I spent four years as an Air Force flight surgeon before I finished surgery residency, and the safety culture I learned on the flight line still shapes how I run an operating room. Aviation learned long ago that the smartest person in the room is sometimes the most dangerous one. Surgery is learning the same lesson, but we are not there yet.
My path to becoming a surgeon was unusual. I did not go straight from medical school into residency. After a surgical internship at the University of Virginia, I spent four years on active duty in the United States Air Force as a flight surgeon. In that role I took care of pilots and aircrew, served on aircraft mishap investigation boards, and occasionally flew in the DSO (Defensive Systems Operator) seat of the supersonic B-1B bomber. By the time I returned to surgical training in 2000, I had absorbed a culture the operating room is only now starting to catch up to. I have been a pediatric surgeon for the nineteen years since, first at Nicklaus Children’s in Miami and now at HCA Florida Lawnwood. In that time I have watched our specialty borrow heavily from aviation. The WHO Surgical Safety Checklist descends from the preflight checklist. The time-out is a version of the cockpit briefing. Hospital team training comes from Crew Resource Management, which reshaped commercial aviation in the 1980s. We did not invent any of this. We are catching up.
The checklist is not the point. The culture behind it is.
If this sounds familiar, it is because Atul Gawande made the case more than a decade ago. His 2009 book, The Checklist Manifesto, took the preflight checklist and showed surgery what it could do with one, and the WHO checklist he helped build is now used in operating rooms around the world. I owe him the debt every surgeon does. But the checklist was the easy part to copy. The hard part is the culture that makes a checklist mean something, and that culture is what I learned on the flight line, years before I learned to operate.
A preflight checklist looks trivial on paper. Flaps set, trim set, fuel confirmed. The checklist is not for ignorant pilots. It is for tired, distracted, overconfident, or rushed pilots, which is to say all pilots on some days. The operating room is no different. Antibiotics within the hour, correct site marked, blood checked. Of course the surgeon knows. The checklist is a defense against the day when knowing is not enough, and it works only when the culture around it works. If the time-out is rushed and mumbled, it protects no one. If the most junior nurse in the room can stop the process to flag something, it protects a great deal.
Authority gradient kills people
The most important thing aviation safety has given medicine is the idea of the authority gradient, and the harm a steep one does.
On March 27, 1977, two Boeing 747s collided on the runway at Tenerife, killing 583 people. Garbled radio transmissions left the KLM captain, among the most respected pilots in the company, convinced he had been cleared for takeoff when another plane was still on the runway. Fog made it impossible for him or the controllers in the tower to see the pending disaster. His first officer believed the clearance had not been given. He said something, but he said it softly, and when the captain pushed the throttles forward, he did not push back. It remains the deadliest accident in aviation history. The fog and the radio calls set the stage, but the disaster happened because a junior officer could not bring himself to challenge a senior one.
Anyone who has worked in surgery long enough has seen the same thing. A senior surgeon makes a call a junior member of the team doubts, and the doubt goes unspoken. Sometimes the surgeon is right and sometimes wrong. The problem is not the call. The problem is the silence.
One of the reasons aircrew use call signs is to remove rank from the cockpit. I have flown missions where the aircraft commander was a junior officer and a full-bird colonel was in the co-pilot seat. Despite the difference in rank, on that flight, in that cockpit, the lieutenant was in charge. I bring this to the OR by using my first name when we do introductions. I will say to the OR staff, “Hey, I was here operating until 1 a.m., and I am tired. Please stop me and say something if you see me doing something that looks stupid or wrong.”
Blame culture and just culture
The last lesson, and maybe the most important, is the difference between a blame culture and a just culture. The National Transportation Safety Board investigates accidents in public and publishes findings the whole industry reads. Pilots can self-report errors without fear of losing their certificate in most cases. The point is not to punish. It is to learn.
I am not writing about this from the outside. In the Air Force I trained as an aircraft mishap investigator, and I served as the human factors expert on two Class A mishap boards, the most serious category, the ones that involve a death, a permanent disabling injury, or property damage of more than $2.5 million. Human factors is the part of the investigation that asks not what the metal did but what the people did, and why it made sense to them at the time. We were not there to find someone to blame. We were there to trace the chain of small, reasonable-looking decisions that ended in wreckage, so the next crew would not repeat it. I have carried that question into every operating room since. When something goes wrong, the useful question is rarely who is at fault. It is what made the error easy to make.
Medicine has often done the opposite. Morbidity and mortality conferences have improved, but a near miss still goes unreported when the person who saw it fears what will happen to them or to a colleague. A just culture separates honest error from reckless conduct and treats them differently. Without that, we never see the near misses, and the near misses are where the lessons live.
What I take from all of this
I operate on children, where the margin for error is small and the cost of a bad outcome is enormous. When I walk into the operating room, I do not think of myself as the captain of the ship. I think of myself as the senior member of a crew that includes anesthesia, the scrub and circulating nurses, and often a resident, any of whom may see something I do not. My job is to make it easy for them to say so. Aviation figured that out after enough crashes. Surgery is figuring it out now. The operating rooms that move fastest on this will be the ones that take fewer children to places they did not need to go.
Colin G. Knight is a board-certified pediatric surgeon practicing on the Treasure Coast of Florida at HCA Florida Lawnwood Hospital. He is a clinical assistant professor of surgery at the Florida State University College of Medicine and at the Florida International University Herbert Wertheim College of Medicine.
He earned his undergraduate degree at Yale University and his medical degree at the University of Virginia. Before his surgical training, he served four years on active duty in the United States Air Force as a flight surgeon, work that shaped his interest in operating-room safety. He completed his general surgery residency at Allegheny General Hospital and his pediatric surgery fellowship at Children’s Hospital of Michigan.
His research spans minimally invasive and robotic pediatric surgery as well as the management of pediatric appendicitis, with work appearing in the Journal of Pediatric Surgery, the Journal of Laparoendoscopic and Advanced Surgical Techniques, and Archives of Surgery. He can be found at ped-surg.com, and shares updates on LinkedIn, Instagram, and X.
