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Changing our culture: adopting the military aviation safety system
  1. Charles William Kerber
  1. Department of Radiology and Neurosurgery, UCSD Medical Center, San Diego, California, USA
  1. Correspondence to Dr Charles William Kerber, Department of Radiology and Neurosurgery, UCSD Medical Center, 4094 Fourth Avenue, Suite 200, San Diego, CA 92103-0834, USA; kaos{at}

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A call to arms

Change is in the air. Problems are brewing throughout the profession of medicine, but especially in our surgical practices. Reimbursements are down. People with no experience practicing medicine are, more and more, deciding what standards of practice will be. ‘Metrics’—developed particularly by the federal government—are being created to judge us: to evaluate our competence, our adverse event rate and even to decide upon whether an adverse event constitutes criminal behavior. Bureaucrats will justify their judgments because complication indices —for example, infection rates, operating on the wrong site, medication errors and, particular for our specialty, errors of judgment—have remained painfully constant over the years.1–8

Why should not we—the physician/surgeons of our specialty—again be the leaders? I mean leaders in changing our culture. The continuing and preventable errors rate, which has not significantly changed over the last decades, demands a change, a change that must come from us before it is imposed upon us by an uncaring administration or federal bureaucracy. Ask yourself: how often has the federal government, once accruing power, ever relinquished it?

As background for this leadership—our leadership—premise, I invite you to go back to the early papers of the 1960s and early 1970s, papers written before there were any national societies or even a recognized specialty dedicated to our work. You will likely realize that we were the ones who developed what eventually came to be called ‘minimally invasive surgery’. We also performed the first image-guided surgery. Was our work not the origin of robotic surgery? Look at the early papers by Amundsen et al,9 Boulos et al,10 Doppman et al,11 Newton et al,12 Hillal et al13 and Djinjian et al.14

Now we are living through another time of great change. This time, though, the federal …

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  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • i I will be the first to admit that this is not a scientifically valid way to compare the two and the calculation is probably close to junk science, but it is an interesting way to look at the two, isn't it?

  • ii Lest my Air Force colleagues take umbrage, exactly the same techniques were developed and adopted by the USAF.

  • iii Aircraft accidents almost always begin with an adverse event poorly handled. An example: It is night, and the right engine begins to run rough. This causes an appropriate adrenaline release in the pilot and, in his excitement, he decides to shut down the engine, but mistakenly shuts down the left engine. As he realizes his mistake, the right one fails completely (I'm not making this up), and he is now in a glider. He becomes further distracted discussing his plight with ground controllers (who actually have no ability to help him), thus failing in his first duty to fly the airplane (if he keeps his airspeed at a certain number, he can safely glide into a rough but survivable landing). But, distracted, he does not notice that his airspeed is decreasing. Suddenly the airplane stalls, then spins into the ground. A fatal sequence, a sequence of events called the ‘accident cascade’. The first judgment error compounds into other judgment errors; the crash results. Analyzed retrospectively, it is obvious that, at some point, the crash became inevitable and, analyzing our adverse events, the accident cascade can be recognized. Critically, if we can recognize that we are in the midst of an accident cascade and interrupt it, we will likely avoid the adverse event.

  • iv Mission creep occurs when someone in control decides to press on beyond the stated goal. I didn't notice that second small aneurysm and the one that bled was really easy to treat, and the next patient won't be ready for another hour and, yes, I admit I didn't talk to the patient about treating any other aneurysm, but she'll probably thank me later … You can guess the rest of the story. On the one hand, we all know of times when it has been prudent or even necessary to press beyond the original goal. “And I got away with it”, we say. But that brilliant outcome may not be as common as we would like to believe. Selective memory is something we all have.

  • v Pilots euphemistically refer to this state as being in a ‘dynamic environment’. This usually means they are deep in enemy territory, a missile system radar is tracking them, and their threat sensors are blinking red. When they say the words ‘extremely dynamic environment’, missiles are actually in the air seeking them. When we make a tiny catheter adjustment, then see it suddenly jump through the aneurysm dome into the subarachnoid space, and the anesthesiologist says, “What did you just do?” we find ourselves in exactly the same extremely dynamic environment (and with the same degree of adrenal response that a pilot feels).

  • vi Pilots are not frightened by threats of imprisonment or monetary fines but they are terrified when somebody says, “I'm going to take your wings”.

  • vii Approach Magazine (

  • viii Phantom Over Viet Nam, his elegantly written military aviation classic. Highly recommended. Try Amazon as the book is out of print.

  • ix Flamboyant is another question. I once knew a thoracic surgeon who wore a black cape lined with red satin and carried an ebony silver-tipped walking stick.

  • x The Marines sends each officer candidate to a 6-month school to learn these skills. You can get a good grounding in the principles by referring to the many articles on the subject in the Marine Corps Gazette (

  • xi If you really want to understand resistance, I can do no better than to recommend Stephen Pressfield's book The War of Art.