Aviation vs Emergency Medicine 4 – Combat vs Commercial vs ED | Resus Room Management

Aviation vs Emergency Medicine 4 – Combat vs Commercial vs ED

I’m currently at the SMACCGold conference, and there is an exciting amount of discussion about human factors in resuscitation. Karim Brohi showed a great video of the resuscitation of a critically injured motorcyclist in the UK, which was a great demonstration that the best resuscitations are quiet, calm and co-ordinated.  And we were lucky enough to see Deniz Tek, ex-Radiobirdman frontman/military pilot, and current practicing Emergency Physician. He spoke about the analogies between skills required in ED resususcitations and combat aviation.  This was a popular session, and let’s face it, who doesn’t like Top Gun (and Radiobirdman)?

However I’m still skeptical about the comparisons being drawn between aviation and emergency medicine, in particular the combat aviation model.  I have a rudimentary knowledge of aviation training from having friends who are commercial and military pilots. What strikes me about this, apart from the obvious workplace differences of the cockpit vs the resus room, is the selection processes, training and assessment, as well as the context of the overall culture of the industry, with standardised language, clear hierarchies and chains of command, and the strong culture of teamwork (especially in the military), which is totally lacking in healthcare.

I’m also disturbed by the use of language like “fight”, “own” and “combat” that some people are attaching to resus care. To me there is a strong undercurrent of testosterone driven machismo in this language, which I think is really unhelpful in an industry where at least 50% of our workforce is female.  Let’s face it, most doctors (and nurses) are lovers not fighters.  There is also a huge difference in the underlying culture of combat aviation compared to medicine: they are training to not hesitate to kill another person when under extreme physical and psychological stress, with active threats to their own life, and the lives of potentially thousands of colleagues on the line (for example an aircraft carrier) if they falter.  If I falter, one patient dies, I and all of my colleagues andI go home at the end the of the shift.

So here’s a video of an Airbus A-380, the world’s largest passenger jet, coming in to land at San Francisco. Compare this to your usual in-charge shift in a tertiary ED.

I don’t know about you, but I can’t see a single similarity between this and what I do at work. Not one. The environment is incredibly quiet. There is zero interruption. There is a small, static group of people. The language is short, sharp and concise using standardised terminology. There are clear operating procedures being followed. And everyone’s polite to each other! The pilot’s have also spent 100% of their shift in the single room of the cockpit, with the same equipment that they have trained with in multi-million dollar simulators and flown with for hundreds of hours, which doesn’t change. In ED, we are constantly interrupted, in multiple ways, every few minutes, for 10 hours straight. Our environment is insanely noisy. We have to work in resus, cubicles, corridors, fast-track, the waiting room, the ambulance bay, helipad, procedure rooms, and in some hospitals we have to go to codes on the wards and in theatre. Equipment varies hugely between all of these areas, and is frequently not re-stocked, requiring us to go hunting around, rummaging through trolleys and cupboards to find the basics that we need to do our job. We frequently have to improvise, or “Macgyver” solutions from equipment, using it for purposes it was not intended for. And we have to do this with a constantly fluctuating, very large group of staff.

So this got me thinking about combat aviation, which is being held up as a better model, as commercial aviation is clearly has little or no relevance to what we do.  I wanted to know about the training military pilots undergo, and how this translates to their practice. So I found this great video from the New Zealand Air Force. It’s pretty simplistic, and New Zealand is not renowned for it’s high-level military expertise, but I think you’ll see that even in a low-level military operation, the differences to ED training and work are striking.

Points I took away from this are:

Selection Process
Combat Aviation
Screening includes aptitude tests, interviews, selection board interviews, psychologists heavily involved.  Trainees are specifically screened and selected for leadership, a proactive attitude and positive approaches to problem solving

Emergency Medicine
No real screening for entering ED training. Anyone can sign up. No formal criteria are used to select candidates. Personality pathology is commonplace.

Leadership training
Combat Aviation
Comprehensive program of leadership, management and teamwork training

Emergency Medicine
Absolutely zero training in leadership, management or teamwork

Team-mate Familiarity
Combat Aviation
Trainees live, eat, study, train, socialise and work together for months on end.

Emergency Medicine
Team mates have often never met, they may have met and not remember names, and frequently have zero awareness of each others skill sets or personality traits.

