TK: Hello folks and welcome to the Dicerra Podcast. I’m Theon te Koeti, CEO and founder of Dicerra. On the Dicerra podcast we talk about human performance in aviation and healthcare. Today we’re downtown Ottawa. This is the Between Two Ferns edition, I’m here with Paul Kissman, who’s one of the most experienced pilots in Canada. Has a really impressive resume, an ex fighter pilot with the Canadian Forces flew F5s and F18s. Experimental test pilot trained with Empire and who became the Chief Test Pilot for the Royal Canadian Air Force and later became the Chief Test Pilot for the National Research Council of Canada. Also the Chief Pilot for Vintage Wings Canada and is now perhaps slightly different pace of operations flying wide body A330 for Air Canada, and is also the lead aviation advisor for Dicerra. So we’re super lucky to have you both on the show and with Dicerra. Paul, why don’t you begin by telling us a little bit about how you got here?

PAUL: Well, first of all, thank you for the invitation, both to participate with Dicerra, and also this podcast. I’ve been super fortunate in my career, you know, I started out, have to give a shout out to the Air Cadets, started out there. You know, the 16 year old kid flying gliders getting my glider pilot licence before I even had a driver’s licence. And it really paved the way for me into military aviation, it gives you a taste of the culture. You know, and it also gives you a bit of a resume that the military can look at and say, yeah, this kid might be something one day. And so I sure owe a lot to that, that process. And I was fortunate throughout, you know, my back in the day, you had to have 20/20 uncorrected vision. There were all kinds of stumbling blocks that you had no control over. That, now some things are more lenient, and you could get by with classes or laser surgery, but we couldn’t back in the day. So I also am thankful for my good fortune, you know, whether it’s in health or in getting through all the hurdles that there were to getting into the military and, and for example, you know, I got straight on to fighters, many people wanted fighters. You know, when I started my course, we had 34 people on my course in Moose Jaw that wanted fighters out of 36 when we started and at the end we got four slots. So I was fortunate to be one of those four and that just set me up through out. I just managed to get through that and in the Test Pilot School and it’s just been one good fortune and enjoyable experience after another.

TK: That’s awesome. And was that the tutor back then for phase two? Moose Jaw? 

PAUL: Absolutely. Yeah, we went Musketeer phase one, which is a small low wing airplane, 180 horsepower, fixed gear. And then right on the tutor jet, which you can imagine was quite a big step up. I can still remember the first takeoff and the tutor. It was like this magical hand was pushing you mysteriously from somewhere because it was so quiet. You know, every airplane I’d flown before had an engine in front of me with a propeller with the vibration and the noise associated. Now you get into this magical jet. And the only thing that you heard was the air conditioning system blowing air. And the jets all behind you and the faster you go, the less you hear it. Yeah, I can. I will never forget that first takeoff.

TK: And then F5s with 419. 

PAUL: Yes. 

TK: F18s and then of course a range of aircraft with test pilot school including the F14D. 

PAUL: You bet. 

TK: So what’s the most interesting aircraft in your logbook?

PAUL: You know, people always ask you normally ask me what my favourite airplane is. And I always say the one that I’m sitting in, you know, I have a broad love for aviation that goes from small piston aircraft still to this day, right up through the airline world that I’m flying in with Air Canada. But I think the one that ties a bow the best on my whole career is the F4. I was an eight year old boy at an airshow in Hamilton. And I think it was Michigan International Guard that flew some F4s by in a fly past. And my parents happened to take me to an airshow and I looked up and said “I think I want to do that.” And, and I didn’t waver from that, you know my passion for maths and sciences was a good fit to that. And working hard in school obviously. And it just kept progressing along that I didn’t take my eye off that ball from eight years old and then ironically, on test pilot school with the empire in England in 1996. At the end of the course our culminating exercise is to fully assess an aircraft that we haven’t flown before. So we got assigned the F14 Super Tomcat which was in Point Magoo in California. The side hustle was that they had F4s that they used as target aircraft for live missile shots. But they were also equipped to be flown so they flew them once in a while until he actually participated in a live fire exercise and probably didn’t come back. But I actually got to fly the F4 out of the front seat with a poor, trusting soul in the back who had no stick, no nothing. No simulator, no, just here’s the book, here’s some guidance and somebody that was, you know, talking to me at various pitches of voice from behind, you know, to me to make sure that we got things going in the right way. But it was really was the ultimate, you know, bookend on a career, because that’s what got me going in my vision in the first place. And then of course, I finished Test Pilot School by flying that aircraft. 

TK: That’s amazing. 

PAUL: And I’ll put a side story to that one too, because it was so unique, in my experience. Because we’re going to talk about safety and various safety cultures. So these aircraft are obviously expendable, because they’re going to be shot down. But we’re not. So you know, there’s a certain interest that we do things right. But as we’re doing a check of the flap system, before we got out of the parking to get going flying, there was a leading edge flap that was hanging up, and it just wasn’t deploying properly. So he calls over one of the maintenance technicians that comes over with these big bolt cutters. And he cuts a triangular chunk out of the leading edge flat, and then they move the flaps they work, he goes good to go. So, you know, speaking of safety culture, you know, that wouldn’t fly, pardon the pun, anywhere else. But in that environment in that day in age and with that aircraft. That was okay.

TK: You couldn’t do that with a Fifth Gen fighter.

PAUL: No, you wouldn’t. I think the F35 boys would have a heart attack.

TK: That’s wild. Well, since we’re, we’re talking about safety culture, then let’s, let’s get cracking and and maybe we can jump into the first question with how is your experience as a fighter pilot and test pilot shaped your perspective on aviation safety.

PAUL: It’s been an evolution sort of like my career. And I was trying to find a way to frame this well, because I’ve gone from fighter aviation and now into high end commercial aviation. And they’re very, very different. And even if you do test flying or research flying in there, which I’ve also had a chance to do, every one of these types of flying has a culture and they have a mission necessity, you know, an urgency of various urgencies, you know. If you’re in the fighter world, not unlike cutting a chunk out of your flap and an F4. But if you’re in the fighter world, there is a known portion of this profession, that is we might get shot down, or actually my role very much could be to go shoot somebody else down in an aircraft. So the safety piece is morphed just a little bit because of the risks of the mission that you’re doing in war, whether you get shot down by a surface to air missile, or by some other aircraft or the the risks that you take on. So the context of the mission that you’re doing, really frames the safety culture, and you couldn’t possibly, you know, overlay an airline safety culture on a fighter aviation mission, because it’s just so different. And the risks are inherently so much higher, doesn’t make safety less important. But it just makes how you apply it different. And that’s really what I learned going through. I mean, I started, you can tell by the gray hair that I started back in pencil and paper, you know, we did flight safety. Initially, it was new. This was, I mean, in the 50s. You know, I think it was 1954 or 56, where Canada in the military lost the most aircraft. In one year in the history of the peacetime Air Force. It was over 200 aircraft. That finally morphed as flight safety became something we even talked about, you know, and the culture of the Air Force changed. To the point when I started, we were doing flight safety reporting when it was happening with pencil and paper. And if you were next door on a squadron, you had no idea what I wrote down, unless I took my pencil and paper afterwards over to you and said, “Hey, have a look at this.” So it was very challenging early on, I think to do flight safety well across even one type of organization, or one community. And then luckily, we of course, came on with computers. So now we could actually put things into a database of some sort that people can search, but it was normally restricted to that computer. And eventually we linked them and it got linked to that squadron. And then we got the internet and I became, you know, broader. And we started to hear about things that happen in different communities, different air forces in different countries. So it’s been a huge evolution in flight safety.

