Evidence-Based Practice, Air Warfare, and the Importance of Asking the Right Questions

Bernardo Schubsky, MD, MSc


October 12, 2021

As healthcare professionals and students, we are constantly being faced with new situations and challenges, but how can we be sure we are keeping the spirit of inquiry alive? The path of least resistance is logically to assume the information we already know is accurate. Or to simply accept that what is being presented by our professors and peers is the best answer.

That approach can lead to the terrible confirmation bias, where we repeat a behavior just because we are used to it, without ever coming back to the basics. But, of course, that is not the best way to consolidate our long-term memories — if we are studying — nor guarantee an effective evidence-based practice if we are clinicians.

And then you are probably asking: Where does the connection between healthcare and air warfare lie?

And here we go!

During World War II, the mathematician Abraham Wald was tasked by the Royal Air Force (RAF) to analyze the bullet holes pattern distribution on the planes that returned from the fight zones and select the most hit areas to determine where to position the armor plates better. Because the aircraft needed to be as light as possible, the goal was to reinforce only the areas that were most hit, to increase the odds of survival.

But Wald realized that the question being asked was profoundly wrong, and the subjects he was tasked to analyze were not correct. To begin with, the planes that he was investigating the pattern of bullet holes distribution were the ones that returned, not the ones that crashed. Tracing a parallel with healthcare, he was not asked to analyze the group that needed treatment. He was asked to examine the group that didn't need the intervention. Hmm, that is intriguing…

His creative approach to overcome the issue was to get back to the basics: Why is the RAF requesting to analyze patterns of bullet holes?

Wald reformulated the question objectively to "How can aircraft survivability be increased without having access to the crashed planes?"

He then analyzed the pattern of "fewer holes vs no holes" and realized that most of the holes correlated with vital structures of the planes, such as fuel tank or engine components.

Wald's method was used again in subsequent wars, becoming the standard analysis method on aircraft survivability.

The lesson is that we should always keep a kindle of inquiry alive and not be satisfied with the most straightforward explanation to every new issue we face. We should be eager to understand the why before the how during our classes. And even if the data presented are still the best information available, we already took a massive leap in understanding and consolidating our knowledge by changing our mindset from passive to active learners.

By taking our brains out of our comfort zone, we enable ourselves to make more connections and store the information in our long-term memories. And in the future, if we are faced with an opposing point of view, it will be easier to recall that previous information and compare it with the new one, formulating further questions and continuing the virtuous cycle of learning.

The practical tip here is to always show up to every lecture and clinical discussion prepared with a bit of information and many questions. During the class, most of the questions will be answered naturally, solidifying our connections. The questions that were not addressed are the ones that will be able to take us to the next level and allow us to advance in our studies.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube

About Dr Bernardo Schubsky
Bernardo Schubsky graduated as a physician, with a master's in healthcare education. He is currently pursuing a PhD in the same field. Connect with him on LinkedIn


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.