Aviation’s lessons for urologists

The quality of performance is influenced by numerous factors, and it doesn’t solely depend on the individual surgeon or a single organisational structure. There must be other factors. For example, Napoleon famously said, “I don’t want good generals, I want lucky ones.” However, modern professionals cannot rely on luck, chance, or coincidence. So, what exactly does good performance depend on?

For a start, good performance is directly linked to technical skills, which include basic skills, knowledge and experience. Under normal circumstances, these are usually sufficient to ensure a positive outcome. This is not unique for the medical profession. For instance, a surgeon thoroughly studies a case, consults with colleagues, and prepares for the operation, much like a pilot plans a flight by reviewing the route and weather conditions. In these scenarios, decisions are often made in a “semi-automatic” mode, based on a mental model of the situation.

Situation awareness

But what happens if a situation deviates from the norm – when it becomes unusual or even an emergency? Suddenly, the mental model of reality changes, and it becomes more complex or difficult to grasp. In such cases, professionals shift from “semi-automatic” decision-making to the “manual” mode, meaning they need to build a new mental model based on the new situation. This process is known as situational awareness (SA). The professional must assess the new elements of the situation, predict how they will unfold, and decide how to respond.

Non-technical skills

If this process is executed properly, the outcome will likely be positive. But if mistakes are made—perhaps because of rushing, stress, fatigue, or confusion—the consequences can be dire. This is where non-technical skills (NTS) come into play. These skills, including communication, teamwork, and decision-making under pressure, are essential to a safe and effective performance. While technical skills are crucial, they are not enough on their own. Aviation is an industry that has learned this lesson well, albeit through hard experience. It realised that even the most skilled pilots cannot guarantee safety in every situation. Humans are fallible, and the environments they work in are often complicated and unpredictable. For this reason, Non-Technical Skills have become a core part of training for pilots, flight attendants, maintenance workers and air traffic controllers. The organisational structure has also evolved, and the way professionals collaborate in this high-stakes environment has transformed.

The aviation industry has transitioned from a “classical” stage – where safety depended almost entirely on the technical competence of the pilot—to a “modern” stage, where performance hinges on the teamwork of various professionals, each with specialised skills. This collective approach has helped make air travel the safest mode of transport in the world. However, the limitations and fallibility of human professionals are not unique to aviation. A 2016 study by Johns Hopkins Medicine found that medical errors are the third leading cause of death in the United States, accounting for 251,000 deaths annually. To put this in perspective, it is as if two jumbo jets full of passengers crashed every day.

Given these alarming statistics, why hasn’t the healthcare sector embraced a similar approach to that of aviation? Why not integrate non-technical skills training for healthcare professionals, thereby creating a culture that values teamwork, communication, and decision-making alongside technical expertise?

NTS in urology training

Some positive steps are being taken in this direction. The EAU Non-Technical Skills Working Group (NTS WG) has developed a tailor-made module to train situational awareness in a safe environment for urologists and residents. For example, in an operation room filled with actors, a participant is exposed to multiple stress factors when an emergency situation occurs. The scenario is observed by multiple colleagues using a standardised observation form. Situational awareness, communication, leadership, teamwork, and other elements are observed. In an extensive debriefing which is led by an aviation safety expert, the topics are discussed with the physician, the observants and the actors. Both participants and observers learn firsthand the importance of collaborating with colleagues, managing time effectively, and building an accurate mental model of the situation to make informed decisions. These simulation sessions were held during recent meetings (EUREP23, EAU24, EUREP24). and were very well-received.

The controlled environment of simulation allows professionals to make mistakes, analyse them, and learn from them. This process not only hones technical skills but also develops and strengthens non-technical skills, which are just as critical in complex, high-stakes situations. If you want to know more about NTS, check out the introduction video here: https://youtu.be/kAEGc4Ln3XY

Improving safety

In conclusion, while technical skills remain fundamental to professional performance, they are insufficient on their own – especially in safety-critical fields like aviation and healthcare. The integration of non-technical skills into training and professional development can lead to safer, more efficient performance. Just as aviation has revolutionised safety through teamwork and situational awareness, healthcare could achieve similar improvements by adopting these practices. Simulation-based training is a promising tool to help bridge this gap, offering a way for professionals to learn, practice, and improve both their technical and non-technical abilities in a safe and controlled environment.

During the next Annual EAU Congress in Madrid, courses will be offered to train your non-technical skills by developing your situation awareness, your communication under stressful circumstances and your leadership. You are cordially invited to attend.

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Authors: Dr. Stefan Haensel, EAU Section of Outpatient and Office Urology Board Member (NL), and Cpt. Gianluigi Zanovello, Ex-fighter pilot (Former Frecce Tricolori Commander), non-technical skills (NTS) expert (IT)