TK: Ironically, that’s the big part of the motivation for Dicerra and healthcare is to bring this model to healthcare looking in from the outside we can see it is in terms of reporting culture. You know, it’s back in time. Many places still use pen and paper, my wife is an RN, and she’s worked in hospitals that are pen and paper reporting. So they go into a filing cabinet. Obviously, no other hospitals are ever gonna see that.

PAUL: Right.

TK: And some of the electronic systems via PDF are siloed within that hospital, and the hospital across the street can’t see them. So, I mean, aviation wasn’t always that safe. Like you said, 200 aircraft, 200 plus aircraft in one year. To now the safest industry in the world. We could probably get there in healthcare as well, by adopting a similar mentality. But to go back to what you’re saying about subcultures. So you know, for non aviators listening in, they might have thought that aviation safety is aviation safety, and it would be the same in the airlines as in the military, but obviously, you just brought up it’s not the case. But even within the military, the difference between the subculture of Fighters versus Air Mobility versus Tactical Helicopter operations. And then, within fighters, the difference perhaps between two different squadrons, it can be quite significant. So have you found in your career that there were specific cultures that changed the way individuals made decisions or approached safety?

PAUL: I think cultures are at the heart of it. Whether it’s a reporting culture, when we’re talking safety, you know, I lived through the era where people were still very reluctant to report as I think you’re probably finding in health care, because there’s a litigious environment potentially, or a fear of retribution for what you’ve written down. And that’s how it was when I started that, that things would happen, and people would hush it up, because, boy, if we admit this, we’re gonna end up losing our wings, as we called it in the military. And it had to get to the point where people were confident in the complete system, the operating inside of that the culture would allow them to report something, and it was for the betterment of everyone. And it wasn’t in order to punish them. Now, you couldn’t go out and rage around and do something completely against the rules and then hide behind the flight safety system. That’s not the idea. But it was more for, you know, stuff happens. And it’s not always what you intended. We all make mistakes. It’s how we learn from those mistakes that we advance a culture. And that reporting portion is what’s so key in advancing that if you can’t report confidently, get the information out and share it, it’s really hard for us to learn lessons and improve how we operate. And again, the mission taints that because sometimes you accept more risk, because of the mission, you can’t you can’t expect that someone going into a war zone with a fighter jet is taking on the same kind of risk as a Airbus pilot flying passengers across the Atlantic, it’s just not the same ballgame, nor should it ever be.

TK: When you talk about risk to, in test aviation, you might have to accept a mitigated high risk, or unmitigated high. Because you’re testing something for the first time and there’s only so much you can do. But you would try and make the test conditions as standardised as possible, mitigate the risks and whatever way that you possibly can. And I imagined it’s the same in the fighter environment in a combat context. It’s just there’s only so so far that you can mitigate those risks before you have to accept them in order to get the mission completed.

PAUL: Yeah, and you’re bringing up a very interesting topic overall, which is risk analysis and mitigation. And I thought about this a little bit before we talked today. And, there’s an interesting difference between flight test and the other communities. I think flight tests tend to be more forward looking. Because we were planning to test something. We get engineers to look at what we’re testing, aerodynamicists and we get all this information ahead of time before we ever dip our toe into the let’s take it flying and see how she goes. We make a build up approach, we sort of mitigate risk or to reduce risk. You know, if we’re trying to go out to a certain maximum airspeed with a new weapon on board the airplane and we don’t know how the aircraft is going to react, well, we’re not going to go out there. We’re going to plan to go out slowly, measure the response of the aircraft, maybe do multiple flights. And so it creates a very different environment now in flight tests and what it used to be. I mean, flight tests first started, wow, you know, the Exploration Program, a Chuck Yeager gang. I mean, there was some serious big kahunas going on out there with what they did, you know, the sound barrier, all these things we had no idea about. So now in test aviation, I consider it to be very forward looking. Whereas in, you know, in the fighter aviation world, it is forward looking in terms of threats, but your risk mitigations in planning a mission are surrounded by what are the threats that we’re going to encounter, you know, be it surface to air missile systems, the other air force that’s we’re working on it working against, obviously, and them trying to shoot us down on what are their defences, it’s more oriented in that direction, whereas the actual portion of flying the aircraft, and how you operate, it is somewhat taken for granted. And isn’t that much discussed in a safety context, it’s more the stuff outside of us that you talk about more.

TK: It’s expected that you know your procedures called. Following the procedures within the manufacturer’s guidelines, both for the weapon system and the aircraft itself, you’re going to be safe, and then you have all of the additional, you know, the enemy gets a vote. So you have your threat, brief, and then kind of merged the two together. I’m curious to know, if you’ve encountered at a time where the administrative side of risk management has gone too far in the other direction, and what I mean by that is, you know, you have so many layers of the cheese. And you want to mitigate risks so that the little holes don’t line up. But there comes a certain point where there’s so many layers, that adding an additional layer doesn’t really increase safety, but it does decrease efficiency.

PAUL: Yeah, I mean, absolutely, I’ve experienced that at various points in my career, some more recent, and some more in the distant past. You’re gonna always, you know, have time, against safety, against efficiency and cost, if you will, in your programs of whatever you’re trying to do. I think that’s probably a pretty common triangle to talk about. You want it fast and cheap? Well it’s not going to be safe. You want it safe and cheap? Well it’s not to be fast, you know, you can do this triangle. And it’s followed me around my career. But one time where we almost got paralyzed by that whole process, and it was a tough position to be in. But the original ejection seat that was in the tutor aircraft of the snowbirds fly, they had found a significant flaw with that, and this is going back into the early 90s. But the test aircraft that we were using to test had the exact same seat and the same parachute. So we wanted to test to help improve this seat on behalf of the snowbirds. But we had to fly a seat that was in test. And so, we had to do a lot of really good convincing of the higher headquarters staff. And I can still remember the colonel that we talked to in Winnipeg and finally convinced. It came down really to a one on one meeting, I was, you know, sat down with him and said, “Sir, you just got to trust us. Like, we can do this. It’s going to take us a year. We know how to do it, we’re gonna do it as safely as we possibly can, but just trust that we can do this.” And to his credit, you know, I don’t know that would happen today. But back then it did. You know, the headquarter staff, I think, had more power at a lower level and more responsibility, and we’re able to take it on. And we were able to succeed with that project. But that was one of those ones where you’re caught in a corner, and then you just can’t mitigate that away apart from taking on some risk, or just stop and you’re done, which is not the answer either.

