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.

TK: All right, so I’m here at the Royal Canadian Military Institute in downtown Toronto with Dr. Brian Goldman, who amongst other things, is a radio talk show host of CBCs White Coat Black Art. Prominent author of at least four books if I’m correct. 

Dr Goldman: Four books. 

TK: 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’re also a practicing medical doctor. 

Dr Goldman: Emergency physician.

TK: Emergency physician.

Dr Goldman: Right up the street at Sinai Health System.

TK: Right on. So I’ve 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 why I reached out, and hope 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, and so on. 

Dr Goldman: Paid for as Sully Sullenberger once told me in blood. Those lessons were paid for in blood.

TK: Paid for in blood. Exactly. And we ignore them at our peril. 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 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 some people are hardwired 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 they became kind and they developed kind of an empathy 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 Ying was the ‘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 in 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 overcome that I wrote ‘The Power of Kindness’.

TK: So expanding on empathy, maybe in healthcare, I wonder, obviously, it’s important to retain a sense of empathy, especially for your patients, but there must be a certain steeling 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.

Dr Goldman: So that’s true. 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, you know the family is coming to grips with their gathering, they’re coming to grips with the fact that their loved one is dying. And meanwhile, outside 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 autopsy or is about to be admitted to the 19th floor of an 18th floor hospital. Discharged 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, you know, humor is a device. But, you know, we find it very difficult to empathize, because it’s because the feelings are overwhelming.

TK: I mean, 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.

Dr Goldman: 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 begin to have an appreciation of what it’s like to be our patients. Very hard to empathize with the situation that you, for which 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: 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 their loved one has died. And I’ve had to learn how to put that aside and be there for the patient. And you know, 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: 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. So how do I know in an aviation we have the benefit of centralised governing bodies, like the FAA, the NTSB, Transport Canada in Canada. CAA in New Zealand, and they were able to require mandate that certain carriers, Part 121 carriers, or the the Air Force adopted specific Crew Resource Management, Human Performance in Military Aviation, Flight Safety models, that became self regulatory, in a sense, 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 totally aware of the training and the the intent behind the training, but in cultured, I suppose.

Dr Goldman: But you’ve also had… 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 at the rate it happened 40 or 50 years ago, and I haven’t seen any equivalent in healthcare. Now, part of the reason we’re also 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 interactions between technology and the human, you know, and the human patient. And, you know. 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 thousands 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 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. And the it’s not as litigious either.

Dr Goldman: No, it isn’t, but I think it’s harder to do the studies that can demonstrate conclusively that we can zero the error rate. We can improve outcomes 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 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, or clot busting drugs or get them to a catheter suite where you can do an angioplasty and unblock that blocked coronary artery. There have been great successes there. 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 thousands 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 taking out the catheter as soon as possible instead of using it as a tool for Patient Management. You know, 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. Where as 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-year, perhaps multi-decade long approach. Before you’re going to see the decrease in incidents.

Dr Goldman: Yes. I think, you know, in theory, the answer is yes. The problem and there are a number of problems. Unlike avionics, unlike communication devices, you know, radar devices, proximity detectors. Whatever kinds of devices you have 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, and that 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 that 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 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 idols, you know. Anthony Fauci was another one. And, you know, I’ve got I’ve gotten to speak to, 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 is trying to teach the lessons of aviation safety to healthcare. 

TK: Really?

Dr Goldman: Yeah, he is. He is. So he told me, you know, 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 cockpit crew and the cabin crew. And, and so, and I can tell you that, until COVID, we tended 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, that’s not exactly true. I don’t know a physician or a surgeon or nurse or respiratory therapist who wants to be party to a negligence lawsuit. To have to relive those moments again, and again, and again, where everybody knows what you did, in retrospect, you know, dealing with college, you know, 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 health care professionals who take 10 years off their life to undo a mistake. If it’s grievous 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 shared destiny, that suddenly the same disease that could kill patients could kill health care 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 and 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 your, 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 that 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 an observation here from one of your books about a… a ‘Code Orange’ from a mass casualty event and I’m trying to find

Dr Goldman: In Ottawa. 

TK: 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 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. Sully’s you know, incredible landing on the Hudson is a perfect example of something that’s been well shared, because it went so well. So probably pilots everywhere have watched it, read the book, thought about it to themselves. Now, what would I have done? What What could I do if I’m, I’m in a similar circumstance? So was that well shared? Is there? Are there some things that happened during COVID, that galvanized teams together that people ought to know about? But don’t? 

Dr Goldman: Oh, yeah, 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 crashed into a station and the top was sheared off. And it was a mass casualty event. And the interesting thing about it, is that it followed another Code Orange, in which the Ottawa Hospital prepared to receive mass casualties and receive no one and they wondered how that happened. How could that have happened, 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 a textbook operation, because it was well done. And it was well disseminated within the Ottawa healthcare community. It was in the Ottawa Hospital in the Ottawa and the Allied services, first responders. And so they, you know, they learned some lessons, one of the lessons they learned was it 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 arrived? And oh, by the way, it’s in the middle of the winter. There’s hyperthermia going on. And we’re 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.

