A Learning Culture


A WW II pilot debrief during Italy, 1944.

After every flight in the US Air Force, there is a debrief. This is bred into our culture from the very first hop in pilot training. In 2,000 hours of flying fighters, I can probably count on one hand the number of flights that we didn’t debrief. Debriefs provided much of our learning and is partly why we are the best air force in the world.


As a medical student, I initially was very surprised at how rarely I saw medical professionals try to debrief. I’ve had some brilliant and caring internal medicine physicians ask me what I’ve learned from the day or if I had any questions. The surgeons I worked with were mostly willing to answer my questions during or after a case but I never saw them sit the surgical team down to discuss how things had gone. At my teaching hospitals, there are weekly classes but they only focus on a few past patients.

Everyone points towards medicine’s Morbidity and Mortality (M&M) conference as a way to debrief tragic cases.1 I’ve only had the opportunity to attend one in all four years of medical school. A scared and embarrassed 1st year resident spent 30 minutes talking about a misdiagnosed patient that surprised his team by dying. There was no root cause analysis and only a cursory discussion of what could have been done better. This hour has amazing potential and should have been a brief description of the facts followed by a directed investigation of what had gone right and wrong. Finally, it was an opportunity for a now-smarter intern to teach better techniques and for senior instructors to pass along nuggets of wisdom.

learnleadsuccessdiceAmy Edmondson published an article in the Harvard Business Review 15 years ago about a study of surgical teams trying to learn how to implement new techniques. Her study found that “debriefs, project audits, and after-action reports so often cited as key to learning weren’t pivotal to the success or failure of the teams.” To be fair, the researchers noted that debriefs were rarely done so its hard to say they wouldn’t help. What flipped on the light bulb for me, however, was when they noted “successful teams engaged in real-time learning.”2

I realize now that it was our culture of learning and constant improvement that made us better pilots. Debriefing is crucial for us but only one of the tools we use. We also studied on weekends, listened to stories from the old guys, competed and went through training upgrades. Medicine doesn’t need to have debriefs after every procedure. The day is already packed. But the physicians and health teams do need a culture that demands constant improvement and provides regular and disciplined learning.

When your world is moving along at 300-700 miles per hour, people are shooting at you and your fuel gauge is racing towards empty, it is a challenge (deadly) to stop and analyze a decision or a maneuver. That is why debriefs were so critical; they gave us a stationary seat and fresh coffee to absorb what we had just done. The flight lead took the team through a root-cause analysis and a review of what could be done better the next time. We needed this hour, (or often much longer) to slowly peel back our crazy 90-minute flight.

A surgeon repairing an inguinal hernia on a 50-year-old dude is not racing unless something has gone terribly wrong. She has time to look at each incision or suture and talk about what they could do differently or better. She can fix the mesh patch she just inserted immediately if it isn’t flat and she can restart the medical student’s sutures if they are sloppy. This is why real-time learning can be effective. A hospitalist will see their patients each morning to ensure that they are healing. If not, they can try something different or even ask other providers for suggestions. They don’t need a formal debrief unless a case is particularly challenging, extended, unusual or surprising.


A “heritage flight” with P-51, F15E, F-4, A-10

Establishing a learning culture requires a disciplined and measured approach. Providers must start with stated objectives for the day, the procedure or the patient. They must be prepared to compare their team’s actual performance to these objectives. Finally, they must have a way to both learn from unintended outcomes or mistakes and to teach all team members how to improve the next time. This can be done during the patient visit or after but should always happen.


This is not easy, particularly if its not part of the culture. Don’t assume that all “smart” doctors and providers are already doing this!

An active approach to learning, whether in real-time or a debrief, can make the provider teams better. A disciplined approach to team learning can provide continuous improvement.



  1. Gawande A. The Checklist Manifesto: How To Get Things Right. New York: Metropolitan Books; 2009.
  2. Amy Edmondson RB, Gary Pisano. Speeding Up Team Learning. Harvard Business Review. 2001.



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