Risk Mitigating Debrief

Huge strides have been made in improving safety through risk mitigation/management by implementing Human Factors techniques. Most of this improvement is through operational TEM strategies for future mitigation and real-time management. Ultimately, a tool is needed that conforms to a Continuous Improvement (C I) model that will drive safety. Continuous Improvement requires the ability to asses past behavior and drive future improvement.  Let’s look at an operational debrief that meets that criteria.

In their postflight procedures, most airlines incorporate a debrief requirement. The obvious goal is error identification, with a secondary goal of error reduction. We do well at error identification, but will identification alone, provide error reduction? The answer is no! Merely identifying the error, brings us no closer to future error avoidance.

Error analysis shows us that causality can be two or three stages removed from the error. We must make causality identification our primary goal, if we hope to reduce errors. Clearly, in many cases, causality is not obvious. In fact, it often hides behind behavioral masking.  Behavioral masking is where we see a miss-applied behavior that superficially describes an error. It is easy to point to a behavior and believe you have identified the error. Problematically, if you don’t continue past the behavior to correct the foundational causality, the behavior will be repeated.

How do we provide the crew with a simple and operationally functional way to address causality and error reduction?  Some airlines use a “Safety, Legality, Standard” debrief format. Let’s use that as an example and explore ways to make it functional.  Typically, the Captain asks the F/O, “Were we safe? Were we legal? Were we standard?” If the flight was uneventful, as most are, the answers are “Yes, Yes, and Yes!” and the debrief is over. But, the question is, were there areas for improvement during that flight? And the answer to that question is unequivocally, yes!  We, as humans, will always make errors. We are incapable of perfect performance in a true sense. We can set standards of performance that we can meet perfectly, but we can never be perfectly standard in all things.  So, on that uneventful flight, how do we mine the event for the nuggets of value that will yield long-term performance improvement?

By taking the above debrief format, and converting it to a causality based format, improvement, from a C I model, begins to take shape.  Applying a priority structure to the debrief, captures the most significant error, creating a mitigation strategy based on priority. In the short time available, at the end of the flight, the debrief must be focused and functional.  A good debrief is specific, positive, focused and defines a clear behavior/action for improvement.  To achieve that in a short debrief is the test of operational effectiveness.

A Continuous Improvement model debrief would look like this: Captain: “Were we safe today?” F/O: “Yes”. Captain: “Did we capture any errors that could have resulted in a Safety of flight issue?” F/O: “No”. Captain: were we legal today?” F/O:” Yes.” Captain: “Did we capture any errors that could have resulted in a Legality issue?” F/O: “Yes, remember when you set the PD altitude for the crossing restriction and I had to remind you to arm it? We may have missed that restriction if we missed that error.” Captain: “Oh, yea, what was I doing that distracted me so you had to catch that?  F/O: “You went into the FMS to set the crossing restriction before setting the FCP.” Captain: “Ok, my goal now is to verify all FCP changes prior to moving on to any other duties.”

Does the short exchange above meet the requirements of being “specific, positive, focused, and defining a behavior/action for improvement”?  First, by using a prioritization model, we move from the most serious criticality, safety of flight, down to the lower criticality of legality of flight. There are no errors captured regarding safety, so the next level, legality, is explored. Upon identifying a captured error regarding legality, the debrief stays focused on that issue until a positive outcome is developed. Good CRM is reinforced through the F/O involvement in error identification and analysis.  Mentoring occurs when the Captain verbalizes a corrective behavior/action and commits to change implementation.

Having identified causality and mitigated the most serious error through behavior/action improvement, the debrief is over. Standardization is never addressed because the more serious error takes precedence.  Prioritization allows for a short, defined, functional debrief, that crews will be able to practice. This simple 3 step approach will yield great improvements daily.  1) Identify the most serious error (captured or not), 2) Discover why it occurred (distraction, lack of knowledge, etc) 3) Commit to a mitigation strategy.

With a Continuous Improvement debrief, crews will have a true means of error reduction. If each crew identifies one error per flight and mitigates with behavior improvements, the annual safety improvement potential is enormous!

 

Operational Culture and Human Factors Challenges for the new Millenia.

Since the Air Commerce Act of 1926 established standards, aviation safety and performance has been improving across the industry.  Those early aircraft were very different from the ones we fly today. As technology was developed, the same historical philosophy and procedural concepts were applied to very different aircraft, and a more complex and challenging air traffic system. Eventually, it was recognized that changes needed to be made. Improved automation and complexity required new and different skills. However, the way we organize information and how we teach it remains, in a large part, the same.

With offerings like the American Airlines video “Children of the Magenta” we began to see unintended consequences of automation dependency.  With two-man crews and more complex systems, task saturation, loss of situational awareness, reduced technical knowledge and deterioration of flying skills have often become problematic. (Air France 447, Asiana Airlines 214, etc.)   We seem to be facing greater challenges, not fewer, therefore we are seeking solutions. But, are we looking in the right place?

If we accept that the systems we interact with are relatively stable, then it is in the human interaction with those systems that we must seek change.  There are two areas to assess in a generational interplay, that may reveal hidden challenges. These challenges are revealed by looking at the design and function of the brain in an operational way.

In “The Organized Mind: Thinking Straight in the Age of Information Overload” Daniel J. Levitin, PHD, says, “The human brain has evolved to hide from us those things we are not paying attention to. In other words, we often have a cognitive blind spot: We don’t know what we’re missing because our brain can completely ignore things that are not its priority at the moment—even if they are right in front of our eyes.”

