It has been quite trendy over the past few years for physicians to use aviation as a metaphor. Perhaps it began with the book The Checklist Manifesto. Recently this poor metaphor has extended to an article published by the American Medical Association. Tweets like the following are not uncommon.As someone with a commercial pilots license and a few hours in the cockpit I can claim with absolutely certainty that if a pilot is performing diagnostics, it’s time to look for an airport and prepare to land.
The biggest difference between the two professions is that professional pilots receive an immense amount of training in making “go/no go” decisions. This training is summarized by one of my favorite Dirty Harry quotes, “A man’s got to know his limitations.”
During commercial pilot training, pilots learn the limitations of themselves, machine and weather. Pilots learn to stay on the ground during times of internal psychological conflict. In pilot vernacular this psychological friction is called ‘getthereitis’ and FAA mandated training raises this friction to a conscious level. Most living pilots have experienced strong bouts of getthereitis at some point in their flying careers. Furthermore, among pilots there is small cohort who refer to themselves as ‘blue sky pilots’ and there is mutual respect from other pilots who take greater risk. All good pilots embrace Dirty Harry’s mantra with a high level of primacy because their lives and their passengers’ lives depend on it.
This FAA mandated training in decision-making, and fact that a professional pilot’s life is as much at risk as their customers’, will forever differentiate pilots from physicians. Unlike physicians, pilots have no moral hazard when they make life and death decisions. Whereas, if a physician makes a poor decision it is their patient/customer who pays the price.
Poor decisions on the part of a physician may result in physical or emotional harm to a patient, yet there is an economic side too. As discussed in the Wikipedia link on moral hazard, information asymmetries between an agent (physician) and principal (patient) may also perversely incentivize physicians to make poor economic decisions. The concept of informational asymmetries is a known source of economic inefficiency and market failures. If physicians have a financial interest in a test or service it is all too easy to bias advice, after all physicians are human too.
Just as pilots are trained to objectively evaluate their physical health, skills, weather and machine; physicians must combat moral hazard and informational asymmetries by first recognizing when they exist. When recognized, physicians should inform patients as best as possible. Across industries, “an educated consumer is the best customer.” This is why few airline customers will grumble about flight delays when they are framed in the context of safety.
Unlike pilots, physicians take an oath to “do no harm” not because they are morally superior, but because physicians can get away with causing harm. When faced with a difficult patient decision I have no problem explaining options and then leading a patient with “If you were me (or my wife/sister) here is what I would recommend.” In my opinion the Golden Rule transcends ethical pitfalls and physician oaths, it also acknowledges moral hazard in a way patients can understand.
Until physicians close the moral hazard gap between themselves and patients, they need to stop using the laudable safety and training record of the aviation industry as a benchmark. Professional pilots deserve more respect, their lives hang in the balance every day.