one pilot son, one medical son

[non-newtonian]

I thought you guys might like tp read the following "personal view" from todays BMJ.
BMJ 2002;324:1105 ( 4 May )


One pilot son, one medical son

Some time ago two of our sons went "off the payroll"for the last time, I hope. The nature
of lifelong learning is such that our eldest, at the age of 28, is now pursuing his third
career post-university, and is a commercial airline pilot. Our second son started work as a
preregistration house officer eight years after leaving school. He had the obligatory year
out to see the world and did a two year intercalated BSc in sports medicine.

On starting work my pilot son's first 18 flights were always with a third, safety pilot, and
for the next 20 flights he was always with a training captain. He was finally allowed full
operational work after having acquired and demonstrated the appropriate competencies.
He works in a profession where there is a planned programme of professional
development and has regular evaluation. On overnight stops he gets accommodation in
four or five star hotels. He regularly undergoes a health assessment to ensure his fitness.
He is allowed to fly a maximum of 100 hours per four-week period.

My medical son, meanwhile, started his career with a shift lasting 26 hours during which
he had no sleep, rest, or food. During this first night he had some dealings with a sick
drug misuser, who subsequently died from overwhelming infection. Because of a cluster
of such deaths in the region the local public health department, the police, and the
procurator fiscal showed considerable interest in the case. The police interviewed my
son's colleagues aggressively. This was my son's initiation to the stresses of working in
the NHS as a junior doctor.

The intensity of work was high. Shifts of up to 32 hours were a regular feature. While my
pilot son's job has continually enthused and inspired him, my medical son's experience
has been different. After the first three months I thought he was depressedcertainly he
was alienated and worn down. Since then he has adapted and coped, but one of his
contemporaries resigned. There was no locum cover for two months. My son then
developed an acute soft tissue infection that required treatment with intravenous
antibiotics and subsequent surgery. During the two weeks he was off, there was again no
locum. Colleagues had to cover his rota and as a result he felt under considerable pressure
to return to work against medical advice.

In the light of my sons' career development, I have been reflecting on the current interest
in doctors' performance. My impression is that government spin doctors have
orchestrated some of the public concern to feed the media in the hope of distracting the
public from political failures to deliver improvements in health care. The NHS approach
to clinical errors is way behind the system in the airline industry.

The culture of medicine is to respond heroically to patients' needs and the demands of the service.
Ultimately, however, this seems to be resulting inmore and more doctors leaving as soon as their
pension benefits allow, which exacerbates the manpower problem. The BMA, the royal colleges, and the
GMC…are not putting enough effort into defining what is an acceptable workload and what are the
parameters of a safe, healthy working environment.

And what of my sons' futures? My pilot son will continue to have regular health checks, strictly regulated
working hours, and rest periods. He will receive planned retraining and routine evaluation of performance,
and will work in a supportive psychosocial environment. My medical son will continue to work in an environment
that is demonstrably psychotoxic, and for a system that strives to meet political rather than health targets,
where there is limitless demand, and where the concept of a safe working environment is poorly developed.

[Captain Stable]

The "Culture of Blame" is still alive and well in the medical profession. It creeps back into aviation on occasion, but is no longer as welcome as it once was. Various medics are making moves (there are several senior people in the BMA pushing for change) to remove elements of blame from investigations into mis-treatment of patients, but they have a very, very long way to go yet.

Makes you think, dunnit?!

Thanks for posting that.

[Sir Kitt Braker]

While interviewing a doctor for a flying job with Big Airlines, I asked him about training for operations in hospital theatres and how it compared with his flying training. His reply, much to my horror, was: "Watch one- do one"!

[slim_slag]

His reply, much to my horror, was: "Watch one- do one"!

It's "See one, do one, teach one"

[Draco]

I think that is an interesting parallel / contrast.

A surgeon friend of mine once told me that I could do most of the operations he does after 30 mins training, particularly hip replacements. "See one, do one" appears to be the rule.

He also mentioned that most of the equipment used for hip replacements is avilable from DIY stores....