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. 

Dr Goldman: My pleasure.

TK: There 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 with 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 quote. “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, you know, 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, they can’t drive a car, can’t get to a 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 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, don’t have access to health care. And they invented a teamwork model that is now inspiring, similar efforts across Canada and around the world, where you have Jonathan Fitzsimon, 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 a toll free number that patients can call and it’s for unattached patients, patients who don’t have a family doctor, and they get plugged into the system. And they’ll talk to either a family physician like Dr. Fitzsimon, 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 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, electrocardiogram, bloodwork, 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. 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, VTAC. 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 accepted and recruited into a team, where the team would consist of a family physician, nurse practitioner, nurses, community paramedics as the eyes and ears doing the house calls, registered dieticians, psychologists, physiotherapist, occupational therapists, speech and language pathologist as necessary, pharmacists all functioning in a team work model. And what they found is that 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 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 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 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 learned how to get the different silos, you know, the hospital culture, the family medicine culture, the specialist culture, paramedicine, 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 best to finish on a positive note.

Dr Goldman: Yes, it is. 

TK: That’s a positive story. 

Dr Goldman: 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 will we do better, but we’ll feel better, will 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 the juice of healthcare, 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 Art’ because it’s an excellent podcast. Even for folks like me who aren’t healthcare professionals. A ton of overlap with aviation and thoroughly engaging. So thank you so much for your time this afternoon. I wish you all the best and I hope I’ll see you again in the near future.

Dr Goldman: You bet. Me too. 

TK: Cheers.

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.

TK: Hello folks and welcome to today’s episode of the Dicerra Podcast. I’m Theon te Koeti, the CEO and founder of Dicerra, a web and mobile platform designed to advance the professions of healthcare and aviation. On today’s episode, we are super lucky to welcome Dr. Bill Bestwick, who has a super interesting career span that I think would take most of us three lifetimes to achieve. A few points to note, he was a Special Forces officer and the New Zealand SAS, and for those who are watching and listening that don’t know what that is, it’s a tier one special force. And there’s actually a great Docu series available on YouTube, I believe called “NZSAS First Among Equals,” highly recommended. But that wasn’t enough, left the SAS, became a doctor and an anaesthetist and just put the icing on top, a helicopter pilot as well. So we’re super lucky to have you, Dr. Bestic. And I’d like to welcome you and ask if you could please introduce yourself and maybe share some of the highlights of your incredible path into medicine.

BESTIC: Thanks, TK. Thanks for inviting me. You know, we’ve chatted earlier, but certainly, I think we’ve got a lot of crossover your background as being a pilot, and in aviation. I think I can certainly recognize a lot of the same mindset that you have, and certainly the various professions I’ve had, although there might seem quite disparate, I haven’t really had to fully retrain in any of those because there’s so much crossover between each of those professions, and we’ll probably touch on some of those crossovers a bit later. But yeah, the the mindset, the skill set of each of those are built on the one previously and certainly when I’ve ended up in the, I’m a very, very junior piloting a very much a fraud to call myself a pilot. But I work part time as a commercial helicopter pilot. And even though I’m very very junior in my flying status, the aviation mindsets really resonated with me. So right from those early days of being trained as a student pilot, the skills and mindset being drilled into me by instructors were stuff that took me years to learn in another professions. So I was really impressed that aviation starts with that approach and the others, it’s either unspoken, or it’s just gradually formed on. So yeah, to go back to your original question. I started in the New Zealand Army. Which New Zealand Defence Force which I know you were a member of as well. And spent a few years there in the infantry and then did selection end up in the unit for a while, and then came over to the Australian Army and spent a couple of years over in the Australian Army decided to go to med school on a bit of a whim, there’s a TV show called ER, if you remember back in the day.

TK: I remember it, yeah.

BESTIC: I thought, yeah, I’ll have a crack at that. The absolute naivety and blustery, youthful confidence without actually fully investigating what might be involved which sometimes helpful, right? 

TK: Right. 

BESTIC: So I stumbled into that following a dream. And in the meantime, paid my way through med school by doing private security consulting in Middle East and South America and other places. And then afterwards, when I had a bit more time on my hands, went and did my commercial helicopter licence and now I just sort of share between the two jobs.

TK: That’s huge. The last time we were chatting we discussed some of the advantages in aviation mindset, have brought to your practice as a physician, particularly in the Human Factors context, which you kind of alluded to. Can you explain to our listeners the difference between, say, aviation and healthcare in the way fatigue for example, is treated?

BESTIC: I think between the two in one industry it’s driven from within. And the other industry, it’s driven from without. So my observation is that, amongst pilots, generally speaking, of course, it’s a bell curve. The concept of managing fatigue is seen to be important. 

TK: That’s right.

