On a calm cloudless evening, a few days after Christmas of 1972, a jumbo jet descended through the skies over south Florida. Until then, the flight from New York City had been routine and uneventful. But now, as the pilots prepared for landing in Miami, they noticed that a key indicator, which would confirm their landing gear was fully down, had failed to illuminate. They radioed air traffic control and requested to be placed in a holding pattern so they could troubleshoot the problem. What happened next would change the course of aviation history.
The accident investigation later revealed that the landing gear was indeed down, and that the tragic chain of events that followed was the result of nothing more than a faulty lightbulb in the cockpit. It also revealed that over the next ten minutes, all three pilots became consumed by concern over the landing gear. It noted that while the captain and co-pilot — realizing that they might be dealing with a faulty bulb — fiddled over and over again with the un-illuminated lightbulb, the flight engineer was out of the cockpit and down in the bay, trying to see outside the plane to confirm that the wheels were down.
The investigation determined that none of the pilots noticed when, in their attempts to fix the bulb, one of them accidentally disconnected the auto-pilot and placed the airplane into a gradual descent. It found that the pilots were so engrossed in their conversation about the problem at hand that none of them heard a chime alerting them they were off course. Only a few minutes later did the co-pilot finally notice a problem. As recorded on the cockpit voice recorder, the last words he ever spoke were: “We did something to the altitude…we’re still at 2,000 feet, right?” By then it was too late. The aircraft slammed into the Everglades, killing 101 of the 176 people on board.
A Tragedy with a Lesson
The crash of Eastern Airlines flight 401 was tragic in the truest sense of the word. In good weather, three highly-experienced pilots at one of America’s most trusted airlines had flown a perfectly good airplane into the ground. But to their credit, the airline industry and the Federal Aviation Administration learned important lessons from this and other accidents and put them to good use.
Within a few years, airlines began training pilots in something called “Cockpit Resource Management” (CRM), a technique for ensuring clear lines of communication and delineation of responsibilities between crew members. Today, CRM is a standard part of pilot training at airlines all over the world. Budding pilots study the crash of Eastern 401 and other disasters caused by pilot error to ensure that they will never repeat the same mistakes during their careers. More than any other single innovation, CRM has helped to bring the accident rate for major airline travel down to nearly zero, and ushered in the era of incredible aviation safety that we enjoy today.
Among the most important insights gleaned from the Eastern 401 disaster is this: a distracted pilot is a dangerous pilot.
It is a lesson that we would be wise to apply to the medical profession.
To Err Is Human…
In 1999, the Institute of Medicine released a landmark report entitled “To Err Is Human,” which estimated that nearly 100,000 Americans die of preventable medical errors every year. At the time, the report made headlines all over the United States, and galvanized the medical profession to embark on reforms aimed at reducing this death toll. One idea that gained currency was to look toward the aviation industry for lessons on how to improve safety.
This idea stayed in vogue, and indeed has brought improvement in some areas of healthcare, most notably in the operating room and the intensive care unit, where the use of checklists (famously described in this Atul Gawande essay) have reduced the incidence of certain errors, such as wrong site surgery and infected catheter lines.
But the overall goal of improving patient safety has not been met, and if anything, things may have gotten worse since 1999.
If a distracted pilot is a dangerous pilot, what about your doctor?
There are lots of reasons for this. For instance: Humans are much more complex and respond to interventions less predictably than airplanes. There are often more people making decisions about a particular patient’s case than there are pilots in a cockpit, and hence more chance for miscommunications to occur.
But let me propose one major problem that the crew ghosts of flight 401 would be sure to mention, if they could tell us their thoughts on healthcare safety: a distracted doctor is a dangerous doctor.
Daily Distractions
Much of the efforts at improving patient safety have focused on hospitals, but more than half of all the healthcare delivered in this country occurs not inside of hospitals, but in outpatient primary care offices.
Our primary care system needs much reform. Primary care physicians are asked to do a lot these days—with billing, with documentation, with trying to reign in the opiate crisis. But in a sense, all of these problems can be considered contributors to one overarching problem: doctors are constantly distracted from doing the work of actually caring for patients.
It is not uncommon for me to be distracted more than a dozen times during a typical visit with a patient.
I might get distracted by a phone call from another doctor.
