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Aviation vs Emergency Medicine Part 3 – Supervision & Training

I’m not normally a nervous flyer. I was born overseas, and had lived on 4 continents by the age of 7, and took yearly trips from Australia to the USA to visit family throughout the 80’s and 90’s (in the old days when it took 4 stops and 40 hours to get from Melbourne to Houston).  That’s a lot of flights.  I currently rely on interstate locum work for a living, so I fly interstate at least once a month.  My favourite TV show however is Air Crash Investigation, so I think a lot about what’s happening on the aircraft, every time I fly.

I took a recent interstate flight on a Dash-8 (with propellers, not jet engines) for a locum stint. It involved flying over a decent stretch of water, on a cold, windy afternoon, in winter.  The flight was delayed 2 hours, “due to late arrival of the incoming aircraft”, and while we were boarding there was an engineer in the tiny cockpit with the pilot & co-pilot, playing with various switches, and frequently referring to a clip-board.  It was pretty obvious there was some sort of technical or mechanical issue with the aircraft.  Dash-8’s are workhorses of the sky, and from what I can gather, are fairly reliable. This one however was many years old, and looked worn, and tired.  As the engineer left the plane, I noticed that the co-pilot was a young woman, who looked to be in her mid 20’s, and didn’t seem to have many stripes on her epaulets.  She looked about the same age as many of the RMO’s and Registrars at work. The pilot was a classic middle-aged clean-cut pilot type, with a calm, experienced voice on the PA as we taxied out, and he apologised for the late departure.

Dash-8

A Dash-8 similar to the one I flew in (this one is much newer!)
Image courtesy of: www.aircraftrecognition.co.uk

As we took off, I did notice that the floor was vibrating so much I couldn’t leave my feet down, the frequency of vibration was incredible, and I had to put my feet on my bag.  It made me wonder about various screws and rivets in the airframe being shaken loose.  There were quite a few bumps on the way over, and as we approached the destination, a small rural airport located right on the coast, we took an unusual route, going over the nearby main town, then back out to sea (which made me wonder if we were going to ditch in the ocean), before sharply banking to line up with the airport, and as I looked out the window I could just see the runway off to our right, disappearing below a blanket of very, very low cloud…  In my mind the following holes in a large piece of Swiss cheese were re-arranging themselves into a nice orderly line…

1)    Flight delayed 2 hours, now an early evening flight – late, tired pilots
2)    Co-pilot quite junior
3)    Old, rickety aircraft which required engineer attention prior to take-off
4)    Bad weather –  windy & bumpy, with a light rain
5)    Bad visibility – very, very low cloud, dusk approaching
6)    Rural airport with unknown emergency preparedness.

As we lined up to land, the way the plane banked felt very sudden and sharp, and the straighten up was quite abrupt too, and as I looked downward to the frothy ocean below, we seemed quite low, rather lower than I’d been on that approach before, it felt like we were barely 100 metres off the water. And I knew from the weather forecast it was about 6 degrees outside. Water temperature – arctic.  And by the jerky, almost over-corrected movements of the aircraft, I convinced myself we were in the hands of the young co-pilot for the landing.  Butterflies-in-the-stomach started, life jacket position reviewed, exits checked, seatbelt tightened, brace position visualised, and I wondered how long I could last in the freezing choppy ocean before the rescuers in this notoriously sleepy part of the world got moving.  As we hit the runway with a thud and a bounce, and the brakes got slammed on, I did feel a wave of relief.  I’d live to catch the same flight home in a few days time.

As we disembarked and my feet touched reassuringly onto terra firma, it made me stop and think about that young co-pilot, and the difference between her supervision during that landing, (which in the end was fine, we all lived), with an experienced pilot right next to her, with no-one interrupting, there to provide individual, real-time instruction and backup, and the way I was supervised during my emergency medicine training.

I could count on one hand the number of one-on-one patient interactions I had where it was just me and the Consultant in the room with no interruptions, no-one else there to distract us, and where I received personalised teaching from them.  More than 99.99% of my patient interaction during my training involved me seeing the patient alone, and reporting back to a Consultant at the desk.  No-one listening to my history taking.  No-one checking my examination technique. I was shown a lumbar puncture and central line insertion once each on a live patient before being let loose by myself (the old see one, do one, teach one). No supervision.  No decent feedback. No simulation.  And that was on day shifts. On nights one was truly “flying solo”. No backup, no-one to jump in when things got bumpy.  This training was “character building”, (ie idiotically stressful) but the main effect was that my peers and I learned our medicine in the “you’re doing it on your own, and if you fuck it up, you’re on your own, so you better not fuck it up” school.  Which is great for making you focus on the task at hand, but given that all educational theory is wishy-washy at best, I think this theory ranks near the bottom for educational utility. Would they let that young co-pilot fly in low, to a poor visibility runway, on a windy evening at dusk, in a rickety old aircraft with recent mechanical issues into to that bad weather, having never done it supervised nor in a simulator, on her own? I doubt it.

