Part 2 - Paul Kissmann Discusses Safety Culture In The World Of High Performance Aviation

TK: So when we’re talking about human performance, we could almost subdivide it. And do you have a opinion as to the importance of personality? As compared with, say, a skill or an aptitude when it comes to peak performance in aviation?

PAUL: Wow, great question. You know, even to this day, we screen for pilots for the military, or for an airline or whatever, or be it for an astronaut in the Canadian Space Agency, they screen highly now for personality and your personality and your adaptation to the culture. And all these things are what will allow you to excel within that environment. If you’re not willing to keep working hard to keep learning, to keep your humility to a reasonable extent, in the environment that you’re in, it’s tough to really get better. It really is.

TK: And it just occurred to me while you’re talking, we’re talking about the effect of having too many layers that don’t really increase safety, but start to decrease efficiency. That reminded me of anecdote from a friend who was in the first ROTO of a Middle East deployment of the Hornet. Six pack of Hornets launched without actually having formal orders and got them airborne, along with the tanker packages are heading across the ocean. They found that they were extremely flexible when they first arrived. And, you know, able to employ effectively. Run a significant number of sorties with a very, very small team of highly, highly motivated people. But then over time, as the ROTO grew, the the wedge behind the front end grew and grew and grew and became a bit of a self licking ice cream and 

PAUL: The bureaucracy.

TK: It became less effective, less efficient, harder to get things done, despite the fact that with all of the additional personnel and resources, he should have been easier. I just wonder if you have other examples of that, in aviation, throughout your career, whether it’s in the military side or on the civi side? And what are the what are the markers where you see it start to happen, and you can steer the course, steer the ship away from it before it gets here?

PAUL: Well, I’m trying very hard not to say fixed wing search and rescue in the military. Which is the program I was involved in. I’ll pause the sentence there and say, whenever I have been involved in a highly successful test program, flying program, something very challenging. It has been because the authority, and the ability to get the result has been moved down to the lowest possible level. 

TK: Power to the edges. 

PAUL: You bet power to the edges, you really have to empower your people that are at the cold face that are getting the job done. The more that power gets vacuumed up into higher levels of management, or leadership or whatever you want to call it, depending on where you are. The more paralyzing it is to success. There is nothing gained by some general or some colonel poking way down into the weeds trying to control flight test program or a operational implementation program. Because they just aren’t close enough to the problem. And the more you can trust your expert center at the coalface that are doing the job. You’ll have way more success. It sort of comes back to that discussion earlier about the ejection seat. You know, that was a colonel that was a rare bird heard and again, the pun but and he and I just looked at each other mano a mano, and I said, boss, trust us, we can do this. And he did. And it wasn’t me. It was my team. You know, I had some really talented folks that are still working in the same field today. But you have to allow that to happen if you vacuum this up and create this bureaucracy behind the coalface, the game. It’s really just CYA, right? They’re covering their asses. They want control because they’re fearful of a negative outcome that might end up looking like it was their responsibility. But the reality is, when you’re at that level, you can’t control that many things. It’s impossible to have control over all the programs, all the fleets, all the aircraft, all the pilots, you’d be working 5000 hours a day to try and do that. So the more that you can put the right people in the right place and the right job and empower them to do it and give them the authority, that’s success.

TK: Actually kind of reminds me and it’s not an aviation anecdote, but the Hurricane Katrina response in New Orleans, where the government wanted to retain centralized control and ultimately slowed them down to a fault. Whereas I think it was Walmart, who was on the ground pushing power to the edges, and was briefing their stores to say, do whatever you can do what’s right, communicate with us as best you can make decisions on the ground. And I think it was Walmart that got water and, and their pharmacy supplies out the fastest. 

PAUL: You bet. 

TK: Really irrelevant. But the, it also reminds me a little bit of, if you’re a junior captain, in the Air Force, the level of responsibility that you have, as an aircraft commander of whatever it is that you’re flying, whether it’s single pilot high performance, you’re on the road in the US with 2, 3, 4 jets, or whether you’re on an air mobility platform, and you’re you’re the AC. People don’t realize, but you’re also the dispatcher, and you’re the flight planner, and when the weather is poor, and you’re supposed to go to the airport X, you’re replanning to airport Y and it is generally the faith entrusted that all of the training to that point, you can make the right decision and nobody’s going to jump down into your. You’re the mayor of cockpit city, you’re going to make the right choice, you’re gonna get to wherever you need to get to and make it safe. And occasionally, you have to call back home to get a diplomatic clearance because you’re flying over a different country and you know, get a new lift message cut from the CAOC. But in general, it always surprised me how much latitude is given to, you know a 25, a 26-year old captain flying a multimillion dollar piece of equipment? Probably to a country I’ve never been to before.

PAUL: And I think you’ll see the output of that is how well regarded our people are in their next careers. You know, in the flight test construct, you know, the most senior and talented pilots that I know from my flight test world are now you know, VP operations at Boeing, head at Cessna, head at Bombardier, and on and on. And this is in a multinational construct. These are Canadians that are out there that are leading in their fields. And I think it harkens back to exactly what you just said, which is that responsibility that were given early on. And so it does work at times for sure. I think culturally, that’s how it’s been. I don’t know that we’re there today in the Canadian Forces. I think we’ve had a pretty big setback in experience and with that, also, a power being vacuumed up the hill in the command levels. A paralysis by analysis, and oversight, that might produce a different pilot. In the next generation. We’ll see how it goes. When we talk again, hopefully in 20 years, we’ll I’m still kicking. And we’ll look at this again and see who’s out there. And how are we doing internationally leading the way? Or is there going to be an echo of this? You know current situation.

TK: Those personalities that you mentioned, the, you know, the Canadians that came up through our aviation system and are are now leaders in the industry. The Chris Hadfield’s and the Billy Flynn’s and people like yourself, would probably also look back on training and simulation, which we mentioned earlier, and say the quality of the training was was very, very good. That’s what allowed them and yourself and other aviators to be safe and to be operationally effective, where perhaps other folks without that training in the same situation would not have been safe or effective. How would you, you know, explained the importance of safety and simulation in particular mentioned Air Canada simulation, so accurate in their simulators that the first time you actually fly is with passengers. To developing a safety mindset, as well, so not just your procedural proficiency with the aircraft that you’re flying, but the the attitude that you have.

PAUL: Yeah, I mean, the attitude comes from how you grew up through the system in learning to be a pilot, and also from the culture of the organization that you’re in. We’ll flavor that for sure. Simulation, done right, I think will always increase safety because we can simulate a lot of critical events. You know, I just came through, you know, wide-body training at Air Canada onto a new platform. And the process, nose to tail was about three months. And people say: “how the heck does that take three months?” How was it possible that you took three months to go through a training, you know. And it’s funny because if I was in the test world, it would have been one week, maybe two, you would read some books, you would have gone flying. But it’s a totally different mission, and a totally different safety construct. You know, in the airline world, from a safety perspective, we have to have an organization with 1000s of pilots, I have to be able to just reach into the bucket of names and pull two names out and say you two are flying together. And the fact that we’ve never seen each other don’t know each other, we have to operate as effectively as two buddies who’ve done this for years together. So there is a an enormous reliance on standard operating procedures, what is said, who says what when, how you operate, who’s overseeing, while somebody’s pushing buttons, who’s flying when somebody’s talking. And that portion of the culture, under the standard operating procedures is what drives the safety, because they have a different challenge, right? If you’re on a squadron with 12 pilots, and you all know each other, you fly together all the time, there’s a lot of inherent flexibility that you’ll get, because you’re just familiar familiar with each other. And you can possibly have a less stringent level of standard operating procedures and more flexibility. If you’re on an airline, and you’re going to pick two names out of the hat. It’s just not that way. And so simulation allows us to learn all those SOPs and how we’re going to operate. It also allows us to simulate failures that hopefully you won’t see once in your career. You know, the one that we talked about, at at length was, you know, some kind of a critical failure over the ocean. You know, you’re we’re mostly flying two engine jet aircraft now over the ocean back in the day, it was more often four-engined aircraft. Now, there’s only a few of those left, the A380, the A340, the 747. There’s a few of those around but generally speaking, you know, certainly at Air Canada, we’re flying two-engined aircraft across the ocean, which with which brings with it certain requirements, regulatory requirements. So 


PAUL: Yes, we call ETOPS. And you have to learn how that works. You have to learn, hey, if this happens, we’re in the middle of night, it’s we’re at 40,000 feet, we’re over the dark, stormy Atlantic Ocean, and we lose an engine or we have an engine fire. What are we going to do and what order? What’s the most important thing? What’s the next most important thing, and we don’t really have an overwhelming amount of time to have a debate in the cockpit, right? I mean, the captain is still the captain, the first officer supports but you both will provide input to the to the solution that you come to, but you have to have thought about this ahead of time. And simulation is absolutely critical, and allowing us to do some of those things. In the relative safety of a, you know, you might spill your coffee in the sim, that’s about all that will ever happen. But because you’re so immersed in a very real environment, believe me, you’ll sweat in the sim. And you’ll think it’s real, you’ll forget that there’s nobody back there. So that’s what takes so long, long answer to your short question. But that’s what takes so long. That’s what builds the safety culture. And I think again, it depends on the mission, right? In the airline mission, because of how we operate, it’s a different scenario.

TK: Do you have an opinion on Air Canada’s reporting system as compared with the flight safety system, or any other flight safety reporting system with, with the other organizations you’ve flown with?

PAUL: I think they’ve they’ve come full circle to be very similar. I think as we’ve gotten along in the years of flight safety being reported, it’s become more practical, you know, we have it on a tablet, you can populate your flight safety report in flight. And when you reconnect to Wi Fi, it’ll automatically send. So you know, pilots are lazy. We don’t want to sit down after the flight and do your writing. If we can have a quiet moment at cruise when we’re not the pilot flying we have a few minutes we can start writing out their flight safety report. So part of that culture is make it easy, because pilots are lazy. You know, I say that tongue in cheek but but in reality, the easier that you can respond. Yeah, the easier you can make the reporting structure, the better off you are, the more familiar it is. So in this app driven world, we fly with iPads everywhere we go. In most of the modern aviation fields, and even in fighters, they’ve got iPads. So, you know, here we go. We got an iPad, we got an app. The culture is established in the organization for there to be no retribution for your report. And so you’ve set the table for the operator to feel absolutely confident about reporting. And I think that is the key. And I think that’s that is pan-organizational to where I’ve been in the last 20 years even, you know, I think the National Research Council was one place that I that I was ended being chief pilot that where we had to work a little bit at creating that culture there were a little bit behind in terms of understanding that there wasn’t retribution. So we had to really create that culture still there. But I’d come from other places that had it. So it was it was easier to make it happen.