TK: So that leads nicely into maybe the next question with a technology lean to it. From your perspective, how has technology evolved to contribute to improved safety measures in aviation?

PAUL: Yeah, I alluded to a little bit earlier there. There’s a number of different technologies we can talk about but one is certainly the enabling of information to be shared by computer and internet. I mean, the fact that you at least have the silos kind of linked between, you know, whether it’s European Aviation or fighter aviation somewhere or commercial aviation. You know, we have databases now that are out there, although often isolated, but they’re still out there at least, that if you go looking for information, you probably can find it. So the computer and the Internet has been a huge enabler, to trying to make sure that we learn from each other. You know, the first thing we want to do is not create the same mistake again and again and again, because we didn’t learn from somebody else’s misfortune. So that’s one key piece. And the other one I alluded to is just the incredible capabilities of aircraft design now, from an engineering perspective, you know, when we bring an aircraft out now, we will have flown a lot of time in a simulator before we ever get into the aircraft that was involved with the C series, which is now the A220 flight test program a little bit after the first flights happened, but we worked hard on the fly by wire flight control system, and tuning how the pilot would fly the aircraft. And it was the same in the airplane as it was in the simulator. So when you got into that airplane, you weren’t surprised, you were just validating what we thought we knew. And by and large, it was either equal or better than what we expected. And that follows through, you know, into what we’ll talk about, perhaps, later, but that’s the, you know, the benefit of simulation to safety. You know, in the airline world, you will get your type rating on an aircraft, without stepping into the actual aircraft, the first time that you fly the airplane, you’ll have a training person with you. But the reality is, there are passengers on board and you have not yet done a takeoff or landing in a real aircraft and you will with passengers on board, that’ll be the first time you do it. And it’s totally safe. The simulators are designed for that. The level of equivalence between the simulator and the aircraft is so high, that it’s transparent. The fact that the cockpit door is closed, there’s somebody back there or not somebody back there and it’s a simulator to the pilot is really transparent. So you cannot do anything but applaud the role of simulation in advancing safety.

TK: Yeah we’re definitely going to circle back and pull more of the thread of the simulation topic. I’ve heard it said many times that aviation is as safe as it is now because of the technological advances. But there is a component of that that rests upon the reporting culture as well, because the technology doesn’t develop in a vacuum, it has to be informed by reports from the hangar floor from the text from the flight deck and from everywhere else. And usually those developments have come from an incident there, you know, the procedures are written in one. And, you know, we probably all know now that the instances of mechanical failure in aviation are increasingly small, right? It used to be a significant chunk of the pie with pilot error, making up a small sliver, but now as the technological side engineering side has become safer and safer, the pilot error portion is comparatively much larger and its contribution to accidents. 

PAUL: Absolutely.

TK: So how important then, is effective reporting culture when it’s the human element. Now, that comprises the majority of adverse incidents, whether it’s a crash or just an incident?

PAUL: Well, I think that’s where it becomes super important. And that’s where you come back to your culture of your organisation. Because what we’re doing by reporting is pointing our fingers at ourselves, you know, if the human in the loop is the weakest link, which I think you’re right, in the majority of the aviation constructs that we fly in now, that is the case, the human is the weakest link. So if we have a good strong reporting culture, that means that human had to be willing to say, “Hey, this is on me, I made a mistake. This is what happened. This is how this mistake came about.” And it’s rarely a singular thing. Right? If you look at aviation accidents, it is reasons model, right? It’s the Swiss cheese, with the holes lining up of multiple elements that came together at the wrong time and the wrong way to cause a serious incident or accident. But underlying that is that ability to report, to not fear retribution for reporting and to be willing in your culture, to point your finger at yourself and say, “Hey, this is on me. We screwed this up. And this is how we screwed it up. And this is what happened.” And then it allows the system to dig deeper into it because, you know, most often unaware to the pilot, there’s probably other layers there that we don’t even know because we’re only one layer. And that’s where you know, that investigative portion of the reporting goes on. And you can really dismantle how that incident or accident happened. And then we can populate the database and hopefully other people will learn from it.

TK: What advice would you give aspiring pilots regarding cultivating the right mentality for peak performance? And it actually goes beyond pilots because what you’re describing when you have to feel comfortable enough coming forward to share something that didn’t go well. And a portion that might be your fault. Or it could be the result of many, many conditions that have led to that, that point. That mentality and the humility to come forward and share it with a group of people transcends just aviation and healthcare. So great sports people, many, many other industries will benefit from having people at their best confess to things that didn’t go well so that it can be the rising tide that lifts all ships. So what advice would you give to people for habits they can slowly build over time to improve their performance?

PAUL: I think there’s a few key ones that hold true in aviation or anywhere else. And that is never stop learning. You know, never feel like you’ve arrived and you’re done. And you’re the woman or the man, you know, you’re not, nobody is. If you can always push yourself to learn more, to improve yourself at what you’re doing. To not accept that last mission as being the best one you’re ever going to fly. To this day, when I go even on the simplest of flights, being with Air Canada or elsewhere, there’s always something that didn’t go the way I wanted, be it a verbal communication that wasn’t quite correct. Or, you know, a handling of the aircraft or whatever, you know, be critical of yourself, and always strive to improve. And within that, keep learning. You know, don’t sit idle ever on your laurels.

TK: Never miss an opportunity to embarrass yourself. 

PAUL: Those come naturally.