When we are distracted, things we have trained and memorized to perform are missed, not because we are not doing our job, but, precisely because we are!

Levitin goes on to say, “Memory processes can easily become distracted or confounded…” and “The most fundamental principle of the organized mind, the one most critical to keeping us from forgetting or losing things is to shift the burden of organizing from our brains to the external world.” This is a critical concept appropriate to our discussion.  How is this involved? We memorize limitations, systems, procedures, policies and a myriad of other requirements.  Much of that is needed in the functional memory, the question is “where can we shift some of that burden to free up brain capacity for increased SA and reduced exposure to error?”

New strides in Neuroscience have helped us understand how to maximize brain effectiveness and things that degrade our abilities. Situational Awareness requires gathering and associating massive amounts of information. Daniel Goleman, PHD, writes in “Focus; The Hidden Driver of Excellence”, “Our mind holds endless ideas, memories, and potential associations waiting to be made. But the likelihood of the right idea connection with the right memory within the right context—and all that coming into the spotlight of attention—diminishes drastically when we are either hyper focused or too gripped by an overload of distractions to notice the insight.

The generational interplay identified earlier, now becomes important. There are multitudes of articles that discuss the lack of memorization required of our young people. Many educators celebrate free thinking, however many lament the lack of mental discipline and foundational availability of knowledge. Regardless of the outcome of the debate we must adapt to the reality of the minds and skills that will occupy our cockpits.

Perhaps we need to take a truly revolutionary view of the task at hand and rethink the very nature of piloting traditions?  We have been a “checklist” industry since there were airplanes. Instructors constantly correct crews when they see a lack of memorized flows, they say, “that is a checklist, not a do-list”.  Can we hold the “millennial” accountable for information taught using “old generation” theory, when we now have evidence showing that “new generation” theory does not process information that way?

Remember Levitin’s “blind spot”? Information processing priority, will dictate whether we see what is in front of our eyes or not. He also showed that by shifting memory requirements externally, we can free the brain for better information gathering and processing, thus reducing the risk of error. Current training requirements are based on old school cultural learning. New crews struggling with memorization based behaviors without the cultural foundation to support it, are at risk.

What if checklists became do-lists.  Why do we place so much importance in accomplishing flows from memory when we could take our time and never miss an item by just following a “do-list”? Do we create unnecessary time compression and task saturation during normal operations? When faced with an abnormal and use the QRH, we insist on taking time, if safe to do so, and hold or delay arrival etc. while we follow (do) the checklist. These solid HF techniques help us gain and regain SA. So why, under normal operations, do we rely on habituated responses where our brain can lie to us?

Considering the change in learning patterns and skills of the upcoming generations, shouldn’t we be responsive and adapt? Shouldn’t we find ways to take advantage of their strengths, and recognize that the teaching skills and learning tools of the previous generations may not work so well to maintain safety in this new age? Moreover, are we attempting to solve a present and future challenge with outdated generational thinking that will miss the mark with the new age of pilots? Can we break from traditional thinking, create a new responsive operational and training environment, and bring on the future generation?

Our Job and Our Health

Researching the effects of diurnal and circadian disruption on the human hormonal system raises some important questions for the aviation community. The effect is serious and needs to be understood if we are going to try to mitigate the negative impact on our lives. This piece is research based with references throughout. However, I have also had to make connections and correlations that have not been studied and therefore are anecdotal in nature based on actual experience and interviews. Research defining the scope and impact of hormonal disruption has increased exponentially during the last 15 years. This piece merely scratches the surface and is not meant to be comprehensive. It is a starting point from which you can begin your own research and explore current information relative to your own experience.

First, all of us react and respond differently to stressors. Some people may seem to tolerate our lifestyles better than others.  Diurnal (working at night) and Circadian (time zone changes) effects are very similar in that they are very stressful to the body and cause release of Cortisol, an adrenal hormone, resulting in high chronic cortisol levels. Cortisol is damaging, by itself, to certain parts of the brain, but is also an immune system suppressor. If we are working at night or in another part of the world and are awake when we should be sleeping, we do not release other hormones that are necessary for health, such as growth hormone, (responsible for healthy replacement cell growth and general organ health), and melatonin, a serotonin releasing hormone, is also tied to the health and function of our Thymus gland. The thymus is the organ that produces cancer-fighting cells, (T-Cells) and empowers our immune system. We are inducing damage through our lifestyles. The result of which is a weakened immune system with which to fight the damage, and a weakened hormonal system unable to repair or rebuild that damage.  To make it worse, all those systems begin to decline naturally in our fifties. We often impede the body’s ability to maintain normal health far beyond that of normal aging. The acceleration of decline after age fifty becomes exponential rather than linear.

Additionally, there have been many recent studies that definitively show a correlation between circadian disruption and increased growth rates in cancer. With a weakened immune system and increased cancer potential, pilots are often in an environment that accelerates cancer growth!

Pilots are go oriented and often place financial or family goals above personal comfort. They will just press on and believe they can hack it.  If they were aware of the actual health implications, perhaps many would make different choices.

This article should raise awareness and help define the questions you should ask yourself, your company, and your doctor (probably not your FAA Doc) about how to stay healthy and increase your potential for longevity.  Much of what is presented is based on research of individual aspects of how our body operates in response to varying situations. As you read this, try to get a feeling for the potential cumulative impact of the different areas discussed based on your lifestyle.

