The day began with a kiss goodbye for my girlfriend and feeding the dogs. My girlfriend has been out of town on a consulting gig, so the few moments I had to kiss her goodbye may be the only 5 minutes I see her for several weeks. I am out of town for 3 days as part of a leadership position for the AAPM&R (www.aapmr.org), the main parent organization for the field of PM&R.
I get on the airplane, and I start profiling. As someone who is 6'3" and 230 lbs, I always hope that I am seated next to a 4' Hawaiian girl. Most of the seats are taken, and I do see one opening ... next to a guy who looks to be about 5'10", 265 lbs. Nice guy, and he is pleasantly in his own space jamming to some Beats headphones. We make some pleasant small talk about the sound quality of his headphones (he likes them), negotiate over elbow room without much confrontation, and then settle in for the flight.
I start reading my book of choice on the IPad- "Fightnomics" by Reed Kuhn. Interesting read, where he uses statistical techniques to help analyze fighting, similar to the concepts Bill James pioneered in baseball, and has been spreading to other sports like basketball (e.g., this great article at Grantland).
This is a topic of great interest to me, both as a Mixed Martial Arts fan, and as a mathematics/statistics fan. Bill James, and his intellectual progeny at the Baseball Prospectus, demonstrated that using more sophisticated statistical techniques could help baseball teams win more games. I think the message of this is that often heard is that "Big Data"- the idea of collecting massive amounts of data and hiring statisticians to look at it- can solve problems that otherwise would not be apparent.
That's true ... but it also misses a lot of what was Bill James's real genius. He didn't advocate for sophistication or numbers, he simply advocated for asking good questions and looking for simple approaches to answering basic questions. For example, one of his biggest insights was that measuring On Base Percentage was a much more meaningful way to characterize a batter's offensive output than Batting Average. There is nothing complicated about On Base Percentage - I literally was calculating mine as an 8 year old- but Bill James realized that asking the right questions was important.
It was also important to not get hung up on stupid details. For example, one of his big insights was realizing that "clutch hitting" is essentially unmeasurable. It may be real, but trying to build offensive strategies around "clutchness" don't work, and was often used as a way to validate someone who actually wasn't that valuable.
This is important because we often get hung up on details that don't matter, or in fact are harmful. I think about this with medicine all the time. My colleague Brian White and I, for example, recently published a Point-Counterpoint article where we are argue that popularly used Patient Satisfaction surveys are harmful, primarily because they change physician behavior in a way that leads to 25% higher mortality, more patient expenses, and higher hospitalization rates. The question of "how could it hurt?" with data is that, with the wrong data, it could hurt a lot.
The debate in medicine is whether usage of Big Data better parallels sports analysis, where the Big Data has clearly helped, or is Big Data like the stock market, where people have arrogantly used Data to cause market crashes because they overestimated how well they really understood the consequences of the data, as outlined in Nassim Taleb's wonderful book the Black Swan. I say it's a debate, but it's not really, since the Affordable Care Act (aka Obamacare) has already made that decision, ruling for Big Data.
Which brings me back to a lady on the plane ..... I was thinking all these thoughts as I started to nap. One of my great gifts in life is that I am great at napping on a plane. As the plane lifted off, I put away my IPad and dozed off. The flight attendants bumped my feet a few time (... which was my fault, since they extended into the aisle), but I got in a solid 45 minutes of napping.
I eventually awoke to take a bathroom break. I was still in a sleepy stupor, my mind wandering from thoughts of my girlfriend to thinking about whether leftys have a competitive advantage in Mixed Martial Arts (.... they do), when I noticed that the woman in the seat behind me was passed out.
She was lying on the seat, with a very white face. She had a bit of belly, and looked to be about 3-4 months pregnant. The excellent flight attendant was in the process of getting some oxygen, and it turned out that the guy with the Beats headphones was an army medic.
As a physician, one of my first thoughts was assessing whether I could be helpful. I think for the things I do every day- treating Achilles tendinopathy or herniated disks- I am amongst the best in the world, and there are certain things I know nothing about (pediatric hematology, for example). This was somewhere in between. I deal with patients passing out after injections with some frequency, and I've dealt with athletes passing out.
I gauged the situation, and Russell the Army Medic had things under pretty good control. I tapped the flight attendant on the shoulder, and let her know "this is outside of my main area of expertise, but I am a physician, and I am happy to help in any way I can."
The experience gave me some flashbacks to 2000. I had finished my PhD, so I was technically a "doctor", and was returning to my clinical med school rotations to finish my MD. Because I spent three extra years working on my PhD, many of the interns and residents I worked with on clinical rotations were former students of mine, whom I had taught Anatomy. As a courtesy to me, some of them would refer to me as "Dr Chimes" in front of patients. I appreciated the thought, but I always asked them not to, because I felt that saying the word "Doctor" in front of a patient implied a knowledge base that I simply didn't have then.