I remember complaining about this once to a Consultant who was rostered on as the “clinical education Consultant” – a job where they were meant to directly supervise and teach Registrars and not see patients – and her response was “well, you seemed quite capable, so I was happy for you to just carry on”! Meaning the only feedback I was getting day to day was “keep doing what you’re doing, on your own, and we’ll only step in if we think you’re doing something wrong”. Yet another awesome educational theory from doctors who know nothing about education.

Imagine this in pilot training. “As long as the aircraft stays in the air, keep doing what you’re doing, and it’s up to you to go home and read some books about flying so you know what to do, and we’ll only step in and teach you something if you really lose control or crash.  Oh, and if you do crash, you alone will wear the blame…”

Other medical specialties such as Surgical training (or any other specialty that involves being in the operating theatre – where you get extended one-on-one interaction with your boss), or even Psychiatry training, where you get weekly “supervision”, which is one-on-one time with a Consultant, are far ahead of us at the subtle as well as the literal or direct transfer of knowledge and experience that comes from close supervision.

Emergency medicine can never hope to achieve this degree of supervision with the way we’ve let administrators structure our workplace.  The demands on the system and the sheer volume of patients won’t allow it either. But next time your Registrar (Resident for the Americans) is having trouble with a patient, don’t just tell them what to do from the desk. Take 5 minutes to go in and see the patient with them, and get them to show you how they approached it.   If they’re doing it right, tell them. If they’re doing it wrong, don’t criticise, teach.  If they’re really struggling, show them the right way, and follow up with some feedback and discussion in a few days to ensure that it sunk in. Not only will you actually make a real difference to their learning, but hopefully they will role model that behaviour when they’re a Consultant.

For those health professionals that live in Australia and are truly interested in learning to teach, not just doing what you think is “good teaching” (because I can guarantee, you’re not half as a good a teacher as you think you are), I can highly recommend the following courses:

Graduate Certificate in Health Professional Education

Graduate Certificate in Clinical Simulation

I’m currently half-way through the latter course, and it has been a real eye opener into how little doctors know about teaching. Both cover educational theories and methods from a healthcare perspective in detail, and I’m stunned that we as a profession have allowed people with no educational skill or qualifications (ie practically all of our colleagues) to “teach” us for so long.  I’d encourage anyone who is seriously interested in gaining some formal teaching qualifications to check theses courses out, take some educational initiative, and you, your colleagues and your patients will be better off for it.

2 Responses to Aviation vs Emergency Medicine Part 3 – Supervision & Training

  1. Amit Maini August 4, 2013 at 11:01 pm #

    An excellent philosophical post Andy.

    As our emergency departments continue to get busier and busier (with no major increases in capacity), our specialty is in a state where service provision now outweighs our commitment to teaching our juniors, with less emphasis on the quality of care provided, and more on the timeliness in which that care is delivered.

    The word “doctor” originates from the Latin word “Docere”, which means “to teach”, and I am hopeful that the pendulum will eventually swing back, and we will have a more balanced approach, where excellence is the goal, rather than mere competence, and quality will be measured in a unit other than time.

    Also, thanks Andy for re-enforcing my fear of flying.

    Amit Maini
    Emergency Physician, Melbourne
    @sithlord2004
    http://www.etmcourse.com

  2. Gerry Considine August 6, 2013 at 10:49 am #

    Great post Andy, the aviation story actually makes me think about putting ourselves in the patients shoes more often. Here you were bouncing and banking around, not knowing what is happening in the cockpit and imagining the young trainee accidentally raising the landing gear at the wrong time. I wonder if our patients (especially in ED) feel the same. Alarms going off, laying in bed not knowing exactly what is happening while a junior doctor runs around.

    Having been in the pilot seat and taking passengers up for the first time, the checklists and explanation about what this and that means and what the plan is certainly impacted on my clinical practice. There was a large crossover between my flying and GP training too: http://www.ruralflyingdoc.com/aviation/gp_flying_training/

    Cheers again

    Gerry

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