Flattening the hierarchy

What fellows can learn about leadership from aircraft crews


Fellowship is a time of great growth for pediatric hospital medicine fellows as clinicians, educators, scholars, and as leaders. Leadership is a crucial skill for hospitalists that is cultivated throughout fellowship. As fellows, we step into the role of clinical team leader for the first time and it is our responsibility to create a clinical and educational environment that is safe, inviting and engaging.

Dr. Brandon Palmer, Children's Hospital Los Angeles

Dr. Brandon Palmer

For possibly the first time in our careers, pediatric hospital medicine fellows are expected to make final decisions, big and small. We are faced with high-pressure situations almost daily, whether it is a rapid response on a patient, tough diagnostic and therapeutic decisions, difficult conversations with families, or dealing with challenging team members.

Soon after starting fellowship I was faced with a such a situation. The patient was a 6-month-old infant with trisomy 21 who was admitted because of feeding difficulties. They were working on oral feeds but required nasogastric (NG) feeds to meet caloric needs. On my first day on service, the residents indicated that the medical team desired the patient to have a gastrostomy tube (G-tube) placed. I was hoping to send the patient home for a few weeks with the NG tube to see if they were making progress on their oral feeds before deciding on the need for a G-tube. However, the patient’s parents pulled me aside in the hallway and said they were considering a third possibility.

The parents felt strongly about a trial period of a few weeks without the NG tube to see if the patient was able to maintain adequate weight gain with just oral feeds. The bedside nurse reiterated that the family felt their concerns had not been considered up until this point. As the fellow and team leader, it was my job to navigate between my resident team, myself, and the family in order to make a final decision. Through a bedside meeting and shared decision making, we were able to compromise and negotiate a decision, allowing the patient to go home on just oral feeds with close follow-up with their pediatrician. Afterwards, I found myself searching for strategies to be a better leader in these situations.

I found a potential answer in a recent article from the Harvard Business Review titled “What Aircraft Crews Know About Managing High-Pressure Situations.”1 The article discusses crew resource management (CRM), which was developed in the 1980s and is used in civil and military aviation worldwide. CRM is based on two principles to improve crisis management: The hierarchy on the flight deck must be flattened, and crew members must be actively integrated into the flight’s work flows and decision-making processes.

The authors of the article conducted two different studies to further understand CRM and its effects. The first study included observing 11 flight crews in emergency simulations. In the study, the flight crew had to react to an emergency, and then conduct a landing of the aircraft. What the authors found was that the captain’s style of communication had a major impact on crew performance in two major ways: Crews performed consistently better under times of pressure when the copilot was included in the decision-making process, and captains who asked open-ended questions (“How do you assess the situation”) came up with better solutions than captains who asked “yes or no” questions.

The authors conclude that “involving colleagues as equal decision partners by asking them questions…aids constructive, factual information exchange.” The second study consisted of conducting 61 interviews with flight crew members to better understand crisis management. In the interviews, the same theme occurred, that open-ended questions are vital in all decision-making processes and may be preventative against dangerous or imperfect outcomes. As fellows and team leaders we can learn from CRM and these studies. We need to flatten the hierarchy and ask open-ended questions.

To flatten the hierarchy, we should value the thoughts and opinions of all our team members. Now more than ever in this current COVID-19 pandemic with many hospitals instituting telehealth/telerounding for some or all team members, it is essential to utilize our entire “flight crew” (physicians, nurses, therapists, subspecialists, social worker, case managers, etc.) during routine decisions and high-stake decisions. We should make sure our flight crew, especially the bedside nurse is part of the decision-making process.2 This means we need to ensure they are present and given a voice on clinical rounds. To flatten the hierarchy, we must take pride in eliciting other team member’s opinions. We must realize that we alone do not have all the answers, and other team members may have different frameworks in which they process a decision.

Finally, in medicine, our patients and families are included in our flight crew. They too must have a voice in the decision-making process. Previous studies have shown that patients and families desire to be included in the decision-making process, and opportunities exist to improve shared decision-making in pediatrics.3-5 Lastly, we should commit to asking open-ended questions from our team and our patients. We should value their input and use their answers and frameworks to make the best decision for our patients.

I wasn’t aware at the time, but I was using some of the principles of CRM while navigating my high-pressure situation. A bedside meeting with all team members and the patient’s family helped to flatten the hierarchy by understanding and valuing each team member’s input. Asking open-ended questions of the different team members led to a more inviting and engaging clinical and learning environment. These strategies helped to lead our team into a clinical decision that wasn’t entirely clear at first but ended up being the best decision for the patient, as they are now thriving without ever requiring supplemental nutrition after discharge.

As physicians, we have learned a lot from the airline industry about wellness and the effect of fatigue on performance. It is clear now that we can also learn from them about clinical decision-making and leadership strategies. When adopted for health care, CRM principles have been shown to result in a culture of safety and long-term behavioral change.6,7 If we can model ourselves after the airline industry by following the principles of CRM, then we will be better clinicians, educators, and leaders.

Dr. Palmer is a second-year pediatric hospital medicine fellow at Children’s Hospital Los Angeles and is working toward a masters in academic medicine at the University of Southern California, Los Angeles, with a focus on curriculum development and educational scholarship production.


1. Hagan J et al. What Aircraft Crews Know About Managing High-Pressure Situations. Harvard Business Review. 2019 Dec.

2. Erickson J. Bedside nurse involvement in end-of-life decision-making: A brief review of the literature. Dimens Crit Care Nurs. 2013;32(2):65-8.

3. Richards CA et al. Physicians perceptions of shared decision-making in neonatal and pediatric critical care. Am J Hosp Palliat Care. 2018;35(4):669-76.

4. Boland L et al. Barriers and facilitators of pediatric shared decision-making: A systematic review. Implement Sci. 2019 Jan 18. doi: 10.1186/s13012-018-0851-5.

5. Blankenburg R et al. Shared decision-making during inpatient rounds: Opportunities for improvement in patient engagement and communication. J Hosp Med. 2018;13(7):453-61.

6. Kemper PF et al. Crew resource management training in the intensive care unit. A multisite controlled before-after study. BMJ Qual Saf. 2016;25(8):577-87.

7. Sax HC et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-7.

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