During WWII, the US Air Force had an issue – pilots kept crashing planes. Actually, one particular plane – the B-17 ‘Flying Fortress’ bomber. Inexplicably pilots were returning safely from successful missions, before suddenly driving the plane into the tarmac with its wheels still retracted, scraping along the runway before exploding into flames.
As no fault was found with the planes, it was decided the problem was the pilots. So the military took the usual approach: more pilot training, more checklists, more reprimands, and finally pilots were dismissed. But nothing changed: over a 22-month period 457 Flying Fortresses crashed after landing.
Exasperated, top brass hired a psychologist to work out what was wrong with the pilots. Instead, he did something no-one else had – he got into the cockpit. What he saw led to a simple solution that not only fixed the issue of Flying Fortresses being destroyed on the runway, but was also the beginning of the change in aviation from a ‘blame culture’ to a ‘just culture’.
In medicine, although we are beginning to learn some of the lessons of aviation we still often come from a position of questioning how to get people to do the right thing, rather than looking at the systems that both make it more difficult to do the right thing, and subtly support them in doing the wrong thing. In looking at the question of overdiagnosis, we may still be falling into this trap.
Overdiagnosis often starts with the basics – blood tests and other investigations. Patients have more of these tests in the hospital setting than at any other time, and these are typically ordered by the most junior doctor on the team with little to no direct senior doctor oversight. Additionally, during the time when newly minted doctors first hit the hospitals, they are suddenly overwhelmed navigating all the things medical school can’t teach – complex IT systems, navigating the rigors of shift work, managing mountains of paperwork, all while they desperately try not to look stupid, mess something up, or kill a patient.
We know junior doctors are overwhelmed and burning out at high rates, with reports of 50% of junior doctors being burned out halfway through their first year. And these just happen to be the doctors ordering the bulk of these initial blood tests and investigations. So how do they manage?
Not surprisingly, they look for shortcuts: ways to make it easier and manage the cognitive overload, including things like ordering a panel of tests with one click. And when you have no time, are cognitively overloaded, and have a panel you can order with one click, you are going to just click.
So perhaps rather than looking at more education and more checklists, we should be considering how we can support our most vulnerable doctors to be able to take the time needed to apply the critical thought processes that will result in less testing. And as with the Flying Fortresses, we might then start to see some meaningful changes.
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