Airline Pilots Follow Lead of Anesthesiologists: Demand Training for Routine Emergencies Should Not Be Mandatory
Following the lead of their counterpart U.S. anesthesiologists, a bevy of U.S. commercial pilots have signed petitions demanding that the Federal Aviation Administration (FAA) no longer require mandatory, routine training for flying emergencies.
Led by the articulate, charismatic Capt. Jack Hubris, the pilots are gaining adherents to their cause, motivated by the success of anesthesiologists and other physician specialists who are fighting requirements that they demonstrate continuing maintenance of their medical skills. Such requirements are fairly recent, replacing the earlier systems that merely had physicians attend a minimum number of hours of lectures every few years. Anesthesiologists successfully cowed their certifying body, the American Board of Anesthesiology (ABA), into making optional the recently created, mandatory one day of training every 10 years for emergencies in the operating room.
While pilots have been training in highly realistic simulators for many years, that capability only became widely available in the past decade or so for anesthesiologists. Forty-four centers had been qualified around the United States to provide the training, which is based on the same concepts that pilots have been required to do after numerous fatal crashes in the 1970s and 1980s that were attributed to failures in teamwork between pilots, co-pilots and air traffic controllers.
For decades, pilots have been required by the FAA to routinely practice technical skills for emergencies, such as loss of an engine or aircraft control, fire, or loss of cabin pressure. Specific training for CRM (cockpit resource management) has been required since 1995.
Although anesthesiologists share many of the same demands for quick action, performance of technical tasks and teamwork as airline crews, with small exceptions (advanced life support skills) they have never had routine practice for emergencies required as part of their training. That is in part because there have not, until recently, been sufficiently realistic simulators and training programs that use them for training.
That is beginning to change. High-realism simulators are now used more regularly in anesthesiology training programs around the United States, although there are as yet no requirements to pass exams to demonstrate competency. The ABA is intending to institute some relatively basic forms of such exams in 2017.
While there is some evidence in the medical literature to support the value of simulation for improving performance of anesthesiologists and reducing errors, some vocal anesthesiologists have written about the lack of sufficient evidence from controlled scientific studies for the value of the training. They also object to the loss of income from missing a day of work once every five or 10 years and the high cost of the training programs, which are about $1,500 to $2,000 for a one-day experience. The training for managing crises is conducted at nonprofit centers, almost all of which are located in teaching hospitals around the country. Since some anesthesiologists live too far to drive back and forth in a day from one of the 45 training sites around the country, they also may incur travel costs, which could add $1,000 or more. For the anesthesiologist who makes $3,000 per day, the total cost, including loss of income, can be as much as $6,000, or $600 annually for the once-every-10-years requirement. That, they argue, is unfair and unfounded.
The pilots have employed the same arguments as the anesthesiologists, pointing out that there are no scientific studies that prove that training in simulators prevents airplane accidents. They also note that their salaries are approximately one-tenth to one-half of anesthesiologists, who are among the highest-paid physicians in the United States, with an average annual salary of $350,000. A prominent leader of anesthesiologists in the United States argued that anesthesiologists already get experience in managing challenging situations in the operating room. So they are, he claims, prepared to manage the rare emergencies that they were being asked to practice in simulators (rapid, massive blood loss; life-threatening allergic reactions; failure of their equipment; fire or loss of power).
Pilots took up the same arguments, noting that they often fly in severe weather, have to decide if and when to abort a flight due to some form of equipment failure, and even deal with unruly passengers. They also point out that, unlike their much higher-paid counterparts in medicine, they were required to practice for emergencies during their training and even to pass tests to demonstrate their ability to successfully manage emergencies. Anesthesiologists have no such requirements for demonstration of performance for managing emergencies, the pilots argue. So, why the double standard?