TK: I could share with you a little bit of feedback from what we’re trying to do with Dicerra, which is something similar. People can voice up, hey, I did this and it didn’t work out, and it’s very non punitive. So we protect, we make sure there’s a level of content moderation, where we can trap people and prevent somebody’s name from being thrown to the wolves. And we thought, you know, AB testing with a few hundred folks across North America to get input. And we thought maybe, we need to demonstrate what a healthy culture looks like to people who haven’t seen it before. So we’ll interleave some aviation posts from people who are very familiar with this culture already. And we’ll combine our two platforms so that when you first log on, you know, every second post is an aviator, saying, here’s all the dumb stuff I did. As a way of showing like, it’s okay to share and it actually makes everyone better. I’m not sure that we’re going to continue with the model of keeping the aviation interleaved with the healthcare because we’ve also had some feedback that people just, you know, not interested in the other profession. But I do, I 100% think that that’s an awesome path forward, I share your perspective on even the catharsis for an individual if just being able to share it and know that you’re not going to be blamed for it. Because we are human. And one thing that I will give to healthcare over aviation is often they’re compared and contrasted as being very similar. We want to learn borrow techniques from one and, and kind of overlay it on the other as though it’s a perfect match. But healthcare is much more and you’ll know this better than anybody, being a helicopter pilot and a physician. Healthcare seems significantly, an order of magnitude more complex. And when we talk about simulation, in aviation, we have a cockpit that is an absolute replica of the aircraft that you’re gonna fly with visuals that are close to what you can expect to see. And you will run over an emergency in a really controlled manner. Probably almost exactly the way it would be represented in the aircraft. But human body is a lot more complex than that. And, you know, you can use simulation training. But I imagine you’ve probably got first hand experience that sometimes symptoms are not well presented in one patient as compared with another with exactly the same problem and sometimes there’s abnormalities within the human body where you’re trying to react to an issue and whatever procedure you have in place for the 99% doesn’t work on the 1%. And then a million other very complex variables that make healthcare much more difficult. So maybe, you know, going back to the point, you mentioned earlier about the difference in mentality when you’re you have that immediate SOP that immediate action, and then you have to make a decision as a doctor, and you’re drawing from maybe an experience you had 10 years ago, and some advice you had from somebody else five years ago, and you’re seeing this condition for the first time. Maybe ever. How, how do you deal with the complexity? And how do you deal with, you know, what we would call proficiency or lack of proficiency in aviation, where if you haven’t practised a manoeuvre for a long time, you have to go back and do it in the sim, or practice at airborne. And you don’t have that luxury in healthcare, you might be doing a procedure once, you know at a blue moon. And when you have to execute, it has to go well. How do you deal with that as a physician? Is there anything that you can borrow from aviation? Or is it really so different? That you have to take a different approach?

BESTIC: There’s a lot we can borrow from aviation that we don’t. One of is the approach to training and something I noticed coming out of the military. Military is pretty good at training. The military’s got a lot of problems. But one thing it does well is train, because most of the military, when I was in sort of warfighting roles, you spend more time training than you do, actually doing your job. In later years in a conflict in Afghanistan, they will probably soldiers spent more time fighting than training. But certainly when I joined, there weren’t a lot of wars going on. And we spent a lot of time training. So we’re very good at organising training, determining what the training needs, we’re good at saying and they will hold courses on training needs analysis. Noncommissioned officers went to this course on how to develop training. You were taught how to run training as part of the officer training. Okay, what’s the competency that I need to what level of that competency? Is it just understanding? Is it competency or is it unconscious competence? And then you work it back to the terminal, the test the build up to the test, you know, if it’s counterterrorism you say, right, the endpoint needs to be I need an individual to enter a room and be able to put two bullets through the brainstem in an instinctive manner, I need that person to have instinctive levels of shooting. So they need to start with learning how the weapon works. And then dry firing, then live firing. And then weeks on the range just getting used to instinctive shooting. And then in fully immersive, live firing with lots of people in the room and noise going off and lights and light and dark. And for months at a time till it becomes instinctive. I go to medical school, there is no list of competencies. It’s just a general sense that you’ll spend a few years tooling around University and the hospital learning stuff. And at the end of it, there’s no, there’s an exam. But you just sort of drift into the job with a gentle understanding that, wow, it’s a vocation you learn on the job. You go to specialty training, same kind of deal. It’s, there’s a terrible expression in medicine called See One, Do One, Teach One. It’s a bit tongue in cheek, but it’s actually really common. So I remember, as an intern, I needed to do a lumbar puncture, put a needle into someone’s back to get a sample of cerebral spinal fluid. I hadn’t done one before. So I said to my registrar, hey, the patient needs a lumbar puncture. And she went “sure, we’ll do it,” “yep, I haven’t done one.” So in the corridor, she tries to explain to me how to do it. “Well, it’s not that hard, you just sort of feel across the top of the pelvis and sort of draw an imagined line there and then feel between the bones and then just keep poking the needle until the fluid comes back.” I said, “Sure, can you show me ?” “Like you know, people under pressure, we got lots of patients.” So she comes in, she sort of horribly shows me how to do it. Okay, good. So that’s you qualified now, because you’ve seen one, that’s the most training you’re gonna get in sticking the needle in someone’s back. The next time you do it, you can now teach someone else. Now, think of all the things that might not have been taught properly. Think of primacy of learning, think if, you know, were you ever interested that you’re doing it, and no one will ever see you do that again potentially. It’s completely autonomous practice. So the system around training is there is no system of training.

TK: Is there an expectation, maybe a cultural one, that once you achieve a certain level of education, that that instinctively makes you just a good instructor or a good, a good teacher? A great lecture without needing any additional training.

BESTIC: Absolutely. And this sort of moves on to your second question around, so the first question is around training there really isn’t any. And the notion around training is not really there. There’s not a system that says, “Okay, we need people to learn how to intubate, put a bit of  plastic into their trachea, we must be able to break this down into steps and run it as a formal course with a mannequin, and then some supervised training in a very structured way by by people who are trained to instruct. And then you would set an exam, a course, a practical assessment, you’d be sign up, but it’s almost like medicine says, well, there’s far too many skills for us to do that. Actually, there wouldn’t be you could absolute, I mean, Christ, look at flying a fighter jet, you don’t start on day one, by getting put into the jet. I assume. You’re, you’re built up through years. With, that’s the endpoint. So of course, you can break it down into steps. There’s no skill that can be broken into steps to track, but that’s not the culture. So. And in medicine, when I finished my anaesthetic training to be a consultant, there’s no final, there’s an exam of my theoretical knowledge. But there’s no practical assessment. You know, when I get my licence to be a helicopter pilot, I can examine it from Kassar. You know, we have an hour in his office with him q&a, me. And then we go flying for three hours. Where we do everything, and all the emergencies. And I mean, it’s exhausting, right. I mean, check flights, you’ve been there. 

TK: Yeah.

