Managing confidence in the cockpit
During and after my flight training, I aimed to be especially diligent and paid close attention to all aspects of flight, in an attempt to counter the widely held perception that doctors are high risk pilots. Where did this perception originate?
The famous report by Dr. Stanley Mohler, “Physician Flight Accidents,” was authored in 1966, a completely different era of both doctor paternalism and lack of self-analysis, and a time of maverick pilot heroics and lack of CRM. To those who were not around during those years, or have not read the archived paper, the “Mohler report” was a manuscript from the Chief of Aviation Medicine in the FAA who was investigating a large series of physician-pilot deaths during the years 1964-1965 (large series = 30 total deaths during the period, or 15 per year.)
However, normalized by the number of physicians flying at the time (3,000) as opposed to the general aviation population (400,000 pilots), this was a death rate that was four times that of the general pilot population. Note that Dr. Mohler’s simple analysis did not even include any accounting of the flight hours flown by the individual: some of the 400,000 pilots in the general pilot community may not have flown much at all, as continues today, and some doctors may have flown a great deal. However, he notes that most of the physician and overall deaths were found in relatively low-hour recreational pilots.
There’s a reason it was called the “forked tail doctor killer.”
The report listed a few of the physician-pilot accidents as a brief narrative, and categorized the variables that led to the fatality, which is a mix of the usual suspects: thunderstorms, night, lack of proficiency, VFR into IMC, drug/alcohol use, and fuel exhaustion. Dr. Mohler concludes that “risk-taking attitudes and judgments appear to be the key underlying thread uniting the major variables studied. For the most part, the flights were undertaken for a purely recreational purpose. The premium physicians place on their relatively restricted opportunities for recreation is highlighted.” Flying was not to be treated like playing amateur golf.
Media and popular culture took immediate note of the Mohler report, and a follow-up study examined the trends for the next six years, which hovered between 12 and 18 physician-pilot deaths annually. This idea of the dangerous doctor in the air became cemented in popular culture, especially among individuals who were flying during those years.
Several family members, when hearing of my starting my pilot training, came back with vigorous defense of the presumed fact that “physicians were terrible pilots,” even though data did not support this broad conclusion. As flying becomes increasingly expensive, busy professionals increasingly become the ones who fly, and consequently, the ones who have accidents. Normalization based on profession alone is quite difficult, and somewhat meaningless given the heterogeneity within professional communities both in subcategory and individual; to say an internist is the same risk in the air as a surgeon is nonsensical, and any GA control group equally diverse.
While it did not deter me from flight training, the repeated, often derogatory comments from disparate individuals of the dangerous “doctor-pilot” left me initially quite annoyed, and later in a state of concern and suspicion regarding the generation of such a perception. Is this actually true, or far worse, is this necessarily true? On my very first lesson with my instructor, as we were talking and heading out to the plane, I commented on my concern that there was a notion that “doctors are bad pilots.” He looked a bit confused, and paused for a few seconds. “Well, I would suppose that bad pilots are bad pilots. I am not sure it really has much to do with being a doctor.”
Overconfident or just really good – how can you tell?
This was, in my opinion, the best response possible, a correct response, and I stuck with him for my private and instrument training. During my training, my CFI treated me just like the pre-professional students at the flight school, and held me to high regard and to fine standards. I was determined to get the best training I could and become the best pilot possible.
After the amount of material learned during medical school, I knew I would not struggle with memorization of rote material or mastery of the FARs (believe me, we have a lot of practice reading and memorizing large texts), so I was concerned that my personal potential risk factors could include overconfidence or complacency, which is indeed a trap for the non-pilot professional. Both of these can be guarded against with personal honesty and integrity, coupled with constant vigilance.
A great deal of offloading to the subconscious of the basics of flight is needed to function successfully in the cockpit. We have all been in the scenario: your instructor gives you a command at the same time as ATC, and you were checking something else at the same time these instructions met your ears, and in addition to copying the instructions and obeying them, you must continue to fly the plane. It is essential that we develop an instinctual feel, which is a valuable safety mechanism. Mushy controls would never go undetected, as it gives an alertness for high AOA flight and low airspeed. Getting this intuition is a good part of the private pilot training as flying becomes perfected, landings are performed with grace and precision, and all bad habits are squelched.