[Stratocaster]

I'm sure surgeons'philosophy ("Watch one, do one, teach one") would be slightly different if they had to slice people like pizzas in the open, with 25 kts crosswind, freezing snow and CATIIIc visibility.
:D

[Lou Scannon]

I always have a laugh when people like the CAA seek the opinions of the docs on the subject of regulations to prevent flight fatigue.

Given the way they treat their own juniors why on earth do we consider their opinion on the subject as in any way valid?

Now if we asked them about sleep deprivation...

[Mac the Knife]

Urrr.. Hate to sound like an old fart but stints on duty from Friday morning to Monday evening (80 hours +) were not that rare when I was a houseman/SHO. Sleep deprivation was endemic - I remember hallucinating on Mondays after a bad weekend. You napped when you could, ate when you could - it was often too much trouble to go back to the doctors quarters and you slept on a trolley in a quiet corridor. Mess food was variable to inedible and often cold when you got to it. Often in the local pub and most of us drank too much. Lots of people smoked. No AIDS so you screwed anything with tits. Getting sick was letting the side and your chums down. Senior backup varied from good to nil. You were expected to make hard decisions alone and mistakes were viewed harshly. "See one, do one, teach one" happened a bit, but you were sometimes paintakingly taught by master craftsmen. You learned from your mistakes and the mistakes of others. There was no job security (no training schemes or training numbers as there are now) and after your six months (sometimes a year) you were on your jack jones. Never knew where you'd be working this time next year. If you didn't get on with your boss you got a cool reference and that was the end of many a career.

Relationships broke up, there were suicides, breakdowns (another career-stopper) occurred, addictions happened. Many dropped out and became GPs (easy in those days - no training required, you just joined a practice). There was no culture of entitlement and you had no rights. It was very hard. Only the tough and cunning survived. It was (of course) not dissimilar to the old style prep and public schools (with fagging but no beatings).

Psychotoxic - yes, I'd say so and I'm still counting the cost. It also bred toughness, independence, survivability and loyalty - only sometimes at the expense of compassion and caring.

Shadows of the cruel old system survive, but at least theoretically the boys and girls now have some rights (still doubt you get much change out of asking for them though). Careers are more structured and less haphazard. Formal training has replaced the haphazard apprenticeships of the past (though I still think it odd when the chaps have more publications than operations under their belts). Consultants are politicians first, surgeons second. The colourful old "characters" of the ward and theatre have been replaced by slick creatures of a Blairean blandness. Sir Lancelot Spratt is dead, killed off by audit and performance assessments, but patronage still reigns. Individual kindnesses has been replaced by committees, social workers watch you for political correctness, patients rights override your own and the lawyers wait to pounce.

Are we better off - patients and doctors? Yes, I suppose so but it's a dam*ed sight duller.

[Fat Tony]

Must show this to my mother!!!! She has got used to the pilot son thing- I've been aviating for about 5 years with the world's favourite (supposedly)- but my little sister qualified about 4 hours ago, after 5 years of work, as a doctor!!!! Does she know what she's letting herself in for I wonder...? I think she thinks that she does! We will see...

It is almost unbelieveable to see what pressure and stress our medical colleagues are put under because of a lack of protection in law.

We don't 'bend' rules (even if our companies try to get us to do so) because at the end of the day it's my license the CAA can take away if I break them. (I refer specifically to areas such as Flight time and limitations)

I think that some similar system of regulation would not go amiss in the medical world....

[Idunno]

Tony..Aviating with the worlds favourite...well, as a fellow member of the Oneworld bunch you might like to know that my employer is now demanding that I work to legal maximums and minimums.

The days of 'hallucinating' pilots may not be far off.

You're probably next.

[Captain Stable]

There are certain elements within the CAA who have intimated to me that, with some airlines having cut back on pilot numbers and with significant numbers of pilots still looking for work, more attention than usual will be paid to airlines' FTL, PDH and roster records this summer. I understand a briefing has been provided to FOI Inspectors.

It was news I was very glad to hear. They will, I am told, be coming down like the proverbial ton of bricks upon anyone who appears to be treating the CAP371 "limits" as targets. If the answer is that they can't do anything else because they don't have enough pilots, they will be told to hire more, or cut the schedule.