BESTIC: And but at the end of it, there’s a sense that right, I’ve met the standard. In medicine, there’s not that same level. The general culture is you have to do a lot of it. So this comes back to some of these fatigue rules. As a consultant, I look back at the trainees and go “Well, if you’re going to get to do half the hours, the training might need to be twice as long. So instead of taking five years, especially training, maybe it needs to be 10. Because in that level of fatigue, I’ve done hundreds of those procedures because I was in the hospital so much. You’ve done dozens of that procedure. So you haven’t yet run into the problems that you should have, because you haven’t done enough.” So there is, that’s this part of why as senior clinicians, we’re like, well, it’s fine just to say safe workouts but we have a general sense that you need to do a certain amount of stuff, find the practice to be good at it. But no one’s really defined that either. So there’s no real sense of what good training should look like. Now, in terms of how we cope with complexity, my experience has been actually, the more complex something is, the more I’m using my human factors training, then my technical knowledge and my experience. I’ve reached the point now, if I’m team leading a, the most complex trauma that we can get, we get horrendously complex trauma, and we’re doing more and more and more patients now than we’ve ever done in the past. So I might have, I think, last time, we counted 25 people in operating here from four different surgical teams, and you’re running all of that. The more experience I get, the more I actually keep my brain empty. And I got that concept from a helicopter pilot instructor who said to me on one flight, “Bill 30% of your working memory should be free at all times for the unexpected emergency. 30% of your brain needs to be empty all of the time that you’re flying.” What a concept. So he said, “you probably didn’t notice it, but you just gave your callsign right in the wrong order. Instead of Alpha Bravo, Charlie, you gave Charlie Bravo Alpha, did you realise that?” I went  “Oh, no, I didn’t.” “Because that’s a sign to yourself that you’re getting protected, you need to pick up on the signs when you’re a single pilot. So recognize that it’s happened, recognize why it’s happened, and start to cognitively offload because your brain is full. So when the engine goes quiet, you’re not gonna be able to cope with it because your brains too full of all the other stuff. Maybe offload tasks to ATC, maybe, if you’ve got a passenger give them a map. It might look unprofessional, but you have to rapidly cognitive offload.” So I’ve applied this in this sort of Team Leader setting where I go, someone will hand me a blood test result for the patient. And I think I don’t need to interpret that there’s tons of doctors in the room that can do that. So I’ll just hand it to someone else, I delegate absolutely everything. Because I don’t need to fly the plane as such, I’ve got enough people that can do that. I can actually stand back from all of it, and be A) available to information B) maintain situational awareness because I’m not diving into a task. And I actively keep my brain into it. I mean, it sounds kind of ridiculous. But it’s this, it’s very counter to the way medicine is taught. If it is a cognitive aid, I’ll use it. You think about the way we teach medicine, we our first experiences of being a doctor or standing at a bedside with our ties on and feeling very sweaty and nervous, with our shiny new stethoscopes around our necks and our bundles of notes and pens, and a very senior professor of something with a bow tie or some such thing in front of a patient. And it’s just training by humiliation, you’re basically “Mr. Bestwick? Is it ? (As I look at your ID card) Why don’t you tell me the differentials of a gentleman with crackles in the lower left base? Come on, you should know this.” And when you don’t know it, you are put down and someone else, “Oh, excuse me, sir, excuse me, I know this.” So the culture is if you don’t have all the knowledge in your head, you’re going to be a bad doctor. Now imagine if the ward round said “if you don’t know this, I’ll wait, you can Google it. Because this is exactly what you’re going to do, when you’re a junior doctor. You’re going to google it. So why don’t you Google it? And then I’ll tell you whether that resource is actually right or not. Why don’t you set up some cognitive aids in your phone, because you’re going to carry a phone. It’s a walking computer, you can have cognitive aids for everything. But your challenge is going to be how to access the right aid, at the right time. Because if you pick the wrong aid, it’ll, you’ll become, you’ll get confirmation bias and you’ll be down the wrong pathway. So we should be being taught how to use the aid not, you’re not allowed to use the aid. So the training culture is different, you know, how do I cope with complexity? I use all the non medical stuff I’ve learned not the medical stuff I’ve learned.

TK: I wonder if that culture comes from you know, that comes from a time pre smartphone and the doctor had to carry around as much knowledge through rote memorization and experience as possible. Of course now we have these extra tools and you can probably increase the safety care and the quality of care because you can access this new tool, so don’t deprive yourself of those tools, use them, like you said, leverage them to the best of your ability. And I wonder as well, you know, you’re talking about stepping back and keeping your situational awareness, by being able to delegate to team members, I wonder how much of that has come from your background in soft as well, where, you know, as a, from a command perspective, you don’t want to be too far down in the weeds. Because you need perspective, you don’t want your bucket to be full, you want to have additional capacity, you want to have your bubble way, way, way out in front to be able to think about all the what ifs and that requires effective delegation. And then it requires trust that the people you’re delegating to a competent, and then they can do what you’ve asked them to do, which I assume, especially in soft, you have a little more of a flat hierarchy, perhaps than elsewhere in the military, where even down to the lowest levels, people are trusted to be highly, highly competent, especially in a small team. So do you credit some of the way that you’re approaching scenarios like you just described as well to some of your military background?

BESTIC: Oh, definitely. I think I’ve been through a transition where I came out of the military, and was and tried to lead in the military way. And it doesn’t work. You know, of course, it doesn’t work. The language is one part, you can’t be dropping F bombs and C bombs, during the brief, which is quite normal in the military. People don’t bat an eyelid, all of a sudden, people’s eyes are getting wider and wider while you’re just chatting. And you’re thinking why they’re looking at me like that. It’s like, oh, people don’t talk like that. Okay, I get it. I mean, that’s one it. The others that we use direct language, we are trained from the start that things work better once when someone’s in charge. So we subscribe to the model, that having a leader means a better outcome than actually having a not great leader, it’s still better than not having any leadership at all. So we kind of buy into that. So that if, and we were out rank openly, we know who’s in charge, we can look around the room and go, who’s in charge me, because I’m the most senior rank until the next senior rank walks in. Now in the civilian worlds and medical thing, there’s actually the same hierarchy, but no one overtly wears the rank, but everyone understands the hierarchy, sort of. So what I found was, I would come in and generally make assumptions that people would accept that I’m in charge and running. But that’s a dangerous way to start something. So I had to modify the leadership to almost get permission to lead. And that frustrated me initially, because in a time critical situation, I’m a big subscriber to authoritative leadership, you know, we’re taught Steve Adairs, models of leadership of participative, and free reign authority, and you’ve got the time for participative leadership is over, you will do what I tell you. And you’ll do it when I tell you to do it, or you’ll leave the room. Now, that’ll get you through that particular situation. And you can get, you’ve got all the skills to get louder and more forceful, and use your brave voice, if you have to, right? You can really dominate from that military training. But good luck doing it the next time. Because people are going to turn off that style really quickly. So I’ve got started to get feedback that, you know, my style was not working, was inappropriate, was too forceful, too intimidating. And in a culture where, you know, people aren’t loving that kind of white male approach to things, it’s time to recognize that the room has changed, and that you need to modify that.

TK: When you say getting permission from the, to lead, what kind of soft skills are you alluding to there?

