Korean Airline Pilots, Arrogant Physicians, and Life-Or-Death Decisionmaking

December 13, 2008

Malcolm Gladwell’s new book, Outliers: The Story of Success (Little Brown), contains a very interesting discussion of the reasons for plane crashes. It turns out that very few plane crashes involve unsurmountable catastrophic mechanical failure. Rather, most plane crashes occur as the consequence of a chain of small human decision-making errors compounded by poor communication between pilots in the cockpit.

Up until a few years ago, Korean Air Lines was plagued by a much higher crash rate than other airlines. Analysis of cockpit voice recorder data from a number of Korean plane crashes revealed that the god-like status of captains and the relative subordination of their second officers frequently led to situations where the captain was fucking up, the second officer was clearly aware of the fuckup, but the second officer was either unwilling or unable to communicate to the captain the fact that he was fucking up.

In one horrifying case, the transcript reveals that just before their plane plowed into the side of a hill, the second officer was saying something to the captain like, “sometimes it is not so easy in bad weather at this airport to see the runway”, when it was clear that he knew they were headed for the hill and should have been shouting, “Dude! Pull up!!! We’re about to crash into the motherfucking hill!! PULL UP!!!”

Turns out that this is consistent with the strongly hierarchical nature of Korean culture, and that once Korean Airlines realized what was going on, they were able to train their Korean pilots to not behave hierarchically in the cockpit. Their crash rate immediately declined to typical industry-wide levels.

A recent New York Times article, Arrogant, Abusive and Disruptive — and a Doctor, recounts the following harrowing situation (h/t PalMD at Denialism):

It was the middle of the night, and Laura Silverthorn, a nurse at a hospital in Washington, knew her patient was in danger.

The boy had a shunt in his brain to drain fluid, but he was vomiting and had an extreme headache, two signs that the shunt was blocked and fluid was building up. When she paged the on-call resident, who was asleep in the hospital, he told her not to worry.

After a second page, Ms. Silverthorn said, “he became arrogant and said, ‘You don’t know what to look for — you’re not a doctor.’ ”

He ignored her third page, and after another harrowing hour she called the attending physician at home. The child was rushed into surgery.

“He could have died or had serious brain injury,” Ms. Silverthorn said, “but I was treated like a pest for calling in the middle of the night.”

Just like the second officer in the plane heading for the hill, this nurse was in possession of absolutely critical information in a life-or-death situation. And just like in the Korean Airlines cockpit, a culture of strict hierarchy resulted in a failure of essential communication of that information.

Many features of the medical training system reinforce the status of physicians as not only different from the other participants in the medical care system–nurses, physician assistants, technicians, etc–but superior, and to be deferred to. This is bad for patient care.

The fact of the matter is that physicians are, on average, no more intelligent, perceptive, or experienced than nurses, PAs, technicians, etc. They are, of course, in possession of specialized information and skills that other participants in the medical care system are not.

These communication breakdowns appear not to just be isolated incidents, as the Times article notes:

[A] survey by the Institute for Safe Medication Practices, a nonprofit organization, found that 40 percent of hospital staff members reported having been so intimidated by a doctor that they did not share their concerns about orders for medication that appeared to be incorrect. As a result, 7 percent said they contributed to a medication error.

Just as Korean Airlines was able to train its pilots to overcome the naturally hierarchical nature of Korean society, we should be able to train medical care providers to overcome the naturally hierarchical nature of the medical care system. This will lead to improvements in treatment outcome, and reduce suffering and premature death.

UPDATE: Check out my colleague PalMD’s post on this topic.

21 Responses to “Korean Airline Pilots, Arrogant Physicians, and Life-Or-Death Decisionmaking”

  1. juniorprof Says:

    Right on Dude! There used to be (and still is to some extent) a huge problem with this in the French Hospital system in Quebec. The McGill model (which stresses teamwork within the medical unit) eventually spread its way out (the McGill hospitals are largely English) into the training for physicians in other parts of Quebec and the situation has improved but more emphasis on teamwork rather than hierarchy is still needed.

    In addition to training, one thing that I have noticed (via my wife, who is a nurse) is that medical teams that hang out together work well together. Activities that stress mixing of different professions in a social situation make a big difference in creating a safe medical workplace with a good amount of checks and balances. At least that has been my vicarious experience.