If told that they need to stay competitive, then they have cut their own throats. Safety must never be subordinated to commercial concerns.

At more than one airline for whom I have worked, I have queried a roster I was given and was told "It's legal, so you'll have to work it." My answer to that is the catch-all clause in CAP371 which states that a pilot, if he knows that he is, or suspects that he may be suffering from fatigue, he MAY NOT FLY.

Disrupted sleep patterns, positioning, dead-heading, taxi rides, use of hotel instead of being able to go home etc. etc. all add to fatigue.

After querying a roster, I generally provide a written note of my reservations and ask for the explanation and justification to be given to me in writing. You'd be surprised at how often the roster is quickly changed!

Remember that, in law, the safety of the flight does not rest in the Rostering or Crewing Departments' hands. It is down to the Captain. Ultimately it is his head on the block.

[Lou Scannon]

It would be nice (and rather suprising) to see the CAA at last take a more proactive role with the companies who use CAP 371 as a target and base their crewing levels on the hours that are possible under that set of rules.

I know of at least one company who, following "9-11", cancelled their scheduling agreement without any discussion or reference to the FTLC. Their pilots are still operating to CAP 371 some seven months later.

Perhaps the CAA wheels grind slowly...

[earnest]

Strange how both medics and pilots, both of whom have others lives in their hands, have been "exempted" from the European Working Time Directive, ie are not limited to the recommended maximum amount of time they can be contracted to work per week. Any politicians/union officials/airline management out there care to explain why? Just curious.

[WorkingHard]

FS - Not only is a doctor's job for life they have VERY VERY protected working environment. You and I the paying public have no say in what a doctor can and connot do. To whom do they report? The average GP for example works to a contract with the local NHS and the details of that contract are never allowed into the public domain. So we the paying public have to go to someone who holds life and death over us, can not see what the terms and conditions are and are expected to accept without question the treatment given. Some comparison with the average pilot!!!!!!! Not only that BUT a good doctor cannot even set up in practice where he pleases. He has to get permission from the appropriate body controlled by thye GPs and will not be allowed to set up where it might be competition to an existing.
Who would rather be a GP than a pilot?

[SRB]

I have to correct you, Scottie, on a few points. A doctor's job is not for life. As Mac the Knife pointed out, the contracts for junior doctors are all short term, and making Consultant grade is in no way guaranteed. You have to have all of the ticks in the box, plus the "necessary" research papers under your belt (hence Mac's comment about surgeons with more papers to their name than operations), then you have to find someone within the NHS who will employ you. There are still more junior doctors aspiring to consultant jobs than there are consultant posts available. If you miss out, then you're in the doldrums for the rest of your career. A permanent first or second officer so to speak, with no chance of switching companies and trying afresh.

The NHS has plenty of jobs, hence no redundancies, but many are quite dire and consequently are filled by locums, many of whom are "passed over" career hospital doctors. All tend to be short term contracts, so no job security there, or job satisfaction.

As for salaries, the starting salary for a hospital consultant in the NHS is not that great bearing in mind the time and effort he or she has put in to get there. It equates to senior FO level in most decent airlines, and you do not have the pick of your work. You do as you are contracted to do, just like the airlines. You can pick up private work later, but only if you work to make a name for yourself, and all UK private health insurers insist their consultant has been appointed as a consultant within the NHS. Their way of keeping up standards.

I also take issue with the rather macho " see one do one" approach to operations as stated by some. (We all exaggerate a bit for effect.) In reality it was rarely like this as the senior surgeons (or physicians or whatever) ultimately carried the can for their team, just like the aircraft captain. Usually you had seen and practised a particular surgical procedure plenty of times before you were let lose solo, and then the boss tended to be not very far away for your first few goes, just in case. That's how it was in the UK at least. On this note bear in mind medical training, at least in the UK, was and still is extremely thorough, even compared to flying training. By that I mean before a doctor qualifies he has really been at the front line of real emergencies, not simulations. There lies the difference when pilots occasionally whinge about "continuity training" for doctors. Every patient a doctor sees has a problem, some serious, and in hospital medicine many are very serious or dire emergencies. Very few pilots see real emergencies, hence the 6 monthly proficency checks. I think flying is the better career these days, but that's just my personal opinion as a guy who has done both.