BESTIC: Someone told me very early on in my officer training, he was a Vietnam veteran. And he said, in a crisis, people look to the leader that physically look at the leader. And that may not be you, even though you’re the platoon commander, but you’ll know who the leader is. And the first time I was involved in a real gunfight I remember crouching in the jungle and hearing shots going off and being worried for my own safety. And I, it was very confusing. It wasn’t like we did in training, where it was very clear what the problem was. We didn’t train enough for confusion and actually having to lead when you have no idea what to do. You know the military training was kind of you work out what to do, then you do it. But I think in real time combat situations, you actually spent a long period of time making decisions and the total absence of really knowing what’s even going on, but you have to keep making those decisions. You can’t just be stunned. And you actually fall back on these Maxim’s that you used to think were a joke, but are actually quite useful. Things like when you’re not sure what to do, move towards the sound of gunfire and kill everything you find. They empower you to do something. Okay, can’t use these analogies in a medical setting, right? Doesn’t, doesn’t wash it as well.

TK: It doesn’t translate, 

BESTIC: Maybe you can modify it, move towards the sound of people dying and save all the people in your path, I don’t know, there’s probably an analogy. But I remember crabs in the jungle. And I had some soldiers left and right of me. And I looked to my left, and they were looking at me. And I thought they were looking at something else. And I looked to my right, and they were looking at me. And I had that moment where I thought, Oh, they’re waiting for me to make a decision. So I just made a decision to go that way. I don’t know if that was the right thing to do. I don’t know if it’s the right direction. But it got us moving instead of doing nothing. And at that time, that’s what needed to happen, we’d lost momentum. So A)recognizing that if you want to be a good leader in the workplace, every time you interact with someone, or do something, it’s setting the conditions for that moment. You bring history to the room. In a good and a bad way. If you’ve got a history of being a collaborative, thoughtful, caring leader, that kind of knows their shit, then guess what people want you in the room, and when you turn up, they’re going to be glad that you arrived. That’s what we all want. But if you’re kind of a dick, or you’re really mean to people, or actually a bit incompetent, people aren’t going to want you in the room. If you don’t have insight into your own performance and how to improve it, then you’re never going to get better. We’re a highly critical society and environment, you’re never going to get everybody on side. And it’s dealing with which part of this criticism is just someone being mean and which part is actually important. That great concept that feedback is a gift. If I can get feedback about my performance, it might not be packaged in the way I want to hear it. But there’s a reason someone saying that to me, I’ve got to fix something. So I did a lot more of, instead of me internalising everything, and then giving the direction which would work in the military, I don’t need to justify my decision to my soldiers in a combat situation, I tell them to do something and they do it. If they don’t like it, afterwards, we’ll have it out. But they won’t question it at the time. Because there’s, we believe in the system of leadership and the military, we subscribe to that. We agree we’ve all agreed on that set of rules. Medical people haven’t agreed on those sets of rules. They have never even been explicitly discussed. Leadership’s never taught or even discussed, it’s, there was mentioned that coroner’s report that there was a lack of leadership, but that’s as far as it went. In fact, with a really good leader, it might have gone just fine, because everyone had the skills in the room. But they weren’t harnessed. There was no one keeping their brain free. They were all engaged in an activity, and they got cognitively loaded. But that’s not a system, not even a coroner can work out. But that’s probably the biggest problem in the room. So dealing with that complexity, I found keep it simple, keep dragging it back to doing this simple stuff well, because in our efforts to be too good and too sharp and too clever, we’re gonna miss the simple stuff. And the simple stuff is what kills people.

TK: Really, like you comment there on you bring your history with you into the room. I think that’s a really interesting way of looking at it, because people need to understand that their reputation will follow them. And the flip side of that, I suppose, is, it needs to be nurtured over a period of time. So you need to earn your leadership daily. And if you falter, all that history and goodwill that you’ve built up over, it doesn’t matter anymore. Everything you’ve done, everything you’ve built, it can fall away, so so quickly. Really, really interesting way of putting that. And I want to we’re running a little bit short on time. So we’ll make this the last question and we can kind of you know, we can see where it goes for 15 minutes. You mentioned when people are looking to you as the leader and in a situation that you gave before in a gunfight where you have to do something you don’t want to be in decision paralysis. So in a medical context, I assume That decision paralysis could come maybe from two different ends of the spectrum. Could come from not enough information, or it could come from having way too much information and then being paralyzed and not knowing what to do. How do you balance between those two ends of the spectrum when you’re trying to make the right decision, and then impart that upon your team?

