Flying lessons

Flying used to be such an adventure, and people actually got dressed up if they were traveling by air. There was a mutual understanding among passengers and cabin crew that we were a favored few and warranted special attention, which in turn engendered proper behavior from all parties. Being addressed as “sir” by flight attendants (“ma’am” disappeared a while ago) is the only thing that remains from the golden days of flying; the accompanying smile was seen as redundant long ago. 

But while the excitement and glamour of air travel sadly has disappeared, we must be grateful that safety (and efficiency, to a lesser extent) seems to have steadily improved. I hate it when others quote US rather than Canadian statistics, but I’m going to do it anyway because the numbers are really very impressive: in 2006, according to the US National Transportation Safety Board, there were 11200000 airline departures in the United States and a measly two fatal accidents with a loss of 49 lives. 

It was the highest number of airline departures ever recorded, but the relative fatality rate remained at the same level it had been for 12 years (except for 2002, when they actually had no fatalities at all). 

I also hate it when uninvolved people become armchair critics, but here goes anyway. The airline industry has done a terrific job of providing safe and efficient transportation for increasing numbers of passengers. Sitting in a passenger aircraft that belongs to an established airline and that is flying on a scheduled route is a ridiculously safe place to be. If airlines can make such a safe environment, why can’t hospitals? You probably remember the article published in CMAJ in 2004 (Baker RG, Norton PG, Flintoft V, et al. CMAJ 2004;170:1678-86) that estimated that about 185000 Canadians annually experience an adverse event while in hospital, and that close to 70000 of these events are pre­ventable. 

The authors estimated that between 9000 and 24000 of the deaths associated with these adverse events (medical or surgical) were potentially preventable. Granted, hospitals and aircraft are very different environments; by and large, hospitals are filled with sick people, and passenger aircraft are full of (generally) healthy people. Nevertheless, the number of people who die in Canadian hospitals as a result of error is inexcusable, no matter how the statistics are presented. Medical error is arguably the next great medical frontier.

So many factors can contribute to medical error that concentrating on a single factor is unlikely to have a significant effect on hospital safety. How­ever, comparing hospital procedures and conventions with airline pro­cedures gives some useful contrasts. For example, aircrew have strict rules to follow regarding how many hours they may fly without rest, and professional pilots acknowledge far more readily than medical professionals that if they are tired they don’t perform effectively during critical times.  

Medical and surgical hierarchies are becoming flatter, but it still takes nerve for a nurse or junior resident to question the judgment of a senior consultant, and in many cases it simply does not happen. Cockpit procedures, on the other hand, are becoming in­creasingly non-hierarchical. If a flight attendant smells smoke, the captain lands the aircraft and then asks questions.

However, not all medical error occurs in the operating room or in the ICU at 3:00 a.m. Errors can involve mistakes in medication doses, lapses in sterilization protocols—the list is almost endless. The problem is that error is often difficult to discuss in medicine. We are all perfectionists whose overriding goal is to make our patients better and send them home, and to accept personal responsibility for error is difficult for all of us and im­possible for some. Aircrew are trained to deal with errors proactively and non-punitively, and the results speak for themselves. We could learn from their procedures.

But, for physicians, flying is not always safe. Some years ago I was on a red-eye flight when an anxious call for a doctor came over the PA system. I waited for the second call (you see, I’m a gynecologist, not a real doctor) and then offered my services to the flight attendants. As I got up to attend to the afflicted passenger, the man sitting across the aisle from me tweaked my arm.

“I’m a lawyer” he said. “I’ll be here if you need me.”

Timothy C. Rowe, MBBS, FRCSC, FRCOG. Flying lessons. BCMJ, Vol. 50, No. 4, May, 2008, Page(s) 181 - Editorials.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.

For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit

BCMJ Guidelines for Authors

Leave a Reply