Signal in the sky

Notable figures such as Atul Gawande and Captain Sullenburger have, when discussing safety in medicine, drawn comparisons from the world of airline operations. Lots of people, actually, have made comparisons to these disparate fields.

If healthcare were more like aviation, the thinking goes, there would be fewer errors, greater transparency, and more uniform ways of doing things (and thus, presumably, lower costs). Gawande and Sully both talk about the egos of doctors, who view checklists as beneath them, who view their patients and practice as worthy of exceptions to guideline-based practice, who view their gestalt as superior to cookbooks and calculators.

No doubt, that's part of the problem. But consider: New York magazine publishes a list of top doctors, but not top pilots. Lots of people brag about the acclaimed specialist they see, but no one brags about the pilot that they've booked for their trip to Paris. I think society's expectations of physicians have never been in line with their expectations of air travel. The relationship between passenger and pilot is nothing like the relationship between patient and doctor, except that we rely on pilots and doctors to get us from point A to point B safely and smoothly.

US healthcare has maddening inefficiencies and rituals. But so, too, do airlines. I'm not even talking about TSA security theater (at least, not this time). Just consider the flight attendant preamble about using your seat as a flotation device in the event of a water landing, or the rules about electronics below 10,000 feet. These always seemed to me to be put in place by cautious administrators, years or decades ago, with a "better safe than sorry" rationale that's hard to study or rescind, once put in place.

These speeches and restrictions always reminded me of the over-the-top, out-of-date rules about cell phones in hospitals. Sure, there's one confirmed case that I'm aware of, years ago, where a mobile phone caused an IV infusion pump to malfunction. But it never seemed reasonable to extrapolate from that event, to banning personal communications at a time when patients and families are most inclined to get in touch.

Recently, the IATA issued a report on passenger-generated electronic interference with flight systems. Via TechCrunch:
The reported incidents were based on 125 airlines’ responses submitted between 2003 and 2009, noting that flight controls, autopilot, auto-thrust equipment, landing gear, and the communications kit were all allegedly affected by electronics use. Of course, not one of the seventy-five incidents were verified to be caused by electronic devices. Instead, the IATA reports that crew-members and pilots believed that electronics were the culprits in those cases.
In one instance, with two laptops being used nearby, the plane’s clock spun backwards and GPS readings began going off. In another example, altitude details were jumbled until the pilot asked passengers to turn off their gizmos. A Boeing advisor, Dave Carson, believes that the signals radiating from portable electronics can mess with sensors hidden in the passenger areas of a plane, and that those signals are far stronger than what Boeing considers acceptable during a flight.

I didn't know some sensors were in the passenger area, where nearby device signals could interfere. Still, the article goes on to say a true cause/effect relationship between portable electronic devices and malfunctioning sensors has not been demonstrated by any of these IATA incidents.

What I found particularly interesting were the outraged comments, in response to the "scofflow" writer who admitted to keeping his phone on during landing. He was attacked for jeopardizing the lives of everyone on every plane he's flown on. With 4000 flights a day in the US alone, and a lot of forgetful or sleeping passengers on each flight, I have a hard time believing that electronic interference poses any measurable risk. Even if all 125 citations over 6 years were really due to electronic interference, there were still no "bad outcomes" (to borrow from medical QA parlance) and the event rate, as commenters point out, was approaches zero and is far less than the odds of being struck by lightning.

Would these same outraged commenters angrily force a patient's family member to hang up their mobile phone, if they saw them talking in the ED near a stretcher? Would they yell at a car driver who's not wearing a seatbelt? Or do these commenters feel people who keep their devices on during plane takeoffs and landings are not just jeopardizing themselves, but perhaps the commenters as well?

This seems like yet another example of our attitudes and behaviors toward risks being poorly aligned to the actual danger. It's more David Ropiek's territory -- though I'm sure Sullenbuger and Gawande would agree, getting the public's perceptions to match the true hazards in aviation would make air travel a good deal more smooth and productive.

As for healthcare, it seems almost impossible to calculate how much money, time, and stress would be saved if patients' risk perceptions were brought into better agreement with true health risks. Yet I'm more optimistic that the culture of aviation -- with its transparency, uniformity, and lack of ego -- is more likely to lead to progressive policy changes and successful public education, when compared to the culture of medicine.