[knows]

earnest, It baffles me too.....
Why is this issue not highlighted?

[Blacksheep]

There are no sinecures. If doctors seem to have it tough, take a look back at pilots' conditions in the early days of commercial aviation just after the war. It was easy to get pilots to fly like that, for at least no-one was shooting at them any more, but it was hardly conducive to safety. The present environment was born out of an appalling safety record at a time when the dismembered and charcoaled passenger victims were usually from the international elite. If the doctors want better conditions then they need to negligently bump off a few Ministers, MPs and Captains of Industry and make sure the press have plenty of shock-horror 'crash and burn' type stories to frighten the public.

BTW, the pilot community have a lot for which to thank newsmen of the "Monty Orangeballs" genre. Their sensationalist reporting of aviation accidents is at least partly resonsible for the conditions that exist in aviation today - at least for the pilots.

**************************
Through difficulties to the cinema

[Capt. Crosswind]

To: Capt. Stable
Many years ago I flew for a company where one was often asked to overlook duty rest cycles. Nudge, nudge, wink, wink it will be okay.
The Union asked a lawyer to look at the consequences of an accident if the flight deck crew were in breach of the regs.
The answer was startling to say the least:
*The Captain was responsible for ensuring he & his crew were within the regs ( NOT the company)
* The Captain or his estate could be sued by all the pax or their
next of kin, the crew or their next of kin & the company!!

I wonder if this still applies ??

[Mac the Knife]

Scottie - "Most competent Doctors are able (sooner or later) to move onwards and upwards into very well paid..." Depends what you mean by "very well paid" and where you are. Very few of us are as wealthy as you suggest.

"..and very secure positions for the last 3rd of their working careers."
Physical fitness requirements are naturally less than for pilots, but your implication of a universal sinecure is far from correct.

"...a flick through the UK tabloids will unearth story after story of malpractice / negligence / incompetence in the medical profession."

Yup. But how many of these turn out to be true and are properly substantiated? How many complaints does the General Medical Council [GMC] receive yearly (many thousands) and how many result in disciplinary measures (very few). This is not a reflection on the zeal of the GMC [which has been restructured to include a large proportion of lay persons] to protect the public (this is now their motto, as if all doctors were intrinsically venal or incompetent), but rather a true figure for the number of unfit doctors.

Some sort of system of revalidation of doctors is currently in place and under very active development in most 1st World countries.

So much for "...since the medical profession will never allow such testing..." !!!

Currently one technique is the system of "Continuing Professional Development" (CPD) points. In order to continue in practice, doctors must rack up X number of CPD points per year. Points are awarded for attending conferences or seminars or filling in MCQ questionnaires at the end of journals to show that one has at least read the article or articles in question. Getting the required number of points is ludicrously easy and proves nothing at all. CPD rewarded drug company sponsored "seminars" (with snacks) have become an industry in themselves. This is not a criticism of a good concept but of it's implementation (quite difficult if it is to be meaningful).

"Performance Assessment" is difficult when the long-term results of a treatment or operation only become apparent years in the future. Proper auditing is expensive, extremely labour intensive and requires not only real actuarial skills but also an in-depth knowlege of medicine and the disease process and procedures in question [this isn't to say that it can't or shouldn't be done]. The long training and stringent recruitment culls all but a microscopic proportion of the truly incompetent. We can all recognise gross incompetence when we see it, but marginal performers are more difficult - for by whose standards do you judge? Of course we all aspire to the impeccable results produced by the handful of academic world experts in whatever it is we do, but are we coalface workers to be reprimanded if we fall short? When the well-funded international expert (who often does little else) boasts a 0.5% complication rate for a procedure, when are we considered derelict? 2%? 5%? 10%? It all depends which of the myriad of available procedures we are talking about and where and under what circumstances it was performed.

"free from the worries of.....testing of his professional skills." Come on now. We are all tested every single day of the week (and often at weekends) whereas pilots are tested only when they are flying or in a sim(which is a lot less than that).

