For the 4th of July weekend, I went down to LA to visit with friends and have a big party to celebrate the holiday. Although that may seem a fairly normal thing to do, I am usually very busy with school, research work, and many other obligations, so I don’t travel very much, and I very seldom get a chance to do something like spend a (long!) weekend just relaxing.
We were out getting ramen that Saturday for lunch when we heard about the crash of Asiana Airlines Flight 214. When we went back to my friend’s home, we watched the news footage for awhile. Usually I try not to watch news coverage of unfolding events, as typically there is very little actual new information being provided, and instead lots of misinformation and speculation. However, I had a pretty selfish reason for paying close attention to what was evolving, as I was going to be flying into SFO airport the next morning, and I wanted to know if the airport was going to be open or if there were going to be substantial delays. In the end, we actually landed on time in SFO the next day, coming down right next to the crash wreckage. I suppose that is a testament to the efficiency of the workers at the airport. Despite the disaster, by the next day things were back to relatively normal activity.
At the time, watching the news I was struck by a few things. The first was that we were incredibly pleased to learn there were fewer reports of casualties than I initially expected would be the case based on the horrific pictures of the plane. I was also proud to hear in the reports about the involvement of my medical school in treating disaster patients, and indeed, recently one of the ED attendings, Eric Weiss, gave fascinating medicine Grand Rounds about the event and the subsequent treatment of the disaster patients.
Something else that struck me during the news coverage was how much of it seemed mildly racist. This ranged from the blatantly, crudely racist to the general tone of coverage with its focus on listing the backgrounds of the people on the plane, focusing on how many spoke English and how many had US passports, etc. Admittedly, I don’t have any ready quotes now from what I observed, but I admit, it made me somewhat uncomfortable.
Finally, on learning that it was a South Korean airline crash, I was reminded about the example of South Korean airlines in case studies of failures and errors. Malcolm Gladwell is one person known for having popularized a mechanism for why Korean airlines have had a history of proportionally many crashes. The theory is basically that hierarchical culture is responsible for limiting communication and preventing lower ranking individuals from drawing enough attention to errors and problems. When underlings are too intimidated to question the judgment and actions of superiors, errors don’t get adequately addressed. Egalitarian Australian culture and the very good safety record of Quantas (remember the scene from Rain Main?) provide a major counter-example. Some, such as this post, have related the Asiana air crash to this model. Others have written cogently in an effort to debunk this “myth” of culturalism.
However, the important lesson is that, independent of culturalism (as analogous to racism), in this model of a source of accidents and errors, the fact is that I am convinced that flattening hierarchies reduces mistakes and errors. People cannot be too intimidated to report problems. Being able to accept criticism and correction from someone else, particularly from a trainee or subordinate, takes cultivating a strong sense of self-confidence and humility. Not everyone works on this.
The first instance of where I really felt intimidated into reticence happened while I was a volunteer in a free clinic, before I was even a medical student. A resident who was assigned a patient, an undocumented day laborer from Latin America with a history of a few weeks of left-sided chest pain, basically refused to see the patient for more than a few seconds and wanted to send him to the county emergency department immediately because he considered him a heart attack risk. After talking to the family for a few minutes, I knew they were not going to go the ED. They were concerned about costs and I’m sure about being too embroiled into a medical-legal system where they might be identified as undocumented. I mentioned that we had an EKG machine there in the clinic, but this was dismissed. I dutifully called the ED and told them the patient was coming, and then asked the the family if they wanted to drive themselves or for me to call an ambulance. They said they wanted to drive, and promptly left. I called the ED at the end of the day to see if the patients had ever arrived. Unsurprisingly to me, they had not. Who was I at the time to question the resident? No one I suppose. Who am I now to question his decision? Still no one, I suppose. He knew his qualifications, competency and confidence in treating the patient; he believed the patient was at risk for a serious heart problem, and didn’t think he could provide a reasonable diagnosis or level of care. Presumably he had thought about all the legal ramifications and thought he was doing the best thing. In retrospect, I just blame myself for not being more assertive and arguing that we were not doing more for that patient. I was intimidated into not speaking up more. I was intimidated into not going to talk to the medical director of the clinic directly. The patient believed it was musculoskeletal injury caused by one of his jobs. I don’t know what it was, but I know we didn’t do the best thing for that patient.
However, the important lesson that I took away is to not ever let myself be intimidated into not trying to do the best job possible. I am not an expert in plane crashes, and I’m not an expert on culture, but I can try to be an expert on doing my job the best way possible, even if that means speaking up in a way that can make me unpopular with my superiors. In the future, I hope I will have the personal courage to always speak up, and the social delicacy to do it with deftness and grace.
