Why it’s important to question authority, even in medicine

Last night I was watching one of those air crash disaster shows. For 60 minutes it followed the case of Comair flight 3272, which crashed in 1997 on its approach to the airport, killing all 29 aboard. While I get bored of the constant analogies drawn between medicine and the aviation industry, I found that this case imparted a powerful lesson.

For those of you who are regular readers (hopefully there are some!) you may have noticed a pattern in my blog posts- they often advocate challenging commonly held wisdom that may come from your seniors. It has not escaped my attention that this is one of those ‘easier said than done situations’. Comair flight 3272 will help me expound why I think this is important, and how to go about it.

Flight investigators were eventually able to conclude that icing had brought the plane down- basically ice forms on the edges of the wings in the right conditions, and the wings lose the ability to generate lift. The puzzling thing was the pilots had recognised they were in icing conditions, but had failed to activate the de-icing boots. This is a length of inflatable rubber installed along the wing edge which inflates, cracking off any ice that has formed.

When the investigators interviewed other pilots who worked for the airline they asked them what their threshold for activating the de-icing boots was.  All answered that they would wait until a relatively significant amount of ice had accumulated on the wings, rather than activating them at the first sign of icing. Their rationale for waiting was that they were concerned about ‘bridging’- after the boots were inflated ice could then form over the top of the inflated boots, rendering them useless.

The kicker was that ‘bridging’ was only a problem when de-icing boots were first invented. This is because they inflated slowly then stayed inflated for some period of time. Modern de-icing boots however rapidly inflated then deflated, meaning there was no possibility of ‘bridging’ occurring.

Yet here we had the majority of pilots, all experts in their field, many long serving veterans in the aviation industry, concerned about a problem that was a myth. This myth was propagated in the Comair flight manuals for pilots, even though the airplane manufacturers themselves had clearly stated in their manuals that the boots should be activated at the first sign of icing.

Experts had failed to keep up with advances in their own field, and the price paid was the death of 29 people, and, upon further investigation, many other close calls from the same problem. This is not to level criticism at the pilots- advances in fields such as medicine and aviation are vast and rapid and it is impossible to keep up with everything. However this is why it is all the more critical to question authority, commonly perceived wisdom, and ‘the guidelines’.

We can find many parallels in myths that are perpetuated in medicine, many of which I have blogged about already. For example the myth of needing to use normal saline in hyperkalemia, the ‘wisdom’ that you can estimate a blood pressure by which pulses are palpable, and the guidelines that suggest only a STEMI is a sign of complete coronary occlusion.

There is of course a way to go about it. As an intern, it is not about being arrogant, or thinking you know more than you do, or refusing to follow instructions, or going off the protocol. You still need to recognise that most of the time, your seniors know better than you. But it is about approaching someone afterwards and respectfully asking ‘why did we do it this way rather than this way?’ It is also about not being afraid to seek a second senior opinion if you feel you are being blown off.

There is an important corollary to this. You may not be aware, but you are an authority figure to someone in the hospital, even if it is your first day on the job- the nurses. Many times they will question you- you need to not get defensive and take it personally but recognise that it is part of doing what’s safe for the patient. If you don’t have a good explanation or rationale for your plan, you might want to rethink it.

I hope you have found this convincing and helpful. How you approach your work can be just as important as what you know, and hopefully we will cover similar topics to this in future posts.

Until next time.

  1. https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9804_body.pdf

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