Fast Jets for RFS

fighter pilot rinzler rfsPrior to residency, I had the privilege to work as a flight surgeon in the United States Air Force.

As the medical officer for a squadron of F-15 Eagles, I learned a great deal about leadership and professionalism. In a recent article for the JACR®, I summarized some of the key methodologies from this elite community. Here, I’ve focused these lessons on some of the challenges we face as radiology residents.


Fighter pilots acquire their basic technical skills over two years of postgraduate training. Once assigned to a combat squadron, they repeat training cycles focusing on leadership and strategy. What distinguishes an experienced commander from a junior pilot is their ability to understand tactical objectives and synthesize data within the larger context of the mission. Similarly, residents must learn to be more than just image interpreters. We must be able to place imaging findings within the larger context of patient care. Simple technical proficiency is not enough: to master our field, we must train to think tactically.

Checklists are ubiquitous in aviation, and are already in use throughout health care. Properly implemented checklists can improve patient safety and workplace efficiency. There are multiple areas in our department that are amenable to checklist use, including fluoroscopy dose reduction, contrast reaction management, CT protocol selection, and MRI safety. Checklists integrated into structured reports have been proven to reduce the incidence of missed findings and reduce textual dictation errors. Checklists are particularly valuable as a trainee, as they can function as reminders when standard operating procedures are still unfamiliar.

Before every flight, pilots participate in a comprehensive review of the upcoming mission. Possible sources of mission failure are identified, and contingency plans are developed so that they can be deployed without hesitation. There is a prebrief before every flight, even for training sorties that have been performed hundreds of times before. The prebrief concept can be applied to any task, even those as routine as case dictation. Consciously examining our strengths and limitations before a task begins allows us to anticipate sources of error and install safeguards to avoid them. By treating even minor repetitive tasks with the same degree of care as larger ones we can avoid complacency related oversights.

Fighter pilots are never alone. They fly in formation, and should someone fail to execute their objectives a wingman/woman will be ready to move into their position. Teamwork is also a matter of survival: air traffic controllers, aircraft maintainers, and other aircrew ensure that elements beyond a pilot’s control do not contribute to a mishap. Residency is no different; our peers can contribute to our success. Cultivating teamwork ensures that we have backup when contingencies arise. In addition, co-residents are an invaluable resource to develop our professional skills. Sharing interesting cases, mentoring procedural techniques, and comparing study sources are just a few examples of how we can help each other become better radiologists.

Safety is already a priority in our departments. As residents, we often have more patient contact than our attending physicians. In many cases, we are the primary operators for invasive procedures; both patients and staff rely on us to prevent medical errors. In aviation, a training system known as Crew Resource Management (CRM) has been a key factor in reducing critical but easily avoidable errors. These techniques have been widely endorsed throughout the medical community, including the Joint Commission. Critical components include two-way communication, cross-checking (using multiple data sources to assess key indicators), standardized operating procedures, and proactive error identification. The heart of CRM is effective communication. Improving patient safety requires commitment at all levels of leadership so that when valid concerns are raised they are not brushed aside and ignored.

None of these systems would be effective without broad acceptance across the fighter pilot community. These methodologies are introduced during pilot training, but acceptance is sustained by fighter pilots’ unique culture. Within this community there is a universal expectation of excellence that drives a demand for continuous performance improvement. Despite a reputation as ego-driven individuals, fighter pilots place great importance on conformity to group standards.

One of the events that reinforces this social structure is “roll call,” a social gathering that highlights the best and worst of that week’s flying. This takes place in the squadron bar. Roll call is a non-punitive forum where mistakes are shared openly. Victories, even small ones, are celebrated. Roll call is a cultural tool. It builds open communication, stresses safety, and emphasizes the importance of mission over individual success. 

Developing a similar culture of excellence in our programs first requires that our leaders model the behaviors we wish to establish. Small changes can create big effects: the culture changing concepts of CRM originated from a single incident, the crash of United Airlines Flight 173. Even the smartest, most skilled radiologists make mistakes. By acknowledging this, we remove its stigma, and can instead focus on developing processes to ensure we do not repeat them. Though we may not be ready for a bar and roll call, as the next generation of radiologists, our collective attitudes and behavior outside the reading room will define our specialty’s evolution.

Ultimately, though individually skilled, it is fighter pilots’ systematic pursuit of perfection that has secured their elite reputation. This rigorous practice would not be sustainable without its cultural foundation. Though there are differences in our professions, by adopting proven techniques from our most elite aviators, we can address some of the key challenges of radiology’s future.

 By Elliot Rinzler, MD, is the chief radiology resident at Eastern Virginia Medical School

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