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Am Fam Physician. 1999;60(5):1576-1579

Often, I tell my friends and classmates that anything I do somehow relates to either flying or medicine. Before I decided to become a family physician, I enjoyed a minor career as an Army pilot. As I pursue my medical career, I am often surprised at how many situations relate to both. There was at least one noteworthy incident in flight school that decidedly shaped the way I practice medicine.

Learning to fly helicopters for the U.S. Army is definitely an adventure. For nearly a year, the thump of rotor blades and the smell of jet fuel permeate every aspect of life for the student pilot. Throughout training, the omniscient teacher and protector of the student is the instructor pilot. Affectionately known as “IPs,” these brave souls guide the novices through training and ultimately to their wings. IPs are chosen for their experience and skill. Patience varies somewhat.

One of my first IPs was quite amazing. I believed there was no situation or attitude I could put the aircraft into from which he could not easily and gracefully recover.

As a novice, I frequently tested his reflexes, skills and patience. His competence gave me the confidence to explore the limits of the helicopter's performance. In addition to routine training in take-offs, landings and hovering, emergency procedures were something we practiced during every flight. Auto-rotations—landing the helicopter after a simulated engine failure—were perhaps the most dangerous. At any time, the IP might cut the engine back to idle.

The student-pilot was expected to react instantly to the loss of power, adjust the attitude of the aircraft and find a suitable landing site. At the altitudes we flew at, the ground was rarely more than 20 seconds away. The controlled fall would keep the rotor blades spinning, allowing for braking with a flare of the aircraft and some cushioning at landing. If near a practice landing field, the IP would get on the controls and “back up” the student pilot to land without power. If anywhere else, the IP would restore power by a certain altitude and recover the aircraft.

One afternoon, while I was flying nowhere in particular, my IP cut power and announced: “Simulated engine failure!” I adjusted the controls while searching for a place to land. We were over some farms; in my mind I knew we would not be touching down. As we plummeted to the earth, I fully expected the IP to recover the aircraft. He did not. When we passed the point of recovery, I fully expected him to back me up on the controls. He did not. Seconds later, we stumbled to a stop in the cow pasture I had selected. My heart still pounding, I looked over at him in disbelief. What kind of test was this?

After fiddling with the map and pouring a cap of coffee from his thermos, he finally looked at me. While I cannot remember exactly what he said, the essence remains: “James, you always fly like I'm sitting next to you and my sole responsibility is to rescue the aircraft once something goes awry,” he said. “One day I'm going to be tired or daydreaming or hungover or just plain wrong. Your total faith in me will have been misplaced and we will die. Simple as that. Regardless of who may be in the cockpit with you, be the pilot. Always.”

I filed this message in the back of my mind during medical school. As third year began, I felt as if I were only playing doctor and my input did not really count. What did I know? What could I add? The student-physician occupies a unique position. While high expectations are placed on us to know our patients, sometimes the responsibilities we are given seem contrived. We cannot make medical decisions or prescribe treatment. Moreover, when physicians countersign our orders and notes, they have assumed all responsibility for what we have written.

Recognizing this, there have been times when I have relied on my interns, residents and attendings inappropriately. I have counted on them to double-check doses and correct them when I have miscalculated. I have made my decisions always knowing they were sitting beside me, ready to rescue.

The instructor pilot I described above placed our lives on the line to demonstrate a point. While he was totally responsible for the safety of the aircraft and its passengers, we would have been just as dead had I failed. His decision was calculated, designed to show me the responsibility I held as a student pilot. I would not expect an attending or resident to do the same with a patient's health. Often, however, this is exactly what happens.

There was a rotation this year in which the attending wanted my note completed and the prescriptions written before I presented the patient. The review of my work was often a signature on the scripts and a wave on the way out, directly illustrating the key role I held as a student physician. Obviously, what I chose to mention in my presentation would affect the course of the patient's treatment. The magnitude of my responsibility in this situation was clear. In other rotations, I began to recognize situations in which the significance of my role was less overt but perhaps more critical. Reporting daily labs may seem trivial, but they are as important to the attending as weather updates are to the pilot-in-command.

Somehow an attitude shift took place. Instead of playing the doctor I started becoming the doctor. I began taking much greater care in the work-up and consideration in the treatment. I set a mental goal: to behave as if I would be the only one who saw the patient. Sometimes, it's difficult to keep this focus when it seems that every order I write gets changed. However, I must consider the interns, residents and attendings with whom I work and how on any day one of them may be tired or daydreaming or hungover or just plain wrong. I may never know when my input is critical or when the decisions I make as a student physician are the ones that count.

If my instructor pilot ever decided to become a physician, I am sure he would tell his students: “Be the doctor. Always.”

This quarterly department features essays written by medical students and family practice residents. Contributing editors are Amy Crawford-Faucher, M.D., a family practice resident at the Fairfax (Va.) Family Practice Residency Program, Sumi Makkar, M.D., resident representative to the Family Practice Editorial Board and Terrence J. Joyce, student representative to the editorial board.

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