Unfortunately we don't have simulators of sufficient sophistication to allow genuine testing of our abilities and decision making skills. I wish we did - it would make my life as a trainer a great deal easier and allow me to do "dry-runs" of procedures that I perform infrequently.

The problem with this discussion is that although there are superficial resemblances between the life and work of doctors and pilots, they really are very different. We are not perfect,but some members seem to have (doubtless through no fault of their own) rather worrying views about our morals and attitude to our work. Obviously that we don't project too well.

Having said that, I think that we have a great deal to learn from the aviation industry. In particular, we have no formal training in CRM and indeed the term is unfamilar to most doctors. PPRuNe has stimulated me to read and learn about techniques of CRM and attempt to put them into place in my environment with some success, so perhaps Danny has achieved more than he bargained for.

[SRB]

Once again I agree with Mac the Knife but would like to add a few more points in reply to Scottie's last but one post. Many competent, and thoroughly decent doctors don’t move into the higher grades because of what Mac mentioned in his first post, ie they have not worked for the “right” people, been seen to do the “right research” etc. Many are sidelined into areas they do not wish to work in, and their career in their chosen specialty is essentially finished from that point on. I have witnessed interviews with competent doctors at registrar or senior registrar grade, with 10 or more years of good experience behind them, applying for lower graded posts just to stay in paid employment. They will never, ever, make Consultant, the equivalent of “Captain” if you like.

I agree aviation is sometimes a precarious industry employment wise, but so are many other jobs, and the people in those jobs also have similar problems regarding the transfer of their skills. Pilots are in no way unique in this. If, however, 90% of Captains remain as one under whatever salaries and working conditions they achieve, then arguably that is not bad. My experience of Captains is that most do not wish to be promoted to management grade, or even into training. The same is true for Consultants.

I am not a nit picker but, as Mac said, you can’t base a profession’s competence on what you read in tabloids (except, perhaps, the profession of journalism). To play devil’s advocate here, if so many aircrew were that competent then would we need to have publications such as Feedback or procedures like CHIRP? I actually think most people in most professions are very competent and professional, and quite conscientious, and I certainly believe this to be the case in both medicine and aviation. On the point of professional testing Mac has said it all, I would only add that the human body and psyche is far, far more complex to deal with than anything I’ve come across in aviation.

An interesting aside on Scottie’s final point about the pilot dying when he screws up. A respected aviation psychologist studied the similarities between the two professions (he used anaesthetists) and concluded that the stress experienced by either the doctor or pilot was actually very similar, ie it made little difference to the stress experienced as to who was actually going to die as a result of your mistakes, yourself or your patient. Surprising, but I think he’s probably correct. (I’d quote the reference if I could find it amongst my old papers but I, too, have to go to work).

You've posted again since I drafted this, Scottie, and of course one can't argue against your personal experiences or those of your consultant friend. Many guys do make it, there's no argument against that, but I am only recounting my experiences within the UK's NHS system and aviation set up. That pilot's have to pay for thier own training is another issue and I sympathise with your feelings on this. There are, however, always people willing to do this. I too have children and I would not encourage them to go into medicine as it is today, or has been for the 20 plus years I've known it. I would recommend commercial flying, though, and I don't know too many aviation colleagues who would follow a different career if they could turn the clock back. Again, it depends on our own relevant experiences doesn't it?

[Captain Stable]

Capt. Crosswind:-
From the UK Air Navigation Order:-

Article 72:-
...
(2) The operator of an aircraft to which this article applies shall not cause or permit any person to fly therein as a member of its crew if he knows or has reason to believe that the person is suffering from, or, having regard to the circumstances of the flight to be undertaken, is likely to suffer from, such fatigue while he is so flying as may endanger the safety of the aircraft or of its occupants.

Article 73:-
(1) A person shall not act as a member of the crew of an aircraft to which this article applies if he knows or suspects that he is suffering from, or, having regard to the circumstances of the flight to be undertaken, is likely to suffer from, such fatigue as may endanger the safety of the aircraft or of its occupants.

(2) A person shall not act as a member of the flight crew of an aircraft to which this article applies unless he has ensured that the operator of the aircraft is aware of his flight times during the period of 28 days preceding the flight.
As I read that, the onus is upon the company and upon each individual crew member, without a general responsibility for all lying with the aircraft commander.