During the private training I got my tailwheel endorsement from a different instructor, and shortly after spent another dozen hours in a Citabria learning aerobatics and the Aresti notation. I had a great time, and this went far, far beyond a spin recovery course, and putting things together I was able to rehearse quite a few routines. I was pleased when the other instructors also complimented my flight skills and precision. Perhaps again overcompensating, but I enjoyed aerobatics and it was better to become expert than remain at the lower limits of ability when all alone above the ground. By the time I took my checkride, I felt more than ready, and immediately continued on to instrument training and obtained that rating.
In talking with other pilots, I have realized that markedly different attitudes and perspectives exist regarding the display of confidence. As a physician, I tend to become very comfortable and confident in what I am doing (would you undergo a routine case by an unconfident surgeon?). However, I am grounded by the highest of expectations and relentless self-critique and objective (well, as objective as possible) assessment. I tend to say things like “I won’t ever take off misconfigured,” because I use and perform the checklists each time, and double check one more time. This is viewed as a jinx to some to dare to utter aloud, and can also sound similar to an attitude of invulnerability. However, to me it is quite the opposite.
“Those who have and those who will,” the saying goes. That’s fatalistic BS.
On the other hand, many pilots express maxims such as “it could happen to anybody” and “there are two types of pilots, those who have landed gear-up and those who will.” I always cringe when I hear these, because I worry those kinds of statements verge on fatalistic attitudes, believing that mistakes are inevitable. In fact, the FAA defines this attitude, taken to pathology, as “resignation,” and the antidote is “I can make a difference.” A gear up landing can happen to anyone being rushed or distracted. If we follow the checklist and are incessantly vigilant, it will not, and such an event is far from a certainty in the attentive pilot’s career.
Confidence is not the same thing as arrogance, and confidence must never slip into the hazardous attitude of invulnerability. Only taking half of the statement “I won’t take off misconfigured” and subconsciously finishing it with “…because I’m smart, or a doctor, or just plain an incredible pilot” would be incorrect and fantastically arrogant. Of course, any number of calamities could happen to me, you, or any other pilot.
However, if one follows a checklist or reliable consistent flow every single time, and is methodical about an approach, the vast majority of potential errors will not happen. Similarly, in medicine the same is true: I have never performed a wrong-site or wrong-patient surgery, because we are set up for reliable fail-safe and multiple check mechanisms to prevent this from happening, as much as humanly and practically possible.
Even without a bad outcome, skipping a checklist or another failure of omission is cause for self-reflection of procedures, attitudes, and abilities, both in the cockpit and clinic. This is true for student pilots, intermediate instrument-rated amateurs, as well as the 10,000-hour professional pilot. The laws of physics have just application for all; they truly do not care who you are, or how many times you have done it correctly in the past. This is the ultimate recognition of vulnerability.
Surgeons are confident; that doesn’t mean a checklist isn’t a good idea.
At the end of the day, both overtly confident and more self-effacing pilots have the same goals in mind. Some desire to remind themselves that they alone are in charge and must own up to critical decisions, boosting their own confidence, and some want to emphasize that they are mortal and must maintain their guard, attempting to limit risks of overconfidence. We all want the same thing – safe flights in our pursuit of aviation excellence. Your own personal expression of confidence might be muttering to yourself, “I can and will do this” or “bad things might happen, do not get overconfident,” or perhaps a mixture of both.
It is true that all sorts of unexpected things can happen in both medicine and aviation in both routine and non-routine flying. Some pilots might have to fly under non-ideal conditions (search and rescue missions) while some might be fun fliers who cancel if there is a cloud in the sky. Some surgeons operate in trauma or in emergency situations, and some only do elective non-urgent procedures.
What is the ultimate metric for how we are doing, or how good we are? The best assessment comes through an unbiased observation of performance and any incidents or events, compared to others in similar conditions. A pilot who routinely has close calls, who has an “adventure in every flight,” who has difficulty with crosswind landings or is startled by the stall horn in the pattern is likely not a calm, confident, reliable pilot. We must judge ourselves by our outcome, overall safety record and (hopefully lack of) incidents and events.
As the adage goes, the superior pilot will avoid demonstration of superior skills through superior judgment. The pilot who is extremely nervous before every flight may have a genuine concern for their ability, but a pilot without any self-questions or ongoing self-assessment may be supremely confident, yet much more dangerous. The best pilot is somewhere in between, extremely confident of his or her polished skill, not arrogant or fatalistic in either direction, and highly aware of the possible risks that flying routinely entails and continuously seeking to minimize them. We should all aspire and work toward this standard, regardless, or in spite of, our outside profession.
Are physicians bad pilots? Well, bad pilots are bad pilots. Some bad pilots are physicians, many are not, and none of us are resigned to any particular fate.