BESTIC: That to fly tired is a really stupid thing to do. That it will cause accidents, that it’s reckless, and there’s nothing cool about being up all night and then getting in an aircraft and flying. Now part of that might be because I came to aviation in my 40s versus my 20s. But it’s generally accepted and I noticed when I worked on the rescue helicopter as a doctor about 10 years ago, the paramedics on the helicopter and the pilots were always most concerned whether the doctor had been up all night. Because frequently we had been. We didn’t think anything of it, we might have been up all night in the hospital and then turn up for a helicopter shift in the morning. And in the morning brief, everyone would look at you as a doctor and go, were you on night shifts or on call last night, and you’d think uh maybe and then if you had been they would take you off the helicopter or they would ground the helicopters for the day. 

TK: Okay. So your like part of the flight crew and 

BESTIC: You’re part of the crew, and your, making your behaviour has made all of us, put all of us at risk with your fatigue. Even though you’re just a numpty in the back as a passenger basically. So I was really kind of like, wow, this is, this is pretty weird. And in fact, the morning brief would finish. Once we started with okay, what’s the status of the helicopters? And how many hours we got left on the airframe? What jobs do we know? What’s the weather? Then the brief would finish, we’d go around the room and there are always two helicopters on generally. So everyone would say anything that might affect them, on this duty today. Someone might say actually, “I’m going through a divorce and my mind is not in the game today.” Someone else might say, “you guys will know, but I’ve got a new baby and I’m trying to sleep, it has kept me awake at night. So keep an eye on me today.” And I would look around the room at all these roughly tufty Taipei blades talking about their feelings and how they might be tired and thinking, “this is really weird. I’ve never seen this.” Now contrast this to the medical world where they’re trying to bring in safe working hours from above, from without. But the culture within, is that “suck it up man.”

TK: And that starts in residency, doesn’t it? 24 hours shifts. “We did it, so you’ve got to suck it up and do it.”

BESTIC: Exactly, exactly is a bit of a running joke about you know, as a consultant, when you leave to go home during the night, usually hand over to a senior trainee, and will sometimes look at them and say, “if you need me, just get on the phone, you know, don’t be afraid to cope.” It’s this kind of thing like, yeah, I’m supposed to tell you to call me but feel free to cope on your own right. 

TK: Right.

BESTIC: Because actually, if you don’t call me, then I’m completely absolved of anything that goes wrong. Certainly don’t call me to say, “Hey, I just want to let you know I’m doing this and I don’t need you” because then you’ve woken me up for no reason.

TK: Right. I mean, all of the the literature on the effects of fatigue on the human body and what it does and how inebriated you can be after 18 plus hours of continuous wakefulness. It comes from the medical community, that’s what’s informed aviation’s, you know, safe practice with respect to crew rest. Yet it seems like within the medical community, from whence it came, there is still a cultural resistance to adopting it. And I imagine not a not a complete dump on, on healthcare. It’s also you know, you have problems with scheduling and with men personnel, and there’s only, you know, there’s only so many doctors, there’s only so many on call staff. And if you need to have an ER staffed perhaps, you have no other choice than to have somebody on for really, really long shifts. Is there another way to mitigate this?

BESTIC: Yeah, I mean, again, there is always a way to mitigate it. You know, if I look at, say, my colleagues that work for some of the airlines, they have standby pilots, right. So if you call in sick, there’s a standby roster to call that we’re in, even by calling fatigue, right? “Hey, I’m fatigued.” And the standby guy gets called. We don’t have even a backup and medicine. If you call in sick for your shift, there’s no cover for you. In fact, it’s just more work for your colleagues. So you’re guilted into coming to the work tired or unwell because there is no system because the system won’t pay for a second set of medical people to be available for the ones that are sick. There’s a bit of a can do culture. If, if I’m running theatres at night, and I work in a major tertiary Trauma Center, we generally are staff for one operating theatre to run all through the night. And it’s not uncommon for us to do that, every single night of the year. If we have to run a second case, to say we’re doing an urgent head injury. And then someone needs an urgent caesarean section for the baby, we can sort of just run two theatres at a bit of a pinch. It’s not full, fully resourced, but we can do it. And then if a third case comes in, which it sometimes does, we’re not actually resourced for that at all, but frequently, we’ll just do it anyway. 

TK: So you’re using the same staff to bounce around between those 3, okay.