TK: Do you get preventative measures pushed out? Through Air Canada channels? Do they aggregate the data or the reports that are coming in, do their own analysis, and then if you know, something meets the threshold of hey, there’s a preventative measure, we should push out, they just push it to your to your iPads, or, 

PAUL: Yeah, we get it via Chief Pilot Notes. So each fleet has a chief pilot, and they do a great job of sometimes modifying the standard operating procedures, sometimes is a change to the flight operations manual that reflects a new reality that we need to consider. There, so the information flows back and forth, for sure, that doesn’t go into a void. It’s analyzed, I mean, we even have we call gatekeepers, that monitor the flight data of all flights. And if there is an excursion of some sort in terms of configuration, or speed, or bank angle, or approach criteria, or whatever, it’s flagged automatically. It goes to the gatekeeper, they look at it. And they’ll call the crew and say, Hey, on this approach into airport X, Y, and Z at this time, we saw that this happened. Can you tell us what a little bit more of what was going on? So that’s a case where perhaps the crew was unaware, which happens, right? You get busy. And you didn’t realize that you had, you know, pushed beyond one limit or another in terms of the standard operating procedures. But it creates a short term full circle, to maybe they go hey, that, well, we didn’t report that. So let’s report that. And so if it doesn’t come to mind, of the crew, it’s another way of pushing the safety out and monitoring safety. 

TK: So yeah, that’s fascinating. I didn’t realize I had that capability. But I bet it keeps pilots flying that approach the plus and minus a couple of knots and make sure they configure exactly on time and land on the 1000 foot markers with that. Well, and deviations.

PAUL: And that’s your friend, right? You know, in modern aviation now. You know, they’re meeting every every year these international councils, be it ICAO, or be it to European EASA folks or the FAA transport and they’re trying to establish a forward looking hitlist, if you will, you know, what, what’s the most important thing to us to try and make aviation safer and when we’re talking about, you know, the bigger airplanes here, you know, over 7000, some odd kilos up into the airliner world commercial aircraft operators, and their things like topically, runway incursions. So those who follow the news will have seen in Japan, the 777 that unfortunately collided with the Coast Guard Dash airplane. That was a runway incursion, it seems I mean, they’re still analyzing the data. So I don’t want to talk out of school too far. But regardless, you ended up having an aircraft landing on the runway that is occupied by another aircraft. And they collided and very sadly, some lives were lost on board the Dash-8. But that’s one of the that’s one of the five on the hit list. Like we already know, looking forward, we’re trying to solve runway incursions because we know how deadly they can be.

TK: Deadliest crash in the world. Tenerife was.

PAUL: Tenerife. Two 747s in the fog, right. And runway excursions are the next one. Ironically, I think yesterday, United, I think it was American Airlines feeder, and it was a feeder airline in Rochester slid off of a runway in snowy conditions. So runway excursions, meaning you unintentionally leave the taxiway or the runway during a takeoff or landing or maneuvering on the airfield. We already know that this is a really important issue to solve. And so forward looking, some companies are bringing either policies in place, or technologies into place to help us reduce the likelihood things like that happening. So this is where the safety network now starts to move forward. Right? Instead of just being a rearward looking mirror. That doesn’t help us in the future. Now it’s like okay, so we know this is on our top five, what are we doing to help solve this problem? And so I am encouraged by us identifying those things, how well we do it, you know, school’s out still, we just got to keep working hard at it.

TK: Being able to push it out rather than as an operator having to draw that information or try and find it framed wherever. Does Air Canada coordinate with other airlines or with NASA through their ASRS? To try and draw out lessons learned from other?

PAUL: I don’t know, because I’m not involved in the actual safety cell of the airline. I’m more on the operator side. So what goes on behind those scenes and how they interface with other operators? I’m not sure. But I’d be, you know, I do know they attend conferences that are multi-disciplinary and multi-airline. So I’m sure there’s a lot that goes on behind the scenes, but I’m just not the one to ask the question.

TK: Well, we’d be remiss if we didn’t talk about, or I didn’t ask you a war story question. Can you think of a time in your career with any of the organizations that you flew with? Where safety culture played a role in your decision making in a challenging environment and challenging situation?

PAUL: Yeah, for better or for worse, shall we say? If you go back to Gulf War One in Iraq, I was on 433 Squadron, and we were deployed to a Red Flag exercise in Nellis. And it was on the Thursday of the week that we were there that the fighting started. And we got a call from the general and back then, Canada was there was a division at at 30 West, which is a longitude, where east of that was the European Command. And a gentleman over there was in charge of our forces, because we still had fighters in Europe back then. Because we’re going to

TK: F5s in Germany. Sorry we’re talking Gulf War.

PAUL: In the 90s, right? We’re talking the early 90s here. So we had we had F-18s teams in Europe, and they were under one commander, and everything to the west of that 30 West Line was North America and there was a different commander. So we were as 433 in Bagotville, Quebec. We were under that North American commanders command. The war starts, and they call us down on Nellis and go, boys, you’re sending six airplanes, six pilots, and we want you there on Sunday. And we are in Nellis in the middle of an exercise in the sun, and it’s Thursday. So this is where the operational imperative interfaced with safety to try and turn that corner, we had to pack up, get the airplanes, first of all back to Bagotville. Then we had to get our personal affairs somewhat in order. So including getting immunizations, getting wills drawn up. Because we were not yet as much of a wartime Air Force. I think as they are today, we weren’t as triggered and ready to go. So there, there was a lot of work behind the scenes that had to happen. We had to get a tanker organized, we had to figure out ways to get across the ocean to try and get to the theater. Of course, the big war is on, you can’t find a tanker. Right. They’re all in theater. They’re busy. So now we have to figure out how to get across the ocean with a six pack of F-18s by hopping our way across World War Two style. Right, this is back to the Bomber Command. Dragon Lancaster’s in Halifax across the ocean, or even fighters for that matter. And so what we would normally worry about like crew rest. Well, you can imagine how little sleep we got between the Thursday and the Sunday, right? We were all absolutely shattered. And when the weather in Bagotville turns into 100 and a 1/4 in driving snow and minus I don’t know how much as time to go. Well, we went. And we went to Sondestrom, Greenland first. And that’s where we got our gas.

TK: That’s a whole other set of challenges flying into Greenland. 

PAUL: A whole other set of challenges, and then out of there to go to Iceland, and that’s where we plan to overnight. Well, you know, we’re in Sondestrom. And we come out to our airplanes after a long first hop. And five of the six are refueled and one is not. And we’re wearing immersion suits and G suits and we’ve got bags and helmets and publications. And I mean, it’s an effort to get yourself strapped into the airplane. And it wasn’t until we strapped in, got our APUs on and got the radios going that we heard from one of the guys hey, I don’t have gas. So now you’re sitting there. It’s the middle of the night. You’re absolutely shattered. And no kidding. We said okay, well, the five out of the five of us that had gas said Well, I’m not going back inside. I’m going to sit here until you get gas. And I literally fell asleep in the airplane. And I woke up when the sixth guy got gas and started his airplane and the APU went on. And I heard wrrrrr. It’s like, oh, you know. So that’s where, you know, safety versus operational imperative really got trimmed, right? The operational imperatives was extremely high, perhaps not in small part due to our fighter pilot personalities and wanting to go go go go go and and make sure we help defend the Western priorities. But yeah, there are times when you you know, like that was one classic where where we really, you know, safety got shaved way down and mission got X loaded. And in retrospect, we look at it now going well, what were we thinking, you know, we should have taken more time.

TK: That’s wild. I mean, it’s non-trivial flying into Greenland in the winter at the best of times, let alone when you’re on min crew rest. It’s snowing, nighttime, and you’re in a fighter as well, which is significantly less comfortable and higher workload for the approach than flying on a RNAV arrival. 

PAUL: Yes. 

TK: That’s, that’s wild. And so and then via Iceland. Shannon?

PAUL: Yeah. Absolutely Shannon and then into Baden–Soellingen. And back in the day 4 Wing. Yeah.

TK: How long were you there for?

PAUL: Well, back to that delineation of authority that we talked about earlier between the two generals. When we got there, the general from the 4 Wing, you know, CENTAF I think it was called back then or I can’t remember the TAF but he came to us and said: “Thanks for the airplane guys have a good flight home.” And we were like: “What do you mean, thanks for the airplane. Have a good flight home.” And so then I guess the generals got into discussion, there had been a misunderstanding. So they arm wrestled, I guess. And in the end, he came back said: “Listen, you guys have a choice. You can go back home. Give us the airplanes, we’ll take him into theater.” Because we had 433 squadron was the last squadron formed. So we had the latest model of the airplane. Not that they were different. But they were just really good airplanes. They were super serviceable, pristine, low hours, and they wanted those airplanes in theater. And so they gave us a choice that you can go back home, get your affairs really sorted out and come back in three weeks to go into theater. Or you can go now. And so being team oriented as you are on a squadron. We said: “No, you know what, we’d rather come back with our whole squadron.” We’ll come back in three weeks. And those of us who know our history know that three weeks is all it took. And, and it was over unfortunately, I think for everyone that was the end of that the air campaign. And we never did go. But yeah, it was quite an interesting time.

TK: Okay. Why don’t we finish up with you explaining to the listeners and viewers what it was like as a commanding officer of a fighter squadron.

PAUL: Boy, the pleasure of my life, to be honest. I had a fantastic squad and I inherited it from Rich Foster, who’s just a super leader later to be three star general. He should have commanded the Air Force, in my opinion. And so the squadron was in great working order when I got it, which is either an opportunity or not, it depends on how you look at it. I think if you’re a commanding officer taking over a squadron, and it comes to you in pretty much perfect condition, your first thought is don’t screw it up. Right. But I got on some majors that were amongst the best people I’ve ever worked with. And, you know, back to the philosophy of pushing the authority, responsibility down to the lowest common denominator. I know I tried to do that, because that was what always ticked me off when I was in their shoes was not getting that ability that opportunity. So that’s how I tried to leave the squadron. But let’s be honest, when you have these super duper folks that are working with you on a squadron, that’s what they’re doing. They’re working with you. Sure, in the military, there’s a gradient and you’re the boss at the end of the day. I tried to just make sure that meant that I was a shit shield, and that they could do their job. And so I was blessed with just a wonderful, wonderful crew. And so the experience front to back, the technicians that we had, the maintenance organization, intel, supply, they were just all fabulous. And all I all I tried to do was to make sure that we enabled folks to do their job the way they felt was the best way to do it as long as it fell within our objectives. At the end of the day when we left, the squadron unfortunately got closed. Tt was part of a restructuring of the Air Force trying to find some positions. But in that last year, we had the highest flying rate of a fighter squadron in the Canadian Forces out of the five squadrons. We had the highest service ability rate, and those don’t go together, right? Necessarily, like normally when you fly hard, you can’t. 

