Elite Flyer Teaches Family Physicians to Soar at FMX 2024

Use Headwinds

Change is a lot like a headwind, Malachowski said — an inevitable force that can create friction and limit action but also allow flight.

“There are two times we pilots will seek out and turn into headwinds: takeoff and landing,” she said. “Aircraft use headwinds to make these smoother, safer, more efficient.”

Metaphorical headwinds, she added, also have their uses.

“With the right mindset, we can harness the headwinds,” she said. “To overcome self-doubt and cope with change and deal with the unexpected in life, the idea is to find the advantages in headwinds.”

Case in point: Malachowski’s path to becoming Thunderbird No. 3, right wing, the show squadron’s first woman.

“There were headwinds all along the way,” she said, and they started with her own nagging doubts, despite her skills and achievements. Then she steered into that force.

“The voice in my head had always told me, ‘Other people become Thunderbird pilots, not you.’ But in 2005, as I was preparing for another combat deployment, I had every single qualification you could have, and a light bulb went on in my heart and my mind. Why not me?”

Now, she said, came a different headwind. The chorus of reasons why not came from outside her head as people kept telling her, “It’s hard to be a Thunderbird. You probably won’t get picked. There’s never been a woman Thunderbird.” The naysayers eventually included the colonel to whom she first submitted her application, hoping to secure his nod.

“I’m not sure we want to waste the recommendation,” he told her.

“What was coming out was the unconscious bias every one of us needs to check ourselves on every day,” Malachowski said.

She took back her application, apologized for taking up his time and left for the officer’s club, she recalled. And there, she later found herself in conversation with a general — who, once one of her fellow pilots blurted out the story of Malachowski’s rejection, would go on to help her join the Thunderbirds.

That general “gave me a great gift,” Malachowski said. “He looked at me, squeezed my shoulder and said, ‘Nicole, nobody wants to lead a scripted life.’ He lifted the weight of the world off my shoulders.

“It’s OK to challenge the status quo and risk failure. Don’t write yourself out of the script. Don’t write people out of their scripts. The power of our words can make or break somebody else’s dream.”

Malachowski tied this idea to family physicians mentoring future family physicians and managing care teams.

“Nothing of significance is ever accomplished alone,” she said. “Family medicine is a noble profession. You save lives. You give people back quality of life. You take care of communities. It’s honorable, noble and good. Don’t ever forget why you do what you do, and that it takes a team to make it happen.”

The Wingman Contract for Family Physicians

When Malachowski joined the Thunderbirds, she embarked on months of technical training that ultimately centered on a crucial intangible: trust.

“The No. 1 question I would get when we did air shows and people saw our jets fly three feet from each other was ‘What does it take to build that level of trust?’ It’s a phenomenal question. I could say that, just as in family medicine, it involves process and procedure, certifications and qualifications. It does, but the answer is this: You build trust by being trustworthy.

In the air, she said, this is the wingman contract.

“That phrase means everything to a fighter pilot. It’s the unspoken promise: I will hold myself accountable to this standard of excellence and hold you accountable, too. It’s who we are. We are each fulfilling a role, being the subject matter expert alongside our teammates. With our accountability and responsibility, the formation comes together.”

The wingman contract looks like different things on different teams, Malachowski said, including medical teams. But in any setting, when it’s applied to everyone equally, it enables and empowers efficient, smart decisions.

“Each and every one of you was called to a unique role because of your skills,” she said. “And you want people to call you because you’re trustworthy. When in doubt, always honor the wingman contract.”

It was at this point that Malachowski showed footage of her botched trail-to-diamond.

“The standard you walk past is the standard you’re willing to accept,” she said, remembering the moment when her fellow Thunderbirds said they would change the parameters of the roll to accommodate Malachowski. She was not willing to accept this lowering of the bar. She asked for help instead.

“My team stopped, and for two days we did that maneuver hundreds of times until I got it right. It was the right thing to do. It honored the wingman contract. My teammates stopped to help me. They did it from a place of caring and shared commitment.”

Malachowski pushed play again to show the formation executing perfectly. Then she earned a laugh: “As of two years ago, the Thunderbirds no longer fly this maneuver.”

Talking about help as part of the way toward trustworthiness, she urged family physicians to ask themselves: “Is what I am about to say or do in alignment with the wingman contract? I want to be out there with patients, making a difference, not calling a meeting every time a decision needs to be made. If I’m in alignment with the wingman contract, move out.

“You are compassionate, you are courageous and you are curious,” she told her FMX audience. “What kind of wingman are you and what kind of wingman do you want to be?”

Tickborne Illness: Recovery and Free CME

Over the past decade, Malachowski, who recorded an upcoming episode of the Inside Family Medicine podcast, required a different kind of help. And today she is a different kind of wingman, working to ensure that others get the help she needed (including treatment by family physicians).

In the summer of 2012, she was Lt. Col. Malachowski — commander of an Air Force squadron stationed in North Carolina, physically fit, at a career pinnacle — when she came down with what she thought was an off-season flu. But accompanying the aches and malaise was a rash, and within a couple of months (and after the first doctor she saw ruled out Lyme disease without testing for it, saying, “We don’t have Lyme in North Carolina”) her condition got worse. Much worse.

At FMX, on the day before her 50th birthday, she said the milestone was one she didn’t think she’d live to see.

“By Christmas and New Year’s, I had major neurological symptoms, word-finding problems, stuttering, slurring, dragging a leg. I had zero memory. I got lost coming home from work.” In a grocery store one day, she forgot what a grocery store was. She sat down in an aisle and wept.

In 2016, Malachowski was finally diagnosed. She’d been living with late-stage tickborne illness. An MRI revealed lesions on her brain. “Five separate tickborne pathogens” showed up in bloodwork, she said.

Flying was out of the question. In 2017, the Air Force mailed her medical-retirement papers; there was no ceremony marking her departure. Her career as she knew it was over.

By then, she had begun what would stretch to two years of treatment, recovery and rehab, starting with “nine months in bed, unable to talk, read or write.” She and her family — her husband, fellow Air Force veteran Paul, and their now-teenage twins — didn’t know whether she could, as one of her physicians put it, “make it all the way back.”

From this low, and on her way to making it all the way back, she learned to “yield to overcome.”

“I don’t mean quitting or giving up,” Malachowski said of this mantra. “I mean: What can you do right now to move forward with what you have? We all have the power to reinvent ourselves.” Bookending her headwinds metaphor with another aviation saw, she added, “The runway behind you is always unusable. All you ever have is the runway in front of you.”

Following her recovery, Malachowski steered into a different headwind, taking up advocacy for other patients suffering as she had. One result: The Air Force convened a task force to support personnel with complex medical conditions and appointed her to it. She’s also an advisory board member with the Dean Center for Tick Borne Illness at Mass General Brigham’s Harvard-affiliated Spaulding Rehabilitation Hospital, where she was treated. And her FMX presentation ended with a slide featuring a QR code for free CME on tickborne illnesses, including courses accredited by the AAFP. (Other accredited free CME on Lyme is available on aafp.org as well.) “It would be an honor and a joy if you did this,” she said.

“What gives your life meaning?” she asked her FMX audience. “What do you value and why? Why prioritize things a certain way? The human beings who can honestly answer these for themselves can more gracefully and completely harness headwinds.”

Family physicians can do more than harness them, she said. They can soar.

“You come to events like this to reconnect with each other and recommit to family medicine. It takes all of you together to guide this profession and to make this a better place to practice medicine.”