Combat Aviation
Strong sense of responsibility for rest of crew.  Mutual understanding and being able to work together are high priorities

Emergency Medicine
Sense of responsibility for crew is not possible to establish when team members constantly change.  Team members work in silos, mutual understanding is never discussed openly as a priority.

Combat Aviation
An in-dpeth, formal, standardised briefing occurs before every flight

Emergency Medicine
Pre-shift briefing is never done.

Combat Aviation
Frequent standardised, objective knowledge/skill assessment via regular written and practical testing with clear goals.

Emergency Medicine
No testing at all during career except two, large, high-stakes exams separated by several years. Informal “supervision” occurs daily, but is of extremely variable quality. Often “good performers” are ignored/given no feedback.

Combat Aviation

Competency must be demonstrated in high-fidelity simulation before being allowed into more sophisticated aircraft

Emergency Medicine
Access to simulation training is rare and variable in quality, and highly dependent on location of training. Possible to complete all training with minimal/no simulation based assessment.

Standardised Language
Combat Aviation
Communication is highly standardised, concise and brief.

Emergency Medicine
There is no standardisation of our communication. Misunderstanding is common due to use of acronyms and colloquialisms.

Combat Aviation
Highly male dominated. Vast majority of the flying workforce is young adult, physically and psychologically robust males.

Emergency Medicine
Workforce is nearly 50% female. Age range varies from mid 20’s to 60’s. Wide range of cultural backgrounds. Two separate industries (medical and nursing) that don’t study or train together are expected to function together.

So no disrespect to Deniz.  I think if you are trained in a military mindset, then using some of the skills you’ve learned that may help you run a resus better is fine. But suggesting that we can somehow take those skills and drop them onto an ED workforce, which is full of a totally heterogenous population of staff, with heterogenous training, and the extreme workplace, cultural, and ethos differences outlined above, is not only unhelpful, but is simply not possible.

11 Responses to Aviation vs Emergency Medicine 4 – Combat vs Commercial vs ED

  1. Luke Regan March 26, 2014 at 7:49 am #

    Love your work on virtually every score…except the above commentary….where you seem to have massively missed the point of aviation commentators such as deniz and martin bromiley when analogising their experiences of both industries.

    Joe Lex agrees with you and says that planes are designed to fly, our patients are designed to fail. Personally I think any aeronautical engineer will tell you planes are designed to constantly surprise their designers by surviving the onslaught of heat, cold, moisture, materials fatigue, air pressure and defying gravity. In comparison our patients have a good few million years of engineered resistance to biological entropy.

    The similarities are that death and human suffering lie on the end of poor decisions in both areas and that both require high leeks of technical and non technical skills in their operators. Rapid decision making and high turnover of technology are also shared. Here ends the similarities. All of the differences you highlight are where aviation has enacted effective methods to improve safety and reduce death. These are the areas we are being gently told we can learn from. And we are. If, ten years ago you’d proposed to spend a whole morning of a three day trauma resus course on ‘human factors’ the medical establishment would have thought you mad, now it’s hard to justify only so small a portion.

    I also disagree with a fair number of the differences you quote… Yes we have a regular merrygoround of ‘flash teams’ in ED….but I work long hours for years at a time with nurses and regs who I get to know better than my own family. There is a formal entry criteria and competitive selection process. There are daily briefings. There is simulation (but there could be a lot more..). There is formal teaching and assessment in leadership management etc.

    Yes there are more girls than boys, but I’m not convinced the Air Force should cease to demand aggressive decision making from its pilots as their gender balance shifts and I don’t think EM should lose sight of the need for aggressive resuscitation and palliation in our wet sick patients due to a stereotype of hormonally induced behaviour. You don’t have to be a bloke to know we are ‘fighting cancer’ or that we want to ‘attack the bug’. I think patients like to know we are joining them in a struggle and appreciate ‘allies in the fight’. But that might just be me.