BESTIC: So I might say to my anaesthetic nurse, who’s supposed to be allocated to my theatre, “Hey, I’m pretty good here for a while, why don’t you duck next door, to the theatre next door.” And we’ll just kind of keep the door open between the theatre and we’ll just kind of help each other out. And we just sort of muddle our way through. Because the alternative is we just let the patient bleed to death, sitting at the entrance to the operating theatre, so we don’t have enough people. And then the next and I’ve had nurses say to me, you know, they’ll get really tired of this, because every time we make it happen, no one fixes the problem. And if I escalate that up the chain to say, hey, look, we had to do this case last night with not enough people, I would get told, “Well, no one made you do it.” So you’ve got two options, as a physician at two o’clock in the morning, you just do it, or you complain about it. And nothing happens. If you did nothing. let that patient die, ethically and morally, it’s pretty difficult to do that. And you’d be widely criticised by your colleagues for what, you were tired? Like seriously, I once called in fatigue, once on the helicopter actually. Because I thought I’ve got a bit of fatigue culture. I’ve been up all day, got called in that evening, went all night doing a fixed wing retrieval of a sick patient. And as I handed them off, at seven o’clock the next morning to a hospital, they redeployed me for a third task. By midday, on the second full day, they tried to deploy me for a fourth task. And this is the medical component of the retrieval unit. And I said, “Hey, look, I’ll do it if there’s no one else, but I gotta tell you, I’ve watched three shift changes of paramedics and nurses in the same time that I’ve been on. Three, and I’m the same person.” And the response I got at the other end was,”oh, were calling in fatigue are we?”

TK: That’s unbelievable. 

BESTIC: So I feel really guilty. Now, this is 10 years ago, maybe things have changed. So so there’s this is real resistance to declaring that fatigue is a thing. Like if you’ve got COVID? Well, no one can debate that and you come in with COVID, we don’t want to give it to patients. So actually, they’re not allowed for you to. But if you don’t test, well, that’s easy, too. You just come in with COVID. So there’s a there’s A. there’s not appreciation that it’s a problem and B. it’s the system’s not supporting you as in paying for it. And C. within the culture, you know, I get a trainee say, “Hey, I’m really tired, because I’ve done two nightshift this week.” My immediate thought is, “well, when I was training, I would have done twice that many night shifts,” you know. 

TK: When you say you know, there’s just not support at the system level. First thing that brings to mind is a couple of things. One, that when an accident happens, or when care is compromised in some way, it usually only affects maybe one or a handful of people rather than three or 400 people at a shot. So it’s not a newsworthy incident, if fatigue contributes to compromise care and healthcare as it is in aviation. And the second thing would be there are probably other data points to support it either. Because when you’re dealing with that single report to a single person in the chain, and they kind of dismiss you like “oh, you’re fatigued, are you,” it never goes anywhere. As opposed to having you know, 30,000 different data points reported over a very short period of time that people at the system level, leadership at the system level have to take into account now the data is there in front of them. And it’s it’s inexcusable. But of course, that doesn’t help you guys on the frontlines at the clinician level. In the interim, it’s going to take time to change culture, it takes time to build up data. So is there anything that you can do when you’re, when you know, you’re fatigued, and you’re, you know, you’re integrated within a team that may not be quite as fatigued as you that you can suggest to your team, like holes in the cheese are starting the lineup and can you provide an additional layer of safety, knowing that I’m potentially compromised right now. How would you approach that at a medical context with your team?

BESTIC: Yeah, so there’s, there’s certainly strategies that we can employ as workarounds to fatigue. In fact, I should find it, there was a memo from one hospital years ago that suggested that you should drink coffee when you’re tired as a doctor. That came from management. So rather than acknowledge that you might be tired. It said just have coffee. Thanks, there’s great, cheers. Appreciate that. I hope you sent email before you went home at five o’clock too, that’s important.

TK: If the coffee doesn’t work, try a Redbull. 

BESTIC: Yeah, so none of the coffee machines work, so you need to bring your own. So I think the workarounds that I’ve developed and seen used well. And so I will get told, for example, by senior colleagues when I finished my training, some of these tips. One of them was when you’re really tired, don’t put any chairs in the operating theatre, then you won’t sit down and fall asleep. To the fact that we even discussed that. Imagine that mentioned in the cockpit, “why are you standing? I’m just I’m too tired. If I sit I’ll fall asleep, I’m just going to try and stand and fly this thing, I should be able to, this will keep me more alert.” So that was one. The other thing I’ve tended to do is and following on from the Aviation style is to say so I’ll give you an example. In that, very recently, I ended up being awake for 18 hours. And then I had a four hour break. And then I did another 11 hour shift. And that’s stupid, right stupid, I shouldn’t have done that. But the way it sort of insidiously comes on is that, you know, I’m in a public hospital on the, on the Tuesday, and then I’m in the private hospital on the Wednesday. So there’s, there’s no real cover for me on that next day. And I happen to get called in for a major trauma that took a lot longer than expected, didn’t finish till two or three in the morning. So I go to the private list, the next morning, and there’s 11 patients on it. And I say to the nurse who I know, “hey, look, I just want to let you know that I haven’t had much sleep. And I know it’s unprofessional. But you need to keep an eye on me.” Because I now have insight that I’m going to make errors that I’m not even aware I’m making. That’s the really, really dangerous part of fatigue is, you know, if you were filmed on a day that you were tired, and they played back, here’s the 14 errors that you made, that you didn’t even know that you made. Did you know that you picked up the phone and said something that was totally unintelligible and hung up and thought that was normal? I mean, all that stuff, right? So I said, Look, I am going to make mistakes today that I’m not even going to, so I need you to be doubly vigilant on me. One of the 11 patients I know has an allergy to cefazolin, and every patient is going to get cefazolin. So let’s together come up with a strategy to stop me accidentally giving that to the patient. How about every patient, you say, “Hey, Bill is this the patient with a cefazolin allergy?” And I’ll engineer out of the solution by not pre drawing it up like I usually do. So worst case, I forget the drug. But it’s only prophylaxis. So that’s better than giving the drug that’s going to kill someone. So I’m sort of managing the risk of it here. Let’s schedule a break at 10 o’clock. Kidney caffeinated, and fed. And I would, because I’m going to be freshest in the morning, I’ll pre draw a lot of the drugs for the cases and label them so that that’ll reduce drug error down the track. And I’ll let the surgeon know that I’m a bit tired as well. So there’s sort of some human factors, strategies that I learned from aviation potentially or some workarounds to fatigue, that have been quite useful, you know, essentially threat and error management. But then I think back to say, time in the military and the unit, we never manage fatigue there either. We just, we just boxed on. But I think we were younger. There’s not as much really at stake. Although we say It’s life and death, it’s actually a lot worse when you’re flying an aircraft, or you’re dealing with a patient.