 

Our physical strength is expressed through our muscles and skeleton, our function and performance rely on our brain driven nervous system, but our vitality and health are driven by our endocrine system (hormones).  Our endocrine system is a complex overlapping system of hormone release and inhibition that manages our body temperature, energy use, blood glucose level management, cell growth and replacement, and immune system function among many other things. The impact of crew life styles and schedules can be devastating to these systems. Some of this may be a bit technical however I think by the end of the article the importance of this information will be clear.

 

My research began some 15 years ago. Since that time much more information has become available.

 

In November 1998, The Journal of Environmental Medicine reported, “The airline industry may be an occupational setting with specific health risks. Pilots tend to experience debilitating effects of erratic time changes resulting from jet lag due to international flying and radical shift changes of domestic flights. Other factors to be considered” the article continued, “are circadian disruption and conditions specific to air travel, such as noise, vibration, mild hypoxia, reduced atmospheric pressure, low humidity, and air quality.”   Another article published in Nature, Neuroscience (June 2001), states, “The long term repeated disturbance of synchronization between the two timing systems (pattern of light and dark and endogenous circadian rhythms) impairs physiological and psychological health and induces stress.”

 

The same article in The Journal of Occupational Environmental Medicine found that “U.S. pilots and navigators have experienced significantly increased mortality due to cancer of the kidney and renal pelvis, motor neuron disease, and external causes. In addition, increased mortality due to prostate cancer, brain cancer, colon cancer, and cancer of the lip, buccal cavity (mouth), and pharynx was suggested”

 

While these studies clearly found a connection between our career and health risks, unfortunately, nowhere was there any cause and effect relationship. Since these studies were printed there have been several studies including the “Nurses’ Health Study” that have now shown a clear connection between circadian/diurnal disruption and increased cancer rates as well as increased cancer growth rates during exposure to disruptive schedules.

 

There is now increasing research into the impact of chronic fatigue. This early study clearly identifies potential health risks:

“Chronic sleep debt has been linked with the disruption of numerous modulators of immune function including SNS hormones, HPA hormones, and cytokines (Vgontzas and Chrousos, 2002). However, the potential role of immunosuppression associated

with chronic sleep debt has received little attention.” S. Sephton, D. Spiegel / Brain, Behavior, and Immunity (2003)

 

 

Stress has also been identified as a major contributor to decreased health. Stress is not always something we can control and it is not always bad. Stress from increased mental challenge has been found to be beneficial. Most physical and emotional stress generates negative responses.  Our bodies are stressed by and react to noise, low oxygen environments, circadian disruption, diurnal disruption, fatigue, poor diet and many other factors that we may not be able to control.

 

An article in the Nature Neuroscience June 2001 magazine, presented a starting point for research.  This study, done by the University of Bristol Medical School, looked at flight attendants over a five-year period.  The group with five days or less between trips with trans-meridian flights had high chronic cortisol levels and suffered temporal lobe atrophy and related cognitive deficits.  In layman’s terms, it means that chronic jet lag appeared to cause stress, which elevated cortisol levels (an adrenal hormone) which damaged a portion of the brain that manages memory and cognitive function. Crews who fly international trips know they stressing their body.  But they really don’t know how or why it is so bad.  To better understand, let’s look a little closer at the role of Cortisol.

 

Cortisol is a hormone produced it the adrenal glands. It is part of the hypothalamic-pituitary-adrenal (HPA) axis. What that means is that the cortisol can’t be understood outside of the interrelationship of the three glands. In identifying cortisol, other related hormones are brought into focus. Some of those that are potentially impacted by what we do are Melatonion, Growth Hormone, IGF-1 (insulin-like growth factor 1), DHEA (Dehydroepiandrosterone), and DHEAS (DHEA Sulfate).  The common link to all, is their involvement in immune system function.

 

Cortisol is an important and necessary adrenal hormone. Too much, however, and for too long, can have devastating effects on our health. Cortisol is released as a response to stress. Under normal conditions once the stressful event is concluded messaging hormones are sent to stop the production of cortisol. In a continuous stress environment that message isn’t sent. Not only that, but there is growing evidence that chronically high cortisol levels damage the hippocampus portion of the brain resulting in the inability to shut down the cortisol production during normal events. This becomes a vicious cycle that results in more and more damage. The hippocampus is also an area of the brain needed for learning and memory. Remember the temporal lobe damage mentioned above?

One of the most insidious aspects of excess cortisol is the suppression of the immune system. In a fight or flight crisis you want all your bodies energies and capabilities available for survival. At some point though you want them back to fight disease and cancer! Significantly a connection has been made in several studies to the inhibition of the cytotoxic (cell killing) activity of N-Killer cells by cortisol.  In one study of women with metastatic breast cancer, those with flat patterns of cortisol levels had earlier mortality than those with normal circadian/diurnal cortisol rhythms. This was directly related to low counts and suppressed N-Killer cell activity.

 

Most of us have heard about melatonin and it’s help in producing sleep due to its impact on seratonin levels. What is more important for us is that the thymus gland has the highest number of melatonin receptors of any organ in the body. The thymus gland takes immature white blood cells and matures them into a variety of specialized immune cells called T-cells. One particular cell of note is the N-killer cell. This cell’s job is to identify and kill cancers. Melatonin is released during the dark, at night, by the pineal gland. Exposure to light during the night can have a negative impact on the amount of melatonin produced. Reduced melatonin production may have a detrimental effect on the ability of the thymus gland to produce proper numbers of N-Killer cells among other T-Cells. Melatonin is normally on an inverse diurnal rhythm as compared to cortisol. It is usually available to the body in a low cortisol environment, at night during sleep. High chronic cortisol levels may have a negative impact here as well. The expectation of facing prostate cancer at some point in the ageing process is very high in all of the male population.  There are now links to the suppressive effects of melatonin on prostate cancer. Recent studies have identified melatonin as one of the most powerful anti-oxidants available in our bodies. It appears to have great value in cell protection in addition to all the above mentioned properties.

