What Naval Aviators Can Teach Surgeons: Flight Training Lessons Reshape Surgical Education Debate

A rare three-way conversation between a surgeon, a flying doctor and a Royal Navy pilot has landed in the pages of Global Surgical Education, the journal of the Association for Surgical Education, and it is stirring fresh debate about how the next generation of operative specialists should be trained. The exchange began when Jenkins, Doberne and Thanawala published a provocative piece titled “A naval aviator’s view of surgical training,” arguing that the aviation world’s approach to producing safe, competent operators holds lessons that surgery has been slow to absorb. Now Cara Swain, Jack Denniss and Karl Cooper have responded with a letter that brings together perspectives from military surgery, occupational health and frontline naval aviation, offering a uniquely qualified commentary on where the analogy holds, where it strains, and what both professions can learn from each other.

The original article by Jenkins and colleagues drew on a comparison that has circulated in medical education circles for years: commercial and military aviation invests enormous resources in structured, simulation-heavy, competency-based training, and aviation has achieved remarkable safety records as a result. Surgical training, by contrast, has historically depended on an apprenticeship model in which trainees learn by doing under supervision in the operating theatre. The aviation argument is straightforward in principle. Pilots are not permitted to learn critical manoeuvres for the first time with passengers on board. They progress through ground school, simulators, dual-control instruction and graduated solo experience, with every stage assessed against defined standards before advancement. Surgery, the argument goes, should aspire to the same rigor, and simulation should occupy a far larger share of the training pathway than it currently does.

Swain, Denniss and Cooper are unusually well placed to test that argument. Swain works at the Academic Department of Military Surgery and Trauma at the Royal Centre for Defence Medicine in Birmingham and is also affiliated with the Department of Learning, Informatics, Management and Ethics at the Karolinska Institutet in Stockholm, a combination that bridges operative practice and formal educational science. Denniss serves with 845 Naval Air Squadron at Royal Naval Air Station Yeovilton, giving the response direct access to the cockpit-side perspective that the original article invoked. Cooper brings experience from the Regional Occupational Health Team Bulford and the Academic Department of Military General Practice, adding a medical workforce and occupational health dimension that is often missing from training debates. Together they represent exactly the kind of cross-disciplinary triangulation that the aviation-surgery comparison demands.

The technical heart of the discussion concerns how competency is defined, measured and maintained. In naval aviation, training follows a syllabus in which each flight exercise has defined objectives, and instructors grade performance against standardized criteria. Progression is not a function of hours logged alone but of demonstrated proficiency, and critical skills are revalidated periodically. Surgical training in the United Kingdom follows a national structured competency-based pathway managed by NHS England and the four surgical Royal Colleges, with progression monitored through the Intercollegiate Surgical Curriculum Programme. The ISCP framework defines assessment and feedback mechanisms that are, on paper, not so different from aviation’s structured grading. The respondents’ letter implicitly probes the gap between that paper structure and the lived reality of training, where case availability, service pressures and rota demands can shape operative experience in ways no syllabus intends.

One of the most consequential concepts in this debate is skill decay, the gradual erosion of learned performance when a skill is not practised. Stansfield and Tai addressed this directly in BMJ Military Health, writing about surgical skill decay in what they call the contingency era, a period in which military surgeons may go long stretches between high-acuity operative cases. The problem has a precise aviation parallel: pilots who do not fly regularly must complete currency requirements and simulator refresher sessions before returning to duty, because the psychomotor and decision-making elements of flying degrade measurably with disuse. For surgeons, especially those in military or low-volume settings, the same decay dynamics apply to complex operative skills, yet the systems for detecting and correcting decay are far less formalized. Simulation offers a partial answer, allowing deliberate practice of rare and high-risk procedures without patient exposure.

