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

The scope of the series, as outlined in the editorial, is deliberately broad. It will welcome research articles examining the foundation and evolution of plastic and reconstructive surgery, including studies of the contributions of individual surgeons and patients, the historical development of surgical techniques and instrumentation, and even the field’s reflections in art and literature. That breadth reflects a central claim of the editorial: every procedure, condition, surgical algorithm and instrument in the specialty carries its own story, and those stories collectively explain how modern practice came to look the way it does.

The historical arc the editorial sketches stretches back further than most readers might expect. It opens with ancient Sanskrit texts describing Sushruta’s procedure for nasal reconstruction, a reference to one of the earliest documented operations in which tissue was deliberately transferred to repair a defect of the face. Nasal reconstruction holds a special place in the origin story of the specialty because the nose, prominently exposed and vulnerable to injury, was among the most socially and functionally devastating losses a person could suffer. Techniques for rebuilding it developed across centuries and cultures, long before the term plastic surgery existed, and the editorial treats this ancient lineage as the starting point of a continuous tradition of innovation that runs unbroken to the present day.

From that ancient beginning, the editorial traces a path to the other end of the technological spectrum: modern robot-assisted surgery. The contrast is striking, but the authors’ point is that the two are connected by more than chronology. The principles that govern reconstruction today, such as careful wound closure, respect for tissue planes and the strategic transfer of tissue from one part of the body to another, were established through accumulated experience rather than invented overnight. Knowledge of this history, the editorial argues, is an important resource for understanding and respecting the sacrifices and contributions of the surgeons and patients whose experiences defined the techniques, principles and standards that define practice today.

A central and sobering theme of the editorial is the role of war. For the most part, the modern techniques used in plastic surgery took root in field army hospitals and were first performed by military surgeons, who were tasked with wound closures of varying complexity, extremity reattachments, burn treatments and other consequences of armed conflict. The scale and complexity of injury seen in the First and Second World Wars necessitated rapid surgical innovation, producing novel techniques in wound closure, reconstruction and microsurgery. Battlefield conditions, in this telling, functioned as an brutal forcing function: mass casualties with unprecedented combinations of injuries demanded solutions that civilian practice had never been required to develop at speed.

The editorial names a remarkable roster of contributors from the first half of the twentieth century, a period when the specialty crystallized into a distinct discipline. Among those listed are Sir Harold Gillies, Sir Robert Jones, Henry Pickerill, Hippolyte Morestin, Erich Lexer, Jaques Joseph, Otto Lanz, Johannes Esser, Vladimir Petrovich Filatov, Archibald McIndoe, Luke Voyno-Yasenetsky, Vincenz Czerny and Suzanne Noël. The list spans multiple countries and national traditions, underscoring that the birth of modern plastic surgery was an international enterprise rather than the achievement of a single school. Several of these names remain familiar to surgeons today through eponymous flaps, instruments and techniques that are still taught in training programs around the world.

What distinguishes this editorial from a conventional celebration of surgical pioneers is its insistence on remembering the other half of the partnership: the patients. It is equally important, the authors write, to remember the soldiers and civilians whose injuries compelled the marvelous surgical progress from which patients continue to benefit today. Their suffering and sacrifice are often overshadowed by the focus on the surgeon or the technique, but their experiences are a reminder that the history of surgery carries a tremendous human cost that must never be forgotten. This reframing is significant for how the series is likely to approach its subject. Rather than treating historical patients as passive material upon which progress was made, the editorial positions them as contributors whose injuries, endurance and outcomes shaped the establishment and evolution of surgical practice.

The announcement also arrives at a meaningful moment for the journal itself. BMC Plastic and Reconstructive Surgery is a new open access title, and the history series appears in its first volume, as article number nine. Launching a focus series on the field’s origins in a journal’s inaugural year is a deliberate statement of editorial identity: the journal is positioning historical scholarship not as a peripheral curiosity but as a core strand of the specialty’s literature. The open access model matters here too, since making historical research freely available allows surgeons, students, historians and the public to engage with the field’s past without paywall barriers.

For working surgeons, the editorial suggests that historical knowledge has practical value beyond commemoration. Understanding why a particular flap design, fixation method or reconstructive algorithm emerged, and under what constraints it was first tested, can deepen technical judgment and clarify which elements of current practice are fundamental principles and which are contingent solutions to problems that may no longer exist in the same form. For patients, the history is a reminder that every contemporary standard of care, from burn reconstruction to microsurgical reattachment, was earned through the experiences of people who underwent surgery in eras without modern anesthesia, antibiotics or imaging.

The series now open for submissions invites researchers to document and analyze this heritage in detail, whether through studies of individual surgeons and patients, the evolution of specific techniques and instruments, or the field’s portrayal in art and literature. As the editorial makes clear, the history of plastic and reconstructive surgery is extensive, complex and remarkable in its depth, and the journal intends to ensure that this record, with all of its innovation and all of its human cost, is preserved, examined and made freely available to everyone the specialty serves.

Subject of Research: The history and evolution of plastic and reconstructive surgery from ancient times through modern military-driven innovation

Article Title: History of plastic surgery: introducing a BMC Plastic and Reconstructive Surgery focus series

Article References: Sinelnikov, M. Y. (2025). History of plastic surgery: introducing a BMC Plastic and Reconstructive Surgery focus series. BMC Plastic and Reconstructive Surgery, 1(1), Article 9. https://doi.org/10.1186/s44452-025-00009-1

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00009-1

Keywords: plastic surgery, reconstructive surgery, history of medicine, military surgery, Sushruta, Harold Gillies, Archibald McIndoe, microsurgery, world wars, surgical innovation, open access, BMC Plastic and Reconstructive Surgery