It's always been striking to me since how others seem so willing to insert their credentials, even when they are substantially less qualified than I was at that stage of my life. I think I correctly assessed my ignorance back then, but I did have some allied credentials- I had a PhD in a medical field (anatomy), had completed 3 years of medical school, had at that point seen hundreds of patients. There are some non-physicians who certainly can understand more than physicians in certain circumstances - Russell the Army Medic has certainly treated far more gun shot wounds than I have - but I've had so many experiences in the past 10 years where people with essentially no medical training has insisted that my knowledge as a physician was trivial in comparison to their experiences.
One such woman interjected while Russell and I were triaging the downed pregnant lady. She spoke up and said "I too work in the medical field, and ..." and gave her 2 cents. This is always a delicate situation. On the one hand, I want to be open to hearing what she has to say, because she may have some useful information, and I was well aware of the boundaries of my ignorance. On the other hand, I couldn't tell if she just felt like interjecting out of some sense of self-importance. I'd like to think that my comment "I'm a physician, but this is not my main area of expertise" helps create a clear boundary of what my strengths and limitations are. Saying "I too work in the medical field" doesn't really help very much.
Russell manned the oxygen, and I assessed her skin turgor and coloration. She was dehydrated, and had a vaso-vagal episode from coughing. We positioned her legs to give her better blood flow, without letting her uterus put too much pressure on the blood coming back from her legs.
She got better. She needed to lie back for the remainder of the flight, and the rescue team took her out for an IV. She did fine.
As I thought about the episode, it led to a few thoughts:
1. Did it make a difference that I was there? Yes. Russell did a great job in oxygenating her, but she was not getting blood to her brain, and she needed her legs repositioned. He may have figured this out eventually, but I helped keep her from going into shock.
From an emotional standpoint, she made a point of letting me know it made a difference. Once the color returned to her face, I spent 10-15 minutes letting her know what I thought was going on, talking to her about how it impacted her future son, and giving her reassurance. I think the fact it was coming from a physician carried some weight with her, and I think that emotional weight was earned.
2. Did Russell make a difference? Yes. He had a better skill set for the initial triaging, and he and the flight attendant set up the oxygen quickly
3. Did the access to a physician over the phone make a difference? No, but I am glad it was available. The flight attendant asked if she should call, and I told her she should. I thought we had things under control, but I also recognized this was outside my main area of expertise, and I was happy to hear other thoughts. Ultimately, our ability to see what was going on in real time was more relevant to her care. I'm glad we had back up if things got out of hand
4. Did it make a difference that this was Alaska Airlines? I think so. My entire experience on the flight was exceedingly pleasant, and it was always clear the safety and comfort of the patient was the #1 priority. I don't know that the same would have been true on US Airways or United Airlines
5. Did the woman who spoke up and said "I too work in the medical field" help? No. She didn't really do any harm, but she was distracting, and if she wanted to help, it would have been more useful for her to have given parameters of what she knows, and what she was observing. For the most part, she was benign.
HOWEVER, her instincts were horrible. I want to give her the benefit of the doubt, but I think she underweighed the cost of her being a distraction, and overweighed the usefulness of her insight.
It happens to be a particular pet peeve of mine, because when it comes to medical decision making in the "Big Data" era, I think that everyone feels like they should have a voice, and the voice of physicians is just another voice in the crowd.
There is a stereotype of the A-hole physician who is arrogant and doesn't listen to anyone else, but while that stereotype has some elements of truth, I think it is incredibly overstated, and it's severely minimizing the role of physicians in health care. I think that as a group, physicians are better than most in recognizing the boundaries of their knowledge, and that is in part because we are so used to working with content expert in other domains. I know I don't know as much about Neurosurgery as my surgical colleagues, and I know this because I talk to surgeons all the time. My physician patients get this too- they are amongst my best patients in recognizing that I have special knowledge based on my experience.
This woman who spoke up- I don't think she gets it. She was surveying a situation that was attended to by an army medic who has expertise in triaging critical situations, with back up from a physician next to him, and a specialist in flight-related medical issues over the phone.
On another level altogether, I think more to the BIG DATA question, and how this applies to medicine. While I've never been called into duty on a flight before, there's a reason that they ask "Is anyone here a doctor?" They don't ask if there is a Hospital Adminstrator, or an Insurance Adjuster, or a Health Plan Adminstrator, or Electronic Health Record Specialist, or any of the myriad of people who contribute to health systems, but don't actually deliver health care.
Because, the bottom line is that when you are a pregnant woman who collapses on a plane, it's comforting to know that there is a physician there who is rooting for you.
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