Tactical Medical Leadership

Medicine is intrinsically tactical.  At its core are the single patient and provider in an exam room, at the hospital bed or in the operating room.  The expert clinician is recognized to be expert primarily by his or her tactical prowess.  It is true that the successful provider eventually learns that operational coordination with the health care team across the boundaries is essential for optimal care outcomes. But it begins with the tactical exercise of one-on-one clinical care.

It is also true that at some level, strategic leadership is everyone’s business.  Determining personal “strategic” goals and objectives both personally and professionally should be every leader’s priority. But in a health care system, overarching strategic planning is the purview of the CEO, the board of directors and for the military, the colonels and generals.  Operational leadership fosters coordination between services and departments.  This role belongs to vice presidents, deputies, chairs and chiefs, and to our majors and lieutenant colonels.  Their work is coordinating between services and corps to get work done across different disciplines.

But all of these more senior leaders enable the work of the clinician, the nurse, technician and provider, our enlisted or our junior officers.  These are our specialists, lieutenants, captains and the younger majors– at the bedside, in the OR and the clinic.  If American medicine in general and military medicine in specific are leaning forward at the very precipice of rapid evolutionary or even cataclysmic change, it is these tactical officers who will lead us forward.  So to these staff members belong the future of medicine.  They are the backbone of our clinical systems.  As a lifelong student of leadership, how can I advise them?  To you graduates, how can I encourage you to focus your energy?  How can you become the very best leaders in your “spheres of influence?”  I think that the key will be for you to focus on these three things:

Competence.  First, you must excel at what you do.  Our patients and your peers assume that you are competent. You have to be more than that honestly, because to say a provider is “competent” is tantamount to an insult. You have to be the very best that there is in your specialty.  You must go beyond being just board certified and be the very best. This level of competence goes beyond just being good at doing what you learned how to do.  You should always be looking for better ways to do things. Don’t become married to the ways things have been done, no matter how persuasive your mentor.  Just because it works doesn’t mean it works the best.  Every shred of evidence-based medicine has taught us that we must constantly seek the best, most efficient, highest quality – and least expensive and least variable – way of executing your clinical processes. Find it.

Brent James, the Intermountain Health Care System Quality Chief recently presented this notion in an article in that described his organization’s efforts to improve quality (Health Affairs June 2011).  His team systematically examined every single process in their health care system in a search for best practice and to minimize variation.  For example, after careful study they introduced formal universal criteria for the elective induction of labor.  Nursing staff used a clinician-developed checklist for every case.  If a scheduled elective induction failed to meet these minimal criteria, the clinician was required to obtain permission from the Department Chief to proceed.  This simple step decreased the rate of inappropriate inductions from 28% to 2%, allowing 1500 more babies to be born a year system wide by assuring that mothers spent a shorter time on average on the L&D deck and on the postpartum ward.  It also affected the cesarean-section rate which declined from 34% to 21% across the system.  The efforts saved $50M a year in unnecessary health care cost.  There is a better way.  Find it.

Remember that control in medicine is not “C2” as we know it: a matter of “command and control” or even simply just knowing the chain of command.  Rather, the medical leadership requires “collaboration and communication” between different disciplines with humility.  As a young general pediatrician, I learned that when children with asthma presented to the ER with a flare of their symptoms, if you were going to prevent their return the next day, you had to do more than the shot of subcutaneous epinephrine.  We learned to “ask ourselves why” and then “do something different.”  I challenge you to do the same for all of your clinical processes.  Be competent, but go beyond competence.

Character.  Character is the combination of talents, traits and values that define who you are.  Never forget that you can always choose the kind of person and the kind of leader you want to be.  You both shape and are shaped by the circumstances you encounter and the decisions you make. In medicine, especially in training, this is can be challenging.  Daniel Goleman, one of the pioneers in recognizing the centrality of emotional intelligence to leadership, has argued that the foundation of leadership skill rests on the leader being self-aware and having the ability to self- manage.  Self-awareness and self-management are the key elements of a character that is apparent to others.  This last part is crucial because people will judge your character not by what they have heard about you necessarily, nor by what you say, but by what they see you do.

Viktor Frankl, was a psychiatrist who survived the Nazi concentration camps at Theresienstadt, Auschwitz and Turkheim.  His parents had perished at the same camps, and his wife at Bergen-Belsen.  He said that “the last of all human freedoms is the ability to choose how one will respond to any given circumstance.”  We can choose how we will respond.  We can choose our character and we can choose what others see of it.

Doctor Atul Gawande, medical writer and author of Complications, The Checklist Manifesto addressed the Harvard Medical School graduating class this year.  In his address, he quoted observations made by Dr. Elias Zerhouni, who left Johns Hopkins to lead the National Institutes of Health.  In 1970, while he was a senior hospital leader at Johns Hopkins, Dr. Zerhouni calculated the number of clinical staff required to the care of their typical hospital patient.  He found that care required 2.5 full-time equivalent doctors, nurses, and ancillary staff.  Thirty years later, it was more than fifteen full-time equivalents.  Gawande conjectured that it is probably even higher today.

Medicine is a tag-team sport.  The days of the cowboy have given way to the pit-crew according to Gawande.  The oil of effective team leadership and functioning is character.  Men and women of character, who know and live the meaning of veracity – the passion to do and say what is right, and loyalty demonstrate the kind of leadership that will be able to forge the teams necessary to invest in the disruptions that are looming in American healthcare.  Abraham Lincoln said that “character is like a tree and reputation like a shadow. The shadow is what we think of it; the tree is the real thing.”  Lead with character.