TK: It’s interesting, you know, going back to what you were saying about some of these suggestions to take away chairs, or just to drink coffee, and that will solve everything. And it seems like addressing symptoms rather than the root cause and what you’re able to drill down to using a little bit of human factors back around from aviation was kind of reverse engineering, the root cause analysis to say, “What could possibly go wrong? And where would we trace it back to? Drawing up these these drugs and the fact that somebody has an allergy and the other 10 Patients are all going to get the same thing. So taking the starting point of where an investigation would go back to and then nipping the potential error right in the bud right at the source. How valuable Do you think it would be for other folks in you know, in health care who have grown up in the culture of just suck it up and you know, the pride of working a 24 hour shifts, who have had no exposure really to the other culture, the flipside culture in aviation, to having maybe some CRM or some human factors training, just to make people a little bit more aware of their fallibility, and that it’s not a pride issue. It’s just part of the human condition that we ought to be aware of. And there’s tools that you can use to leverage the team around you. How important would training be and how important would leadership be, like the small team level to implement that?

BESTIC: Oh it would be critical. Like I said, it has to come from within. The physician, the individual has to feel that fatigue is a problem. And I think when we’ve started to look at culture and cultural issues with institutions that I’ve worked in, I’ve found the most successful approach is to vouch it in terms of performance, because everyone’s, you’ve got to find a self interest. People are pretty self centred, I think. So if you can say “This will reduce your error rate, this will make you better, this will make you better than the rest. This will be a performance advantage, a life hack.” People are more interested than saying, you know,”This is a safety issue. It comes from above.” So I think that’s important that it’s vouched in terms of performance. The second issue is that you alluded to it earlier around investigation. I have never seen an investigation into a medical error. That’s mentioned fatigue, even asks what the doctors roster was like, not once ever.

TK: That is quite, that’s shocking, actually, from an aviation background where it’s always a question of threat.

BESTIC: So this week’s been quite interesting, in Australia. There’s been a very public reporting about a death of a young man, in a hospital Intensive Care Unit. It was a motor vehicle accident, and on about day 12, we had a tracheotomy. So that’s a tube in through directly in the front of the neck. When patients are intubated through the mouth for more than nine or 10 days, the intensive care unit, they’ll frequently take the tube out and put it in through the neck because it can last longer. And he also had facial fractures. During his admission, this got dislodged and he ended up dying of hypoxic brain injury. And the coroner has just published their report. This is open source reporting, anybody can find it. There’s some interesting points out of that. The coroner has referred something like four of the doctors for disciplinary action to the medical board for unsatisfactory professional conduct. So this raises some really interesting issues, that they had a bit of a strategy that they’ve pre written a plan. And when they followed the plan, the plan didn’t work. So they were heavily criticised for following the plan. They were told you should have exercised better clinical judgement. And I think this report speaks to the heart of the conflict that doctors have at work. If we follow it blindly, follow a protocol we’re criticised. If we breach a protocol, and it goes wrong, we’re criticised. Those doctors gave free and open evidence at the coroner’s report. And are now having that evidence used to find them unsatisfactory. So what’s the level of trust for other doctors when they read that for future coronial inquests. You better lawyer up, and you better keep your mouth shut, because this can be used against you. The family were highly critical that the hospital seem to be hiding notes and not providing information to them. And that probably speaks to the hospital’s litigious defensive nature and the people involved. So when when an accident happens, people generally run for cover, because the hospital is very quick to shock you out if they can do it, because they want to protect their own reputation. And you contrast this to aviation where when you buy a ticket, you indemnify the pilot from personal error. Doesn’t mean the pilot can’t be found responsible to some level. But you as a passenger can’t to my understanding go and personally sue that pilot. You can do it to a doctor.