TK: You break things.

PAUL: You break things, and they don’t work work well. But you know, I just had this inherent belief in the people, and rightly so they were fantastic at what they were doing. And I can still remember, you know, it’s certainly, it’s funny how the small snippet of stories that stayed with you over the years, but we had been blessed, you know, you go and do a morning briefing with the maintenance staff and the pilots every morning before you start your day, called the ops briefing. And during that, they’ll inform the commanding officer and his staff, you know, what the status is of the squadron? How many airplanes do we have, the scheduler will say, here’s what our plan is, for the day, we’re going to fly this many airplanes on one or two waves of launches. And this is what we’re trying to achieve. And that’s sort of set out in a weekly and a monthly objective. And we’d always had, what we needed to do it. Maintenance always provided the airplanes. When we came in this one Monday morning, and the maintenance officer had the sheepish look on his face. And he comes up he goes, you know, listen, Boss, we’ve only got two airplanes serviceable. And, you know, we just had a couple things go wrong, blah, blah, blah, some inspections came in, or whatever it was, right. But this hadn’t happened in two years. And he just goes, listen, we can give you two, we can do a two-turn-one. So he fly two in the morning, fly one in the afternoon, and, and my scheduler is pushing, Oh, I gotta get these missions done cause I want to upgrade this guy. And I want to do this. And I kind of just looked at at my squadron maintenance officer and said: “Listen, how long do you need to get us eight airplanes?” And, you know, he came back. And I should remember the number of days, I think it was two or three days. He said, boss, I need like a couple of couple or three days, I just looked at my training officer said, Alright, put on some ground school were given the maintenance all the airplanes and looked at him and says you have one job is to get us get us back on the pile. And that was, you know, the there was grumbling in the pilot community because they all love to fly right there. You know, your leashing the dogs and they’re not happy. But, you know, it was one of those examples of trusting your maintenance organization that they’re giving you the best they can. And that if you give an opportunity to recover from an unusual situation that they will and that really defined how we operated it was really enabling the people to excel and and I had great people. So.

TK: I like a happy ending. Paul. Right on. Let’s wrap up there, and let me express my infinite gratitude for your time and for coming on board with Dicerra. I can’t wait for the next conversation in there. There will be another one. We’ll have you back on the podcast again.

PAUL: Well, I’m looking forward to pushing safety to a new level, you know, and, and finding a way for us to even evolve further in the aviation field, even though we know the medical field needs a lot of help here. But even in the aviation field, like I said, keep learning, keep getting trying to get better and that’s what we hopefully will do. 

TK: Excellent. Cheers Paul. 

PAUL: Well, thanks again. 

TK: Thanks.

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Paul Kissmann, Dicerra's Lead Aviation Advisor, is a former fighter pilot, Commanding Officer, Chief Test Pilot for both the Royal Canadian Air Force and the National Research Council, Chief Pilot for Vintage Wings Canada and a wide-body airline pilot for Air Canada. He speaks about lessons learned from high performance cultures within different aviation organizations and their different approaches to safety and human performance.

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Full Interview - Dr. Brian Goldman On Improving Healthcare Delivery In Canada

TK: All right, so I’m here at the Royal Canadian Military Institute Institute in downtown Toronto with Dr. Brian Goldman, who amongst other things, is a radio talk show host of CBC’s, white coat black art, prominent author of at least four books, correct? Four books,  including one that we’re gonna talk about today, the power of teamwork. And also the night shift, which I don’t have with me, but which we will talk about. And on top of that, if it wasn’t enough, you are also a practising medical doctor,

Dr Goldman: Emergency physician, emergency physician at Sinai Health System.

TK: Right on. So we got you here today, there’s some some really interesting perspectives on the power of teamwork that have an aviation Nexus, which is my background. So that’s part of the reason why I reached out and we could have a discussion on looking at what we can do in healthcare to implement some of the valuable lessons learned that we’ve had and the developments with threat and error management, Crew Resource Management, Safety Reporting. 

Dr Goldman: And so on page four, as Holly Sullenberger once told me in blood, those lessons right there, they’re paid for in blood.

TK: Paid for in blood. Exactly, yeah. And we ignore them at our peril. Yeah. You obviously are no stranger to these facts. And you’ve mentioned them at length in both books. I’ve only read two of the four books. So what are your other two titles?

Dr Goldman: So the other two books are the power of kindness, why empathy is important in everyday life. And, it’s basically, it was my quest to meet the kindest people on the planet, learn their stories, and and, you know, find out, learn about their acts of kindness, but then ask questions like, were you always that way? Were you born that way? And so people are hard-wired to be super empathizers. And then, but I think, I think the majority of people develop deep empathy, by suffering, they suffer, they’ve suffered a loss in childhood, a divorce of their parents, when they were small kids, maybe they lost a parent, or they suffered, you know, terrible dislocations, from immigration, you know, moving to another country having to having to start over whatever it is. And, and they became kind and they develop kind of an empathy for for other people in similar circumstances. And then the other book that I wrote, which is kind of if, if the power of kindness is the Yang, the Yin was the secret language of doctors, which is basically a look at the culture of modern medicine, warts and all, as evidenced by the slang that we use to describe unpleasant situations and patients and family members as well. And I got a lot of criticism for that book, and to cleanse that to cleanse my palate to get out to to overcome that I wrote the power of kindness.

TK: who were among the most kind people that you met?

Dr Goldman:I met Dylan glass, who is a computer programmer who was developing Erica, which is an Android color, a kind or empathetic Android. So he, he was all about creating simulated empathy. And, you know, one of the things that I met, I met Dylan in Japan. And, you know, his, his kindness, I think, came from isolation, the sense that he was different from other people and but he had one redeeming a close relationship with his dad, and the two of them used to go to the local junkyard, and fish out old batteries and old parts and make beautiful things like I now this is, this is your thing. Is it a tribute? Che? Yes, excellent, would build a catapult and military thing to do very military thing to do, but he, you know, he went to Japan to teach English and then he was already a computer programmer, and he could, and he was interested in robotics. And, and he met up with a man named Hiro Goshi, who, who told him that he could get paid for doing what we love to do, which is to create Erica Erica is an empathic robot. So so that that was one of the kindest kinds of people that I met. And then another woman, Shalon Montero, who lives in South Paulo befriended a homeless man and man who had been homeless on the streets of South Paulo, for over 40 years, 19 years in one patch of like an island between two large boulevards, in the middle of right, right near to the right near the University of South Paulo. And, you know, where did her kindness come so she befriended him she did, she built a Facebook page, featuring this guy who everybody had stepped over and suddenly he became a celebrity. And then suddenly his brother said, I know this guy. And, and so she reunited him with his family of origin.

TK: A beautiful act. So expand on empathy maybe in healthcare. It’s gonna lead us to later in the conversation, but it seems like certainly frontline first responders and ER doctors have no shortage of trauma that you’re your witness to. And not only, you know, from the patients, but also the patient’s families. Dealing with death, not an easy thing to do. There’s, there’s obviously overlap there perhaps with, you know, with other first responders, law enforcement, and with the military as well, but

Dr Goldman: I’ve interviewed paramedics who have very severe post traumatic stress disorder. So there that’s there’s a strong kinship between between paramedics and other first responders, law enforcement officers and and military and, and firefighters who witnessed trauma firsthand and are often so overcome by it, that they become so impaired, that they’re unable to work. 

TK: You’re seeing it day in day out for over the course of, you know, potentially decades of a lifelong career. I wonder, obviously, it’s important to retain a sense of empathy, especially for your patients, but there must be a certain stealing over of your nerves or a dark humor that you’re that manifests itself amongst both physicians and nurses who have to deal with that in order to be able to go on doing the job that you’re doing. So

Dr Goldman: That’s true, a dark humor is important. And you know, one of the reasons why I was interested in the in the secret language of doctors is that there’s a lot of dark humor, in the terms that are used, for instance, to describe death. You know, a patient who is waiting in the ICU to die. Sometimes the expression we use is actively dying. And care has been withdrawn. They’re receiving comfort measures only. And, and, you know, the family is coming to grips with their gathering, coming to grips with the fact that that their loved one is dying. And meanwhile, outside the, the ICU room, in the the room where they have rounds, or just outside the hall, they might be saying something like, you know, Mr. Jones is waiting for a pathology consult pathology, meaning that autopsy and, or, or is is about to be admitted to the 19th floor of an 18th floor hospital, discharge to heaven. You know, those are, and that’s one of the ways that we cope. But I think in many respects, we don’t cope. And that’s it humor is a device. But, you know, we find it very difficult to empathize, because it’s because the feelings are overwhelming.

TK:  For most of us death, it’s a rare and unpleasant thing that punctuates certain periods in our lives, usually with loved ones or friends. And it’s not our profession to deal with it. It’s the most unpleasant of days, and then we struggle to move on for that for the rest of our lives.

Dr Goldman: I’m grieving the death of my sister right now. She passed away just almost four months ago, and I was her caregiver. I was her essential family caregiver. And she lived in long term care for the last seven months of her life. And I can tell you that I’m grieving, I’m still grieving, partly because I’m the last surviving member of my family of origin. And I didn’t think that was going to happen, you know, I would have thought 10 years ago, when, when my sister and I were taking care of our parents, that we would have a good 10 or 15 or 20 years to reminisce and to and to grow old together. And that didn’t happen. She had young onset dementia. So So you’re absolutely right. So I now have empathy for, for, for a lot of my patients who are grieving because I’ve been, I’ve been there. So if we haven’t experienced death ourselves, we find it hard to empathize with our patients. And that’s why younger physicians, nurses, respiratory therapists, they have to live a little they have to grow into their adulthood, begin to lose their parents to to begin to have an appreciation of what it’s like to be our patients, very hard to empathize with the situation that you for what you have no kind of frame of reference. So that’s one thing. Second thing is for, for people, and I’m an emergency physician, and when death happens suddenly, unexpectedly in the emergency department, the reaction of family members is understandably very strong.

TK: So in terms of laying blame or?

Dr Goldman: Laying blame, or just being grief stricken, shocked, and, you know, the first time I have that conversation, first of all, if I’m if I’m afraid that I’m being that I’m about to be blamed, that’s a terrible attitude to bring into a room where you’re telling somebody that that their loved one has died, and I and I’ve had to learn how to put that aside and be there for them. patient, and you know that it’s an it’s not just a method, you know, there are ways of approaching somebody breaking bad news to them. But you also have to be able to park any feelings of internal distress that you have. And we’re often not good at that.

TK: No, it’s tremendously difficult thing to do. And it’s, it’s, it’s a non medical aspect of your profession, that you have to debrief a close family member in that way, often, when emotions are highest.

