The afternoon air had a palpable starchiness to it, cool and damp but still thick. As I arrived at the airport around 3 p.m., a bright haze lingered in the sky. Only a few other people were present as my brother and I walked toward the hangar: a flight instructor and her student debriefing from their lesson, another pilot shuffling around his plane filling the fuel tanks, and five or six other planes sitting parked, scattered along the ramp. Inside the hangar, the afternoon light streamed in through the gaps of the corrugated metal construction. The rusty wheels groaned in protest as the large hangar door raised, their grating screech reminiscent of nails on a chalkboard. With the door open to the beautiful vista outside, I set my bag on the floor and pulled out the checklist. Stained blue from the occasional drips of aviation fuel, this small piece of paper was my Bible.
My training as a pilot means that I’ve become an ardent supporter of checklists, and I hope, an effective user of them. As a medical student, I’ve had the privilege of observing many different surgical teams, and while my experience in the OR is still growing, my background as a pilot has given me a unique perspective on the value of checklists. I’ve noticed that in medicine, some of my colleagues seem to suffer from checklist fatigue – a very real challenge that I believe stems from a misunderstanding of what checklists are truly meant to accomplish. The purpose of my checklist as a pilot is to: 1) help correctly configure the aircraft, consistently; 2) mitigate human factors by assuming humans are imperfect; and 3) prompt me, the pilot, to brief the tasks that do require adaptability and judgment.
These days, I walk around the plane scanning the leading edge of the wing with my eyes and running my hand over the rivets and screws that hold it together, often without ever glancing at the physical paper. I’ve gotten so used to the flow of my pre-flight checks that I don’t need anything to remind myself what to do. However, it was hammered into me as a student pilot that mental flows like this should always be backed up with the physical checklist — just in case. It’s become a habit now, that after the exterior pre-flight, I pause and read each item in my checklist out loud. Crucially, as I read each item aloud, I actively recall inspecting it.
For example, one of the lines reads: “Tires / Brakes / Struts.” It’s easy to simply read it off rotely, without fully being aware that you’ve checked each separate item. I’m certainly guilty of this too. Now, as a more experienced pilot, I realize that doing so is a disservice to myself, my passengers, the people on the ground without any control of the matter, and all those who place their trust in us as pilots.
On that cool afternoon day, as I read that line, I thought to myself:
- “Did I press hard on the tire to feel its pressure and rebound?” I remembered pushing down on the tire and looking at the treads and seeing that, while the front tire was well-worn, it would suffice for a few more months before needing replacement.
- “Did I move the wheel ever so slightly to see the gap between the brake pads and the rotor?” I remembered looking at the pads and the rotor, not seeing any grooves from contaminants that might have gotten lodged in between.
- “Did I look at the struts to see that there was plenty of space for suspension travel?” I remembered seeing the characteristic wear of the strut sliding up and down, absorbing all of the previous landings. It was clearly not bottoming out its range of motion.
This mental exercise took altogether less than a second. It’s a backup that gives me a chance to correct a deficiency while still on the ground. It’s a reminder that the checklist is not the physical piece of paper, but instead is the act of actively recalling that each item was inspected or set correctly. I fully believe that this attitude contributes greatly to my safety in the air.
The same applies for medicine. Checklists must be specific; to each procedure, or at least specific to the specialty. Checklists must be sparse, only including the most critical elements that cannot be missed. Checklists should prompt the team to dig deeper where required, such as for particular procedures that need certain post-operative considerations or pose a greater risk of a sharps mishap. Checklists must encourage the team to brief the complexities where judgment is necessary. And perhaps most importantly, teams should be trained to use checklists effectively, starting with the pilot-in-command: the surgeon.
My hope is that when you come across a bad checklist, you can take charge to customize the checklist to work for you. Perhaps you can remove unnecessary items, or adjust the verbiage to say “Imaging available / As needed” instead of a yes/no checkbox, or create different checklists that include imaging only in procedures that actually require it. The success of my flights has reinforced my attitude toward checklists: I see them as tools for ensuring consistency, safety, and clarity, not as burdens or boxes to check. This mindset allows me to embrace their purpose and see beyond their limitations. With a well-designed checklist, and the right mindset, you’re not just following a procedure; you’re enhancing your ability to provide the best care possible in all situations.
While checklists are invaluable for ensuring consistency and covering critical elements, they are only part of the equation. Equally important is the role of briefings, which complement checklists by allowing space for the nuances and complexities that require professional judgment. I want to emphasize an important distinction in terminology. A “briefing” is different from a “checklist.” A checklist might prompt you to do a briefing, but the briefing enables you to consider the specifics of the particular scenario. It allows you to bring in that clinical judgment that can be lacking in surgical checklists. For example, as I’m sitting at the threshold of the runway, my pre-departure briefing prompts me to consider what obstacles will be ahead, what radio frequencies I will use to communicate to air traffic control, and what heading we will need to fly to get on course toward the destination. I think through the specifics that aren’t accounted for in a checklist.
This approach isn’t limited to the cockpit. Whether managing a flight or diagnosing a patient, the discipline of checking everything thoroughly – and questioning anything that seems off – is crucial. In both fields, safety and success depend on recognizing that the checklist is an essential tool, but not a substitute for critical thinking, human judgment, or intuition.
The checklist is more than just a series of rote tasks; it’s a physical manifestation of a core philosophy in aviation: humans are not infallible. Aviation embraces a systematic approach that acknowledges our human limitations and proactively builds in safeguards to reduce errors. Whether it's a checklist, a pre-departure briefing, or simply reading things aloud, these are simple tools that help me fly safely. This philosophy recognizes that no matter how experienced we are, we all have blind spots and moments of complacency. By transferring this mindset to medicine, where the stakes are equally high, we can create systems that support clinical judgment, prevent oversights, and ultimately improve patient outcomes. Embracing the aviation approach in medicine means accepting that even experts need checklists, and that doing so is a strength, not a weakness.
What are your thoughts on checklists? Share in the comments.
Sahil Nawab is a medical student at UMass Chan Medical School in Worcester, MA. He is an avid aviation enthusiast and private pilot who enjoys exploring the world from many unique perspectives. Sahil is a 2024-2025 Doximity Op-Med Fellow.
Image by GoodStudio / Shutterstock
