Monday, August 8, 2011

Surgeons Are Not Pilots or Long-Distance Truck Drivers

I have blogged before about the inappropriateness of comparing surgeons to pilots [here and here]. Recently, I have seen some comments that lump surgeons, pilots and truck drivers together. Commenters are in high dudgeon about those three occupations working long hours citing the fact that pilots and truck drivers have strict rules about how many consecutive hours they can work and surgeons do not.

There are several problems with the comparison. Long-distance truck driving involves many hours of boring work. When driving a long distance on a straight interstate highway, most people have had the experience of realizing that they have just covered 10 miles and do not recall a thing about the scenery or the traffic. Except for taking off, landing and occasionally telling the passengers to fasten their seatbelts, flying a modern airliner can be equally boring. The planes fly themselves, hence the name “automatic pilot.”

Being a surgeon has no similarity whatsoever to piloting or driving. When a surgeon is on call for 24 hours, he rarely is awake the entire time. When he is, he is not doing monotonous, sleep-inducing tasks. For example, I might get a call at 2 a.m. to see a patient with appendicitis. I go to the hospital, examine the patient, schedule the surgery, perform the surgery and go back home. None of those activities is boring or repetitive.

Let’s say that while I am waiting for the operating room team to set up the case and have dictated my history and physical exam findings and written admitting orders, I have nothing to do. If I put my head down and take a 15 minute nap, no harm is done. This is not the case if a truck driver or pilot falls asleep on the job. Even if pilots are distracted by other things such as playing with their laptop computers and overflying their destination by 150 miles or receiving oral sex in the cockpit [no pun intended], the plane flies along without incident.

I suppose I am overstating the obvious, but neither of the two activities described above is possible while performing surgery.

So please, stop comparing surgeons to pilots and truck drivers.

13 comments:

tialaramex said...

Hmm, maybe. Is there really nothing that becomes routine, automatic in your surgery? No step that goes the same way so often that you could almost do it blindfold?

Pilots are under unique scrutiny. Most people are aware that plane _accidents_ are investigated. Did you realise that even non-accidents make a difference? Any incident which, had things turned out differently, could have resulted in an injury or damage to property is reported and analysed.

As a result of this unique scrutiny, things began to show up that you'd take centuries to notice if you looked only at (mercifully rare and getting rarer) accidents. Fatigue is a big one.

When people suffer fatigue they don't just fall asleep -- if only it was so simple. They miss the obvious, they make unjustified assumption, they react slowly to unexpected stimulus.

Without measuring the effects fatigue has on surgeons and their unique patterns of work we can't know how dangerous it is. But past experience (in aerospace and railways) says that professionals themselves are very bad at guessing how their performance is affected by fatigue.

Skeptical Scalpel said...

Thanks for the comment.

I am aware that pilots report near misses and are not penalized for them. Too bad that is not the way it is in medicine.

The effects of fatigue have been looked at in surgery. Two months ago I blogged about two papers that show that sleep deprivation had no adverse effect on outcomes of two different types of thoracic surgery procedures [http://is.gd/TBnRRI].

An Expat who learned metric said...

While oral sex in the operating theater is rare, and almost always extra-curricular, the same in the consulting rooms, either with patients or nursing staff, is common enough to count as 'significant'.

I don't think this point invalidates your thesis though. Nice article.

Vince said...

I'm a surgeon. And i can clearly remember many MANY close calls and mistakes due to fatigue. Some first world medical students and residents are lucky because of laws which limit working hours. No such luck in my country.

Usually we have a 3 day schedule. Day 1: Operate or do other stuff all day (7am to beyond 5pm). Then Spend the night trying to sleep. If you're unlucky you have problematic patients who keep you up. Day 2: endorse or hand over to the incoming team (6-7am). Then operate or do other stuff (7am-beyond 5pm). Then go home. Day 3: operate or do other stuff from 7am to beyond 5pm then go home. Then repeat

Vince said...

I'm a surgeon. And i can clearly remember many MANY close calls and mistakes due to fatigue. Some first world medical students and residents are lucky because of laws which limit working hours. No such luck in my country.

Usually we have a 3 day schedule. Day 1: Operate or do other stuff all day (7am to beyond 5pm). Then Spend the night trying to sleep. If you're unlucky you have problematic patients who keep you up. Day 2: endorse or hand over to the incoming team (6-7am). Then operate or do other stuff (7am-beyond 5pm). Then go home. Day 3: operate or do other stuff from 7am to beyond 5pm then go home. Then repeat

Skeptical Scalpel said...

@Expat-I'd love to know where you work. Also loved "...almost always extra-curricular."

@Vince-Sounds like an "old school" tough schedule. No days off or time to nap?

Anonymous said...

I am a surgeon. I think the most valid comparison is that to active duty soldiers. I'm surprised that similarity is rarely (never?) mentioned.

Skeptical Scalpel said...

@Anonymous

I agree that comparing surgeons to soldiers is valid. I have blogged about this. With all due respect to the valiant Navy SEALs who lost their lives, see my post which was written In late June of 2011. http://tiny.cc/cn0s3.

tialaramex said...

Thanks for the link to those papers (re: fatigue). It's unintuitive that it should make no difference in this field, but I can't argue with these results.

Yes, it would be great to get "no fault" incident reporting in medicine. Perhaps we have more chance in the UK than the US.

t. a. said...

Scalpel: I'm working a 1 in 2 roster like Vince. It's pretty tough.

sam neame said...

Gary

If flying is so easy why not get children and the elderly to do it, would save companies millions. Idiot!

Anonymous said...

You may enjoy researching into military aviation. I can guarantee you even a
"routine" flight in Tactical Aviation, Search and Rescue, or a catapult launch from a carrier is by no means boring or exempt from small errors which can be caused by fatigue. The environment in which these indivuduals operate may prove to be a truer comparison for a surgeon. I work in Aviation Physiology; fatigue is frequently addressed, trained against, instructed to avoid, regulated against, etc.

Skeptical Scalpel said...

Thanks for commenting in a more civil way than Gary above.

As I mentioned in answering your comment on another post, I am intimately aware of what it takes to be a military aviator. To protect my anonymity, I won't disclose details.

Again, I exaggerated to make a point (lost on Gary).

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