Dr Goldman:And their triggers, they might say, what happened? What happened? What happened, and you can feel the tension in the back of your neck? They want to know where I’ve screwed up. Or, you know, was there a moment when, when things could have gone differently? And, you know, and I can’t lay it on too thick and say that that, you know, we say that we did the best we could. Sometimes it’s obvious, often it’s obvious, but sometimes, but sometimes there’s some uncertainty and doubt, and there are some families that will magnify that uncertainty and turn it into a quest for justice,

TK: which in turn makes it very difficult to create the kind of safety environment he talked about, and not only in your books, but in your, your TED talk from many, many years ago to about 11 or 12 years ago. 

Dr Goldman: Yeah, doctors make mistakes, can we can we talk about that I did it just up the street on Bloor Street at the Royal Conservatory.

TK: And you mentioned it is you really have to underscore the fact said we do because it should be obvious to anybody that is not just incompetent doctors that make mistakes, everybody makes mistakes, time compressed environment, complex adaptive environment, and sometimes some cases, systems or symptoms are misrepresented. Or fatigue creeps in, or one of any, any number of factors creates an adverse incident.

Dr Goldman:  Easy for you to say that. In medicine, we don’t say that at all. I mean, we can we were beginning to talk like that, you know, we’re beginning to to, to adopt some of the patois that you’ve just described. But you know, in our culture, it’s I alone, I alone, you know, stride into the resuscitation room bark orders and know exactly, you know, I figure out what’s wrong in 10 seconds, and I and I bark orders and the patient lives and if they don’t live, then I must have screwed up. And that’s our and, you know, we say things like, if I need a floor cleaner, you know, a service assistant to to point out that the oxygen is no longer attached to the oxygen delivery device in the you know, in the wall in a resuscitation room. And that’s why the oxygen saturation is going down the patient, then I don’t deserve to practice medicine. If I can’t read this EKG. Like, you know, for instance, we have a procedure in the emergency department where time is heart muscle, you don’t want to miss a heart attack, seconds count, minutes count seconds count, you want to get the patient to to unblock their coronary artery as soon as possible. And I have had instances in which people have shoved an EKG, what they do what the nurses do, according to the procedure is whatever you’re doing, they shove an EKG in front of your face and say Here, read this now. And

TK: regardless of what you’re doing?

Dr Goldman: regardless of what you’re doing, you might be you might have a septic patient here and a code stroke patient here where you’re waiting to get a call back to to transfer them to a facility where they can unblock one of their carotid or their cerebral arteries. And then in the middle of a or you might have just dealt with a patient in their family who are yelling and screaming about the about the fact that they’ve been waiting two hours to be seen or waiting for a surgical consult or waiting for a CT or waiting for a report of a CT scan. And there’s a lot of tension there might be microaggressions going on tension between different professionals and in the middle of all this under shoves an EKG in front of your face and says here read this and I’ve had colleagues who have said to me, you should have dropped everything and dealt with that first. It’s hard to make those judgments

TK: you must be familiar with the term sterile cockpit and how on the on the flight deck know your critical critical periods in the flight. No interruptions are permitted. So we call it a sterile cockpit through a specific checklist. If you’re in a certain phase of flight that’s considered critical. The the task at hand must be completed before anybody introduces a new a relevant piece of information.

Dr Goldman: They tried in health care. There are nurses like chemo nurses who would make grievous mistakes in dosage errors and patients would die wrong delivery system wrong dose and they put literally a cone of silence over their head. Try not to laugh too much. I mean, the whole idea is to remove distractions. In medicine, we believe that that competent physician can multitask can live Listen to a million distractions going on all around us. We have in our emergency department an intercom system that begins with a beep. That, you know, I guess the first time I heard it sounded okay. But it has become progressively more and more irritating. And it breaks my train of thought every time I hear. It’s kind of a, it’s like a whistling tone like, Bob. It’s annoying. And then by protocol the person announces makes their announcement and then does it a second time. And whatever I’m doing at that moment, I stop and pay attention to that as if it’s the most important thing. There’s no, there’s no curator. There’s nobody. There’s no concierge who’s saying, Brian, you need to do this first, then this than that than that. So I love the idea of a sterile cockpit. I’d love to have a sterile resuscitation room. 

TK: Have you ever heard of anything like being trialed? Aside from the cone of silence that you mentioned, is this a subject that’s been pursued anywhere in healthcare that you know of?

Dr Goldman: There are a million pilot projects. But one of the limitations when it comes to health care, is the medical mind that says that until you prove it to me, I don’t need to pay any attention to this. So it would be unusual to have a single initiative that is piloted down to be so successful that everybody adopts it all the ones. Now, there were in history in medical history, for instance, the idea of counting instruments in the operating room so that you don’t leave any inside the belly. Yeah, you know, there was a there was there were cases, case law came up, maybe 100 years ago, where, you know, what, you can’t just say, you know, shit happens. We, you know, we left a scalpel, you know, we left that we left, we left forceps in the in the abdomen. And so that changed overnight. But a lot of these initiatives that you’re talking about, I’m sure they’d happened? Oh, sure. We know distractions are important. Are you aware of the OR blackbox?

TK: I read only through the book, the power of teamwork. You mentioned in one of the chapters, that’s as the the extent of my understanding.

Dr Goldman: So the OR black box is a perfect example of a technology that should be adopted everywhere. But it’s a hard sell. And so just to explain it, it’s patterned after the after the the flight data recorder and the cockpit voice recorder. It’s supposed to capture visuals, audio and data in the during the entire operation. And it also captures the environment, whatever was going on at the time. So if there were distractions going on, for example, people going in and out of the operating room is a distraction. It not only introduces the risk of infection, but it’s also distracting. And there are, you know, the surgeon Dr. Taylor Bradshaw, who was the kind of the genius behind it, he’s the he’s the team leader. He doesn’t he hasn’t invented it, but he shepherded all the all the all the the parts to go into to the development of the or black box. He he says that there are surgeons who cannot continue operating until they know what the distraction is about why that person is going into the operating room.

TK: So yeah, there have been crashes, actually from similar incidents on the flight deck of aircraft, pilots becoming consumed with random stimulus that is not actually relevant at the time and subsequently either losing situational awareness on their fuel and crashing or crashing for other reasons.

Dr Goldman: So I talked about the LR blackbox, because I think it’s a promising initiative. But Taylor grants Roth has had to be very careful in how he introduces it to institutions like Vanderbilt and MD Anderson Cancer Center is Duke University, he introduces it first of all, by pixelating, the video and by disguising the audio so that there’s no name no shame, no blame, okay? Because we’re very good at that in healthcare. We don’t like uncertainty. And there’s a lot of uncertainty surrounding mistakes just surrounding bad outcomes. I said mistakes, because they’re not always mistakes. They might be, you know, multilayers complex. Yeah. And, and but one way of ending the uncertainty quickly is to find somebody to blame. And unfortunately, we do that all too often in healthcare. And I can tell you something in our medical culture, right now, when we want to get rid of somebody, we just don’t like who they are. Maybe they’re getting a little old. Maybe they’re getting a little set in their ways and a little too much attitude. An easy way to get to get rid of them is to pounce on the first mistake that you’ve detected that they’ve made.

TK: Not indicative of a healthy reporting environment. It’s not but it wasn’t always the way it is now in aviation. In the 50s and 60s, I think it was probably fairly similar to what it is in healthcare right now. And it was certainly a power gradient with Captain on a flight deck was always right, the loss rate of of aircraft was quite high. And it was just assumed it was the cost of doing business to dangerous environment. And, you know, we trained like we fight and so on.

Dr Goldman: And they would have been, you know, forgiven for believing it was because of the complexity of technologies and cardio it was, but most of the mistakes turns out, according to that, that famous NASA report was due to human factors, human bad communication.

TK: And even now, I mean, technology has improved considerably. Our safety with, with the human factors in aviation systems side of things, and the way we treat teamwork on the flight deck and Crew Resource Management has improved considerably, but it’s improved at a slower rate than the technology that we’ve adopted. So consequently, in the late 2000s, the, you know, the error rate, the primary cause of 80% of general aviation accidents in the US, whereas human factors, pilot error, even though it’s a pretty healthy model for how to share things, not only that went poorly, but that went very well so that everybody can learn from from one another’s mistakes.

Dr Goldman: And, and you’re lightyears ahead of healthcare.

TK: So how do I know in in aviation, we had the benefit of centralized governing bodies like the FAA, the NTSB, Transport Canada and Canada, CA and New Zealand at night, they were able to require mandate that certain carriers part 121 carriers or the the Air Force adopted specific crew resource management, human performance and military aviation flight safety models, that became self regulatory, who were charged with the responsibility of increasing aviation safety. So we were able to do that kind of from the top down whether people liked it or not, it was mandated, you shall take this training once a year. And over time, people became more and more, not only aware of the training and the intent behind a training, but encultured, I suppose.

Dr Goldman: But you’ve also added, don’t sell it short, because you’ve become successful, you have outcomes, you know, it is vanishingly rare to for a plane for a passenger plane to go down. I mean, it happens, but not not at the rate has happened 40 or 50 years ago, and I haven’t seen any equivalent in health care. Now, part of the reason we’re also like, like aviation, healthcare is becoming a lot more complex. We’re dealing with patients who are older and have 10 diagnoses, we’re able to find more, discover more, treat more. The treatments themselves are more complex, there’s a greater risk of drug interactions, there’s there’s interactions between technology and, and the human, you know, and the human patient. And, and, you know, it’s like it’s, I think, at some point, the analogy between, you know, patient and aircraft breaks down. I think human beings are a lot more complex. And I think, you know, you’re dealing with you’re dealing with 1000s of diagnoses. You’re dealing with one plane and the avionics and the general principles are the same.

TK: Yeah, I would agree. Healthcare is is far more of a complex adaptive system. And aviation, while a complex system can be maybe relegated to a complicated system at times rather than a complex Yeah. And I suppose litigious, either.

Dr Goldman: No, it isn’t. But I think I think it’s harder to to do the studies that can demonstrate conclusively that, that we can, we can zero the error rate, we can we can improve outcomes by by zeroing or substantially reducing the error rate. Now, there are very specific successes, one of them is heart treatment, you know, developing a time as muscle approach, so that what you want to be able to do is arrange the system so that you’re diagnosing the heart attack as quickly as possible. So you get the patient either blood thinners, clot busting drugs, or get them to a catheter suite where you can do a an angioplasty and unblock that, that blocked coronary artery, there have been great successes, they’re a little less success on stroke management, but also successful. So there are there are very specific examples, but those are three or four out of 1000s of diagnoses. And you know, and there are, you know, we can do across the board initiatives like reducing catheter infections in elderly patients by by taking out the catheter as soon as possible instead of using it as a as a as a tool for patient management. You use it to get a urine sample if you need it and remove it as quickly as possible so that the patient doesn’t get infections. So That’s creating rules that improve safety and and better patient outcomes.