TK: That route of litigiousness and medicine is a differentiating factor between these two industries and a big one, a significant one because blame culture for medical stuff is, it’s very different. And I can absolutely see how it would undermine the trust of people to report freely and openly with the intent of sharing advice on best practice, knowing full well, we are fallible, and oftentimes when things happen, it’s not even that a mistake was was made, or an error was made, it could be a broken process. So, I mean, an investigation should be, let’s look at the root cause analysis and look, maybe the process needs to be fixed. Or maybe there’s some other systemic problem that we can address, we actually can be informed by these four people that were involved, to help us make the system better. Coming down on them with punitive measures, and saying, ”We’ve figured out the answer to the problem, and they are the problem. And if we punish them, the problem goes away,” doesn’t really help anyone, and it creates a whole other problem, which is now people don’t want to report like you mentioned. I don’t know what, kind of the best way for it is for the Australian system. I know that New Zealand recently, fairly recently, within the last maybe five years implemented an approach towards non punitive and anonymous reporting. Perhaps partially influenced by the way reporting is conducted and aviation. And I’m not sure what the data is on how many people have whether there’s been an uptick in submissions, because people are more open to report. But I think that what you said earlier about framing it in terms of human performance might be a really valuable thread that we should pull on here. Because when you frame it in terms of, “Hey, this is a safety problem,” and it implies that somebody’s responsible somewhere, whereas if you think it from a performance problem, you’re thinking, “how can I just get better? Instead of how can I punish someone else?”

BESTIC: Well, anonymous reporting is interesting. You know, there’s been some powerfully negative data out of the United States around anonymous reporting. And we’re starting to implement what we have already implemented, Anonymous Reporting systems in Australia, under this beautiful title of speaking up for patient safety, I mean, who wouldn’t want to implement a program called speaking up for patients sake, just a marketing genius, right? And the evidence is that these programs are widely flawed. The evidence is that these programs, they call it the weaponization of safety systems. The vast majority of reporting is actually geared around airing personal grievances, dobbing in your competition. You know, if you’re a up and coming, plastic surgeon and you want to knock off some competition, you can put on a stack of anonymous reporting around their performance and they get suspended, investigated. Online, you know, reviews of doctors, people with grudges. A nurse that is unhappy with a particular doctor on the ward can put in, can get her and her friends to put in a stack of complaints against a doctor. Maybe the nursing unit manager speaks to one of the junior nurses to say about her punctuality at work and that junior nurse decides to initiate a series of anonymous complaints against the nursing unit manager. So that’s what the evidence shows. In fact, the United States experiences that it skews the reporting towards minority groups and females and pregnant females. So it hasn’t been successful. 

TK: Is there a way to? Because the, I can definitely see how that can be weaponized. And I can actually think back to a case in aviation, where a flight safety system was weaponized by an individual going after other people as well in a very similar method to exactly what you described, which is, you know, you gotta avoid that at all costs. So would a, an appropriate measure be that when you have these systems, it’s not, there is no mechanism by which one individual can inform on another individual? The anonymity is, I want to bring something up that’s process related or even, you know, I succumb to, to make sure everybody knows about it. But there are, there’s no identifying features of anybody involved, so that the data points we have are “okay, well, this individual and we don’t know who, what it was, was awake for 27 straight hours, this cluster of events happened. There’s a systemic problem here. And we can log that as a single data point and then compare it with 30,000 other very similar ones, to now bring a case for some kind of change.” You would have to remove the mechanism by which one person can, you know, leverage a career against another person. That would be you know, fundamental, it’s, it’s surprising that you know, Australia is pursuing a model where that is the case, knowing the way that humans are the way that you just described.

BESTIC: Well, it sits very well from a executive and management perspective. You know, there is a trend definitely away from strong leadership. Strong leaders are not rewarded for being strong leaders. If you want to survive in an executive position, you don’t make strong decisions. So it’s a bit like we see with politicians, you don’t make a decision, you make a referendum, you have another inquiry, you have another royal commission, you let someone else make the decisions. And we see, we see this a lot in health care. People don’t want to put their head above the parapet, they don’t walk the floor and talk to people and find out what the problems are because they don’t want to know what the problems are. And by having anonymous bottom up reporting systems, you actually de-empower managers at every level, because that manager now is watching their back all the time. Why even bring up someone for punctuality? Just keep your mouth shut, you’re better off doing nothing. Because the moment you start engaging with people and have interpersonal conflicts, which has to happen when you’re a good manager, if you want to manage performance and performance and safety, to me, are linked. If you’ve got a high performing organisation, they’re safe. So all those little things matter, people’s behaviour, level of professionalism, and so on. That often requires a manager to correct behaviour, and in really mature organisations, individuals correct each other. 

TK: That’s right. 

BESTIC: But if you’ve got a system that empowers all of your subordinates to complain about you, and puts weight to that, then you’re going to encourage managers to take a backseat. And it looks great from outside. “Yeah, look, we’ve got a system called speaking out for patient safety, high five, look at all the report and look at all the reports were generating and all this person didn’t wash their hands, check that out.” I mean, we just get an absolute emphasis on when you shy, and like you’re saying we don’t have the data points to say, well, is that actually important? And we’ve got two groups of people that are trained and think differently, doctors and nurses. Opening a can of worms here.

