What Aviation Taught Me About Becoming a Better Surgeon

Every instrument approach begins with an assumption: you are probably not going to land.

That statement sounds almost backward. After all, the entire purpose of the approach is to arrive safely on the runway. Yet one of the best flight instructors I ever had insisted that I think about it differently. As you descend through the clouds toward minimum altitude, you should expect to execute the missed approach. The runway appearing should come as a surprise. Landing should be the unexpected outcome.

At first, I thought he was simply teaching me how to fly instruments.

It took another decade, thousands of hours in the cockpit, and thousands more in the operating room before I realized he was teaching me something much more valuable. He was teaching me how to think.

The distinction matters because judgment is one of those words we use constantly without ever stopping to define it. We often confuse it with experience, confidence, or intuition. I have gradually come to believe it is none of those things. Judgment is the ability to recognize when reality no longer matches the model you have built in your mind, then having the discipline to abandon that model before your patient or your airplane forces the decision for you.

That is exactly what the missed approach represents. Pilots do not go missed because they lack confidence. They go missed because they refuse to let hope replace reality. Continuing below published minimums without the required visual references because you are convinced the runway must appear another hundred feet lower can be deadly. The missed approach is not a failure of flying. It is disciplined decision-making under uncertainty.

It took me years to realize how closely that philosophy mirrors surgery.

One of the biggest misconceptions about instrument flying is that once the autopilot is engaged, the work is essentially over. In reality, that is when the real work begins.

The airplane is perfectly capable of maintaining altitude, tracking a course, and even flying an instrument approach with remarkable precision. My hands are doing very little. My mind, however, is doing considerably more.

Every few seconds I am scanning engine instruments, fuel flow, weather, terrain, traffic, navigation, air traffic control instructions, aircraft performance, and the instrument approach itself. I am constantly comparing each piece of information with the mental model I have built of the flight. I am not asking whether the airplane is flying. The autopilot can do that remarkably well. I am asking a much different question.

Does everything I am seeing still make sense?

One of the most fascinating aspects of instrument flying is that many of its greatest hazards are invisible. You cannot see the mountain hidden inside the clouds off your left wing. You cannot see the weather deteriorating fifty miles ahead. You cannot see the thin layer of ice that has just begun changing the airplane’s performance. Safe instrument flying depends upon building an accurate mental model of a world you cannot fully see.

The longer I practiced surgery, the more familiar that way of thinking became. Patient deterioration is not always heralded by the one thing everyone notices. Complications usually begin quietly. The physiology no longer matches the diagnosis. A handoff leaves out one important detail. A member of the team notices that something feels wrong but hesitates to speak because the attending appears certain.

Those are our mountains. We simply cannot see them yet.

One of aviation’s greatest contributions to safety was recognizing that technical skill alone does not eliminate human error. Airlines did not develop Crew Resource Management because pilots lacked stick-and-rudder ability. They developed it after discovering that highly skilled crews continued making serious, sometimes fatal, errors. Communication failed. Assumptions went unchallenged. Hierarchy silenced team members who possessed the information that might have prevented disaster.

The solution was not simply to train better pilots.

It was to build better systems.

That realization fundamentally changed the way I think about every operating room I enter.

Not long ago, I was performing what should have been a routine laparoscopic appendectomy. As I positioned the stapler across the base of the appendix, my scrub tech, Michael, hesitated. The anatomy was a little less straightforward than either of us would have liked, and he asked a simple question that made me stop before committing to the staple line.

Nothing dramatic happened afterward, and that is exactly why the moment mattered. I paused, looked again, confirmed the anatomy, adjusted my staple line, and completed the operation uneventfully. The patient recovered exactly as expected. Nobody outside that operating room will ever know anything important happened, but I have come to believe those are the moments that define high-performing teams. Success is often measured not by the complications we manage, but by those we quietly prevent from ever occurring.

Afterward, I joked with Michael that he was no longer allowed to speak during my cases since he was slowing me down. We both laughed because he knew I meant exactly the opposite.

I do not want an operating room where everyone waits for the surgeon to have every answer.

I want a cockpit.

The same flight instructor who taught me to expect the missed approach also happened to be an engineer. Looking back, I don’t think that was a coincidence. He rarely answered my questions by telling me what procedure to follow. Instead, he explained why the airplane behaved the way it did. We talked about aerodynamics, systems, and physics. He explained why a wing stalls, why structural limitations exist, why an instrument approach is designed the way it is, and why the airplane communicates information to the pilot in a particular sequence.