Growth Hormone (GH) is released usually at night during deep sleep. Disruption of sleep patterns on a regular schedule can have a significant impact on reducing the release of Growth Hormone. This hormone circulates in the body for only about 15 to 18 minutes after release. The individual cells throughout the body use GH for cellular growth and replication. GH has been identified as an integral part of immune system maintenance due to its support of the associated organs. It is also plays a major role in the health and availability of replacement cells through out your body. In patients with pituitary damage, one sign of loss of GH release is early aging. Once GH has been circulated to the individual cells in the body the rest is scavenged out of the blood by the liver. The liver then produces a sub hormone called IGF-1, which it releases into the blood throughout the day.  IGF-1 acts like insulin in reducing blood sugar levels. Insulin stores the sugar; IGF-1 drives it into cells for use in energy production and regeneration. Loss of IGF-1 causes and imbalance in the blood sugar management by the pancreas and may cause difficulties in weight control among other medical impacts. On their web page, The Pituitary Society states “In adults, GH deficiency may cause a decrease in energy and physical activity, change in body composition (increased fat, decreased muscle mass), a tendency toward increased cardiovascular risk factors/diseases and decreased quality of life (including an increased sense of social isolation).” https://pituitarysociety.org/patient-education/pituitary-disorders/hypopituitarism/what-are-the-symptoms-of-hypopituitarism   Resistance exercise (weight training) can help stimulate production of Growth Hormone and mitigate some of the effects of loss of sleep.

 

DHEA is important for many reasons. Low levels of DHEA and DHEAS have been linked to depression, prostate cancer and may identify the pending failure of the adrenals due to chronic over activation.  Significantly it is the ratio and relationship between cortisol and DHEA that we must pay attention to.  This is usually a 10:1 ratio DHEA to Cortisol. Part of what makes this work is that DHEA has a very low circadian variance where cortisol has a wide variance.  Cortisol peaks in the morning and declines late in the day. DHEA remains relatively constant providing a buffer to some of the damaging effects of cortisol. If operating in a stressful environment with excess Cortisol production, it may be beneficial to have counterbalancing levels of DHEA. One specific benefit is the reported stimulation of the immune system through increasing IL-2 and N-Killer cell activity and overcoming the immuno-suppressive effects of cortisol on T-cell function. This benefit helps directly with the body’s ability to fight disease and cancer. DHEA is also thought to be a precursor that is converted to testosterone and estrogen, and as such beneficially impacts other hormone levels. DHEA is an adrenal hormone that naturally reduces with age. Tests are available and level should be checked by a healthcare professional prior to considering supplementation.

 

It is also important to realize that the impact of circadian disruption is not a linear problem. After several days, depending on the individual, we seem recovered. The reality is that almost every different organ has its own recovery rate. For example, the liver can take up to two weeks to recover from jet lag. What happens if you are doing week on week off international flying?  Your liver is in a constant state of flux. With its prominent role in so many areas of your health and health maintenance, that can’t be good.  The day night disruption and change in dietary patterns impacts your body’s digestive processing and blood sugar levels. All these things create stresses that cause decrements to our health.

 

Hopefully, what you have gleaned from the above discussion is that there is more to the effects of circadian and diurnal disruption than just fatigue. Those are just two forms of stress to the body that we face.  Chronic stress causes increased cortisol levels, potentially reduced melatonin, GH, and IGF-1. This may result in severely compromised immune system function as well as actual damage to memory and cognitive ability. There are tests available to check these levels. It is also possible to have your blood work checked for immune system health and specifically for t-cell availability. Hormone supplementation can be dangerous and should never be considered without the advice of a healthcare professional. Even just taking supplements at the wrong time of day can shut down your natural system and do irreparable damage.  

 

Women, much of this is even more complicated for you when you deal with monthly cycles, pregnancy and aging.  There are issues with stress and cortisol and the fertility process that you need to research, as well as prolonged noise, vibration, and low oxygen exposure.  Menopausal impact can be aggravated by many of the issues discussed.  Know also that the immune system impact is not gender specific. Women who work on rotating night shifts with at least three nights per month, in addition to days and evenings in that month, appear to have a moderately increased risk of breast cancer after extended periods of working rotating night shifts. (Schernhammer E S, et al)

 

Right now, you should maintain a good diet (balanced) that is not overly dependent on carbohydrates, which break down into simple sugars. Eating smaller amounts more times a day minimizes the bodies energy fluctuations and may stabilize your insulin responses. Do your own research and see if you feel vitamin or mineral supplementation is appropriate. Exercise is a requirement! Just walking for 30 minutes to 1 hour 3 to 5 times a week at a brisk pace can have tremendous impact on all areas of your health. It is resistance training, however, that provides GH stimulation as well as bone density improvement. And again, if you have not been exercising regularly, see your healthcare provider to ensure a safe approach to exercise is initiated. Sleep when you can.

