A recent analysis of the Boeing 737 Max disasters concludes that while technical malfunctions contributed to the crashes, “an industry that puts unprepared pilots in the cockpit is just as guilty.” Journalist William Langewiesche uses the term “airmanship” to encompass an array of skills and experience necessary to the safe and effective guidance of an airplane. “It includes a visceral sense of navigation, an operational understanding of weather and weather information, the ability to form mental maps of traffic flows, fluency in the nuance of radio communications and, especially, a deep appreciation for the interplay between energy, inertia and wings. Airplanes are living things.”
Airmanship is reminiscent of “physicianship,” an uncannily similar word describing the cumulative skills, attitudes, values, and experiences that provide a “visceral sense” of clinical practice, an ability to integrate multiple sources of information, to form diagnostic understandings and therapeutic agendas, a capacity to listen and an ability to engender trust. After all, patients too are living things.
The graduates of certain pilot training programs were described as “rote pilots, the guys standing up in the back of a sim [flight simulator].” When faced with problems in actual flight, such pilots lacked the flexible responses and trained habits from real flight experience required for emergencies and the unanticipated. Routine, repetitive training may not provide the skills to deal with uncertainty, the unexpected, and the unknown.
Contemporary medical practice and education are on a similar trajectory. Medical simulators are a boon to teaching and training, permitting repetitive attempts with no risk to patients. However, when they become engines with standardized algorithms and predetermined correct answers, they presume uniform patients with a one-size-fits-all mentality. If airplanes require pilots with flexibility and adaptability, living persons need surgeons with resourcefulness and equanimity. Pilots and surgeons develop embodied cognition and a sense of the airplane or a feeling for the tissues of the body. In neither craft are simulators bad—problems surface when pedagogical practices calcify to produce rote practitioners.
Providing access to the increasing volume of clinical data has led to the electronic health record. Computers, whose efficacy rests on standardization and regimentation, are excellent for data storage and retrieval. However, the electronic chart omits the qualitative descriptions that reflect the person who is the patient. The traditional medical chart afforded written observations, the story of a patient’s illness and thoughtful summative reflections by attending clinicians. While pictures and charts of numbers can make us think, stories are better at posing questions and stimulating reflection and are conducive to an integrated understanding of the person who is ill.
New technologies now have attractive tags of smart machines and learning systems. Image analyzers effectively read routine chest x-rays and ordinary skin lesions, saving time for radiologists and dermatologists. However, machines learn from materials with correct answers assigned by humans. We thus relearn what we know, limiting the capability of deciphering the strange, rare and surprising. Computer-based diagnostic systems often direct conundrums to live clinicians, rather reminiscent of autopilots on airplanes that hand over to pilots when situations become chaotic. However, humans require experiential learning with a great variety of examples, and can best learn to understand the rare against collected memories of the usual and commonplace. This mode of learning is reminiscent of John Dewey’s concept of experiential learning, dependent on actual experiences tailored to the learners and sensitive to the demands of the situation. The needed reframing and reorganization of knowledge depend on active teachers, real-world subject matter and motivated reflection. Clinical answers and decisions are critically dependent on context, circumstances and idiosyncrasies of a given patient. Medical choices and decisions must often deviate from items on a checklist, yet clinicians are becoming rote pilots.
A concurrent risk emanates from new concepts in pedagogy. Competency-based medical education arises from an articulation of the specific tasks and objectives of practice, and training students and residents for the skills necessary to a complex clinical environment. However, the very disaggregation of clinical acts into isolated modules and focused competencies mirror the dropdown menu of the electronic chart and the formulaic exercises of the simulator—excellent for analysis but lacking in synthesis.
Airbus decided to address the problem of poor airmanship by designing a fly-by-wire, almost robotic airplane. The answer was at hand if only “…Airbus could get airplanes to protect themselves from pilots.” We cannot judge the wisdom of that choice. We can however assert that patients should not need protection from physicians with suboptimal physicianship. Relationships and trust engendered by adept and thoughtful physicians are the core of medicine and healing.
Featured image credit: “Passenger airplane” by Jordan Sanchez. CC0 via Unsplash.