TK: Is it? Would it be fair to say, it might be easier to advance safety and health care from a medical device standpoint, rather than a culture standpoint, in that you can you can bring a medical device through a series of trials, you can demonstrate in the trials that it has fewer adverse outcomes than competing brands, or competing medical device. And it’s a technical solution that’s more easily adopted. Whereas trying to trying to drive home that the culture towards how we perceive risk, or how we perceive error needs to be changed over a multi multi year, perhaps multi decade long approach. Before you’re going to see the decrease in incidents.

Dr Goldman: Yes. I think, in theory, the answer is yes. The problem and there are there are a number of problems. Unlike avionics on unlike communication devices, you know radar devices, proximity detectors, whatever, whatever kinds of devices you have all in on aircraft, you have systems that are designed to talk to each other. What if I told you that in health care in the intensive care unit, that the cardiac monitor doesn’t talk to the blood pressure monitor doesn’t talk to the temperature monitor. Because at night, different device manufacturers have a source code that they could share with one another but don’t share it with one another because it’s proprietary. Like we’re shooting ourselves in the foot. And patients are suffering at the same time.

TK: And it places an additional burden on the healthcare professional to be the intermediary between all of these systems that don’t talk with one another.

Dr Goldman: Yeah. And and and bear the consequences because it’s got to be somebody’s fault. And I know I’m sounding like a cynic when I say that. But you know, I think the difference between Sully Sullenberger who I had the pleasure of interviewing on white coat, black art, you know, one of my one of my idols, you know, Anthony Fauci was another one. And, you know, I’ve gotten to speak to some great luminaries, but he, you know, Sullenberger talked at length, he’s now become, you know, now that he’s retired, he’s become a consultant, and he’s trying to teach the lessons of of aviation safety to to health care.

TK: Really?

Dr Goldman: Yeah he is, so he told me, you know, what, what are some of the differences between between, you know, dealing with the consequences of aviation mishaps and dealing with medical malpractice, first of all, a shared sense of destiny, that, you know, if the plane goes down, it’s not just going to kill the passengers, it’s going to kill the the the cockpit crew and the cabin crew. And, and so, and I can tell you that, until COVID, we tend to have this dichotomy where, you know, well, the patient, you know, you know, the surgeon is going to feel very bad, the anesthetist is going to feel very bad, the internist, the emergency physician, the nurses, but they don’t, they’re not going to die, they’re not going to suffer the consequences. You know, I, that’s not exactly true. I don’t know a physician or a surgeon or nurse, respiratory therapist who wants to be party to a negligence lawsuit. To to, to, to have to relive those moments again, and again, and again, where everybody knows what you did, in retrospect, you know, dealing with college complaints to the College of Physicians and Surgeons, the College of nurses, I don’t think anybody wants to, I think, in fact, I’ve met plenty of healthcare professionals who take 10 years off their life to undo a mistake. If it’s egregious enough, until COVID, there was no sense of shared destiny with COVID. That was the first time in my lifetime in my professional life that I saw a shared destiny, that suddenly the same disease that could kill patients could kill healthcare professionals too. And boy, did we suddenly galvanize together, you had these protected code blues, where it once it was called in the hospital, people would rush from different parts of the hospital, they would all be there, how can I help? How can I help you, which we often don’t have in healthcare, it’s kind of like, it’s your problem, you deal with it.

TK: You know that brings up an interesting point, because we talk a lot about sharing the mistakes that happen. And then obviously, is, is actually a healthy way of doing things if we’re ever to learn from any of them. But we also ought to share the things that go well, and with a code example. I’ve got a a an observation here from one of your books about a code orange from a mass casualty event and I’m trying to find out in Ottawa, and how it galvanized an entire team together and I just wonder if examples like that are well shared so that other people who perhaps will never or experience or maybe only have a mass casualty event, once every 10 years. They can learn from everything that went well and then try and replicate it in the same way. Sally’s incredible landing on the Hudson is a perfect example of something that’s been well shared because it went so well. So broadly, pilots everywhere have watched it, read the book, thought about it to themselves. Now, what would I have done? What What could I do? I’m, I’m in a similar circumstance. So is was that well shared? Is there? Are there some things that that happened during COVID? That galvanized teams together that people ought to know about the dawn? Oh, yeah,

Dr Goldman: I think so. And, you know, I think the the example, the code orange that I that I wrote about that was involving OC Transpo. And it was a bus that that crashed into a station and the top was sheared off. And it was a mass casualty event. And the the interesting thing about it, is that it followed another code orange, in which the Ottawa Hospital prepared to receive mass casualties and received no one and they wondered how that happened. How could that have happened? And and they did a root causes analysis and did a simulation. And funny thing, that simulation that they did, which was which they completed days before the actual incident, resulted in in a in a textbook operation, because it was well done. And it was well disseminated within the Ottawa healthcare community, within the Ottawa Hospital on the auto and the Allied services, first responders. And so they, you know, they learned some lessons, one of the lessons they learned was it was to was two way communication. So you have the paramedics in the field, communicating with the dispatchers, and giving them a perfect sense of, or at least an optimal sense of how many casualties are going to be? And who’s going to go where, and how many minutes until they arrive until they arrived? And oh, by the way, it’s in the middle of the winter. There’s hypothermia going on? Are we going to be treating that as well? Yes, we need to treat that as well. So, you know, all of that came from dealing with a bad situation. And it is so important to talk about mistakes. Do because though, that’s the royal road to improvement. And that’s the hang up that we often have in healthcare that we don’t like talking about mistakes, except in a way that’s medical legally kind of sanitized. So that that there’s no there’s no chance that a lawyer is going to or lawyers are going to are going to kind of research this topic and find, you know, pleas of guilty people, people admitting guilt and so that they can just cut straight to the settlement.

TK: So, on that topic, just a couple of quotes that I noted from your book, nightshift, you mentioned, I believe one of our responsibilities is to create a culture of safety in hospitals and doctors offices, doctors must feel as though they can admit they have heard and then he gave an example of discussing your own, you know, an error that had occurred in the company of other physicians and how you got the impression that was making feel awkward. So how do we move beyond that culture? And you get some comparisons with it, you know, that we talked about already the death rates in aviation, you know, on the order of 50 to 60 per year as compared with the same order of magnitude per day due to adverse incidents. Right. And in medicine. You You mentioned a case reported by Dr. Landrum about a nurse requesting He replaced the attending ER physician who was treating a motorcycle crash victim it was on white coat black art. And the the attending physician was doing a poor job of dealing with the patient comment, the doctor Landrum, who was asked to exclude intervene, commented, it wasn’t a medicine issue. It all the medicine isn’t a challenging part. It’s all these administrative and personal issues that come up. Kind of speaking to the culture of how do I manage this, the situation has gone poorly, but I don’t want to necessarily tread on toes, and how do I deal with it

Dr Goldman: well, there’s an art to that there’s a there’s an art to that, and, you know, you it shouldn’t be necessary to shame the person into backing down, you should be able to have a quiet conversation. And you know, one of the ways to do that, well, you know, I if I were running, if I were running the system, I would have simulations in which I designed them so that every bad thing that could possibly happen would happen all the time. I would want people to feel comfortable. You know, if the aim was to say, you know that, like, Would you like me to take over? There’s a way to do it. And you know, I’m less tired than you are. I just I’ve just arrived here half an hour ago. You’ve been here for eight hours. I know what’s up Would you like me to take over? Sure. And, but you know, we deal with the consequences, or we live in fear of the consequences. And there’s this, you know, one of the things, you know, we started the conversation by asking a question, you asked me about empathy, lack of empathy and health care. And I haven’t, I haven’t told you the major reason why we don’t have empathy and healthcare, I believe it’s, it’s shame over making mistakes, shame, anticipatory shame, you know, the kind of toxic shame that that we tend to feel when we make mistakes. And when and, you know, I’m not talking about the healthy kind of shame, which is more like guilt, the idea that, you know, you slipped up a bit, but you’ll do better next time. It’s reparative, you want to find out what you did wrong, so you can fix it. Toxic shame is, is living in this almost morbid, Dread, that with your next mistake, if people found out how flawed you were, they would immediately fire you and they would excommunicate you and tell you to leave the group, which is, you know, your fear that you that you’re not worthy that You don’t belong in the group. And I think a lot of us in health care. I can’t prove it. I think a lot of us I think shame is more pervasive than we let on. We you know, if you looked at the at the literature, like the the the psychology of physicians and other health care providers, going back maybe 15 or 20 years, you find the word shame was not mentioned even once. Now there’s we’re starting to see a respectable literature developed, developed. And I mentioned this because in when you’re in the throes of shame, you can’t empathize with other people. Because you are tero so terrified that other people are going to discover your mistakes that you kind of you block communication you don’t you don’t want people to know how you’re feeling. You don’t want people to know what you’re thinking. You certainly don’t want people to have an open kind of a sense that they can read your mind. And you tend to be hostile with patients Curt hostile, particularly if you’ve made a mistake recently, and you’re terrified of being discovered. Just think about how bad how unproductive that is to developing a culture of safety.

TK: a high consequence environment. It leans toward thinking about yourself having to put yourself first if the consequences are severe. There’s an example from, again, from the nightshift. You mentioned with respect to fatigue, if you make a mistake, don’t ever admit that sleep deprivation played a role. 

Dr Goldman: Yes. The shifts are, it’s well known, the shifts are extremely long, especially for resident resident physicians 24 to 36 hours. And of course, we all we all understand the medical literature on what it means to be fatigued and equivalent to being to alcohol intoxication. And and, you know, I can tell you that I know surgeons and other health care providers who’ve done studies to try to show that that’s not the case. We were very good at debunking literature, even when it’s pretty obvious that sleep deprivation, that it’s not healthy, to be up all night. That, that your ability to to to perceive it’s not it’s not the big stuff, often we’re very good at the big stuff, we can kind of get get activated to to respond to a resuscitation. But noticing that a potassium is higher than it should be. And that if we if we did notice that we would take measures to reverse that. And if we don’t, the patient’s heart might stop. You know, that’s the kind of stuff that it’s the boring stuff that you don’t notice. And it’s the boring stuff that can kill patients.

TK: Is there any success stories, moving towards a less punishing rite of passage for physicians and then having to go through these extremely long shifts where your likelihood of making a mistake or at or at least encountering an adverse incident? Perhaps it’s not a mistake? Perhaps you just were too tired to notice something? Something very abnormal.