 

Those who have done the hub turn/red-eye to a dead head home trick, must now realize that you are doing real damage.  Any sleep during the beginning, middle, or end of the night is better than sleep during the day. You may feel worse for a short time but there is a clear benefit of a 30-minute nap (no longer). Lastly, the obvious, sleep at night as much as possible, keep long breaks between international trips and rest when you can. Will that stop the damage being done? No, but until we have more definitive studies and can change our scheduling practices to include these considerations more aggressively, you must do what you can.

 

 

Finally, there have been studies of people that seem to do well doing shift work. Their bodies seem to make some adaptation, so not everyone is impacted at the same rate or severity.  While they may seem less affected daily there is no correlating information as to longevity.

 

That brings me to one last point to consider. There has been much discussion over the years as to the reduced longevity of pilots. A study from the FAA, of pilots who retired between 1968 and 1993 claims, “The expectancy for lowered life expectancy for airline cockpit crews was not supported by the results of this particular data set.”  I would agree, since the comparative used in the study was the general population based on the 1980 census and they eliminated everyone who didn’t make it to age 60.  They placed us at the statistical average age for mortality. We should be compared to highly educated individuals who are at the very top of fitness (on average) when starting their career. It is my supposition that we should be at the high end of the mortality curve dragging it upward, not buried in the middle.

 

On a positive note, we are more health aware now than ever before. We must accept that there are health implications in the career we have chosen. By understanding what is happening to us, we can minimize and mitigate the negative impact, improve our health, and live to enjoy the retirement we have worked so hard to secure. We can bid in ways that are consistent with our individual health needs and make educated assessments regarding the risk/benefit of upgrades vs seniority loss.  We must drive scheduling improvements and contracts based on science and safety. Safety, not just for our passengers, crewmembers and company bottom-line….but for our families and our own lives!

 

 

 

 

Captain Paul Westfield is a 15-year member of the FedEx Aeromedical committee. He is currently an A-300 Captain, Line Check Airman, Human Factors Subject Matter Expert, and FAA Aircrew Program Designee.  Certified as a Leadership and Physician Development Coach, his recent work is focused on optimal performance for technical professionals. A former USAF A-10 Fighter Weapons Instructor School Graduate, Paul has been instructing in Aviation for over 30 years. A lifelong athlete, he has focused on physiology and fitness since his days as a college wrestler. His BA is in Communication studies with a minor in Coaching.  He can be reached at paulwestfield1@gmail.com

 

 

Additional references:

 

Sephton, S.E., Sapolsky, R.M., Kraemer, H.C., Spiegel, D.,

  1. Diurnal cortisol rhythm as a predictor of breast

cancer survival. J. Natl. Cancer Inst. 92 (12), 994–1000.

 

Circadian disruption in cancer: a neuroendocrine-immune pathway from stress to disease? Sandra Sephtona,* and David Spiegelb 2003

 

Women who work on rotating night shifts with at least three nights per month, in addition to days and evenings in that month, appear to have a moderately increased risk of breast cancer after extended periods of working rotating night shifts. Schernhammer E S; Laden F; Speizer F E; Willett W C; Hunter D J; Kawachi I; Colditz G A.  Journal of the National Cancer Institute, (2001 Oct 17) Vol. 93, No. 20, pp. 1563-8. Journal code: 7503089. ISSN: 0027-8874.
“Night-shift work and risk of colorectal cancer in the nurses’ health study”. These data suggest that working a rotating night shift at least three nights per month for 15 or more years may increase the risk of colorectal cancer in women.

 

Female cabin attendants had a significant 1.9-fold incidence of breast cancer and a 15-fold incidence of bone cancer compared with the national average BMJ 1995;311:649-652 (9 September) Incidence of cancer among Finnish airline cabin attendants, 1967-92 Eero Pukkala, researcher,a Anssi Auvinen, senior scientist,b Gunilla Wahlberg,

 

As early as 1990 studies were beginning to show increases in cancer among airline pilots. These were relatively small groups and the research was focusing on radiation not endocrine related causes. The significance is that there were increased levels of cancer identified, and that this information has been available for some time. Band P R; Spinelli J J; Ng V T; Moody J; Gallagher R P Aviation, space, and environmental medicine, (1990 Apr) Vol. 61, No. 4, pp. 299-302. Journal code: 7501714. ISSN: 0095-6562. Report No.: NASA-90253344. . English.

 

Antiproliferative action of melatonin on human prostate cancer LNCaP cells Moretti, Roberta M.; Marelli, Marina Montagnani; Maggi, Roberto; Dondi, Donatella; Motta, Marcella; Limonta, Patrizia Oncology Reports (2000), 7(2), 347-351 CODEN: OCRPEW; ISSN: 1021-335X. English.

 

HPA dysregulation has been associated with increased risk for a number of other human

illnesses, including type 2 diabetes, stroke, and cardiovascular disease (Rosmond and Bjorntorp, 2000).

 

The Importance of Emotional Intelligence in Human Factors Error Management in Medical Leadership.

As a former USAF fighter pilot and career airline captain my training was always focused on error avoidance and error management. In the aviation world, errors can kill us and others. The concepts of Human Factors and Error Management for aviation, transfer directly to the medical community.  While the aviation community has been addressing the issue of error mitigation/management for quite some time, it is relatively new to the operating room (Helmreich, 2000).  Studies indicate that as many as 100,000 patients die in the US each year from medical errors (Bohnen & Lingard, 2003; Helmreich, 2000). Recently, a Johns Hopkins Study places medical errors as the third leading cause of death in the US, topping 250,000 per year.  Emotional Intelligence (EI) is gaining importance as a major component for improvement in leadership and Human Factors (HF) integration.