    I do alot of medical student teaching and one thing I always do is insist that students use my first name. First off, I cannot stand being called Dr Juniorprof. Second, I think that such small things help students understand that hierarchy is bullshit. I also make sure to tell them that I will eventually tell them something that is wrong (I can’t know everything after all) and that I expect them to call me on it. Trainees must understand that there is nothing wrong with being wrong now and again. The problem comes when you start denying that you have been wrong or when you stop listening to the criticism.

    Finally, in terms of scientific training, as you have said many times before, it is absolutely essential to mentor in such a way that trainees understand that there is no hierarchy in terms of experimentation and hypothesis testing. Labs that are secretive and hierarchical should be avoided at all costs if you are looking for a place to learn to become a scientist.

  2. the improp Says:

    CPP – Outstanding post. I think I have an analogous story, in fact, that occurred last week. It’s not to the extent of the Korean Airlines or the Doctor example, where there are lives at stake, directly, but I think it’s relevant. If not, then please verbally smack me right in the face. I have to speak in vague terms, because it’s a pretty sensitive legal situation.

    So two companies are suing each other for breach of contract, and the company I work for (in which I am one of a two person North American legal department)has done business with both companies. My boss, who is more qualified from me in a business experience sense, but not from a legal perspective (she graduated law school just one year before me) is supposed to have a conversation with one of the lawsuit company’s attorneys. Our documents have been subpoenaed, and I’ve been in charge of the process, but I’m still a background player.

    I tell her, quite bluntly, that she needs to tell the person something risky, despite the fact that it might violate an agreement, to avoid us being sued. She ripped me up and down for even suggesting it. Said I was irresponsible, I didn’t have the company’s interests in mind, that I had a lot to learn about business, and that doing what I suggested could eventually bankrupt our business from the resulting lawsuit. I felt like about a million bucks worth of shit.

    In the phone conversation, she divulges what I had suggested. The attorney on the other line just said “I know this was risky, but it was going to turn up in the process of discovery anyway. And I am sitting here looking at the complaint I was going to file Monday to sue your company, and you telling me this just prevented that from happening.”

    The lawyer on the other line might have been full of shit. But I think it’s yet another example of how listening to subordinate advice sometimes could pay off big in the long run.

    And even if he was full of shit, I’m willing to accept it as being a true statement for the sake of me feeling better about myself.

  3. PalMD Says:

    There has been a lot of talk comparing the safety record and procedures of airlines and medicine, and unfortunately, air travel can only inform certain (important) bits of medicine. The OR is a fine example, but the Keystone Project has the potential to revolutionize the way things are done in hospitals.

    Of course, medicine doesn’t happen only in hospitals, and the widespread, diverse nature of medicine in the US makes some of these fixes quite difficult.

    For ex., medicare has a project called “PQRI” which “asks” primary care docs to track certain illnesses, and fill in certain codes to help track them. For example, there are about 6 or so parameters for diabetes, each of which is associated with a particular code, that can be sent in with the billing codes. Medicare will eventually withhold part of their payments unless you do this. Of course, there is no easily accessible central repository of how this system works, so we in primary care have been asked to do what is quite possibly a good thing, and will be penalized for doing it wrong, but we have no way of knowing how.

    The whole healthcare system needs to be redesigned.

  4. The whole healthcare system needs to be redesigned.

    Preach on, brother! Tell us what you’re thinking!

  5. Katie Says:

    I served on a committee that addressed required changes to the training environment in the medical school. When I saw that we were creating a rule that stated doctors were not allowed to physically strike, kick, shove or spit on their trainees, I was grateful my term was only one year.

    I think there are both amazing and horrible physicians here in the middle of the country. But I’ve seen men I consider very fair shut down valid arguments without allowing for discussion during tumor boards. So a redesign of the system seems great – I just don’t have a clear idea of how that would be implemented. How did the airlines pull it off?

  6. PalMD Says:

    I’ll have something for you to chew on regarding that in a few minutes over at my place.

  7. Agreed. On a related note, it’s a delicate balancing act to treat everyone as valued contributors or equals without diminishing the leadership/responsibility of the person in charge. (Not that I think the medical system is in any danger of this!) It’s interesting to watch different labs in action to see the extent to which the PI tolerates dissent, listens to trainees etc–but does NOT back down from the responsibility of making key leadership decisions. Not all PIs are good at hitting this balance.