In a recent press conference, Capt. Hubris said, “We’re tired of the government telling us what to do. We know our own skills. We know how to fly. We don’t need a bunch of bureaucrats to run our lives. It’s just another ploy to control all of us and a waste of taxpayer dollars and a money-making scheme for the simulation companies. If we feel we need to practice for some kinds of emergencies in simulators, then we’ll get the practice on our own. After all, we’re not stupid: When there is a crash, we’re likely to die too. Anesthesiologists don’t have that problem.”
Let’s Get Serious…
I wrote this spoof because I am baffled about where the outcry has come from in opposition to practicing for emergencies—that’s what the MOCA [Maintenance of Certification in Anesthesiology] part IV so-called “simulation” option is; it just happens to be done via simulation. Why do some anesthesiologists feel so strongly that they don’t want to practice for rare events that they spoke out against it, to the point where the ABA had to make it optional?
I’ve read some of the angry writings that rail against MOC generally and MOCA specifically. I write as someone who doesn’t have to participate in any type of MOC for anything. And I clearly have a bias because I’m one of the first promoters of the concept of using simulation for training in crisis management. But I also have seen many anesthesiologists participate in courses. I’m a co-author of a paper that analyzed the practice improvement plans that were created by individuals motivated by their simulation experience.1 I’ve read many of those plans. What is impressive is how many of those plans there are and how the simulation experience led to positive safety changes.
I’ve heard countless stories and been thanked profusely by so many people for what they perceive I’ve had to do with disseminating this incredibly practical, useful training in anesthesiology. My family and I are all prospective patients. I just can’t imagine why anesthesia providers wouldn’t be practicing how to manage a rare critical event where I might be the patient (really practicing, not just reading about or mentally simulating). It just doesn’t make any sense.
What kind of data are needed to believe that most humans won’t do well at managing an unusual situation in a crisis if they don’t practice periodically? Every major high-risk industry does this. They do it a lot. Why is it that anesthesiologists, whose specialty is credited with being the patient safety pioneer, have pushed back? Or, is it just a very vocal minority? There have been over 5,000 participants in MOCA crisis management (“simulation”) courses. The evaluations about relevance to practice, value of the experience, and impact on changing personal behaviors is overwhelmingly positive (all over 90% positive ratings).
I do sympathize with anesthesiologists and all physicians for the torrent of regulations, documentation, and other demands that are being put on their time. I also sympathize with the anger over being forced to take tests that are not relevant to one’s work, as many have said some MOC tests are. And taking a written test every 10 years is not likely useful for the intended purpose of maintaining physician competence.
The ABA has taken a great step forward with the “MOCA Minute.” But practicing for critical events, which is an educational experience with no personal score or passing grade required, is completely different. It’s not just novel; it seems like a no-brainer. I hope the spoof explains my feelings about the complaints about doing a simulation every 10 years—for example, the cost, the time away from work, etc. Those are lame excuses, in my opinion.
Almost all of the over 5,000 board-certified anesthesiologists who have had the experience of the one-day “simulation” experience as part of MOCA seem to believe it has high value, that it changes their practice for the better. We’ve been doing MOCA-like courses within the Harvard teaching hospitals since 2001, motivated by an incentive from the captive malpractice company, CRICO.2,3 The premium savings, determined by the actuaries, is now about 40% annually for training in CRM, via high-realism simulation, once every 2 years. When we ask participants in our courses how often they should repeat the training, the response averages out to about once every 1.5 years. That’s still a lot less than pilots do, but it’s way more than once every 10 years.
So, for me, something doesn’t add up. The excuses that there are no data, that it’s too expensive, that it’s just a profit-making business for those of us who deliver the programs (an insult to those of us who have poured so much of our lives into this kind of patient safety work), or whatever other misinformed or cynical arguments that have been made against the requirement for this kind of training, are just that—excuses for not doing the right thing for patient safety.
I just don’t want to believe that this profession, to which I have devoted my entire professional life’s work, reflects the kind of thinking in this satire. I hope those who have had positive experiences will express their views and demonstrate that anesthesiology is the kind of medical specialty with which I can still be proud to be associated. I hope that sooner or later, periodic training for emergencies will become a requirement again. Your patients deserve nothing less.