The concept of EI is fairly new and is still the subject of debate.  For the purpose of this discussion let’s look at Daniel Golemen’s definition of Emotional Intelligence as cited by Wiley (2003).

The good news is that, according to Goleman, Emotional Intelligence can be learned. There are five dimensions to this, he says. These are:

  • Self-awareness: We seldom pay attention to what we feel. A stream of moods runs in parallel to our thoughts. This and previous emotional experiences provide a context for our decision-making.
  • Managing emotions: All effective leaders learn to manage their emotions, especially the big three: anger, anxiety, and sadness. This is a decisive life ski
  • Motivating others: The root meaning of motive is the same as the root of emotion: to move.
  • Showing empathy: The flip side of self-awareness is the ability to read emotions in others.
  • Staying connected: Emotions are contagious. There is an unseen transaction that passes between us in every interaction that makes us feel either a little better or a little worse. Goleman calls this a ‘secret economy’. It holds the key to motivating the people we work with. (Wiley, 2003)

EI has documented acceptance in the psychological and business communities.  This exploration is not contingent upon detailed variations in the concept of EI but in the gross application of the general concept as a skill. The need for improved EI is cross cultural as presented in the article, Doctors’ emotional intelligence and the patient-doctor relationship (Weng, Chen, H., Chen, H., Lu, & Hung 2008). This article begins by confirming that EI is an important component in the patient-doctor relationship. Weng et al. describe how EI is being assessed in some medical schools to screen applicants (p. 703). Most importantly for this discussion, they identify that their study is unique from previous studies because they did not rely on doctors’ self-ratings (p. 704). In comparing the relative EI score of the doctors, it was discovered that self-assessments did not correlate to EI scores garnered from external evaluators relative to the doctor patient relationship (p. 706). This particular point is developed in Helmreich’s article “On error management: Lessons from aviation.”(Helmreich, 2000)  Helmreich discusses the personality commonalities of pilots and doctors, how both groups suffer from inaccurate self-perceptions (p. 782). Epstein and Hundert further define this problem in their analysis (2002).  They claim that errors in medicine may be due to doctors believing in the infallibility of their judgment, especially during times of stress (Epstein & Hundert, 2002).  One can see how each article identifies the same problem using different terms based on their perspective.  The inability of doctors, like pilots, to accurately assess their emotional state and thereby misjudge their abilities and impact on other members of the team, is definitely a clear problem that can result in errors.

Identifying a problem and addressing it properly is not always easy.  It is important to drill down to the foundation and ensure that the causal factors involved are identified.  Of the referenced studies only one identified the base contributor.  The other authors failed to go deep enough.  Weng et al. identify that communication skills, the basal factor missed by the other authors, are based on EI (p 705).   Helmreich (2000 p. 783), Epstein and Hundert (2002 p. 227,) and Bohnen and Lingard (2003 p. 328) all identify the need for doctors to communicate better.    They clearly understand that better communication is needed to avoid errors, however, they do not describe how improved communication occurs and do not provide a basis for that improvement.  There are many scholarly articles written about EI, most agree that EI is developmental (Weng et al. 2008 p.704).

My training and background in communication led me to understand that one’s ability, or lack thereof, in exercising EI will dictate one’s interpersonal relationships through the communication expressed.  Our emotions are expressed in body language, facial expressions, tone, volume and tempo of our words, etc. and to the least amount, the words themselves.   Any attempt to improve communication with permanence will have to improve the awareness and management of the emotions behind the communication through improved emotional intelligence.

Bohnen and Lingard correctly identify the vector for change in the operating room.  First they identify the fact that there are few systems developed for error reduction, they then place the responsibility for improvement on the Surgeon/Leader. Mentoring, avoiding intimidation, improving communication, and reducing tension on the team are all improvement tactics recommended (2003, p. 328).  Managing one’s emotional state prior to communicating, through EI skills, or taking action, is foundational to most of the recommendations.  Helmreich discusses behavior countermeasures to combat errors (2000, p. 783).  He does not go beneath the data to evaluate how to change the causal factors that dictate the behavior in question.  He, like Bohnen and Lingard, places the primary responsibility for improvement on the team, therefore the leader in the operating room…the surgeon. Epstein and Hundert focused on assessing competence and also arrived at the need for mentoring (2002, p. 233). Mentoring can be done from various positions in a team environment, however, it is generally accomplished by the most experienced or knowledgeable individual.

Clearly, an effective way to mitigate the huge problem of medical/surgical error is through coaching physicians. If physicians understood the negative impact they have on others in their team through lack of EI skills, they will be motivated to participate.  Once the team leader (physician) is demonstrating improved skills the rest of the team will follow.  It is unrealistic to expect our healthcare system to be able to train every person who is involved in surgery on error reduction through improved communication by enhanced emotional intelligence. That would be costly and time consuming. However, if the medical community is seeded with skilled EI/HF practitioners who mentor those around them during every medical event, measureable improvement will occur with resultant error reduction, patient satisfaction and organizational prestige.

As a trained instructor/facilitator I have experience in improving error reduction through increased self-awareness and the resulting HF behavior modification.  I can now support this anecdotal experience with scholarly research in an attempt to further define Emotional Intelligence as an actionable skill more easily evaluated in the surgical theater.  The resources available that discuss surgical error reduction methods are few (Bohnen & Lingard, 2003 p. 328).  This research is just the beginning, although I believe it is representative of the current medical/surgical environment in many of our communities. By using Human Factors Error Management processes, the improvements described above can have an exponential impact on the organization, reducing HR costs, improving employee satisfaction and stability, and reducing risk management costs.