Or by an alert going off on my electronic medical record, reminding me to discuss something with the patient that may not have anything to do with their particular concern that day. For instance, “Mr. Jones, I know you are here to discuss the horrible grief you are suffering after your wife’s death, but have you considered being screened for prostate cancer lately?”
Or by an urgent message pertaining to another patient.“Dr. Bittermilk, I know you are in the middle of your visit with Mr. Jones, but one of your other patients is calling, and he states he’s been vomiting blood for the past two hours.”
Or by the patient themself, who might blurt out a new question just as I’m in the middle of reviewing their recent lab work to ensure nothing requires follow-up.
In my years of practicing medicine, the problem of distraction has only gotten worse. We have been mandated to tend to more and more paperwork, “quality measures,” and other tasks that have little to do with our fundamental job of seeing patients and evaluating their medical concerns.

To give some idea of just how much distraction doctors face, a team of researchers recently published a study in which they determined that it would take 26.7 hours for a primary care doctor to complete all of the tasks expected of them on an average work day. In other words, even a hypothetical super doctor, who never needed to eat, sleep, or have any time outside of their job, would literally not have enough hours in the day to get all of their work done.
Nor is this problem only a recipe for medical errors. Overworked and distracted doctors are more likely to be perceived by their patients as gruff, uncaring, and unfriendly. Doctors are more likely to report feelings of burnout and professional dissatisfaction, sometimes even abandoning the field or retiring early, and thus exacerbating the ongoing physical shortage.
Going back to our aviation analogy then, primary care physicians of today are like captains of jumbo jets who are expected to not only safely fly the plane, but also to fuel it, maintain it, check in the passengers, load the baggage, and serve drinks in first class.
In short, we have made the task of pilots more simplified and streamlined, allowing them to focus on what they most need to do, and they have responded as a profession by improving their safety record. We have done the opposite to doctors, and are shocked when things go awry.
The Solution Is Not a 26.7 Hour Day
There is no one solution to this problem. By the very nature of what we do, doctors can never have our task load streamlined to the level of an airline pilot’s.
But unless we do something to scale back the extraneous workload on doctors, medical errors, physician burnout, and dissatisfied patients will continue to be the order of the day. Faced with the above, let me propose that the cost of attacking this problem would be a tiny fraction of the cost of allowing it to progress unfettered by any restraint.
To this end, I would suggest we create a new job: Doctor Advocate.
Doctor advocates would be tasked with finding ways to simplify the lives of practicing physicians. They would spend time with in-the-trenches doctors and find ways, big and small, to reduce the number of minor tasks that physicians are asked to do, whether by streamlining a process, implementing a better IT solution, or offloading the task to a more junior member of the work staff (a nurse or a medical assistant, for example), if it can be safely performed without the input of the physician. Advocates would also be at the table any time major decisions were made about changes to the way work or billing are done, and would be there to point out the unintended consequences of policy changes that, however well intentioned, often serve to increase physician workload.
The cost of solving for this would be a tiny fraction of the costs we bear by allowing it to progress unfettered by any restraint.
Doctor advocates could be employed by insurance companies, Medicare, government regulatory agencies, hospitals, large physician practices, medical schools, and anybody else who has an influence on the day-to-day operations of the healthcare industry. Indeed, in the long-run, these are the organizations that have the most vested interest, financially and otherwise, in ensuring that the physician workforce is competent, happy, and thriving. Additionally they would likely realize tremendous cost savings in areas such as physician retention and productivity that would more than offset the cost of employing such a person.
Doctor advocates would ideally come from a number of different backgrounds, so as to create a synergistic approach to solving some of healthcare’s toughest organizational challenges. Many would be physicians or nurse practitioners who have first-hand knowledge of the challenges healthcare providers face, but people with backgrounds in IT, business operations, system design, and engineering would also be appropriate candidates for the position. In other words, people who have experience troubleshooting complex organizational problems would be welcome to apply. Perhaps a few retired airline pilots or aviation executives could even join the ranks.
If the healthcare profession is ever to make good on its aspirations of emulating the aviation industry’s admirable track record of safety improvements, solving the problem of physician distraction needs to be priority number one.
This is one of an ongoing series from Dr. Bittermilk, offering solutions to a variety of issues surrounding the U.S. medical system.
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Dr Reginald Bittermilk