Space missions are enormously difficult to conduct. Despite the effort that goes into flight preparation, very few missions have been flown perfectly. Accordingly, space agencies have developed operational and management approaches to address the risks inherent in our business.
I wonder if practices and tools from the space program (as well as painful lessons-learned) could be constructively applied and bring benefit to other societal undertakings. The Canadian healthcare system comes to mind. Healthcare delivery in our country is in crisis. Long wait times for appointments, under-staffing of clinics, and overcrowding of emergency rooms have become the unfortunate norm in our strained system.
While I am not a policy expert, I am a big fan of the doctors and allied professionals who oversee our health and mental wellness. I care deeply about the universality and excellence of Canadian healthcare. Accordingly, I wrote the following op-ed for the Globe and Mail newspaper. I suggest root cause failure analysis as an approach from spaceflight that could be used to identify the source of our nation’s primary healthcare crisis.
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When a spaceflight mishap occurs, a problem-diagnosis framework known as Root Cause Failure Analysis is utilized to learn why the mishap occurred. In this regard, I think often of my seven astronaut colleagues who died on this day – Feb. 1 – in the Columbia accident of 2003.
NASA grounded its space shuttle fleet while an investigation board scrutinized the cause of the mishap. After months of deliberation, the board established the proximate cause of the accident – a piece of foam insulation had fallen off the shuttle’s external tank shortly after launch and damaged the leading edge of the left wing. The resulting breach in the wing doomed the crew during Columbia’s fiery re-entry through the atmosphere at the end of the flight.
The STS-107 Columbia crew. Credit NASA
Loose foam, however, was not the underlying cause of this tragedy. The investigation board learned that, in the months leading up to the launch of Columbia, several engineers had expressed concern to senior managers about other incidents of shedding foam during prior flights. Working under schedule pressures, shuttle managers had swept aside these clear warning signs from expert engineers.
The investigation board accordingly attributed the root cause of the accident to a faulty management culture at NASA, findings that shook the space agency to its core. A humbled agency took corrective actions over the next two years not only to eliminate foam shedding, but also to revamp management processes and organizational culture with safety of flight as the highest priority. That shift may well have prevented other tragedies from different causes.
As a physician and retired astronaut, I share the concern of countless Canadians regarding the current crisis in our health care systems. Most troubling to me is that six million Canadians do not have a family doctor, with little hope of finding one soon.
Could it be that health care problems would benefit from the analytical discipline used not only by NASA, but by many quality-conscious companies and safety-focused hospitals? Could it be that we have been addressing proximate causes of accessibility rather than the root cause?
For instance, the Ontario government recently announced that the province will limit admission to its medical schools to students who reside within the province. The government’s hope is that by restricting medical school enrolment to Ontario students, it can boost the number of practising physicians in the province. As it turns out, most medical students in Ontario are already Ontario residents. Other provinces have similar policies, and they too are facing challenges with primary care services. This doesn’t seem to be addressing any root causes.
Indeed, I view this policy as isolationist and fraught with unintended negative consequences. My class of 160 budding physicians at McGill University included 25 students from outside of Quebec (and, I might note, another 25 from outside of Canada). Training with this eclectic cohort exposed me to perspectives from other regions, histories and backgrounds. In an era when Canadians are facing unprecedented challenges in our relationship with our large neighbour to the south, isn’t such exposure a good way to build a medical Team Canada and perhaps ensure that medical graduates at most move to a new province rather than to the U.S.?
More recently, the province of Quebec announced that it will require physicians newly graduated from its medical schools to remain and practise in the province. Directing physicians where and how to practice is coercion and will aggravate the “us vs. them” dynamic between provincial health officialdom and physicians. For regional medical schools with a unique mandate to serve a specific sector of the Canadian population, it makes sense to recruit regional students. For medical schools in Canada that are clearly national resources and also play a major role in health care research and academia on the world stage, it does not.
All this takes me back to NASA’s tragic accident. Proximate causes and technical faults are rarely the sole explanations for system failures. In many cases, a flawed organizational culture is at the heart of the problem, and it’s hard to overlook many indicators that suggest the root cause of Canada’s physician shortage is also organizational in origin.
Medical practitioners are burning out at a disconcerting rate. While our health care system collapses, family physicians are doing their best to deliver care but are on the verge of collapse themselves. It is a challenging, stressful and lonely job. I can understand why fewer medical school graduates are opting for family medicine careers, why doctors avoid setting up practices in certain regions of our country, and why established physicians are closing their practices to retire early. It has little to do with a medical student’s province-of-origin or a physician’s resiliency skills. The intolerable working conditions of family physicians – heavy workload, lack of clinical support, inflexible payment modalities that do not support multi-professional practices and endless administrative burdens – explain why provinces struggle to attract and retain practitioners.
On this anniversary of the Columbia accident, I remember the crew that we lost. In the same way that space agencies rely on and support astronaut crews to accomplish ambitious mission objectives, the delivery of health care in Canada rests heavily on the shoulders of our family physicians. In this regard, I firmly believe that Canada urgently needs a rigorous and methodical inquiry that goes beyond first- and second-order factors and discerns the actual root causes of our family physician shortage. Only then can organizational changes be made and resources deployed to support measures that are truly corrective, rather than performative and potentially wasteful or even harmful.
Credit: Harvard Business Review
Contributed to The Globe and Mail; Published 1 February 2025