  8. Ouyang Dan Says:

    That was an excellent fucking comparison.

    And freaked me out a little…since we are moving to Korea and will be on Korean Airlines soon.

    I already know how arrogant doctors are.

  9. Deb Says:

    Right on. As you know I have one of those “quack” degrees. I’m an acupuncturist and very proud of the work that I do. Not so proud of the majority of my colleagues who didn’t pay attention in Anatomy, Physiology, Pharmacology or Biology (yes we take those classes and quite a few more) but I learned enough to know when a doctor is blowing smoke up my ass.

    My mom, who is 78 and has vascular dementia at the very least, has been having serious problems keeping weight on her body. All her doctor cared about was that her BP wasn’t under control and no amount of explanation about her severe fecal incontinence was listened to. I don’t want to be gross, but there is no way any drugs were staying in her system long enough to do their job. His response? He turned me in to Adult Protective Services and they came out and surveyed all the food in the house (there was plenty) and warned me that if I didn’t take better care of my mom they would put her in a home and I would be forbidden to see her.

    It took me a week to calm down and am now in the process of trying to change her doctor to one that listens when I try to explain that she wakes up choking in the middle of the night, that her face is purple and she was diagnosed with a splenic artery aneurysm four years ago. I finally found one who is scheduling her for an ultrasound and will be changing her medication.

    My impression of the medical community lately has been that they watch way too much House to be practicing medicine effectively.

    Sorry, this whole thing has been a thorn in my side and I had to vent about the arrogance of some in the medical field. He never once scheduled her for any therapy after her stroke and I know that isn’t right.

    I personally prefer to go to teaching hospitals because contrary to popular belief, acupuncture does not cure everything. It may alleviate pain, reduce fever and swelling and is pretty good at preventative stuff, but it does not cure everything.

    Medicine should be practiced as a team and while there may need to be a leader, he doesn’t have to be Stalin.

  10. ScienceMama Says:

    Thanks for a great post, CPP.

  11. Becca Says:

    Is the problem in the second case really purely “the hirearchy”?
    That nurse knew she was right, and persisted (and probably saved the kid). She hadn’t internalized the hirearchy to the point of not being able to function (unlike, perhaps, the Korean pilot).
    Maybe the problem in this case (besides Dr. Douchebag as an individual) is also sexism.

    Now, as a general principle, a hirearchy that prevents questioning the doctor is incredibly awful for patients. I’m with you there. I’m just not sure about that particular example is only due to that one problem.

  12. Word I heard was that, as of a few years ago, JAL has the same problem and it was getting worse, because all of the American pilots, who were the senior captains, were being retired/pushed out.

  13. […] Comrade PhysioProf, how ingrained hierarchy often puts lives in danger, especially in our nation’s medical […]

  14. george.w Says:

    Apparently not limited to KAL. Check out the excellent NOVA program, The Deadliest Plane Crash. The investigation found pretty much the same thing in the Royal Dutch Airlines crash, that the pilot was headed down the runway in dense fog, and neither the controller or the co-pilot were certain that the runway was clear. He was a top pilot – had been featured in their ads as a paragon of professionalism – and nobody would question him.

    Deb: “My impression of the medical community lately has been that they watch way too much House to be practicing medicine effectively.”

    Does that mean I’m a bad person for getting a big kick out of watching House? I’m not a doctor or anything.

  15. Morten Says:

    I wonder how no one seems to even comment the accusations about doctors being on par with other “members of the health care team” in terms of intelligence and perception. Is everyone truly buying that? It seems to me a bit of truly ridiculous political correctness.

  16. bikemonkey Says:

    yeah that intelligence thing is probably bullshit. but who wants to dredge up the references? too much work.

    Matarazzo and Goldstein 1972 was it? reported something like 125 IQ in physicians or med students.

    more recent studies of physicians reported for malpractice, maybe Turnbull et al 2000, Madden 1988, Perry and Crean 06? reporting normal intelligence suggesting that those who squeak through the process with the lower end of the IQ distribution are disproportionately error-prone?

    someone else can pull up the nurse IQ stats…

  17. Jae Says:

    Hi Physioprof,

    This is quite an interesting article. If you know of any Korean medical students, please share this article with them. It is about scholarships.



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