    Otherwise loved your post and reckon its great to ponder whatever lessons we can pull from other professions in our ‘fight’ to improve services…


    • Andy Buck March 26, 2014 at 10:03 am #

      Thanks Luke
      This is what ResusRoom.mx is about – generating discussion. I’m not sure where you work, it sounds great, but I’m giving the perspective of someone who went to university in Australia, and I’ve worked as a doctor in Australia for 15 years. And in that time, this is what I’ve experienced:
      * Selection: Apart from my university/med school entrance, which was based on a single number academic score at the end of high school, there were no criteria to meet, no interviews, and absolutely no selection process for my specialty training in EM. I simply filled out a form, paid a fee to the College, and voila, I was an EM trainee. Anyone could (and still can) sign up. I’ve since seen colleagues with serious medical incompetence, workplace bullies with serious personality disorders, and sadly some with physical health, mental health and substance abuse issues all continue to work. Compare this to the military aviation model, where candidates are relatively thoroughly screened and selected for specific academic, physical and personality attributes.
      * Training: I faced absolutely zero testing during my training, apart from the ACEM first part basic science exam, and the Fellowship exam. This was over a period of 7 years. There were no tests, no monitoring of skill acquisition, and no standardised teaching. I had a total of about 6 hours of simulation teaching in 7 years. There was weekly, ad-hoc, death-by-powerpoint “teaching” at most hospitals I worked at, and most of it was utter crap, and was not based on meeting any standardised learning objectives or goals. There was a 6-monthly sit-down review with one’s director of training (the infamous green form), which usually lasted about 5-10 minutes.
      * Leadership and management: In 15 years, I’ve never heard these words uttered in a hospital. My 7 years of EM training involved a sum total of zero minutes on leadership and management. And whilst I don’t have a full time job at one institution at present, I’m still unaware of any formal leadership or management training for EM Consultants in Australia. This is an area of total absence in current Australian healthcare training. On this note, there is no comparison with the military.
      * Standardisation: In Australian EM training, no two doctors will undergo the same training. There is absolutely no standardisation. In fact, two people can do the same rotation (ED, ICU, Anaesthetics, Paeds, Med), one after the other, or even at the same time, and have wildly different experiences. Apart from the ACEM exams, there is no formalised testing to ensure minimum competency before one starts working in high risk areas like resus. Instead we have an apprentice model, where one is supervised by someone more senior (the amount and quality of which varies wildly between individuals, between shifts, and between hospitals, and is non-existent overnight, and is provided by people who often have no teaching skills or qualifications), over several years. This results in Consultants who have very different skill sets and abilities. For example, despite the necessity for a paediatric rotation and to apparently be competent assessing and managing children in the ED, I work with some Consultants still who “don’t do kids”, and will actively avoid seeing paeds patients. Also, EM trainees must move hospitals every couple of years to complete their training (no hospital is accredited for more than 2 years of training), ensuring that teams are constantly mixed. Some Consultants will work at the same hospital for a long time, but a lot of us don’t. I currently work at 3 different hospitals, and locum at others, so dynamic teams are very, very common.
      * Culture: In the military, there are fairly strictly enforced standards of behaviour and language. Uniforms and clear displays of rank ensure status is immediately obvious to everyone in the room. Disrespecting or disobeying a senior officer has serious repercussions, and may result in discharge from the service. Compare this to the ED. A lot of us wear scrubs, so I can usually spot whether someone is an ED-person or an outsider, but this is not 100% accurate. I can’t differentiate the Surgical HMO from the Registrar, or Anaesthetic/ICU Registrar from Consultant unless I ask them specifically who they are. We do not have formalised language, and communication skills vary wildly, and are hugely personality dependent. Due to the lack of entry screening, a total lack of repercussion for bad behaviour, and other factors such as the hungry/angry/late/tired phenomenon, people can behave like total A-holes when they come to ED, and there is absolutely no repercussion, and sadly this poor behaviour is often demonstrated best by more senior clinicians. There is little or no inter-disciplinary training in most Australian hospitals, and despite the recognition that this is a huge problem, due to major rostering and administrative challenges, there are very few hospitals that have any interdisciplinary training to address some of these issues.
      * Gender balance: I never implied the Air Force has to do anything. This article is about trying to overlay male-dominated military concepts on a healthcare workforce that is, when you take nursing staff into account, over 50% female. Your comment about “hormonally induced behaviour” sadly misses the point entirely. If you need to go into work in a fightin’ mood to “fight cancer”, or “attack the bug”, then good for you, but a lot of us don’t have that perception of what we’re doing. I think “fighting” is a really bad analogy for what we do.
      * The overall goal: Someone tweeted me a link to a video on this topic that to me sums up the final, striking difference between military aviation and healthcare. It has to do with what our ultimate goal is. Whilst yes I agree aviation has a good safety culture, and healthcare needs one, I struggle to take advice from an industry that has killing as its ultimate objective. This clip has a cool rock’n’roll soundtrack, and some absolutely amazing cockpit footage. But what it shows is people being blown out of the sky. Firing $1 million dollar missiles out of $50 million aircraft and incinerating other human beings, and laughing and cheering about it, has absolutely nothing to do with what I do at work every day.