That way of thinking resonated with me because it was how I had always approached problems. Even in medicine, I found myself asking why long before I asked what. Once I understood the underlying principles, the countless facts of medicine stopped feeling like isolated pieces of information and became the logical consequence of understanding how the system worked.

Early in practice, I relied on algorithms, guidelines, and protocols, just as every young surgeon should. They provide a safe framework within which experience develops. Over time, however, patients stop reading the textbook. The physiology no longer matches the imaging. Laboratory values fail to fit the clinical picture. Operations that once seemed inevitable become unnecessary, while patients who appeared reassuring only hours earlier suddenly require immediate intervention.

Those are the moments when algorithms reach their limits. Medicine has become increasingly protocol-driven, and I think that has helped make patient care safer.

But no protocol can anticipate every clinical circumstance. Eventually every surgeon encounters a patient who refuses to follow the textbook, and in those moments the surgeon must rely on an understanding of the system itself. Looking back, I think that is where engineering influenced me most. It taught me that when the recipe no longer fits the patient, understanding the system matters more than memorizing the recipe.

There is one more lesson aviation taught me, and in many ways, it has become the most important one.

A few years ago, I found myself navigating one of the darkest periods of my life. Professionally, everything appeared exactly as it always had. I was taking trauma call, operating, seeing patients, flying, and carrying the responsibilities that come with being a surgeon. From the outside, I doubt many people noticed anything different. I convinced myself that whatever was happening outside the hospital could remain there because my patients deserved nothing less than my complete attention.

Looking back, I no longer believe that is entirely possible.

The realization did not come because I suddenly forgot how to operate or because I began making reckless decisions. It came because I eventually recognized something much more subtle. My thinking had changed. Decisions that had once felt clear required more deliberate effort. I became more anchored to my first impressions and less naturally curious than I had always been. The change happened so gradually that I never recognized it while I was living through it.

There is one patient from that period whom I still think about. I made a decision that, looking back, I believe was influenced by where I was mentally rather than by the level of judgment I had come to expect from myself. I cannot change that decision, and I cannot know with certainty whether the outcome would have been different.

What I do know is that it still haunts me. Not because I lacked the technical ability to care for that patient, but because I had failed to recognize that I was part of the system making the decision.

Only later did I appreciate what aviation had been teaching me all along. In aviation, the pilot is never viewed as standing outside the system. Fatigue, stress, illness, distraction, and emotional burden are all recognized as operational realities because they directly influence judgment. Somehow, despite believing so deeply in systems thinking, I had spent years evaluating every variable surrounding my patient while assuming that I was not one of those variables.

I was wrong. The surgeon is part of the system.

For years, I thought wisdom simply came from experience. I no longer believe that. Experience, by itself, teaches very little. Wisdom comes from continually refining the mental models through which we interpret the world.

I see that every time my trauma pager goes off. Before I ever walk into the trauma bay, I begin constructing a picture in my mind from the mechanism of injury, the prehospital report, the vital signs, and a few brief lines of text on a pager. Sometimes that picture is remarkably accurate. Sometimes it is completely wrong. Either way, it serves an important purpose. It gives me a starting point from which to recognize, as quickly as possible, when reality is trying to tell me something different.

Instrument flying demands exactly the same discipline. Long before reaching the runway, I have already built a mental picture of where the airplane should be, what I expect the instruments to show, and what should happen next. The safest pilots are not the ones whose predictions are always correct. They are the ones who recognize earliest when those predictions no longer fit reality.

I have come to view wisdom as nothing less than that process repeated over thousands of flights and thousands of patients. We build a mental model, compare it with reality, refine it, and begin again. Over time, judgment becomes less about finding the right answer and more about recognizing, without ego, when it is time to let go of the wrong one.

Looking back, I no longer believe the most valuable lessons aviation taught me were about flying airplanes. They were lessons about judgment, humility, and the discipline to continually question my own assumptions. Those lessons have shaped the surgeon I have become far more than any textbook, operation, or technical achievement ever could.

For years I thought my instructor was teaching me how to fly.

Only much later did I realize he was teaching me how to become a better surgeon.

Disclaimer

The thoughts and opinions expressed in this article are solely those of the author and do not necessarily reflect those of the ACS.

Dr. Ronen Elefant is the trauma medical director and chief of acute care surgery at University of Pittsburgh Medical Center Williamsport. He is also the founder and CEO of ACES National Surgical Team, a direct surgical care organization focused on improving access, coordination, and transparency in surgery. An ATP-rated pilot with more than 25 years of aviation experience, Dr. Elefant brings lessons from the cockpit, including preparation, standardization, communication, and disciplined decision-making, to surgical practice and healthcare leadership.

Bibliography

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