MD;
I would like to categorically lay to rest (pun fully intended) the myth that doctors do not have any scrutiny over each and every case they deal with. They certainly do. If they did not, I would be out of work, and believe me my desk is piled high.
Thanks for your again-thoughtful comments MD. A lot has been written on how aviation's CRM process "should" assist medicine and as I was writing I was considering and perhaps recognizing the differences and where the model might break down given their vastly different tasks, responsibilities and processes. Down in the details of design and execution of effective approaches, CRM is not be a panacea nor is an OR QAR!
What drove CRM in the very beginning was the unpleasant-at-the-time recognition brought about by several prescient observers whose names we know causing shifting of points of view that contrary to the socially-accepted views of the time", (called myths when we no longer believe such points of view),
the captain didn't know everything and actually made "the occasional mistake" and that if others didn't speak up, the captain could (and did) kill everyone.
While such authority-figures "occured" in a society where top-down "command and control" was a characteristic of a post-war economic and social structure much was learned about how this structure and an unquestioned allegiance to authority alone could threaten end-goals such as preserving life, property, wealth and even 'a way of life', etc.
"What, not Who" slowly became the focus of change, that being the first signs of what was later recognized and labeled as "human factors".
Such development was neither natural nor easy for as late as the late 20th century, man (and his works) was still viewed philosophically as "perfect" or the "pinnacle of perfection", even in the face of major events showing quite the contrary. Philosophically, man's encounter with himself and the encounter with such events which showed not all was within man's control, expressed itself in the notions of existentialism.
I will stop there before those remaining drift off to sleep, but there are clear and definitive connections between what most would reasonably consider esoteric and largely irrelevant philosophical world views and such practical and seemingly "obvious" safety processes as we are discussing. In truth, it's philosophy all the way down...
To complete the point, the authority of the captain, though never undermined or denied, began to be viewed differently. I can recall my first CRM course very well because there were a lot of older captains made angry by the thought that "speaking up" was in fact challenging the captain's ultimate authority. Of course, nothing of the sort was intended and that view gradually "retired".
CRM is neither a way of "being polite or respectful" nor is CRM a challenge to the authority of the commander who is always legally responsible, but is instead a way of raising concerns or handling an abnormality (but not necessarily an emergency, which has its own procedures). Everyone has the authority and responsibility to speak up; sometimes the final outcome is a group decision and sometimes the captain makes the decision which may even be contrary to the results of CRM discussion. The key understanding in CRM is in expressing concerns,
not flying the aircraft by committee.
It is impossible to state how many lives such an altered view has saved but the accident rate, which plummeted from the mid-60's on, is partial evidence that it worked. Of course, technical, mechanical and computerized solutions to aviation's primary accident causes of the time contributed heavily to the trend.
It is my impression that this view (changing authority gradients and the legitimacy of intervention) is extending itself into the OR and that's partially why, along with other observations, I made the comments I did.
I sense too that patients are embracing such a view. For my parents in the 40's, 50's and even 60's, the medical profession could do no wrong, "the Doctor" was never questioned, and one never sought second opinions for fear of offending or undermining confidence. Part of this is living in small communities of course. That is no longer the case, interestingly I think, because such a response is largely informal as society's views of authority changed, as described.
These are very black-and-white statements I know and I would expect that they offer only metaphorical "grains of truth" rather than definitive prescriptions for "the way things are/should be". I think that is the nature of John Farley's excellent contributions, which suggest and point rather than prescribe, as I read him anyway.
Your reassurance in your comments accomplish their purpose, thanks. - PJ2