TK: Tread carefully this is a minefield 

BESTIC: Yeah, might need to edit this out. The general mindset for the nursing training is protocols are important. Protocols save lives, systems and protocols and procedures exist, and they’re important and must be followed. The medical training is a little bit encourages independent, free clinical thinking. In the military context, we would call it an immediate action, patrolling in the jungle, you get shot at all the soldiers are trained to perform an immediate action to that response to being shot at and that allows the platoon commander to then make some decisions. So there’s an immediate reaction followed by deliberate decision making. Same in counterterrorism or anything else, you know, that’s what SOPs do. They, they take away that, “okay, here’s my immediate response. I have an engine failure and helicopter, I immediately enter auto rotation, and then I consider what I need to do next.” So from a medical perspective, it’s like, right, we’ve had immediate reaction, now the doctor arrives and starts to make clinical decisions. That’s what we can clash. Nurse goes “but there’s a protocol for this,” doctor might be, and may not be articulating it very well, sure. But I’m gonna deviate from there, because I’ve got experience in the area or what have you. And you look at this latest coroner’s report, the doctors are criticised for not showing independent clinical thought. So when you put those two systems together, they’re going to clash. And if you’re going to say, because the belief system within the nursing culture is a bit more, when you deviate from protocol, it’s bad, then every time they see that deviation, they’re going to report it. So the system is going to get swamped with things that may or may not be relevant, and it’s going to become wildly distracted about things that are not actually important. So we’re going to chew up an awful amount of our cognitive space as an institution on stuff that’s just not important. And in the meantime, leadership just sails off into the distance.

TK: If you’re going to implement some version of this reporting, it must be non punitive. And if you have a punitive element where you’re still looking at “who can I blame for something,” instead of “what can we fix?” And the answer might be nothing can be fixed right now, the answer might be we need a little bit more time and data and we’ll figure out a bit of a better way ahead. Or it might be a technological fix that we haven’t come up with yet. But it really ought not to be “let’s find the person, the individual to blame,” because that’s just such a, it’s such an unhealthy culture. And I think we’ve managed to get to a space maybe in aviation where that’s not the case. It would be a rare case that somebody is, faces a heavy penalty for negligence and aviation. Most of the time, it is the human factors, the H-Facts classifications, you know, somebody files a report on themselves for runway incursion on the NASA’s Aviation Safety Reporting System at an airport in the US and they do a thorough background check and they classify it in terms of the human factors in involved in and they publish it for everybody to read and learn from. That pilot can, you know, conceivably may not lose their licence. They may not be punitive measures because they might not be warranted. But, you know, health care, like you said, you need to get to a point, it’s a mature culture where, where peers keep each other in line without punitive measures necessarily needing to be mandated, and it requires strong leadership. And those two things, it’s going to take some time to build that kind of a culture that has been allowed to grow in a different direction for so long, right?

BESTIC: Yeah, I don’t know. It’ll be interesting whether it can ever happen. Yeah, the Civil Aviation Safety Authority in Australia, CASA, publish a regular flight safety magazine. It’s ironic, when you compare the two professions. If you write in about your own error, and people are writing about the dumbest stuff, you know, “I flew when was dark, and I don’t have a night riding, I flew into a storm, despite the fact that it was,” I mean, you know, you wouldn’t script it, they get $500, if that gets published. Now, in the medical world, if I stand up at a department meeting and admit, “hey, look, I made a really bad error the other day, and the patient ended up dying or something bad happened,” or there’s a proper outcome that, me talking to the department that could be subpoenaed and used by the family’s lawyer against me. So when we discuss cases in a department, that’s not, it’s not privileged. So that information can be subpoenaed. So everyone’s a bit careful about what they say. Two hospitals can be over the road from each other, they won’t share their near misses with each other.

TK: Yeah, and it’s no, you’re in no position to advance performance or advanced the profession when it’s that solid. And when people are afraid of blame culture.

BESTIC: The only thing we can do is within our own, we can actually use the silos to our advantage. And this is what I’ve, the point that I’ve come to in my career is, I’ve given up trying to fix the system, because it’s exhausting. And I’m not sure, you can’t fix something that doesn’t want to be fixed or doesn’t see that it has a problem. You know, there’s this narrative concept of narrative fallacy. Humans like a simple story. We don’t like complex stories, they’re too hard. So we like the story, when it’s more appealing the story that the doctor made an error. Because to look at all the causative factors, you know, it just takes a long time. Where aviation, the immediate understanding is that there are going to be more than one cause to this crash. Always, always a contributing factor. Sure, the pilot might have made a really bad error. And maybe in this particular crash, fatigue wasn’t an issue. But when we look at the culture of this particular company, there is a culture of over rostering, and not letting people call in sick, that is going to cause another problem down the track. And because all those little organisations know that, if a crash happens, the investigator is going to come and look at everything. That you know that carrot and stick kind of works. And when investigators come they are professionally trained investigators from external body. We don’t really have that, we might just get a doctor from another hospital come and investigate. So we don’t have this professional body that moves around investigating things, and we should. I made a controversial statement A while ago saying, How would people feel if we had, we recorded by voice all the theatre conversation? For every case,

TK: Like an FDR or a CVR.

