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Comment by jostmey | Hacker News Reader

The FAA responded to a number of high profile aviation accidents by making a series of important changes in the cockpit. Their studies revealed that some mistakes happened because subordinates were too afraid to question the captain. After these changes, the captain was still left firmly in command but a new environment was created where subordinates felt (more) comfortable to voice any questions or concerns.

A similar thing needs to happen in medicine. Doctors walk around like gods in the hospital but they are still human and make mistakes. The problem is that everyone is too afraid to correct the doctors when they make obvious mistakes. Don't get me wrong---the doctors must remain in charge, but they will still goof up so people need to feel free to offer advice and criticism.

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And it'd be nice if they treated their patients with some respect and as if they had a functioning brain instead of as objects. Obviously this does not apply to all doctors but this happens with alarming regularity.

How often has this been said to programmers/tech startups? The answer is typically shield the nerds from customer support by introducing extroverts. And doctors who are often nerds are forced by design to deal with people constantly. No easy solution here.

I've always found my doctors to respond to my inquires with any amount of detail or sophistication I require. Both in Canada (my home) and the United States (where my girlfriend is from).

This was touched on (in the context of surgery rooms) in The Checklist Manifesto - as I recall, having everyone introduce themselves helps make people more willing to communicate and correct.

> Doctors walk around like gods in the hospital [...] The problem is that everyone is too afraid to correct the doctors when they make obvious mistakes.

This is a blanket statement that is untrue in my first-hand experience as a medical student. If you see a mistake is being made and can back up your opinion, you are treated with respect.

The problem is that medicine is very complicated and there are often not single 'correct' solutions. Given competing reasonable interpretations, the physician liable for the patient will (and should) make the final choice.

There is an alarming amount of anti-physician bias here. Physicians walk around like Gods? No, they walk around like people who generally have a very good clue and years of experience about what they are doing and are constantly attacked for issues outside of their control or completely outside of their patients' understanding, despite their best intentions and efforts.

> If you see a mistake is being made and can back up your opinion, you are treated with respect.

Are you treated with misrepect if you feel a mistake is being made, but you can't back it up ?

I believe students and young doctors should be pushed towards raising their concerns even if they can't back it up. From an external viewpoint I also believe progress can be made in that direction (I never worked in a hospital).

If you can't support why you think something is a mistake, why do you think it is a mistake?

Because of feeling?

Our subconscious mind recognizes something and predicts a bad outcome, which gives us a feeling of something being wrong.

That's what expertise is essentially. Being able to offload things that took conscious effort before into the unconscious. So a bad feeling from an expert (subordinates are experts as well) should be voiced, and investigated.

Say I'm a medical student and during an operation I notice unusual numbers on the screen. I don't even know what the numbers mean (hey I'm a student!) but they look freaking unusual. Should I tell Dr. God about these numbers ? Last time he told me to shut up because I could not support my concern.

There are hundreds of situations where you believe something is a mistake but can't give clear supportive arguments. I hope blaming young medical professionals for raising their concerns in these situations is not the norm.

Point taken, but I am not sure about this scenario. You can always ask "What do these numbers mean?" You might look stupid, but I'm pretty used to that by now.

The original parent referred to "obvious mistakes" made by physicians, which I don't think your scenario encompasses.

You have implicitly answered the question...and demonstrated the attitude that is the wrong answer.

When experienced people see something that doesn't fit, they often don't immediately know what subconscious cue let them know that something was wrong, and it is often someone else who can supply the critical piece of information. If you want good outcomes, you DO NOT push them to suppress their thought process. Instead you encourage them to speak up, everyone tries to figure it out, and then the final result helps train people's intuition of, "This is OK" and "This wasn't, you were right to wonder what about this situation reminded you of that case we saw last year where someone died."

If you are serious about finding problems, you need to not prematurely shut off feedback. Requiring people who think something doesn't look right to have backed that opinion up before they speak up is a problem.

It's a very good point you make and many have already made great comments in reply. But as a physician who strives to prevent errors, I will throw in my two cents:

The culture is changing. The youngest physicians are working more reasonable hours and spending more time learning about errors in medicine and being collaborative in preventing them. I can personally say that I have seen techs, nurses, medical students and even other physicians prevent a potential error by simply asking a question. Of course, ego can still get in the way... but that's when your tact can help. Something as simple as, "what if we did this instead?" or "did you mean to order this?" can make it easy for a person to admit their mistake and move on.

I encourage you to read one of Atul Gawande's books for a very approachable treatment of the topic. This is the emerging culture in Medicine.

I believe Malcolm Gladwell has written about this. Others have as well. Typically this is less of a problem for US pilots, and more so in other cultures. For example, some of the studies showed that this type of thing was actually more prevalent in cultures that tended to be hierarchical, and where elders/authority figures should not be challenged (The usual example is Asian pilots.) I believe that the high profile accidents were Korean? (I could be wrong)

There are ways to measure this type of hierarchical control (better terminology escapes me at the moment), such as the Power Distance Index [0][1]. I've always enjoyed thinking about this as basically, how likely is an underling likely to tell his boss that's he wrong and he can go shove it? In this case, you can see why it's one aspect of the psychology/geography of where and why entrepreneurial activity occurs.

[0] (Wikipedia actually sucks at discussing PDI: http://en.wikipedia.org/wiki/Hofstede%27s_cultural_dimension... [1] better information: http://www.clearlycultural.com/geert-hofstede-cultural-dimen...

how did the FAA change things so that subordinates felt more comfortable?

http://en.wikipedia.org/wiki/Crew_resource_management

Thanks for the citation. Forgot to include it.

> The problem is that everyone is too afraid to correct the doctors when they make obvious mistakes.

Why do you think that is the core of the issue? Sorry to be that guy, but massive citation needed.

Not only that, but it appears (based on the wiki article below) CRM procedures you are mentioning have already been widely adopted by the healthcare industry.

Sorry to disagree, but they are certainly not widely adopted, although there is a fair degree of buzzword compliance without meaningful implementation.

I'm an ER physician in the US, and have worked in 5 hospitals in the last six years during residency and afterwards. Some of them occasionally would have some kind of 'patient safety' didactic lecture, but none had the specific small group training between doctors, nurses and other staff that CRM requires. If a hospital were serious about such things, they would pay staff to attend such training, and measure the behaviors, and make a portion of pay dependent upon adhering to the principles: I have never heard of a hospital doing this. I think there is good evidence that CRM works (http://www.ncbi.nlm.nih.gov/pubmed/12546286) but the hospitals won't do it unless forced to by a regulator or accrediting organization such as jcaho, in my opinion. I'm curious to know whether the airlines took on the concept by choice, or we're forced to by the FAA...Of course, it's a lot harder to 'hide' a plane crash than a failure to correctly treat a sick patient. There's also some perverse incentives: if a hospital does the wrong thing, and makes someone sicker, that often means that the hospital can bill more for a higher level of care, for a longer period of time: you can always blame the underlying illness...

> Sorry to disagree, but they are certainly not widely adopted, although there is a fair degree of buzzword compliance without meaningful implementation.

That may be true, but OP implied that nurses being too afraid to correct doctors was the main cause of avoidable patient death, which is a massive stretch. Especially when the article itself is so prone to the obvious bias of life-threatening surgeries not taking place when doctors aren't working.

> I'm curious to know whether the airlines took on the concept by choice, or we're forced to by the FAA

They were forced by the NTSB, not FAA.

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