      So thanks for the comments, and I hope this post generates more discussion on these important issues.

  2. Luke Regan March 26, 2014 at 9:56 pm #

    Thanks for the reply Andy and I reckon it’s likely to be a mostly ‘agree to disagree’ discussion on this one.

    I think folks will all see a varying degree of similarities and differences between the two environments and people will take what they feel is useful and discard what is not…for me I think it’s been a one way street of lessons from aviation to medicine so far…but hopefully we have something to give back sometime soon.

    Appreciate you adding such depth of context to your comments. Really interesting to hear the story of your training and experiences across Aussie EDs. My own context is having undergrad and a few years postgrad in Australia then the last decade in UK crit care training with post qualification time spent in variety of EDs and also back with an Aussie prehospital/retrieval service. I would always say there are far more similarities than differences across these jurisdictions but I guess its the differences we notice and I’ll speak to those – most of them could get the general heading “Be careful what you wish for…”

    * Selection: My med school was one with an initial academic requirement, a psychometric test, and a formal interview. I believe there is also a basic science test there now. ED training in the UK has multiple barriers to entry and following a shake-up in 2007 (MMC/MTAS now considered swear words by most UK consultants) there are shortlisting, interviews, nationalised scoring systems, and competitive re-entry at later points in training (although this is in flux). The initial result of this process was that of 16 docs on my local ED rota, I was the only one to get a place on training scheme. I believe Australia benefited from the mass computer failure generated migration of junior docs that followed this selection system. At the time I suggested that if the public was told that on one day of the year every member of the air force was going to be forcibly relocated to the opposite side of the country and made to change both specialty and level of seniority the public would se
    e it for the dangerous madness it was….but in health it is for some reason ok to take such gambles with infrastructure.

    Training: On paper, there is enforced standardisation of number and types of ‘Workplace Based Assessments’ across all UK training schemes. There are designated curriculum-mapped themes and procedures in which these should be performed. The quality/usefulness of these is perhaps just as user dependent as in the Aussie model but carries the danger of a rubber stamp that says ‘trained and competent’. Approval for training can be removed from individual departments and it does happen, but the same respect for hierarchy which makes these systems easier to implement in the UK makes it harder for juniors to blow the whistle on when things go wrong.

    * Leadership and management: Management. The NHS has perhaps got a 50 year lead on this one. The empire crumbled and there had to be somewhere for all those administrators to go…The knock on effect is that NHS consultants are arguably expected to be managers first and clinicians second and teachers somewhere further down the list. The positive side to this is that the CEM has L&M embedded in the curriculum, it is formally tested at the fellowship exam and trusts have both online and live courses for senior trainees in these skillsets.

    * Standardisation: Similar to Aussie experience, two docs can have very different experiences in the same rotation. In ED training and employment, however, there is far more stasis and isolation of practice than in Australia. People generally work in one place for a long time. Moving site is the exception not the norm. So you get the benefits of knowing your team and system intimately with the cost of insularity and practice fragmentation in each centre.

    * The Fighting/Agression/Killing thing: I think it’s very much a personal opinion/approach in this realm and I very much respect your view on this when it comes to how you see your role and how you motivate yourself and others at work. Again I see more similarity than difference. Military aviators didn’t start the war, its a difficult job, glad I don’t have to do it, glad someone does it for me. Might sound a bit sanctimonious but the military aviators I know are not bloodthirsty killers and are as likely to reflect on the morality of their actions as the consultant ED doc you describe refusing to see a sick paeds patient in their own department. The most common description an appalled member of the public gives to my workplace is “it’s like a warzone” and yet I choose to work there….

    As much as I’m playing the contrarian here, I’d hazard we agree more than we disagree on this and again appreciate your thoughtful commentary. Would love to hear other’s thoughts on this.


    • Andy Buck March 26, 2014 at 9:57 pm #

      Awesome, thoughtful reply Luke. Much appreciated. I’m glad you’ve highlighted the huge differences in training and practice in EM between Aus & the UK, and how this relates to the aviation analogy. Hopefully some others will chime in!