Dr Goldman: So the answer is yes and no. There has been a tremendous effort. It started I guess it started with a with a case of a young woman, young adult think Libby Zion, let me Zion was a was a young woman in New York City who died of of a toxic medication into drug interaction. So she was given Demerol she was on antidepressants. And the two of them conspired to raise her level of serotonin. So she developed hypothermia and in adults seizures as a direct result of that. Her father happened to be a New York Times reporter and he mounted a campaign and this campaign resulted in something called duty hours. And and so the issue was that was that the I talked about it in the night shift. So the issue that was that was So that was raised was that she was looked after by residents and the residents were up all night and were to sleep deprived to function properly. So this, this big started a process that continues to this day to restrict the number of hours, the residents are supposed to work, they’re supposed to be able to go home the next day. It’s complicated, because when a resident goes home the next day, they must hand over to a physician who is a resident who’s who’s now, you know, well, presumably well rested. Although nobody monitors you to see how well rested you are when you could have been up all night party, but you weren’t on duty. And so there’s literature evidence to show that you may be it may be a trade off, you may be getting a less sleep deprived resident, but you’re getting more handoffs, and with each handoff, they have to hand over information about the patient. And that in and of itself is fraught with, you know, increases the risk of mistakes, because you may forget to tell somebody really something really important about the patient. I can tell you that in the culture of surgery, that surgeons have have spent a lot of time trying to debunk the value of duty hours, it should be intuitively obvious, but they spent a lot of time trying to debug the value of restricting hours. What’s the argument? The argument is you you they’re finding they say that young surgeons don’t have the clinical case experience that they had when they finished the residency, which means they haven’t done as many appendectomies themselves, many gallbladder operations or, you know, thorough economies, you know, chest operations. And you know, there is some sense to that. But the other thing that I want to point out here is there is a strong culture, it’s almost like an immune system, it seems like the the newfangled idea comes outside of medicine comes from aviation, restrict duty hours, so that you have less tired people makes a lot of sense. And so that’s the invading idea. And the antibody response for medical culture comes down with antibodies and just get rid of it. And you actually have, there was a surgeon in the city of Toronto who said, We are not airline pilots, she said, we are fighter pilots.

TK: She realizes fighter pilots have duty days as well.

Dr Goldman: Maybe they get doped up on low Daffodil and, and and and an Adderall. And so that’s how they’re able to function. I don’t know. But But I mean, we carry that to ridiculous extremes. But the point I’m trying to make is that and this is this comes up again and again and again, that there are lessons from that aviation can can pass over two to anesthesiology, two to two surgical culture, but that we are resistant and often resistant to those ideas, in part because of the shame that I’ve talked about. That’s a shame response when I say if I need some, if I need a pilot, if I need Sully Sullenberger to tell me how to practice surgery, I shouldn’t be a surgeon. It’s hard to argue with that may not be true.

TK: And it’s, I mean, it’s not even a question of advice on the practice of surgery or advice on the specifics of your particular specialty. It’s advice on best practice in terms of how you can function most optimally, which of course, everybody should pay attention to, which is why pro athletes on occasion look toward the military and vice versa. Special Operations Forces Command will look towards pro athlete from a cognitive psychology standpoint to absolutely get the best possible out of their people. So I mean, I can understand where somebody might be coming from that this these ideas or outsiders ideas, and they may not apply. But, you know, for somebody who’s interested in and passionate about human performance, if we want to operate at the best that we’re capable of doing and whatever specialty or whatever field that we’re in, we probably ought to look at what we can learn from people who are also operating at their best and other in other domains. 

Dr Goldman: You don’t have to convince me I, I agree with you completely. And you know, it’s one of the reasons why I did my TED Talk, doctors make mistakes. Can we talk about that, because, you know, I wanted to break through the shame by and one way to break through the shame is to simply name the things that you’re ashamed of. And you know, every once in a while, you’ll get a physician or surgeon who has a history of substance use, and they talk about it, because that’s part of their recovery. And when they do, they’re depriving the secrecy you know, they’re depriving that information of its its ability to enslave you by by keeping it secret. There is an expression that a colleague who had substance use issues had alcohol use disorder, he said to me, it’s, it’s it’s in the secret that lies the sickness. And if it you know, the way to deprive those shameful secrets, including medical mistakes, of their power to kind of keep you quiet, keep you terrified of being discovered as to is to out yourself. And that was what I was trying to do with my was my TED talk along the way. I discovered a whole bunch of people who wrote to me who said things like, Wow, I’m so glad you talked about your mistake, because this is what happened to me. And including some people and one person. This is a story that I held the dearest, somebody who said they were in a hotel room. And they wanted to end their life because they made a medical mistake. And they watched my TED talk, and they changed their mind.

TK: I wonder how many other people out there were in a similar situation who weren’t fortunate enough to watch your TED talk?

Dr Goldman: I don’t know. I don’t I do know, I do know that right now, among students, medical students and residents, the rate of suicide, suicidal ideation, suicide attempts, completed suicide, much higher than the general population. And I don’t think we’re so there’s so there is, there actually is a in a perverse way, a shared destiny, you know, harming patients, and then and then turning the harm on yourself, because because you can’t bear the thought of living with the mistake that you’ve made. And, you know, i My heart goes out. I, I don’t I wouldn’t wish a medical mistake on any colleague. And yes, we are. And you know, there’s this whole literature of referring to health professionals, that’s the second victim of medical malpractice. And, you know, once patients and their families caught wind of it, they said, How dare you? I lost my father, how dare you talk about being the second victim. And so we can’t talk about that. But I can tell you that it is an experience that we should all strive to try to prevent if we can by learning the lessons that are out there.

TK: And reminds me of those three little words that you do write about in the nightshift, which also ruined a Jack Johnson song for me that I liked by the same name. Do you remember? Can you speak to that a little bit? I don’t know. I’m sure all of our listeners and viewers will have…

Dr Goldman: Sure. Yeah, that and I, you know, that was kind of the the framing device of my of my my TED talk. I wrote about it in the night shift. And I talked about it in my TED talk that the three worst words a and an emergency physician will ever hear, or do you remember? And it’s usually the beginning of a story. Remember that patient you saw last week that it’s not always if you practice long enough, you might discover that that? Well, you know, it turned out that that they had this diagnosis. And so we were able to, you know, we were able to address the problem. But in our worst fear. Do you remember is the beginning of a story that the patient died after after you sent them home? And I you know, I interviewed a number of people, I had them on white coat black art, including one physician who, who had seen young adult with autism spectrum disorder, ASD, autism, who would be brought to the emergency department by his caregivers, to be to be to receive an enema, because he got constipated. And he got he got banged up and needed to be disinfected. And this emergency physician you know, was urged you know, can you he’s he’s yelling and screaming, can you get him out of here and and he acceded. He agreed to the enema. He didn’t he didn’t take another look and sent the patient home and got the came back a few days later for his next shift, and was told following do you remember? Yeah, I remember that patient found out that he died. And at the autopsy, he had a ruptured appendix appendicitis. And he died of septicemia. And, and you know, I think that, you know, I haven’t thought about the phrase. Do you remember, by the way, I can tell you there’s another three words that emergency physicians don’t like to hear, and that is you look tired. We were talking about that a while ago, because you’ve been being that because because an astute emergency physician knows how to get enough sleep. Can you imagine like, how, how would you feel if somebody admonished you to get more sleep, or you’ll be fired? You know, I think I would go home and be preoccupied with FOIA. I better get to sleep tonight. And I’d be pounding the pillow and I get four hours of sleep and there I’d be sleep deprived.

TK: And not to not to mention just the length of your shift, but switching between day shift night shift regularly. You know the effect that it has on your circadian rhythms and the quality of your sleep, not just the quantity but the quality of your sleep. The amount of time you spent in an REM versus your deeper sleep.

Dr Goldman: And you know what I was one of the first to like, I’ve been practicing over 40 years and and I was one of the first to bring Chrono biology into into into the shift work that we we did at my hospital, I was one of the first to say we should be switch, we should be going from days to evenings to nights, and then have a suitable period of time off. And, you know, we’ve done that. I think that across other disciplines in medicine, you know, they’ve they’ve gotten into ship port ship work is actually better than being up for 36 hours. And so doing, you know, for instance, having an obstetrician doing night duty, arriving at 7pm, or 8pm, and being there for the rest of the night, or having three shifts a day. It’s just, it’s hard to do that, because there’s fewer obstetricians, and there are a lot of other kinds of professionals. But that would be and that is that that’s actually an advance. You’ve talked about, you know, I know, the sense I’ve got for you is that is that you’re thinking about shift work as you’ve got to do it, right. If you don’t do it, right, you’re gonna have people who are sleep deprived, and that is true. But I can tell you that shift work, you know, for an anesthesiologist is far better than having them up all night, you know, working all day, being up all night, and then having to go to work the next day, and function during the daytime. You know, I haven’t having shift work, I think is actually an advance. And that may be surprising to people who are who are steeped in aviation and shipped duty schedules for pilots and other cockpit crew.

TK: I wonder if, you know, going back to the reluctance to share errors. Some of it might be down to the language around error, and the fact that we’re talking about mistakes, and therefore there’s a shame involved with with a mistake. Whereas in military aviation, least in the Canadian Forces, you really hear those terms being used. The term FlightSafety is used as a catch all for anything. So it could be a mechanical error, it could be a bird strike, it could be a misinterpreted clearance, or miscommunication. Or it could be a mistake. All of those would be a flight safety. So the pilot, the crew, whoever’s involved gets down from a trip. And I’ll say, I think it was a flight safety, I think we should write up a flight safety, and then the flight safety is written up. And then as the director of flight safety takes a look at it, and they, if there are preventative measures, they publish preventative measures for everyone. It’s, it fosters a just culture where you know that there’s no punitive measures involved, because what you’re trying to do is bring people’s attention to something that’s preventable. I don’t think I’ve heard people use the term. There was a mistake, or there was an error, it’s usually there was a flight safety. And I wonder if something similar to that, and healthcare might start to move people away from the mindset that I can’t talk about it because it’s a mistake. Maybe it’s a trauma, resource safety, or it’s a medical safety or something. It’s a nomenclature thing. But perhaps.

Dr Goldman: It’s an interesting thought. My sense is that people in health care would see through that. And they would be thinking, oh, yeah, they want to know who to blame. Right? This is just code for who to blame. And

TK: How important is anonymity? How important is anonymity, then if we’re talking about, let’s, let’s share as much information as possible with as many people as possible to do it in an anonymous way where, you know, hey, there’s going to be no punitive measures here. I just think people ought to learn from this and not not even necessarily learn from a mistake. But something something could have happened, but didn’t happen. We had a near miss, and it’s probably not going to be captured anywhere or reported on but I think other people outside of our hospital or outside of our healthcare region ought to know about it, because it’ll probably happen somewhere else, too. It’s a matter of time.

