CRM in the Operating Room

Great Debates
1

Over in the Omnibus Stupid MFers in the news thread (Part 2), @Llama_Llogophile posted:

That strikes me as a very interesting discussion to be had. Given the comment about frustration and power dynamics, I think this should be in Great Debates. Mods, I’ve no objection to this thread being moved.

I’m very addicted to watching Mayday/Air Crash Investigation. In a number of episodes, the narrator discusses Crew Resource Management (CRM) for aviation. As it turns out, the maritime industry has Martime Resource Management. Llama_Llogophile’s post brings up some questions for me.

  1. What issues are currently known to hinder ORRM (Operating Room Resource Management, to coin a term).
  2. What issues, not currently proven, could appear in implementing ORRM?
  3. How could the medical field cure those?
  4. I’m really focusing on the bit about checklists. How manageable would those be? How could they be used in the Operating Room?
  5. And here’s a biggy. How can the hospital management get the lead surgeons to actually follow these without “going cowboy”?
  6. I’m sure there are other questions/issues/dire warnings/etc. to add here.
2

Well that was quick!

So, a little background on what I know about Crew Resource Management (CRM) as it applies to aviation and medicine. I’ve been an airline and charter pilot and have thankfully worked during the time that CRM has been a standard component of the industry. I know some guys who were flying in the 60s and 70s and they have some hairy stories to tell - they were basically at the mercy of god-like captains who could be dismissive and abusive with no consequences. Of course, that dynamic led to a number of high profile crashes and much loss of life, which led to the development of CRM. Everything had changed by the time I arrived in my first professional cockpit.

From day one in my career, I was treated respectfully by even the most senior captains. Most of them urged me speak up if I saw or sensed something going awry, were grateful when I caught mistakes and I felt the same when they caught mine. Flight attendants and other personnel are also considered crew for this purpose and the idea is to make use of everyone’s abilities, especially when problems arise. It’s been a huge success and is almost certainly the most important reason we now live in a golden age of airline safety.

Why was this huge change so successful in aviation? Because major mistakes cannot be hidden. Back in the day there were, literally, smoking craters on a fairly regular basis because of crew mistakes. Things like captains running out of fuel while troubleshooting lesser issues and nobody being bold enough to say something.

So why isn’t medicine being quicker to learn these lessons? I’ll continue in Part II…

3

Part II - Medicine and CRM

So, I’m not a medical professional. My information comes from a number of friends who are pros in that field, and a couple of people with expertise in both aviation and medicine. Both of those people are involved in bringing CRM to medicine. One of them has all but thrown up their hands in frustration.

We’ve all heard horror stories about some poor patient who’s had the wrong leg amputated or the wrong kidney removed. I’m told that sort of thing had been largely obviated through the use of checklists and practices such as using a marker to actually write on the person’s leg - AMPUTATE, or something similar.

But as I said in the other thread, checklists are the easy part of CRM. The hard part is changing the culture.

It’s getting people with power (captains / doctors) to give up some of that power. It requires allowing colleagues with less experience and stature to participate and speak without fear of consequences. They must be allowed to say something when they sense a mistake being made, even if they aren’t certain exactly what it is. From what my friends tell me, that’s a very hard sell when it comes to doctors and nurses. There’s a lot of history there, a lot of formalized relationships. And one other big one…

Medical mistakes are much easier to hide than plane crashes. I’ve seen statistics claiming medical errors are in the hundreds of thousands per year and account for a lot of deaths. That is confirmed by both of my aviation / medical colleagues. One feels it is the scandal of our age and their solution would be an “FAA for medicine”. Apparently there is no single body enabled to set standards and discipline doctors in the way the FAA oversees pilots.

That’s all for now - I’ll look at other posts and see if anyone wants to further engage with what I’ve said.

4

ETA: I did not have a chance to read @Llama_Llogophile’s posts yet. So the below is written without benefit of his insights.

I have MD/DO doctors, NP/PAs, & nurses amongst my friends. My current GF is an OR nurse.

The central issue IME is that medicine is still mostly a cottage industry. If 100% of the doctors, techs, and nurses inside Hospital X were direct employees of Hospital X, then Hospital X could request, then demand, then enforce new ways of doing business. Assisted by the Federal Medical Administration that promulgated standards and could issue corrective action, like license suspension or loss, when folks refuse to get with the program.

Instead, there is no FMA, there’s sort of a Doctors union (AMA and state level similar), and pretty much every doctor is self-employed. Or a member of a 10-person company / partnership of docs.

Lots of nurses are contractors, working for a staffing agency, and in the course of a week might work at 4 local hospitals. Many others are itinerant, accepting 3 month jobs in a different city each time. In exchange for a very nice wage.


Getting CRM going in aviation took a LOT of head knocking by powerful agencies and large employers fully willing to crush a few employees on the way to getting compliance from the rest.