The evidence base for simulation in surgical education has grown substantially over the past two decades. Aggarwal and colleagues, writing in BMJ Quality and Safety, synthesized the case for training and simulation for patient safety, arguing that simulated environments allow teams and individuals to rehearse technical and non-technical skills, from instrument handling to crisis communication, in conditions where errors carry no human cost. High-fidelity simulators can reproduce tissue handling, bleeding scenarios and equipment failures, while virtual reality platforms track metrics such as economy of motion and error rates that provide objective performance data. McGhee’s recent doctoral work on surgical technology faculty perceptions of high-fidelity simulation adds a practical layer, examining how the educators who run these programs view their value and their limitations. The respondents’ letter situates itself within this evidence landscape, and the aviation comparison sharpens the point: aviation did not adopt simulation because it was fashionable, but because decades of accident analysis showed that errors made in training carried over into operations, and that rehearsal in a safe environment prevented them.

Yet the aviation analogy has limits that a naval aviator himself would be the first to acknowledge, and Denniss’s involvement in the response gives that acknowledgment weight. Aircraft are engineered systems with standardized cockpits, quantified performance envelopes and near-complete environmental control. Patients are not. Anatomical variation, tissue quality, comorbidity and intraoperative surprise introduce variability that no simulator fully reproduces, and the surgeon’s task includes continuous intraoperative reassessment that has no clean equivalent in flying a certified airframe. Moreover, aviation’s safety gains rest not only on training but on an entire ecosystem: mandatory incident reporting, just-culture investigation, crew resource management, and checklists enforced by regulation. Surgery has imported some of these elements, most famously the surgical safety checklist, but importing training structure alone, without the surrounding safety culture, would capture only part of what makes aviation safe.

There is also a cultural dimension to how trainees learn from error, and this is where the letter’s occupational health perspective becomes relevant. Lee and colleagues, writing in Global Surgical Education, examined how individual, cultural and systems factors shape surgical residents’ experience with medical errors and their ability to learn from mistakes. Aviation’s non-punitive reporting culture, in which pilots can disclose errors without automatic career consequences, contrasts with surgical environments where error discussion can still carry stigma. A trainee who fears blame will conceal mistakes, and concealed mistakes cannot become teaching moments. Building educational systems that treat error as data rather than as failure is arguably a deeper lesson from aviation than any simulator syllabus, and it requires engagement from the occupational health and wellbeing structures that Cooper’s affiliation represents.

The timing of this exchange matters. Surgical training worldwide faces converging pressures: reduced working hours, financial constraints on theatre time, rising subspecialization, and, in military contexts, operational tempo patterns that can leave surgeons case-starved between deployments. Simulation-based and competency-based training are often proposed as solutions, but they carry costs of their own, in equipment, faculty time and curriculum redesign. The value of the aviation comparison is that it offers a tested template for allocating scarce training resources: identify the highest-risk skills, build structured rehearsal for them, assess against explicit standards, and revalidate periodically. The respondents’ letter, by bringing a surgeon’s, a flying doctor’s and a pilot’s perspectives into a single conversation, models the kind of cross-professional dialogue needed to adapt that template intelligently rather than transplant it wholesale.

What emerges from the exchange is less a verdict than an agenda. The original article by Jenkins and colleagues asked whether surgical training should look more like naval aviation training. The response from Swain, Denniss and Cooper, published as a letter in Global Surgical Education with the backing of the Association for Surgical Education’s journal, suggests the question is worth taking seriously precisely because the two professions share the same fundamental challenge: producing operators who perform rare, high-stakes procedures safely under pressure, with training systems that must be efficient, evidence-based and honest about human fallibility. As surgical education moves further into simulation, virtual reality and structured competency assessment, the aviation world’s hard-won lessons about currency, standardization and safety culture will remain a reference point, and letters like this one ensure the borrowing is done critically, by people who have sat on both sides of the cockpit and the operating table.

Subject of Research: Cross-disciplinary comparison of naval aviation training methods and surgical education, including simulation, competency assessment and skill decay

Article Title: A surgeon, a flying doctor and a pilot’s response to Jenkins’ et al. “a naval aviators’ view of surgical training”

Article References: Swain, C., Denniss, J., & Cooper, K. (2026). A surgeon, a flying doctor and a pilot’s response to Jenkins’ et al. “a naval aviators’ view of surgical training”. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 126. https://doi.org/10.1007/s44186-026-00529-z

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00529-z

Keywords: surgical education, naval aviation, simulation-based training, skill decay, competency-based training, military surgery, medical errors, patient safety, Intercollegiate Surgical Curriculum Programme, virtual reality training, Royal Navy, training reform