaw existed, but no one thought that two O rings would fail at the same time. They did on that cold Florida morning.
In the Columbia incident, mission control assumed that there was nothing that could be done about the suspected wing injury from a chunk of foam.
In each of these situations, disaster arose from a combination of poor communication, incorrect assumptions, and a focus only on what was known; there was insufficient questioning about what people did not know.
I was very impressed by Gibson’s humility, pride, commitment to his profession, and his pursuit of excellence.
So how does this translate to health care? Many make aviation analogies to emphasize how we can improve quality and safety in health care. Let’s take it a bit further.
Our young physicians are selected much like pilots are. There is lots of competition, but we think the process means that we get the best of the best. We should treat them and train them with the same respect and commitment to their professional development. Pilots and young doctors definitely pay their dues, but we need to make sure this is done with in a professional and respectful manner; it will engender the same behaviors in them.
We should make sure that the time young doctors spend in training is focused on producing the best product. We underuse simulators; we don’t teach enough self-reflection; we are not honest about human errors. We have young physicians to performing a lot of activities that may make them good technicians, but are these the important experiences that will make them great physicians? Do we involve them early enough in the strategies and challenges of health care delivery so they can develop as leaders?
We should teach them that everything they do could have an adverse outcome, could be that O ring or piece of foam that appears not to matter but could cause irreparable harm. Do we tell them that it is what they don’t know that can be the most dangerous variable?
We should teach them to be both humble but proud of their profession.
In talking to many residents, I learned that some have to work at pushing the bitterness away; they feel that we don’t value them or respect their contribution to care. They believe we don’t think about how we can give them the best educational experience. They don’t care about the 80-hour work weeks, but they want the time they spend to be meaningful. I think we often miss the opportunity to make medical students and residents feel proud to be part of a great profession.