Dr Goldman: If you believe, as many people do in health care that good doctors never make mistakes, then all of that effort is is extra work that you made us do, like, see what you made us do. We had to have a morbidity and mortality rounds because of your mistake, see what you made us do. I sound utterly cynical, but I haven’t seen this change. I haven’t seen this change in decades. And, you know, I and there will be I mean, there was I’m sure there’ll be healthcare providers who who look at this conversation who will say, Oh, Brian, you’re you’re decades out of date. Now. We don’t do that anymore. I can tell you that and it takes me it takes a special person. I may be maybe I’m thinking about antiquated or outdated leaders who subscribe to that. You know that view that the easiest the most expeditious way to deal with a mistake is to find someone to blame. So you can say we’ve solved the problem because we punish the guilty.

TK: Are you seeing any, any developments or advances in terms of maybe flattening the hierarchy, or the power gradient a little bit more developmental teaching more Socratic method, maybe more empathy towards residents, instead of putting them through the punishment of a rite of passage?

Dr Goldman: I, you know, I think there’s some of that happening. And, you know, certainly there are venues where residents can discuss cases, in a, you know, in more of a just environment, where they’re able to just say what they, you know, say what they’ve seen. And, and, and talk about it, and in a way that is, that’s healthy, they’re able to share their experiences, they’re able to talk about how they feel, you know, I think they’re, there’s more of that than there used to be.

TK: Yeah, what kind of tools are out there for that? I mean, we’ve got, you mentioned the same work, the use of F minor, I’m not sure if it’s pronounced and retain tabletop and digital games as proxy simulation to reduce errors. By encouraging participants to speak up where they see a way to improve care.

Dr Goldman: There’s tools that have been that have been created for and by the Canadian Patient Safety Institute, based in Edmonton. There are, you know, there, there’s Greg swings. You know, Greg was a man who died of metastatic testicular cancer, he actually had a blood clot in the days following surgery, in the immediate aftermath of surgery and, and his family created Greg’s wings, too, as a as a teaching device to it. So they created a documentary they paid for a documentary that described his his his journey through the healthcare system, in an effort to provide lessons and those lessons have been taught to medical students, residents, allied health professionals. And so, there are these these these teaching tools exist. Elaine Bromley who I talked about in the power of teamwork. Her husband Martin Bromley, and airline pilot, commercial airline pilot, created a trust called Human Factors research based in the UK and he, his human factors, created a produced a documentary called just a routine operation, and describe what happened and in my book, The Power of teamwork I talked about that particular case, this is a woman, his wife, his late wife, Elaine Bromley, a young mother at the time, who went into a private hospital in the UK for routine sinus surgery. And, you know, within 25 minutes, 30 minutes or so, 45 minutes, had suffered irreversible brain damage because she had a complication, a rare complication, which I guess is the equivalent of a stall. In, in, in aviation, it happens in the operating room, they couldn’t, they tried to the nuisances, tried to insert an airway to oxygenator. He had he was unable to insert an airway and he was unable to oxygen in nature and over and she had been given medications to stop her breathing to sedate her. So that to make it easier to to to insert the the airway device and she so she she had a recognized complication, called the can’t intubate can’t oxygenate Kiko also sometimes called the can’t intubate can’t ventilate scenario for which there is a fix, and that is a surgical airway, tracheostomy. And, and, and, you know, I and so this video that’s been, that’s basically an hour, like a minute, not hour, but Minute, minute by minute account of what happened to Elaine has been has been used the world over to teach anesthesiologists and emergency physicians like me, because sometimes we have this kind of a clinical scenario. And, and, and I, you know, I talked about the reason I talked about about this case, to use it as a framing device for my book, The Power of teamwork, is that I believe that teamwork is one of the answers to reducing errors. We haven’t talked about this yet. And I learned teamwork is important. In that, you know, teamwork means that you have a leader who has situational awareness, who is managing a team and not doing the job of the team members. So there was nobody in the operating room who noticed who could say, what’s our situation right now? What’s the CIT rep, you know, and you know, you need that in aviation, whatever. Got bird strike, two engines knocked out, you know, avionics fail, like we have a glider here and nothing else, you know, that was that was that was solely selling burgers. You know he had situational awareness. But in that operating room you had you had to anesthesiologist, the second one during the first one, and then the ear, nose and throat surgeon who was supposed to be doing the operation each sequentially trying to secure the airway each failing. And in fact, there were nurses who came in one nurse who said, we’ve got we’ve secured a bed in the ICU. This was a patient who is supposed to go home after an hour and a half, you know, routine surgery, elective surgery and go home. Why have you in what you needed? What, you know, why would you tell me that there’s an ICU bed available, and maybe the nurse might have replied, in a culture with a flattened hierarchy, which we talked about? That? Well, I’ve been looking at the oxygen saturation needs to be, you know, north of 90. And it’s been it’s been in the 40s for the last five minutes. And and you know, set your set your stopwatch and 10 minutes, and they might have irreversible brain damage at that point. And then another nurse that I brought a still small voice that I brought the surgical airway tray in to do the tracheostomy What did you see that made you say that? And I in the book, I talked about ways of using that information?

TK: Was that the say it see? See it say it?

Dr Goldman: See it’s a culture do Do you have that incur resource management? We do? Yeah, well, if you do, yeah. And we don’t have that in, you know, we started to have it. And we are doing say I don’t wanna make it like we are doing practicing more teamwork, we are doing more simulations, where people do are able to act out their different roles, including acting out the role of leader that they can learn that their job isn’t to fix everybody else’s problems, but to but to be to ask the questions that gathers the wisdom of the room.

TK: The use of simulation, kind of going back to the code orange, we talked about the mass casualty event and how the simulation occurred prior to that, and it prepared everybody to do much better to perform much better as a team. That’s obviously second nature for for aviation and any operational crew will go through quarterly biannual or annual recurrency emergency flight training devices, emergency simulators, where exactly as you described as the worst possible scenarios are thrown at the crew for four straight hours. And then then you switch from the role of, for example, Pilot Flying pilot monitoring, or vice versa. If you’re conducting a recurrency, with another aircraft commander, or an aircraft captain, then one of you will be a first officer for four hours and the other one, and then you’ll switch so you get an opportunity to be the leader as well. And you have a chapter there, Dr. Nigel Downey, a thoracic surgeon and commercial pilot.

Dr Goldman: Yeah, probably the only one on the planet, I would think.

TK: Must be rare. You know, he probably applied to European Space Agency for for astronaut with a spell the only credential left off his resume. So in that chapter, you’re dealing with crew crew resource management, how it’s applied in aviation, how it could be applied. And I believe you mentioned a little bit on threatened error management, as well, because you’re talking about, you know, the various evolutions of career resource management and aviation. Can you expand on that? A little bit?

Dr Goldman: Sure. You know, I think the, you know, the ID and I built it very slowly and carefully. So the SE et Cie, it comes from something called Visual Thinking Strategies. And this is just this is just a technique that was designed to, to increase the enjoyment of museum goers in the experience of watching viewing exhibits in an art gallery or museum. And it was born out of the idea that that you know, they said they liked, you know, museum goers said they liked the experience, but they were getting nothing out of it. And frankly, and so this, this was the the idea behind it is to plug people in front of a work of art, people who know nothing about art, and you don’t have to have a degree in art. You don’t have to, you know, have have a degree in art appreciation and ask them three questions. What do you see? Sculpture painting in front of you? What do you see that makes you say that? You know, for instance, I see I see a woman in bed. I see a woman who looks sick. What do you see that makes you say that? Well, her complexion is different from from the complexion of all the others who are around her. And and then you ask a third question. What more can we find and then invites other people in the group to just say what they see, you know, someone else says, I see medicines on the on the night table or I see a crucifix in the background or I see a woman Standing over the woman in bed, who is holding a palm leaf. And, and, and the the whole point and this has been this has been used adapted for medical students. So in the, in the book in the power of teamwork I talk about Alexa Miller who adapted this for medicine. So she in a pilot program 20 years ago plumped first year medical students from Harvard Medical School, look, delivered them from the medical school across the street to the Museum of Fine Art, plug them in front of the work of art, and ask those questions. What do you see? What do you see that makes you say that? What more can we find? And the whole idea is, is to develop something called Team cognition, which is a relatively new concept. But the idea that that you know, in aviation that everybody in the cockpit is getting a sense of what the emergency is. And that each person with their unique perspective and unique experience, is able to contribute things that can help assist in, in developing overall situational awareness that it’s doing is creative. And this is really important is creating a culture where you feel safe to say what you see. Without that, plans are gonna go down and patients are gonna die. And can you can you can you develop that? Yeah, you can. And through the simulations that we’re doing protected code blues, learning how to how to how to get past making mistakes and learning how to cope with unforeseen circumstances or barely foreseen circumstances? 

I think I think that is my I think it’s, it offers a great hope to improve safety and health care.

And the excellence wouldn’t work. If it was one on one, you need a group there to provide the additional information on what else do you see.

And you need people in their roles. So if you have, for instance, a multidisciplinary resuscitation, you want surgeons to play surgeons, you want nurses to play nurses, you know, there is benefit to rotating so that they can empathize with, you know, you know, so that a surgeon, for instance, can empathize with in any statistical analysis can empathize with that with, with a surgeon? Or, or, and that’s important, because it’s, sometimes you need that to to appreciate that you’re not the only one in the operating room.

TK: How often are simulations conducted with a multidisciplinary team outside of the training context outside of med school or the university?

Dr Goldman: I think it’s neither in both cases, it’s seldom, and they tend to be special events, they tend to be special events. And like the code orange that I talked about with OC Transpo, where they were the Ottawa Hospital, did a code orange simulation. And then you want people in their roles, because you want them to be able to function you want you want to, you want to be able to predict how they’ll function. And in a in a real scenario, and you want to be able to uncover as many of the of the potential errors or bad outcomes as possible. I think that, you know, the limitation with multiple disciplinary simulation training, is that it’s hard to coordinate schedules to get everybody available on the same day.

TK: Yeah, it makes it I mean, on the one hand, culture won’t remain strong. If it isn’t nurtured, it will be eroded by other norms over time. So there’s a repeatability requirement in order to maintain a high standard. But on the other hand, you have the complexity of scheduling, which we already talked about how fatiguing it is to be a resident and possible that is, I’m sure this, this is not enough people in any of the medical professions, I imagine that scheduling is the way it is, in part, not just because it’s a rite of passage, but because it’s the pragmatic solution to try and squeeze as much as you can out of the people that you have available.

