SGEM Xtra: Lead Me On – What I Learned from Top Gun - The Skeptics Guide to Emergency Medicine

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Date: October 5th, 2022

Reference: Top Gun 1986

Guest Skeptic: Dr. Chris Carpenter is Professor of Emergency Medicine in the Department of Emergency Medicine at Washington University in St. Louis and co-wrote the book on “Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules”. Chris will be moving to Rochester, Minnesota soon to become the Vice Chair of Implementation and Innovation at the Mayo Clinic.

This is an SGEM Xtra episode about what we learned from the 1986 movie Top Gun. It is similar to the episode with kindness guru, Dr. Brian Goldman, on how Star Trek made us better physicians.

When Top Gun Maverick was released on Memorial Day Weekend May 27th, 2022, I hosted a weekend extravaganza. This involved watching the original movie, playing beach volleyball and then seeing Top Gun Maverick. It was an epic weekend with friends from around the world. Chris Bond from Standing on the Corner Minding My Own Business (SOCMOB) and I even stood up and sang She’s Lost that Lovin’ Feeling at the local movie theatre. You can click on this LINK to see the performance.

Chris Carpenter was booked to attend the Top Gun long weekend but COVID had other ideas. He tested positive a few days before the extravaganza. Chris did not want to become a citizen of Canada for two-weeks in isolation, so he stayed home and missed the fun.

We were back together again at ACEP22 in San Francisco. Each year we co-present at the Rural Section meeting. This year we reviewed ten recent publications, provided some critical appraisal of the studies and then discussed if the evidence would be applied differently in a rural or critical access hospital compared to a tertiary or urban centre. You can download a copy of our slides at this LINK.

Being together again for the first time since 2019 was a great opportunity to record the Top Gun SGEM Xtra episode. There are so many different lessons/takeaways from the movie and we covered eleven (my second favourite number).

Lessons Learned from Top Gun

1) Be Prepared To Fail: Lieutenant Pete Mitchell (Maverick) takes risks and sometimes they work and sometimes they do not work. He dropped below the hard deck to get the kill shot during a training session but was reprimanded. Maverick also took a chance in the bar and tried to sing She’s Lost that Loving Feeling.

Lieutenant Commander Rick Heatherly (Jester): “That was some of the best flying I’ve seen to date — right up to the part where you got killed.”

Working in the emergency department mean you will fail (make some mistakes). You need to learn from these experiences and not let previous failures prevent you from trying. It’s not the falling down that is the most important, but rather the picking ourselves up.

2) Never Leave Your Wingman: Maverick comes into Top Gun a bit of a loner. Only real friend is Lieutenant Nick Bradshaw Goose. He needs to learn to work together in a team. Have your team’s back (RNs, techs, docs, admin, etc). Early in the movie he helps a fellow pilot land his plane.

Commander Tom Jardian (Stinger): “Maverick, you just did an incredibly brave thing. (Pause) What you should have done was land your plane!

Maverick also leaves his wingman at one point at Top Gun while in a training session and loses. Later in the movie he stays with his wingman in combat and is successful. This leads to the exchange between Iceman and Maverick

Lieutenant Tom Kazansky (Iceman): “You can be my wingman any time.” Maverick: “Bull—-! You can be mine.”

Working in an emergency department takes teamwork and you need to be there for each other. This will be discussed further.

3) Asking for Permission: Sometimes it is better to ask forgiveness than permission. Maverick asks for permission to buzz the tower. He is told no but does it anyway.

Maverick: “Requesting permission for flyby”. Air Boss Johnson: “That’s a negative Ghostrider, the pattern is full.”

Maverick and Goose get in trouble for this and learns another valuable lesson. Don’t disobey orders.

Remember to put patient care at the centre of your decision making. This means at times you might be treating first and asking for permission from administration later.

4) Lack of Knowledge or Attitude: What gets us into trouble is often not our lack of medical knowledge (or our capacity to absorb new knowledge into our clinical armamentarium), but rather our attitude.

Iceman: “Maverick, it’s not your flying, it’s your attitude. The enemy’s dangerous, but right now you’re worse. Dangerous and foolish. You may not like who’s flying with you, but whose side are you on?”