 

Captain Paul Westfield is available for group presentations and facilitated discussions.

Coachinghumanfactors.com                                                                           901-553-5894

References

Bohnen, J. M. A., & Lingard, L. (2003). Error and surgery: Can we do better? Canadian Journal of Surgery. Journal Canadien De Chirurgie, 46(5), 327-329.

Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. JAMA, 287(2), 226-35. Retrieved from http://search.proquest.com.library.capella.edu/docview/211381260?accountid=2796

Daniel Goleman, emotional intelligence, 1995. (2003). In The ultimate business library, Wiley. Retrieved from http://search.credoreference.com.library.capella.edu/content/entry/wileyultbuslib/daniel_goleman_emotional_intelligence_1995/0

Robert L Helmreich. (2000). On error management: Lessons from aviation. British Medical Journal, 320(7237), 781-785. www.bmj.com

Weng, H., Chen, H., Chen, H., Lu, K., & Hung, S. (2008). Doctors’ emotional intelligence and the patient-doctor relationship. Medical Education, 42(7), 703-711.

 

 

I signed up to be a Doctor! What’s with all this leadership stuff?

I’m a doctor”, you tell yourself, “I have earned the right to just do what I am trained to do. And on top of that, many of my patients don’t do what they are told and then blame me when they don’t see the recovery that they should! Someone should be leading them! They are the ones who don’t get it!”

Well……you are right, and you are right……. but where is the solution? The really great news is that the solution is literally within your grasp. It’s part of that leadership stuff! Many physicians are natural leaders, growing up as team captains, Boy Scout or Girl Scout leaders, class leaders, band leaders, science club leaders, and many other leadership roles. Many may never have had the urge, opportunity, or the personality to step into those roles, and that is ok too. By the time you were in medical school how many other activities could you lead anyway? You signed up to be a doctor, right? Yes, you did, but maybe there is more to that than what you were taught in school!

There were 661, 400 physicians and surgeons in the United States in 2008, according to the 2010 Statistical Abstract of the U.S. Census Bureau. This represents about 0.6% of all employed persons in the United States. As is the case with statistics, there is probably some variance. This number was probably close in 2010 however; it may have changed since then. The point of this is to show that you, Doctor, are actually part of a very exclusive club. Six tenths of one percent of anything is not very much. You achieved what you did through various levels of dedication, perseverance, focus, intelligence, and sacrifice. That is quite a list of characteristics, which are built on an additional list of values that you relied on to carry you forward. Was there any leadership involved? Yes! Absolutely there was, and that leader is still there for you to access. The traits that supported you through all your training are the traits of a leader.

For many years, leadership has been defined by looking at the effect leaders have on others. All the styles of leadership; autocratic, democratic, Laissez-faire, etc., address outward impact. Some claim there are four basic styles some six, it really doesn’t matter as long as we understand that leadership is dynamic and impactful. Let’s look at leadership from a different perspective. I have already given you a hint at where we are going……. self-leadership. All of you have all the basic skills of self-leadership or you would not have made it through your programs. At various times, I am quite sure, that you have motivated, cajoled, guided, mentored, acknowledged and rewarded yourselves! You created your own culture of excellence and held yourself to a high standard of performance. So, actually you know quite a bit about basic leadership.

Recent studies in leadership have shown some additional traits that make a truly successful leader. Empathy has proven to be a critical component that informs both self-awareness and relationships. Empathy is one of the competencies that Daniel Goleman lists under the domain of Social Awareness. It is part of his model of Emotional Intelligence, including three other domains, Self-awareness, Self-management, and Relationship management. He describes empathy as “sensing others’ emotions, understanding their perspective, and taking active interest in their concerns.” Why is this important to you? There have been several studies that now show that patients who feel they have been listened to, and have a relationship with their doctor, still rate the doctor very highly even with a problematic outcome. They trust that the doctor did the best he or she could and they are unwilling to place blame to blame on someone they trust and respect. The converse was also shown. Doctors with very high technical ratings and few errors get very poor patient ratings, even with good outcomes, if the patient felt the doctor was cold or aloof, didn’t communicate or establish a relationship. There are also studies, of which I am sure you are aware, that connect patient optimism with recovery. Where do you suppose that optimism comes from in many cases?

T he study of neuroscience has made great strides in the last 5 years in mapping and describing the brain and and oscillator neurons. As we interact with each other we cannot help but take in the nonverbal messages that are being transmitted. We tune ourselves to those around us. If we see someone smiling at us it is difficult not to smile back. Those are the mirror neurons engaging. When we match the movements or energy of those around us, the strength of a hand shake, hug, or open welcoming body language, oscillator neurons are at work. According to Daniel Siegel, for this rapport to develop, there must be full mutual attention. Ask yourself, “when was the last time I truly focused on my patient, accepted and understood their perspective of their condition, and made them feel heard?”. When it comes down to it, what people really want, is to be heard. If you hear them, they will trust you. If they trust you they will believe in you. If they believe in you they will follow you. Hmmm, sounds kind of like leadership doesn’t it?