  3. rfdsdoc March 26, 2014 at 10:44 pm #

    Hi folks..well I work with pilots every retrieval shift…and whilst I think there are some parallels between aviation and medicine, Its pretty clear we do different things, we think differently

    the idea that we view EM as combat and fighting is a useful model for better resuscitation care…I agree with Andy here. it doesnt serve everyone well. I think Levitan said it best in describing the Cricon surgical airway concept as being problematic cause “its not thermonuclear war, Scott!”

    and really , I dont think most of us walk into a shift thinking we are fighter pilots, or Delta Force or the SEALS..have you ever wondered why no on uses the Australian SAS as a fighting elite example!?!

    And Andy, I thought saying NZ military was not as high level as others was a bit unfair. ANZACS I think earnt their place in military history.

    • Andy Buck March 26, 2014 at 10:54 pm #

      Thanks Minh
      Interesting to hear the opinion of someone who’s practicing medicine in the back of an aircraft every day. Great vantage point on this topic!
      Re: NZ military, it’s not a comment on standards, rather size & activity. Compared to the USA, for example, with multiple massive aircraft carriers, thousands and thousands of combat aircraft, hugely complex international operations… That’s all. As you can see by the video, their standards are as good as anyone’s. (I hope you were being sarcastic…)

  4. Kath Woolfield March 26, 2014 at 11:51 pm #

    Hi Andy,

    As somebody who sat enthralled to Deniz Tek’s talk, I don’t think his point was “combat aviation = emergency medicine”. It was more that comparatively, combat aviation was closer to emergency medicine than was the commercial airline industry. And it was interesting that he had used some of his experiences in the military to inform his clinical practice (dare I mention checklists?).

    As far as training experiences go, mine seem significantly different from yours (and I work in Australia):
    – Selection: Well, none to ACEM (yet) but SHO and registrar jobs in my current place of work have become highly competitive!
    – Testing: yes there was the primary and (too soon) fellowship exam. But I feel I am tested everyday working on the floor. I have benefited from excellent bedside teaching, an innovative education program and 4 hours of simulation every month. I have had formative assessments every three months in most places I have worked, with an initial “how are you finding it?” session at the beginning.
    – Leadership and Management: Although I may have only had one or two specific education sessions on this, good leadership and management is embedded in the culture of the ED. It is part of the job I do everyday – managing 2-3 residents, running a resus (or 3) with appropriate supervision. Leadership courses are frequently advertised (and free)
    – Standardisation and competencies: yes, training will naturally be different depending on location but in each emergency department I have worked I have had to demonstrate competency before performing: procedural sedation, ultrasound-guided cannula and central line access, femoral blocks etc.
    – Teammate familiarity: It is hard changing terms frequently and working with large numbers of staff. But it has only ever been a problem for me in the first few weeks of a rotation. By the end of a rotation I have always felt part of a cohesive “team”.
    – Briefing: Often done before a shift in many places I have worked. Done as part of preparation for a resus.

    We should not take the flying analogy too far, but as Luke said, we can learn from other fields.
    (Yesterday I learned from my dentist)
    Maybe you were a little unfair?


  5. Andy Buck March 27, 2014 at 12:38 am #

    Cheers Kath
    You are lucky to be working wherever you are (as long as it’s not in QLD as all the specialists are about to resign…!)

    On the floor teaching disappeared overnight when they brought in KPI’s in Victoria when I was a couple of years into ED training. We became experts at disposition, and nothing else. The “leadership” I witnessed bordered on workplace bullying and harassment, as it was just about getting patients out of ED ASAP. In my last 3 years of training, I can literally count the patient-centred, on-the-floor, Consultant led teaching moments I experienced at work on one hand. This is not a joke. I even wrote them down once as it was such a sad indictment on my training experience.

    You can read about it here:


    If you’ve even had one teaching session on leadership or management, that’s 100% more than I’ve ever had. And what amuses me is how we have a whole generation of expert Consultants that have never been taught anything about this, with young upstarts like you coming through that will be all savvy about how to “lead” us into the future. It’s an interesting dichotomy.

    I’m glad to hear that training has improved in some places, and the new (dare I say “dreaded”) WBA’s that are coming in may go some way to ensuring ED trainees get a more standardised training experience.

    I do still however think that this discussion is highlighting more differences than similarities from combat aviation. If anyone wants to list some combat aviation concepts that they think are useful in EM, I’d love to hear them

    First one goes to Kath: Checklists

    (& thanks for your comments everyone, great discussion!)