As clinicians, scientists and healthcare leaders, we need to have an attitude that we are a team working together for patients.

5) Time to Think: Often in EM we do not have time to think. We need to make life and death decisions at times quickly on limited information. This is why training and high-fidelity SIM training can be helpful.

Maverick: “You don’t have time to think up there. If you think, you’re dead.”

6) Thrive in a Chaotic Environment: The emergency department is often a very chaotic environment. Multiple things happening at the same time can distract us from a patient-centered and empathetic approach to care. Constantly being interrupted. Density of decision making. Cognitive load. An ever-expanding tethering to computers to document more in the electronic health record. The pressure (personally, professionally, legally) to be correct all the time. But we love it.

Charlotte Blackwood (Charlie): “You’re not going to be happy unless you’re going Mach 2 with your hair on fire.”

7) Back Story: Everyone has a back story. We know little about each other. Everyone is potentially fighting a battle we know nothing about. It could help explain and understand certain behaviors. Maverick was struggling with many things but one of them was living in the shadow of his father’s reputation as a navy pilot.

Goose: “Every time we go up there, it’s like you’re flying with a ghost.”

8) Teamwork: Optimal emergency care requires a great team working together. This is what was demonstrated in Top Gun. It is not only the pilots that need to perform at a high level but also all the team members that get them in the air, stay in the air and land safety. We could not do what we do without nurses, techs, support staff, etc. And the mission of Skeptics’ Guides to shorten the Knowledge Translation (KT) window also requires an exceptional team of medical educators, local opinion leaders, researchers, and Implementation Science experts to be successful. You can learn more about the power of teamwork in Dr. Brian Goldman’s book on the subject.

9) Communication: Good communication is such an important aspect of a highly functional team.

Maverick: “Talk to me Goose”

10) Clinical Judgment: Where it exists, this is the evidence that informs our care and guides our care, but it should not dictate our care. We need to assess the potential benefits and potential harms and apply the evidence using our clinical judgement and in the context of the situation and the individual patient’s priorities and preferences.

Charlie: “A rolling reversal would work well in that situation.” Maverick: “If I reverse on a hard cross I could immediately go to guns on him”. Charlie: “Yeah, but at that speed it’s too fast… a little bit too aggressive.”

11) People Still Die: You can do everything right and still patients will die. This is an important lesson to learn in medicine. We try to do our best but everyone will eventually die and you might be the last physician to have contact with that person. Doing the right thing and not committing any errors can still result in a patient dying. This is what happened when Goose died and Maverick was cleared of any wrongdoing.

Anything else you learned from watching Top Gun in 1986 compared to re-watching it in 2022?

Lt. Chris (EBM) Carpenter

I was able to see Top Gun Maverick on Father’s Day when my college-age children were in town for the weekend. They fooled me by telling me that we were going to see a Pixar movie and then walked me into the Top Gun theater. As I sat there on Father’s Day 2022, I noticed a philosophical tear emerging from me emotionally. I had seen Top Gun as a soon-to-be college Freshman in 1986 at a time when I felt young and certain of my worldly knowledge – and completely invincible. Maverick was me and he was always on the moral high ground in every scene.

Fast forward to 2022 and I saw Maverick realizing that he had at times been unnecessarily careless and wanted his students to learn from his mistakes. With great power comes great responsibility and sometimes that means deviating from the norm, taking a different path that may be less fun or a little more arduous. Stinger, Jester, and Viper were not trying to hold Maverick back or suppress his talents, they were trying to keep him alive and help him to see that the squadron working as a team was stronger than any individual on that team. As an older pilot in Top Gun Maverick, he had realized those lessons and helped the team survive impossible odds to succeed.

Top Gun Maverick is ultimately a movie about maturing into adulthood and finding redemption for our past mistakes. None of us wants to be wrong, but all of us sometimes are. That’s life. While we still have today, we should absorb those lessons, take a deep breath and step into tomorrow with courage, humility, and the ideals that we value. Carpe diem.

The SGEM will be back next episode trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. The ultimate goal being for patients to get the best care, based upon the best evidence.