And then it took about 30 years for the entire crew force to turn over, so everyone at every level of the company had grown up and spent their entire career in a CRM-centric world.

I retired almost a year ago after 34 years in the big airline biz. The oldest of the old I ever worked with were born in the 1930s and hired in the early 1950s. By the time I started in 1989 most of them had grudgingly accepted the new way, but could still be formidable curmudgeons and blisteringly sarcastic at any rookie who pushed back in error.

I’m happy to say the newbies I was working with the last few years universally report there’s nearly none of that attitude anywhere anymore, and they simply won’t stand for it.


My bottom line: It starts with turning a cottage industry into an industrial behemoth. The it takes serious management effort, both carrot and stick. Finally, it takes 15-20 years of generational turnover to get to the fat part of the benefits.

There’s more to say, but I want to get this on the wire and move on to something else.

5

Adaptation of CRM to the operating room has been going on since the 1980s, with apparent success.

How well this applies outside groups like OR and emergency department teams is another matter.

6

Several doctors have told me there is a consistent problem with internal medical oversight performed by doctors who will ignoremistakes that should be studied and prevented in the future. The problem is not simple, complicated by the nature of malpractice law, egos, and internal competition. Admitting mistakes, or even that a mistake happened is not part of MD culture. Department heads have too much power within a hospitable to affect the careers of the staff doctors. They don’t want things to change, they want to retain that level of control.

You probably recall the South Korean airliner shot out of the sky by the Soviet Union after entering their airspace. Investigation showed absurd undue respect for airline pilots that would keep the rest of the crew quiet even while the pilot is making a deadly mistake.

7

Disclaimer: I work in neither aviation nor healthcare.

I would imagine one reason CRM caught on much sooner in aviation was because the consequences were simply much greater per incident, and much more heavily covered in the news, as was alluded to above.

The failure of a crew to practice CRM could lead to 300 people dead, direct/indirect loss of $500 million, and an incident that makes front pages around the world. The failure of a surgeon and his nurses to do CRM in the operating room might get zero media coverage.

8

CMS (Centers for Medicare and Medicaid Services) and the Joint Commission sort of serve that role. Most hospitals in America get a substantial percentage of their patients from Medicare or Medicaid, so for CMS to tell a hospital that it’s not going to approve any of its members going to that hospital for treatment could very well kill the business. So hospitals take Joint Commission audits very seriously.

9

I’ll just mention that I’ve long been a fan of the surgeon and writer Atul Gawande, whose writings I first discovered in the New Yorker, and have since read all his books. One of his books, The Checklist Manifesto, is directly related to this topic, and specifically talks about applying lessons from the aviation industry to the practice of medicine.

That aside, for those interested, I’d also highly recommend Complications: A Surgeon’s Notes on an Imperfect Science, and Better. There’s also Being Mortal: Medicine and What Matters in the End but that one is rather depressing.

10

CRM in aviation has another factor. Two pilots with equal credentials. One does the work, the other supervises the work. An hour or 3 later they swap roles.

Imagine a medical practice where two docs (Doc A and Doc B) walk into your exam room. Doc A interacts with you and your issue while Doc B sits there quietly paying attention. At the end of the exam, A turns to B and says “What else do you want to add or change? Anything I skipped or misunderstood?” Now Doc B may poke and prod at the patient themselves, or just ask questions, or say “Nope; I agree that was thorough and I agree w your conclusions.” Now they both look at what was entered into the case notes (paper or computer) and both sign them.

Your encounter is over and they move on to the next exam room. Where Doc B takes the lead role while Doc A watches.

Tomorrow Doc A won’t be paired with Doc B. Instead Doc A will be with Doc J, while Doc B is working with Doc T today.

The same process would apply to every specialty in an operating procedure. One to do and one to throw the penalty flag as soon as they see the beginnings of a mistake. Because mistakes / oversights / non-optimal play happens continuously. Every procedure has them. And until there’s real-time monitoring by someone of equivalent stature / expertise, there won’t be goof reduction / more optimal play.

That continuing mixing and matching of equals is an utterly necessary part of the program. If the system can’t / won’t pay for the redundancy of two equal experts, the system will fail.


Semi-related to the above, the medical biz has the problem of docs & nurses who have different, but overlapping expertises. The situation is not at all analogous to pilots and flight attendants.

In reality now, medicine uses nurses as an informal “copilot” to the doctor’s “captain”. But without the official credentials to be a real copilot. Although often they have similar or better expertise for the particular event or error about to be committed.

A very loose analog might be the many bizjet operators in the old days who’d use any unqualified warm body lightplane pilot as their copilot. That person was more useful than a bag of salt, but far less useful than a truly qualified experienced copilot rated on that jet. And the captains in those situations expected to do everything themselves, where the copilots’ role was specified to be: “Sit there, shut up, and do just what I ask when I ask for it. Period.”

With the expected high accident rate.