BESTIC: Yeah, this happens a lot, actually, particularly in severe trauma, you don’t get any, more frequently, patients come directly to the operating theatre from the helipad, or, or screaming from the air, we bring the ambulance stretcher directly into the theatre, we bypass the emergency department completely. So the patient arrives, straight off the injury. They might have to scoop then run, put them on a stretcher, board them and that person might be in pieces. So you don’t know the extent of their injury. There’s lots of noise in the room, nurses are pulling open surgical packs, surgeons are arriving, people are crashing into there. And we don’t even know everyone. Everyone’s stress, you don’t even know their names, they’ve got masks on. You don’t know if that’s a surgeon, or a scrub nurse or an orderly. Those are situations where I find I immediately start to feel overwhelmed. I’m worried about my own performance, I’ve got fear that I’m going to make an error, that I’m going to miss something really important, that the patient is going to die and afterwards someone will go, “You miss that? Really? How do you miss that?” Because always in that hindsight, retrospective scope, it’s really obvious what the problem was. So I find in those situations, I’ve got to take a breath, you know, the first pulse you take is your own, you control yourself before you control the environment. I’m acute, it’s like I leave my body. I imagine what everyone else sees when they look at me. And I need to give them what they need to see, I need to look like I’m calm. I want to take a minute to control my voice. I learned a lot of this from, more from yes, the military, but also from aviation. When we speak, when we transmit, when we’re flying, that’s a very considered statement. We don’t press the transmit button and just start talking, we have thought about what we’re going to say in the way that we’re going to say. And if it’s an emergency, we also want to make sure we sound cool. Because we don’t want our last transmission to us whaling like a baby on transition, right? So these are the rules of Special Forces: one know your shit, two look cool. Three, if you don’t know your shit look cool anyway. So we get quite accustomed to taking a breath. And then delivering it in a very, you know, we’ve got obviously strict phraseology as well, but we give consideration to how we’re transmitting. So if I take a breath and give a thought to the first thing out of my mouth and how I deliver it, it’s going to set a tone. It doesn’t matter whether I’ve, my heads still spinning, but I have to give the impression that it’s not. So I’m faking it a bit. But people need to see that someone is in charge, otherwise, it will unravel. And then I think right and I dropped back to airway, breathing circulation, I just go, if I dumb it down to the simplest possible things. I don’t try to overreach. I even say to myself 80% solution on time is better than 100% late. It’s better that I do the basics well and miss something rare and complex that they die off, then pursue the most awesome, amazing kickass resuscitation, but miss the fact that we didn’t even put the tube in the right place. So calm down, let the situation play, listen to the noise, listen to the room, get it to really tap into your environment. And don’t over control it. Yeah, there has to be a level of noise. There might be times we get everyone to be quiet. But those moments that you transmit, how you say it isn’t important as what you say. It’s got to be short and sharp and directed. And there’ll be afterwards it’ll never make your own standard. There’s no time I do something where I feel, yeah man there was nothing to fix there. And that’s when I defaulted controlling with 14 and two squadrons in New Zealand on the Inaki and Skybell. And then we’ll take ourselves flying. And what really struck me about those fighter squadrons is how critical they are of each other. The debrief is longer than the flight. And there is nothing that’s not picked up. But it’s never taken personally. It’s always an understanding that this is important if we want to be better at what we do, and we do want to be better at what we do. So yes, yeah, we can be our own worst enemy. And sometimes when I’ve gone to mentors, they’re like “You’re overthinking mate, you did a good job, let it go.” But it still burns you. I don’t want to make that error again. And that’s why I think we took that standard about performance. And perhaps the aviation medical model, people are getting a bit worn out of that model. So you can look to other fields, the All Blacks or or any, pick any high performing sports team, they have all these cultures, they know that fatigue, they’re not going to keep the team out the night before the game. They’re going to make sure they’ve got a quiet, temperature controlled environment to sleep, they’re going to control their diet, they’re going to control their attitude, their stress, all of that if they want a good performance. So it’s like if you want to be a high performer, well guess what fighter pilots do and all blacks do and special forces do, they all have exactly the same approach to performance. And the beauty of it is that it’s highly learnable. All of us have the ability to do it. Most of us are not innately talented at things, some of us are better at things than others. Most of us get there, just through hard graft and application. You got insight into your performance and you want to get better, you don’t have to do much to be a lot better. But the highest yield is actually around human factors, not technical ability. Medicine’s very bad for this, we put huge emphasis on how good I am at a technical procedure, can I put a cannula and can I intubate? Can I do a lumbar puncture, without having five goes at it. But we don’t put any metric on that, actually speak to the patient. When I asked them why they’re having surgery, and they said, they only got told last week, they’ve got cancer and start crying. There’s no metric for saying you are a compassionate human when they started crying. The metric starts with the procedure. So junior doctors, if they’re being watched by senior doctor will want to be really good at their procedure, because that’s what they’re most stressed about. The more cognitive space they’ve got, the more there’ll be a human to the patient. That’s the doctor you and I want. I’m not actually fast, if the doctor misses the candle only three times, as long as I know, they’re highly professional. And they have my interests at heart and all the rest of it, right. So it’s switching the metric. And I think all of us have the ability to tap into this Goldmine, where the highest yield once you’ve learned your basic trade. Really, it’s attitude, and insight, that’s going to make you really, really good. And you don’t have to be amazing at any job, you’ve only got to be good enough.

TK: That is an excellent point that I think we can wrap up on. Really, really thrilled to have had you join us for this podcast. And I think I’d like to have you back because there were 100 questions that are constantly going through my head that we could have pursued. So many different avenues, you’ve got a ton to offer. And we only just scratched the absolute surface, just the tip of the iceberg. So, you know, we’ll reach out again and try and coordinate a time that works for you as well. But I want to give the last words to you. Any parting thoughts that you want our viewers and our listeners to take away from this episode?

BESTIC: I want to really acknowledge and commend you for what you’re doing. You know, I’ve probably at risk of feeling overwhelmed by my frustration with things not being as good as they could be. And my response has been to become increasingly siloed. But I’m really encouraged and motivated by people like yourself, who see that as a challenge to take it on and make it better. And if we don’t have people like you doing that, it won’t ever get better. And I think Dicerra’s a great start to actually starting that conversation. Because there’s probably a whole lot of like minded people out there. We just don’t really have a voice. And we feel a bit silenced. So I think what you’re doing is commendable. You know, if I finish with a bit of an anecdote that I read about a book I read, he’s a war surgeon. And he’s travelling the world operating in far flung places. And he’s also a pilot, a commercial pilot. So I loved it. It’s a great book called War Doctor, I think. And he’s on a helicopter, and he’s flying over this massive refugee camp in the Middle East somewhere. And there’s something like a million people in refugee camp or something like that incredible number, right? And the guy he happens to be sitting next to he doesn’t know, and he says to the civilian next to him through the headset, I’ve been operating near this refugee camp, and I reckon there’s at least 20, 25 people that I managed to save through my surgery. And the guy next to him went, Oh, that’s fantastic. That’s great. And the surgeon says to the guy, what are you doing? He goes I’m a water engineer, we just put fresh water into that refugee camp. He thinks he’s probably just saved half a million people with one water pipe. And I’d save 20. And it made him reflect on, if I really want to do the most good for the most people, I’d be a water engineer. So in actual fact, solving malaria, fixing mosquito problems, solving poverty, save far more people than the one at a time that I might be doing in the operating theatre. So what you’re doing is, has a far greater impact on actually saving lives by even just fatigue. If we just solve the fatigue issue, and approach fatigue in a different way in the healthcare industry, millions of lives would be saved every year. So what you’re doing and is actually having a far greater impact and it’s and we just need to keep hearing that message.

TK: Thanks So much, Bill. I really appreciate it. Thanks for joining us and I can’t wait to talk to you again soon.

BESTIC: Thanks for the invite. Appreciate it. See ya. 

TK: Cheers.