  6. Luke Regan March 27, 2014 at 7:43 am #

    Some cheeky ones perhaps to lighten the mood and sign off from a great discussion – you describe the collapse of good teaching in Victorian EDs following the introduction of KPIs. A similar sad phenomenon followed the introduction of the 4 hour rule in British EDs. Flt Lieutenant Joe Bloggs is handed a ‘target’ he has not himself chosen, may disagree with on multiple levels…but must chase 1000% in order to get the job done.

    Despite millennia of warfare in many thousands of languages and cultural traditions…the modern military aviator follows practice and evidence from his trusted allies in UK/US/Australasia who coincidentally but conveniently all speak the same language, sound familiar?

    Pets are not allowed in the cockpit or resus room.

    No matter how important the meeting, there is never wine served with lunch.

    If you take all the badges and bars off a flightsuit, you are essentially ready to start work as a painter and decorator…ditto scrubs.

    The percentage of time spent in the cockpit or resus room is the exact inverse ratio of the amount of time we envisaged spending in the cockpit or resus room when starting our jobs.

    An ability to clench long past the point any other reasonable job would have allowed a toilet break. Although I wonder if it’s perhaps even easier to find somewhere to pee at Mach 2 and 30000ft than in the middle of a busy trauma call…

    The opposite sex finds our jobs glamourous and exciting until they discover we are essentially civil servants with unreasonable hours, much paperwork and limited control over where we’ll next be sent to work.

    Every time we initiate a new treatment or fire a weapon, somewhere in the government, an accountant starts crying.

    Ready access to grease and lubricants is necessary for many of our daily procedures.

    Almost all of our functional roles will soon be replaced by drones (I swear I’m referring to web based advice fora here and not nurse practitioners).

    A regular portion of our days are spent examining undercarriage.

    And so on and so forth….


  7. rfdsdoc March 27, 2014 at 8:21 am #

    checklists are useful but not always. end of discussion. get a life. lets move on!

    Luke I love your cheeky musings so please dont sign off..continue!

    I would love to debate on the usefulness and validity of aviation paradigms to medicine, particularly emergency medicine/resuscitation! bring it on!

    The. podcast mike is warmed up and ready to anyone interested!

    on the whole leadership skills and how to learn these in ED..i agree with Andy yet again..#damnitbuck
    I dont think the ED is a great place to learn leadershio skills. too many chiefs, too many competing interests. I would like Lukes opinion on this but I suspect out of hospital settings are better places to learn how to lead people/teams/strangers.

  8. Luke Regan March 27, 2014 at 8:59 am #

    Yeah I think you’ve nailed a lot of it there Minh. For me the closest (and most useful for patient safety) comparisons are in the single patient high stakes time poor scenarios that line up nicely with the aviation emergency situation. Running a resus. Performing an RSI. I think the usefulness slides when scaled up to the whole dept for the whole day. But I don’t think commentators like deniz tek or joe novak were ever making that stretch. In that perspective I often feel the person who best appreciates my daily job description is the unlucky punter who’s been a major incident officer more than once in their lives…

    When Andy describes the ‘quiet’ environment of the a380 cockpit as wholly unlike resus…he’s (perhaps) not been as lucky as I or you have been to work in prehospital and retrieval services that have already gone much further down the lessons from aviation road. Mostly because they see up close every day how well they work. I tell as many people who will listen that the quietest place on earth is a prehospital RSI with a SydneyHEMS paramedic and doc. A large part of the reason for that?…checklists, constant drilling and ‘flight currencies’ for high stakes procedures, boldface emergency algorithms, simplified kit, pre briefing etc etc. All from aviation. Maybe it’s only prehospital medicine that can make this stuff work for our patients benefit but I’d like to think prehospital ain’t so special as all that…

    As to learning leadership…. I’ve been on courses and doubt they gave me much. I’ve had similar experiences to you andy in seeing prolonged and marked absences of leadership from folks who should have been teaching by example. Much as I hate to quote the ever quotable Cliff Reid on this….he made strong reference at SMACCGold to the power of the negative behaviour example as a motivator to do better himself. I’ve known many inspiring ED clinicians but my main motivator is having seen leadership go sit in its office when it should have been counselling a sick kiddy’s mum that the resus was everything we could do. I think it can be taught absolutely but in EM I think the classroom should be the shop floor and the teachers should be every consultant who sign a contract to staff it.


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