Article 43, Pre-flight action by commander does not include any injunction to check crew members' duty hours. However, if the fact of one or more members of his crew being out of duty hours, or fatigued to a degree to which they would not be able to perform their duties were to be brought to the commander's attention and he still commenced the duty, he could quite possibly be held criminally negligent and therefore liable as per your post. The company and its directors would, however, also be jointly and severally liable. The offence of corporate manslaughter is still untested in the UK.

[Capt. Crosswind]

To: Capt Stable
Thanks for the info.
The UK regs seem to button things up nicely.
No doubt over the years due to BALPA's efforts.
The situation I mentioned was in the distant past (1960's) and the OZ ANRs applied. They certainly then did not cover the subject with the thoroughness of the UK regs.

[Ignition Override]

Earnest: are British airlines "managed", so to speak, by the same species of attorneys and accountants which very often run the US airlines? If so, good luck to pilot union solidarity in the UK (useless without total situational awareness among leaders). Without both, you are 'gator or shark bait waiting to be consumed.

From what I've read in many articles, Southwest Airlines leader, Herb Kelleher, is a rare exception to the reptilian attitudes of so many of our so-called airline "upper managements".

I never knew that the brand new doctors over there had such cold treatment with so little support from the higher ranks-it must be really rough on the brand new nurses, also? Is a nurses' role in the medical profession (US or Britain) about what a Petty Officer's role is said to be in US Naval Aviation, they actually run the operation but never have the more prestigious titles or rank next to their names?

[Captain Stable]

IO, yes, mostly our airlines are run by lawyers and accountants.

And our hospitals are run by "managers" who, often, have no clinical knowledge at all. Money is the overarching consideration, not patient care, nor the fatigue state of junior doctors, nor the working conditions of the nursing staff.

[Ignition Override]

Capt Stable, Sir: And so much of the medical system (maybe some airlines too?) is managed by the type of jerk on the BBC show "Waiting For God"?

It is interesting how often we pilots in the US hear about middle management bonuses, possibly for shafting our own passengers?: reportedly paid for cost compliance versus superior passenger service. Can't mgmt somehow quantify the need/expectation for people (who keep us employed) to be allowed to get to the gate, or as often happens, allow the gate agent to keep the main cabin door open so that last minute folks can step onboard? We often, after finishing the "preflight" and "before start" checklists, might still be waiting a few minutes for the two cargo doors to be closed and/or need a pushback crew with tug.

Once at NY's Laguardia Airport, a mechanic told us a few years ago that due to a broken jetway, passengers had been forced to stay on a plane about 30 minutes, in order to shuffle some planes around between gates needed for the early morning departures-if the A-320 had been allowed to park after initial taxi-in, overtime would have been paid to certain employees in order to swap planes in a longer sequence for the later needs.

Pardon my long sermon to the yawning choir. Maybe some US airline middle mgmt types would care to respond?

[cirrus driver]

Non-Newtonian,

Thanks for the post. It outlines the ridiculous and unsafe demands which can be made on RMO's in the name of 'training',aka slave labour.
I was an RMO nearly 40 years ago and disagree with Mac that it is the ideal system.
Fatigue related mistakes were made. They were not the great old days.The attitude of the health administrators was ridiculous.
In Oz, now those days are over.
We recognise that a sleep deprived individual has the reflexes of an intoxicated ( alcohol) individual.
Such a person should not be in charge of an aircraft / motor vehicle or a HUMAN LIFE.

Cirrus,( retired consultant physician, active pilot)

[Mac the Knife]

gee Cirrus, I'm pretty sure I never said it was an ideal system because it certainly wasn't. I do admit to a certain rose-tinted nostalgia though. Also, I'm a bit disturbed by kids who can recite pages and pages of government regs. and who know all about the minutiae of practice management yet cannot percuss a chest and have to be taught empathy. The very strict limits on working hours are now leading to problems of reduced experience so I guess the ideal system still has to be worked out.

[Bally Heck]

Who was it that said that doctors are incapable of discerning between subsequence and consequence? ;)