Michael Sandler: So you asked for a clinical scenario that highlights the issues that clinicians face when it is relating to safety. And I think every single one of us, regardless of how long we’re going to practice that can identify with less safety incidents that occurred to us with our patients. And one that comes to mind for me, it just really encapsulates the whole issue around safety was a medication error that I was working in a large coronary referral intensive care unit, in province, and in, in Canada. We was a night shift, it was a weekend, I had come to work already fatigue, it was my third night shift in the row. It was Saturday night. And I remember that because the Olympics were in town and Sidney Crosby had just scored the golden goal. And we had spent the afternoon reveling in the amazingness. That was Team Canada. And I was assigned to a very sufficient, and I started off the shifts with no firing on all cylinders, obviously, I was tired, I was fatigued, I was a bit hungry, I had a whole host of distracting pieces in my life, including the fact that all of my friends were still celebrating the golden golden I was at work. And, you know, I had this I was in this space that probably was already at a risk for safety or quality issue. The individual that I was taking report from was just as excited to be gone from there as I was unexcited, to be there. And so our handover was less robust than is normal. And we miss the opportunity to exchange some very important information about the patient. And I was working with a crew, who was slightly less experienced than you would normally expect to see in the unit that I was working in with a crew of supporting residents and allied health practitioners who were also less experienced than you would normally expect to experience in an ICU of that size and nature. All related, of course, to the Olympics and external issue that had nothing to do with the patients who were in the unit and deserved our undivided attention and care. And, of course, at one o’clock in the morning, which is always a dangerous time for the application of clinical care. And you would you are aware of the research that indicates that after 16 hours, it is like operating a vehicle under the influence of alcohol with a blood alcohol level, I think of point five, if I recall. And then as you move past that you get more and more intoxicated. And I say that not in the sense of being truly intoxicated, but your reaction times and your thought processes and all of the things that you need to safeguard your patient against an error are impaired the same way they would be if you had been drinking. And so I was undoubtedly impaired. And my patient’s blood pressure was falling. And I was confused as to why this was happening. I didn’t have a good clinical understanding of what the scenario was. And it’s not a common issue to see a fall in blood pressure in an intensive care unit. And yet I had this inability to be able to solve the problem that was in front of me of these cognitive and cognitive barriers, both physical, emotional and mental. And I ended up choosing a course of action that in the cold light of day in retrospect, you would look back on this course of action and say to yourself, What exactly were you thinking when you decided that that was a good idea. And so what I said ostensibly did was instead of using the medication that was already at the bedside, and refusing to allow the patient to support their blood pressure, I decided that I would go get an entirely new one and start this new medication when that would solve the problem. And so I did that I went to the AMI cell which is our medication dispensing machine and I put in the patient’s name and phn number and I put in the medication that I wanted and it said to me, are you sure you want to do this big like warning? Like, you know, this is a high risk medication and you really want to do this? And I remember thinking to myself, yes, yes, I really want to do this. Just give me the medication this time. sensitive scenario, I would like to do this. And so I brought this medication back to the bedside. And I got to the point where I was about to administer it. And we also have a policy in place and other forest function that says you need to bring someone else into double check to make sure that this is a good idea. Because really, we don’t want you doing this entirely by yourself when you’re tired and fatigued and hungry and okay. So you know, knock on the glass, hey, come help me out. And this is where your biases come in. This is where bias training is so important. And I had none of those things at the time. And I remember holding up the medication saying, hey, is this medication X? Yep, this is the, this is what you see. Yeah, you see this? And so unfortunately, my partner was like, oh, yeah, it’s exactly what I see. Because I told them what they received. In fact, it had nothing to do with what I was holding. And so, you know, now I’ve completed this independent double check in pegging this medication. And I start the medication. And I go to chart the medication. And a colleague who I’ve known for a very long time is literally walking by with a cup of coffee. And this is where you definitely don’t want to predicate your safety systems on the individual walking by with a cup of coffee as the final check in terms of making sure that someone doesn’t get irreparably harmed. And they happen to glance over at me. And they happened to look down and what I was doing, and they asked me a question, what are you doing, I just started this medication. And she said to me, well, that’s not what you’re writing down. It’s not the medication that you’re writing. And I looked at her, and I looked at the medication that I was running, which was not the medication that I was thinking that I was reading. And I was positive that I was giving this patient a medication that was going to solve a problem, when in fact, I was giving them a medication that was going to make problems. And so thankfully, I had this interaction at that moment before there was any irreparable harm. But it just aligned for me, the safety conversation that we have in the practice environment every day, some people refer to it as the Swiss cheese model. Some people refer to it as the bias model and the slow channel, fast channel thinking, there’s all of these ways in which you can look at it, but I had slid into I had let my petite my human factors get in the way of my thinking process. And then I had slid into a fast channel thinking process which removed the final safety barriers that should be applied in any safe system. And it was by force of luck, that I was in a position to not arm the patient, there was an opportunity to create great arm, and was provenance that somebody wandered by at the right moments, and had the wherewithal to actually look at what I was doing, that probably saved this patient’s life. And it is those near miss events in your career that forcefully propel you into the conversation around safety, and why safety and safety systems, human factors training, and the ability to spend time really engaging with what a good safety process should look like becomes so important, because I think every clinician has experienced what I experienced, which is that near miss, that could have just turned out disastrous, but didn’t. But only because we got lucky. And luck is not a great way to engage in delivery of care. Yeah,

TK: I absolutely agree. And I agree with your statement that everybody else has likely experienced some version of that over the course of their career. And if they haven’t, they will, the hierarchy triangle that you see in aviation, where you have one fatality at the top of the triangle, and underneath it, there’s 10 major accidents, and underneath that is 30 minor. And then underneath that there’s a wedge of 600, near misses, which is, I guess, this just cool research and the likelihood of a near near miss contributing to a catastrophe in aviation. And I would wager that it’s something very similar in healthcare in terms of the number of near misses that happen, just getting people off on sheer luck, whether it’s all the holes in the cheese lineup, but one at the very end, whether it’s fatigue that’s getting in the way or systems in the way, there’s so many of those near misses, that we ought to learn from that we probably have no way of capturing or at least haven’t captured. And we got to wrap up here for time, but can you close this out and maybe on whether or not that event was was captured in a in a write up of some kind?

Michael Sandler: This is the issue. So the event was captured in the safety system that was provided at the time and it went to an individual who reviewed it and came and talked to me about it concluded the investigation there and there is no further opportunity to really delve into the slices of the Swiss cheese that had lined up so perfectly that evening, there was no conversation about fatigue mitigation, for example, utilizing scheduling, or utilizing staff composition or scope of practice, or any of those things that could have led to interrupting that process. There is no conversation around systems safety training, there is no conversation around. There’s no conversations around human factors training and being able to identify the antecedent pieces that have led to some of that decision making. So there was no safety checklist that we developed out of that conversation and said, Hey, listen, if you show up to work, and you’re fatigued, you’re hungry, and you’re tired, and we never implemented any of those things. And we could take learnings from the aviation industry safety checklist, this is what you need to do to be safe to come to work, you have to have so many hours of pillar time before you can you can’t have all of those things we never spent any time taking a look at after the fact. And so I think this is our opportunity to really dig into a process that allows for not only organizations to take a look at what those pieces are than how they lined up, but also for clinicians to feel comfortable sharing that and saying listen, this is where I was this is the slice of cheese that this is my slice in this process. How can I ensure that that hole doesn’t line up with the other three that are on either side? So I’m hopeful that Sarah is well positioned to be able to answer that question and but I am confident that I am not the first or the last clinician to have a conversation with this.

TK: Thanks, Michael. Much appreciated.