BESTIC: Exactly right. I say why don’t you like the monitoring on the anaesthetic machine, that’s all your flight data. I record that. Sometimes manually for a whole case. I do. The very data that might hold me responsible. I’m the person recording it. So when the blood pressure is a bit low, it’s on my honesty, to actually accurately record that, that shouldn’t be like that. That should be recorded in a way that I can’t access. But when I suggested the recording people were like, “why would we do that?” I said, “Well, cockpits are recorded. It doesn’t stop me talking about whatever you want to talk about. But.” So there’s this absolute, there’s no way we want visibility on what we’re doing inside our operating theatre. Absolutely not. People are mortified about the recent cases where patients have hidden listening devices on them. Little USBs in their hair bun or something and then recorded it. There was quite a famous case out in States, where patient had a colonoscopy and an anaesthetist and surgeon were disparaging about the patient and then went to the media with it. But it shouldn’t. You know, the horrifying thing shouldn’t be the patient’s recording it, it should be that there should be nothing happening that we don’t mind visibility on. But because we’re personally liable and responsible then changes the nature of it. So I think there’s A. got to be that understanding that there are always more than one causative factor. And I’ve even noticed in aviation, when I’ve had a colleague recently, who had a minor crash. People are very careful not to actually, I mean, there’s human nature to oh yeah, well, I’m not surprised he did that or you know, we’ve got a competitive nature where we want to kind of put that person down if we can, makes us feel better. But Pilots I’ve found are very critical people. People say to me, the only thing two pilots will agree on in a room is that they’re better than the third pilot who’s not there. So pilots are very, very critical of each other. But they’re also quick, I found to say, we’ve got to wait for the whole report. That doesn’t happen in medicine. We won’t talk about accidents, we’ll keep it quiet. And so the only way to change it, coming back to the sort of siloed thing to use that as an advantage is to say, “Well, why don’t you as an individual stand up to the department and talk openly about your errors?” That will have the courage to do that, that will create a culture amongst junior staff, that it’s okay to talk about errors. And then the tertiary hospital I work at that’s generally what happens, the most senior respected, most capable people will frequently jump up and talk about something basic. I want to introduce a system called Consultant Confessional, where just the consultants talk about the dumbest things I’ve done in the last week. Or the cannulas they’ve missed or anything because what it does is it tells people that we’re human, and we’re not pretending to be something that we’re not, and that would open up the door a bit. 

TK: Have you implemented that yet? Are you, is that a future goal?

BESTIC: No, we’ve got it on an ad hoc basis. You know, I’ll, yesterday in fact, on a Thursday, so two days ago, I, in front of junior trainees, I said to one of my senior anaesthetists who, mentored me, I’ve got a great deal of respect for the guy. And I said, Chris, I need to confess something to you that I did yesterday. And I told him that I’d given a drug to a patient that I shouldn’t have. I said, “I gave this drug, the patient was in heart failure. They nearly had an arrest, it was a really dumb thing to do.” And he goes, “Well, that was stupid. I’ve told you not to do that.” I said, “I know,” he goes, “Did you think of me when he did it?” I said “I did.” “Because did you have a bad sleep last night?” “I did.” “Do you feel better for telling me?” “A little bit.” I said, “I just feel annoyed with myself. That this far into my experience, I’m still making basic errors, it really annoys me.” But the reality is, of course, we’re making errors all throughout our career. But a part of it is I’ve got to get that off my chest and not hide it. I’ve got to give it air time. And it also encourages other people. I went back to one of the trainees and I said to him, “hey, look, you saw me get that drug yesterday, you know, I shouldn’t have right.” He said, “I did think that.” Some people are people now but anyway. So look, this is not solving the world. It’s not changing the whole system. But when we get overwhelmed with the frustration of “Well God how do I fix this?” We can just start at our own level. We can start by you know, when an instructors pushing you to do a pre flight that you’re gonna want to take more time to do this properly. We can affect change within ourselves, and seek mentors and show leadership. It’s not going to change the world, but it’s going to make you a better human. And again, we’ve come back to performance. If the greatest accolade we can get as a physician is would our own nurses that see us every day trust us with their family. So cause they see us at our worst. So if they trust us, and if you want to know maybe your mom or your dad or if someone needs to see a cardiologist and you don’t know any cardiologists you ask a recovery nurses or the nurses that work with other cardiologists. They’ll know. 

TK: Yeah.

BESTIC: Because they see.

TK: I was an instructor pilot for a number of years and I had a similar thing, would I want my family flying with this pilot, if they were a student that I was teaching or checking.