Culture is one of those words that everyone uses but can't define. There is pop culture or the culture of another country. There are cultures within cultures. For the anthropologist, culture is the sum total of all things that make up a way a people live that is transmitted to the next generation.

John Nance, a former Air Force lieutenant colonel and airline pilot, goes around the country speaking about the transformed culture of flying airplanes safely and the current clinical culture of crashing. He landed at our new hospital to talk about the difference between the culture of leadership and the culture of command.

The occasion was the very first meeting of the medical staff of a brand-spanking-new hospital. It was like the flight crew coming together for that pre-flight briefing one sees in the movies. The dashing pilots in their flight gear gather, first slowly, then the top gun steps to the podium and begins, "Gentlemen, our mission today is ...."

On this occasion, Nance gave the assignment to be something different than we had been trained, schooled, and cultivated to be. We were told to abandon our traditional culture of commanding the medical or surgical ship by control and intimidation.

The airline industry and culture since the 1970s have completely changed, especially in the cockpit. Before, the captain was king. Contradict and you die, was the motto. The pilot was earthly deity airborne. Intimidation was the rule of the day. What the boss said went. The problem was that sometimes the whole plane, including passengers and crew, went into the ground or a mountain because someone else didn't speak up.

The results were disastrous. There were problems in communications, perceptions and assumptions. There was a National Guard transport in which the pilot said, "Take off power," meaning he needed more thrust to clear the obstacle, and the result was that the engineer took off the power, crashing the plane. There were the errors of perception of trained professionals not seeing the flaps in the wrong position. There were assumptions in the cockpit that the runway was clear, when in reality, a big 747 was literally dead ahead. Death followed.