T he tricky part is to really hear them, not just listen while you treat a condition. People are smart in unconscious ways. When your words and actions are not in sync it creates dissonance and that is recognized by your patient. So how do you train yourself to connect with your patients in a short period of time? Start by taking a moment before you open the door, do a few seconds of controlled breathing. This takes control of your reactionary brain, part of the limbic system, and pulls your awareness up to the thinking brain in the neo-cortex. Now you can choose how you spend that few minutes in the best way for you and your patient. You can choose to be curious about the patient, not just the condition. Ultimately this will lead to enrollment of the patient in their own care and improve compliance and recovery. The dynamic nature of medicine combined with the pressures of administration on providers continues to challenge the ability to establish trusting relationships with patients. Be creative; find other ways for developing better patient relationships. Improve the office environment and engage your staff in your vision. If needed you could hire a wellness coach who will spend the time with the patient, ensuring they feel heard, answering questions and providing follow up support. This is also a great tool to reinforce an optimistic attitude and compliance in recovery.

So, ask yourself another question, “Am I a leader that my patients and staff want to follow?” Do you set the example for your staff on how to lead? If you had to move, would your staff follow you, or are they just punching a t ime clock? Are you sharing all of you, not just the “MD”, with those around you? Are you burning out? Are you sacrificing your family? Have you any hobbies left that give you joy outside of your work?

Did you struggle with some of those questions? If so, you are not alone. That is why so many CEOs and business leaders have coaches. To truly see yourself you need a mirror, accurate and unbiased, non-judgmental. That is why athletes at the top of their game use coaches, to absolutely get the best performance they can, they need someone who only cares about what they care about. You have invested a lifetime in becoming a physician, are you where you want to be?

Captain Paul Westfield

Between stimulus and response there is a space… within that space we create opportunity!

Many may recognize part of that phrase as being credited to Austrian Psychologist Viktor.E. Frankl. While it turns out that he may never have said it, the truth in that first sentence is irrefutable. Within that space there is unlimited opportunity for positive changes in our lives.

Operational Human Factors Integration in healthcare embodies the concept of using our skills in communication, emotional intelligence, knowledge, and technical skills to reach optimal performance. Human Factors coaching is all about finding the opportunity in our response to stimulus. It’s greatest impact is in moments of great criticality, like surgery.

Remember a time when you were confronted by someone challenging your action or position. What feelings came up, defensiveness, insecurity perhaps, inferiority, anxiety, maybe even panic. Now imagine being open to the position of that person and being able to integrate their message, in a timely and positive way, into your plan for the task at hand. How different that would be for both of you! Your team will experience increased integration, motivation, cooperation, reduced errors, and in healthcare, dramatically improved patient outcomes. The opportunities that are created by our choices while we are in that “space” are truly life changing.Human Factors Integration

Surgeons operating using surgical equipment
Surgeons operating using surgical equipment

The Active Medical Monitor (AMM)© and Error Management

Active Medical Monitor (AMM)©

The role of the AMM is to maintain a watch for error producing behaviors. This is a person who has a good situational awareness and familiarity with all the roles and responsibilities in the room.  They of course will have their own duties; so how do we safely add more?

In aviation there is the Pilot Flying (PF) and the Pilot Monitoring (PM). The PM has responsibilities and tasks that need to be accomplished as the non-flying pilot yet their designated role as PM requires them to go outside their duties to maintain an awareness of the overall state of the flight.  The frequency and intensity of the monitoring is based on the phase of flight and the vulnerability to errors.  Takeoff and landing are very vulnerable areas so the frequency and intensity are very high.  Cruise on autopilot at altitude allows low frequency low intensity monitoring.

There are two distinct monitoring behaviors, active and passive.  We are all familiar with passive monitoring, we are just “along for the ride”.  We watch the things going on around us as a spectator and we react, after the fact, to what we have observed.  Active monitoring is very different.  We observe our environment and the actions occurring based on a plan of action. We compare what is occurring to what we expected to occur and evaluate any differences within the scope of standard practice and safe outcome.  We have all probably experienced active monitoring with poor execution and just didn’t realize it! Consider the “back seat driver”.  They are constantly driving the car from their seat and have no qualms about directing what should be done next.  The problem, is, they have their own standards and procedures which may not be safe, standard or appropriate. In addition, the guidance is usually delivered very poorly!   What they are doing, however, is thinking ahead of the car. What would they do, what would happen if this or that is done, what is the faster way, the shorter way, and so on.

What would that ride have been like had the driver explained the exact route and planned speeds and other details of the trip. First, the passenger would have had the opportunity to share their knowledge of short cuts, delays, or speed traps before ever departing. That in and of itself would reduce the volume of unwanted or unnecessary discourse during the trip. It also would have offered valuable information so the driver might alter their plans for a better outcome.  Now the passenger will be watching to be sure the driver does what they said they would do since there is a defined expectation.

That is the foundational essence of Monitoring, having a plan. If there is no plan, then the best observer is only a back seat driver reacting rather than evaluating.  Sharing the plan in advance creates what is called the “shared mental model”, everyone in the event has the same expectation of process and behavior.  This is commonality of expectation is critical because it allows for immediate identification of deviations from the plan.  In developing the plan, it is important to have the greatest input possible to insure the plan covers all possible requirements.  In aviation it is called gathering “untainted” input.  The Captain, will ask the crew what they see as the problem, or what options they think are appropriate, before offering his own plan.  The Captain will take all the best ideas from the crew and integrate them into his or her plan.  This is part of good Crew Resource Management (CRM).  Your team is a resource with vast experience and different perspectives. You must access that value to the greatest extent possible.

Before we go further it needs to be understood that what we are discussing is situational.  As we spoke earlier about phases of flight, so too, there are phases in any medical procedure.  The time available and criticality of response will dictate how much planning is available. So in a critical event, the basis for active monitoring is standardization and team continuity which will be addressed in another post.