Doctors teaching pilots: What is good for the goose…

Abstract

Authors: Names and affiliations provided on request. (To request author details, please send a postcard of a donkey to the Intensive Care Society office together with a blank cheque made out to: Editor-in-Chief, Journal of the Intensive Care Society, United Kingdom).

For years, commercial aviation has been held up as the exemplar of safety and reliability. As a result, it is entirely appropriate that Critical Care Medicine and Anaesthesia have sought to translate lessons from the airline industry: whether in simulation, human factors, or crisis management. Since doctors have undoubtedly learnt much from pilots, we believe we owe it to our less earth-bound friends to search for applicable lessons from our high-stakes industry to their high stakes industry. Given the communications difficulties that resulted from a major airline’s recent Information Technology breakdown, we felt we could start by offering a few tips on how to break bad news.

We invited Captain Moncaster, a First Officer from Beta Airlines, to attend our simulation centre for a one-day course in communication skills. Overall, the course was well received, and we are grateful to the Captain for allowing us to publish the following excerpts:

Session 1 debrief

INSTRUCTOR:	How do you feel that went?
CAPTAIN:	Pretty well, I thought.
INST:	Talk me through it.
CAPT:	Well I got one of the nurses take the family in to the relatives room and then I carefully and clearly explained that the patient was going to die.
INST:	Yes, about that. It’s a good idea to take the family to a quiet room before breaking bad news, and very sensible to take a nurse with you. We don’t normally ask the nurses to double check that the door to the room is locked though.
CAPT:	Really?
INST:	Yes. And what’s more we normally find it helpful to go into the room with the relatives, rather than talking to them through the door.
CAPT:	Really…you mean you talk to the relatives face-to-face?
INST:	That’s correct.
CAPT:	Only those from first class though. Surely you wouldn’t…
INST:	We don’t really separate our patients by class. I suppose you could say that we consider all of our patients and their relatives to be in “first class”.
CAPT:	Really. Well I never.
INST:	We don’t really separate our patients by class. I suppose you could say that we consider all of our patients and their relatives to be in “first class”.
CAPT:	Really. Well I never.

***Transcript ends***

Session 2 debrief

CAPTAIN:	You must be pleased with that, it seemed to go very well.
INSTRUCTOR:	Yes, you certainly took on many of the suggestions from the last session.
CAPT:	Thank you.
INST:	I have a few comments, if I may.
CAPT:	Please, go ahead.
INST:	Well, I’ll deal with the most striking episode first. If you remember, we discussed the need to give the relatives some sort of warning shot. A few words just to allow them to mentally prepare for the bad news you are about to break.
CAPT:	Yes?
INST:	Well I’m not sure I would go with shouting “Brace! Brace! Brace!”. I’d probably recommend going with something a little less alarming. Maybe a simple “I’ve got some bad news, I’m afraid.”
CAPT:	I see. Anything else?
INST:	Well, now you come to mention it, having a checklist of points balanced on your knee also doesn’t go over very well. Did you notice how they all looked a bit shocked when you ticked off the “is going to die” section?
CAPT:	I just thought they were a bit upset.
INST:	And I should probably point out that we don’t normally offer the relatives a cup of tea until after the conversation is over…it really doesn’t help having a nurse walk in halfway through pushing a fully loaded drinks trolley complete with complementary wine and beer.

***Transcript ends***

Session 3 debrief

CAPTAIN:	I must say, this breaking bad news malarkey is much harder than it looks.
INSTRUCTOR:	Well, I must say, you did much better that time around.
CAPT:	Well, the alterations to the scenario helped a lot. I’m not really very good at all of the one-on-one stuff we practiced earlier. It all became much easier as soon as you changed things so that I could pretend that I had to talk to 215 patients, all of whom were going to die in the next ten minutes.
INST:	Yes, and how did you find the idea of providing time for reflection?
CAPT:	Interesting you should mention that. I felt the fact that I then said nothing more for ten minutes gave them more than enough time to contemplate the true meaning of death.
INST:	Anything else
CAPT:	Well, I felt I demonstrated empathy and compassion. After all I knew I was also going to die.

***Transcript ends***

Session 4 debrief

INSTRUCTOR:	So that was a tough scenario wasn’t it?
CAPTAIN:	Yes, I never would have thought that talking to patients could be even harder than talking to their families. I never considered that one might need the passengers’ agreement before initiating a flight plan.
INST:	Oh yes, autonomy is very important in decision-making.
CAPT:	But, do the passengers know anything about planes or flying…I mean medicine?
INST:	I’m sorry but I’ll have to stop you there. That sort of “pilot knows best” really has no place in modern communication skills training.
CAPT:	But there are so many passengers…I mean patients.
INST:	Well, perhaps you could have asked the “passengers” to elect a spokesperson
CAPT:	Oh, I see
INST:	Well yes, you see, you actually don’t need just the passenger’s agreement. I would suggest you should have also contacted their families.
CAPT:	But it has nothing to do with them, they’ll all be on the ground somewhere.
INST:	Yes, but imagine the scenario – a passenger becomes unconscious during a flight. How would you know where they wanted to fly to? Who better than their family back home to tell you exactly where the plane needs to be flown to?
CAPT:	But…

***Transcript ends***

In conclusion, the day was a great success, and the many parallels between modern aviation and healthcare were thoroughly exposed. For our next session, we intend to invite a group of doctors to handwrite flight-plans for several major airlines and see exactly where the planes end up.

The views expressed in this column are those of the authors and do not necessarily represent, and should not be attributed to the Journal of the Intensive Care Society, the Intensive Care Society, the Editors, or the Publisher, SAGE.