Dr Goldman: Yeah. So and we have you know, I think we’re constantly fighting the enemy of time pressure in healthcare, and that may be one of the major differences between a Yeah, I’m not I’m not sure you know, because I know that that airline schedules are very, are, you know, this is all this this is partly or largely about profitability, because the margin between you know, between between profitability and loss is you know, a lot of airlines are in the red a lot of the time and and so on time departures are important and yet you’d want to have on time departures with the safety culture. We are caught in healthcare constantly facing time pressure, particularly in the emergency department. My head is on a swivel. I’m like a pinball. I’m just bouncing from one thing to another to another to another to another and and the ideal scenario, the ideal way of doing simulations would not be to have a sheduled simulation, but to have an in situ simulation where we’re here, code code blue Code Blue Room 52 You, and everybody comes right into code blue. And, and they discover that it’s that it’s a recessive anti doll, who and this is, this is probably the best way to do it because and you have it on the ward where they work. So they can’t say I’ve gone to the special Simulation Training Center where none of the equipment is the equipment I work with. It’s their equipment, their supplies, and they uncover very quickly, you know that they don’t have adequate supplies of epinephrine and you know, other resuscitation drugs, etc.

TK: How much agency would you have as a physician to to create that simulation without needing to go necessarily through, say hospital leadership

Dr Goldman: In, on your own ward? Well, if somebody accused you compromising patient care, because everybody in the emergency department was preoccupied with with attending to this fake emergency, the simulated emergency when patients were Meanwhile, in the waiting room who were waiting to come in, yeah, I think, I think we’re very good at raising objections. But that, you know, that’s, that certainly is, you know, that’s what Glen Posner does. He he’s an OBGYN in in Ottawa, who runs these in situ. He’s the one who carries dummies around. That’s the and people are kind of pissed off when they come into the room realize that they’re facing a simulated patient. But you know, the intent is to. So I guess you need a maverick. You need a maverick, who says this crazy idea might just work.

TK: Maybe your fifth book will be the power of leadership. And that’ll be the the maverick may discussion? Were there any particularly strong teams that you’ve worked on? Worked with? Throughout your career that came to mind when you were writing the power of teamwork?

Dr Goldman: Personally yeah, I would say some of the strongest teams that I’ve worked on are the ones I’m working with right now. In the emergency department at Sinai Health System, I’m not just I’m not just touting, signing, because I work there. There have been some very strong leaders like there was a time when we worked. We provided solo coverage. I remember on a Saturday, you know, Saturdays and Sundays, we had 12 hour, we were offered 12 hours, and we were the only physician on duty, we had to see every patient over 12 hour period, and then we’d hand over to the night doc or the night Doctor handover to the day doc. Now we have triple and often quadruple coverage. So first physician arrives at six second arrives at 9/3. One arrives at 11/4 arrives at 1/5 physician arrives at 4pm. And then the sixth position arrives at 6pm and the seventh physician at 9pm. The night doc arrives. And you know, they’re working for eight, typically six to eight hours. So you do have a pool of colleagues who are available. So the first thing I’ve noticed is that once you start having triple and quadruple coverage, you can have cross talk, you can have you can have one physician saying to another, you know, I’m having a little trouble with this patient why? Or look at the ultrasound I just did, what do you think of that? You have a you know, I’m thinking of a of one of my colleagues who showed me a better way of reducing a fracture, just because he happened to be around. In fact, he was doing anesthesia when I was doing the reduction and he just said there’s a better way to do it. And he taught me right there. So, you know, and I you know, I don’t I don’t remember that team spiritedness and it may be that maybe younger physicians, he’s younger than I am. But I’ve I have some some idols. Now I have some some heroes that I work with who are younger than I am and maybe very promising. 

TK: Is there something unique about Sinai, that is the perhaps other hospitals, not just in within Ontario, but elsewhere in Canada, or further afield could learn from?

Dr Goldman: Oh, yeah. You know, I think I think that, you know, I think Sinai can can teach it I think University Health Network is good at a lot of the hospitals in Toronto are are learning and you know about about the teamwork model, you know, my colleagues have Perlman directs the the simulation center at Sinai. And he’s, he’s taught simulation training around the world. And he’s so so he’s, he’s another person that I respect greatly, I would say as well. I mentioned the Ottawa Hospital. You know, it tends to be teaching hospitals, because they’re teaching the next generation of physicians and then you know, there’s good simulation training in the United States as well.

TK: Is that primarily how a good practice is fostered? It is at the teaching hospitals or is there another way to get across interesting novel ways of new ways of doing things? Sure. You mentioned an interesting study published in the Journal of American Journal of the American Medical Association in 99. Found the average length of time physicians letter patients speak before interrupting was 18 seconds. And once interrupted, the patient’s never got back to fully describing the situation. And so you notice how silence can be used as a technique for gathering more information about a patient’s background. And I wondered when I read that how many other physicians know that? And how are there avenues outside of a teaching hospital, where you’re communicating with one another on a relatively regular basis with just interesting, perhaps non medical tips like that the use of effective silence to improve your diagnosis,

Dr Goldman: I would say that WhatsApp is probably the the vehicle of choice, you know, the medium of choice for sharing that kind of information.

TK: Is that because it’s encrypted, and people feel a little safer? 

Dr Goldman: Yeah, yeah. I, you know, it’s time consuming. Because you know, when you have a group of 35, or 40, physicians who belong to the WhatsApp group, there’s a lot of there’s a lot of postings to go through. And if you haven’t checked in, well, you could, you know, there could be 30, in a day could be 30, or 40, or 50, even 100 in a day, depending on on how spicy the topic is, or how pertinent the topic is. But yeah, that’s okay. That’s one way that we do it.

TK: All right, so we’re getting to the end of our conversation here. I do have to thank you very, very much for your time this afternoon. My pleasure is a ton of overlap between aviation and healthcare, and I could talk about it with you for hours. I think I’d like to finish up a quote from your book, your most recent book on teamwork. And then I’ll let you close it out with your thoughts on this. Every single day without fail, if I tried to do my day on my own, every single day, there would be an element that would not function as well, because without the team, I wouldn’t have the input of somebody else.

Dr Goldman: So that was uttered by Dr. Jonathan fitzSimon, who is a family doctor in Arnprior, which is part of Renfrew County. It’s in the lovely and austere and remotely populated part of northeastern Ontario that encompasses the Ottawa Valley, Algonquin Park. And the County of Renfrew has, in addition to stark beauty, it has some logistical problems, it has a large number of older patients who don’t have a family doctor, and who, you know, if you can’t drive car, can’t get to medical facility, there are almost no walking clinics, there’s there’s no public transportation. And so they have two options, they can call 911 and be brought to an emergency department. Or they can sit at home and get sicker and sicker or, you know, maybe if they’ve got a loved one, you know, an adult child who can transport them to a doctor’s office, and then that would be that would be helpful. So in that system, they discovered that they had a huge problem. And that is, how do you care for people who don’t have a family doctor and don’t have access to health care, and they invented a teamwork model that is the that is now inspiring similar efforts across Canada and around the world, where you have Jonathan fit Simon, who’s functioning as a family doctor, if he had to go out and do house calls on every patient, he’d be spending his entire day driving from place to place, well, that’s not very efficient. So he stays in his office, there is a dispatcher you know, there’s there’s all a toll free number that patients can call. And, and and it’s for unattached patients, patients who don’t have a family doctor and to get plugged into the system. And they’ll talk to either a family physician like Dr. Phil Simon, or they’ll speak to a nurse practitioner. And if it would be beneficial for them to come to the office. If someone can transport them, they’re fine. If they can’t, then they’ll send a paramedic to the patient’s house. And they function as the eyes and ears of the primary care provider. They can take vital signs. So these are this is a different kind of paramedic, it’s not the paramedic who is a first responder to emergencies. This is a paramedic who arrives in a specially equipped vehicle. They have special training, they can do sutures, they can put in IVs, which every paramedic can do. They can take vital signs they can do point of care, ultrasound, electrocardiograms, blood work, they can deliver medications. And you know this system was in place prior to the pandemic and with the pandemic. They had the added pressure or in the early days of the pandemic, they didn’t want patients with COVID to be brought to the emergency department. If it wasn’t necessary, so they developed something called the Virtual triage Assessment Center V TAC. And so this was a toll free number that patients could call and could get advice on managing COVID could also by the way, get advice on managing everything else. And they were they were accepted and recruited into a team, where the team would consist of fam family physician, nurse practitioner, nurses, community paramedics as the eyes and ears doing the house calls, registered dieticians, psychologists, physiotherapists, occupational therapists speech and language pathologist says necessary pharmacists all functioning in a teamwork model. And and what they found is that the the the the, they were able to take care of patients who previously had no family doctor who would have had no option but to go to the emergency department, they were able to dramatically reduce the number of unnecessary visits to the emergency department. And they did it without transmitting co COVID-19. And the program was so successful, that it recently received full funding to carry on indefinitely. We should all be doing something like that. Now, one of the things that people people who’ve been watching the healthcare system as I have for decades, we get tired of pilot projects that go nowhere. We want this thing can be scaled up. And we know for instance, that, you know, community paramedicine in Alberta, which also has austere and remote areas of the province that are not well doctored Well, in a teamwork model, you can look after those patients where they live. And I think this is the kind of thing I’d like to see right across Canada, and certainly in, in the United States and around the world. And, you know, it’s the brainchild of Chief Mike Nolan. Michael Nolan is the director of Paramedicine for the County of Renfrew. And he’s a visionary management expert who has who has learned how to get the different silos, you know, the hospital culture, the family medicine, culture, the specialist culture Paramedicine, first other first responders to play nicely with one another. And, you know, it takes a special kind of leader to be able to make that kind of kind of thing happen. He’s done it very well.

TK: It’s nice to finish on a positive note. 

Dr Goldman: Yes, it is. It’s a positive story. Teamwork works. You know, teamwork saves lives in aviation, it saves lives in health care. And the more we espouse to the principles of teamwork, not only not only will we do better, but we’ll feel better. We’ll actually have less burnout. Fewer, you know, fewer accidents, better safety record, better job satisfaction and a better sense of bliss, ecstasy, from all of us doing a job. Well done. Like, when was the last time you said we did it? We did it. We all did it. And I think that’s that’s the juice of health care, just as the juice of aviation as well.

TK: I couldn’t agree more. Thank you so much for your time, Dr. Goldman, I encourage our listeners and viewers to go out and purchase the power of teamwork. And to take a look at White Coat black. That is an excellent podcast. Thank you, even for folks like me who aren’t healthcare professionals. Very a ton of overlap with with aviation and thoroughly engaging. So thank you so much for your time this afternoon. Wish you all the best and I will see you again in the near future.

Dr Goldman: You bet me too. Cheers.


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