Consistency.  Early in our time living in Hawaii attended a wedding of the daughter of a local friend.  It is traditional for the bride and groom to give speeches as part of the celebration.  On this afternoon in a pavilion on Pearl Harbor, the bride thanked her family and friends for “being there” for her during the difficult years of her young life.  “Being there” is a lesson we can all learn.  It means as leaders that we are reliable, dependable and predictable.  It is the essence of the most popular of all leadership words: integrity.   To have integrity means that there is congruence between the story I tell myself and the story I find myself in.  What I say about me and what you see about me are the same.  Integrity is the foundation of trust in any relationship.  And if “relationship” represents the economy of life, trust is most certainly the currency of that economy.  Whatever else we bring to the operating room, the examination room or the hospital bedside, if we don’t being the kind of trust that is rooted in consistency, then what we are bringing will not accomplish the kind of outcomes we want.  Our patients will not adhere to our recommended regimens.  And our peers and subordinates will not follow.

It is imperative now more than ever for you to get this right.  All over military medicine we are embroiled in change.  In San Antonio, enlisted medics from all of the Services now share joint elements of their training in what may be the biggest integration and building initiative in military medical history. Recently I read the legislation that has been introduced to Congress as part of the Defense Authorization Act directing the establishment of a Unified Medical Command under a medical four-star flag officer.  It may not clear committee, but it speaks to change.

In Washington, we are working through the last months of an ambitious building and renovation project at Bethesda and Ft. Belvoir – a cost of more than two billion dollars and two million square feet of new construction.  We are in the final stages of what has been an arduous merger between Walter Reed and the National Naval Medical Center.  There is much work to be done in our last weeks.  But I have no question that the merger will be successful, because I know that the leaders like you at the ground and deck plate level will make it happen.

Competence.  Character.  Consistency.  The foundation of the kind of tactical leadership that the AMEDD, BUMED, Air Force Medicine and Joint future states will need to help us negotiate the stormy seas ahead.  If you asked me how I thought we were going to be successful at keeping out eye on the ball through the looming change, I would tell you it is by remembering “why.”

True confession.  The year before I left Hawaii I was in the beginning stages of securing a job at a local Honolulu hospital.  The plans were taking shape for a retirement one year later.  I found myself paging through the physician directory one evening and wondering why these doctors had chosen to work at this civilian institution.  And it struck me: they don’t have a single “why.”  Their “why’s” are almost innumerable. It is not a slight of their system, but simply a statement of fact for a civilian organization and a real challenge for civilian leaders.

In uniformed medicine, we do not have that difficulty. And if you ever wonder, listen to your patients’ stories.  Your patients, each one of them, are telling you a story today about their lives, their struggles, their pain and their passion. And all you have to do is ask them, and listen.

On labor and delivery today there is a mother of three about to deliver her fourth child. Her husband is back in Afghanistan and he was only home from his last deployment long enough for her to realize that he was no longer the man she married. She brings this child into the world without him at her side. She wonders whether he will ever really be there again. Amidst the joys of childbirth, she is petrified that she will have to raise these children alone.  Listen to her story for even a moment. And you will remember why.

In the ER, the veteran whose infected finger nail you are treating flew B17s in World War II. He appears much younger than his eighty five years so you might not think to ask why this retired lieutenant is eligible for care. He wants to tell anyone his story of the proudest, most meaningful moments of his life spent over the skies of Europe as a young man. Listen to his story.  And you will remember why.

In the Orthopedic Clinic sits a young man with hollow eyes whose back hurts, but whose real pain is the loss of his closest friend. He aches as Achilles before Patroclus’ pyre but he has never told a soul. And what’s more, he has never come to terms with the haunting images that stalk his dreams every night; of young men seen through his M4 scope.  He sees their eyes in his memory even still. Yet no one has ever asked him. And he dares not tell. Listen to his story.  And you will remember why.

The power of the human experience is woven into the tapestry of each patient’s narrative, and it is in those stories that we will always find our “why.”  I implore you to never stop listening.  That mother can deliver her baby at Inova.  The veteran can get his finger treated at Kaiser and the young man can see an orthopedist downtown.  But none of those providers will think to ask the questions that are second nature to you. None of them will hear the stories.  You know to ask because you will have been there too and you will be there again.

And I can promise you that if you don’t stop listening, if you continue to find delight in speaking with that young mother waiting for her records, the five year old who just braved his “shots” or the Red Cross volunteer, a retired Army Nurse who helped liberate the last concentration camp in World War II – I can promise you that you that you will never lose sight of why.

This is my third decade in uniform.  It is no exaggeration to tell you that I am convinced that the future of my Army, my AMEDD – and now even my BUMED – rests squarely on your shoulders, and the shoulders of men and women like you graduating from programs across the country today.   Selfishly I know that one of you may care for my first grandson or daughter born at an Air Force Base, or my son if he were ever to be wounded overseas, or my wife as a retired dependent family member.  You are all charged to care for our system – one I solemnly believe is the very best, most integrated example of an “accountable health care organization” in the world.  Most importantly, you are charged with the care of America’s sons and daughters.  It is an honor for me to pass on our business and our patients to you in a covenant of duty and trust, and to see you on your way.

When I think of you and the career ahead of you, I can find no better words than those of Ralph Waldo Emerson,

“So nigh is grandeur to our dust,
so near to God is man,
when duty whisper’s low “thou must”
and youth replies “I can.”

Pro cura militis – for the care of the Warrior.
Chuck Callahan, https://henryv43.wordpress.com