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First a confession. I practiced medicine in the military system for three decades. My only time in “civilian” health care were the three years of my pediatric fellowship at an urban children’s hospital and the last two years in my current (largely) administrative role. So I admit up front to a bias that comes from having spent the bulk of my post-pubertal life in uniform.

A second bias comes from being a pediatrician and working alongside pediatricians for much of my professional career, a group that my wife has identified as inherently nice people. (She has her own biases.) Although my last decade or so in uniform was spent helping to run military hospitals and health systems I still always gravitated towards uniformed pediatrics as a source of professional identity and perspective.

It from this biased perspective that I have recently considered some of the distinctly positive advantages of military medicine; advantages that remind me how good American medicine could be for all Americans.

For those who might wonder why we even have pediatricians in the Armed Services, military physicians have cared for the children of American service members for as long as the nation has had a standing military, peace to maintain and “frontiers” to defend. These conditions were first realized in the late nineteenth century during the wars against the Native American peoples of the North American west. For example, enterprising clinicians were cautioned in the 1884 Defense Appropriation Bill that “The Medical Officer of the Army and contract surgeon shall, wherever practicable, attend the families of officers and soldiers free of charge” (Potter. Mil Med. 1990;155:45).

American pediatrics and pediatric training in both military and civilian facilities emerged from the shadow of internal medicine in the early twentieth century (Callahan et al. Pediatr 1999;103:1298). The need for military pediatric care became urgent in pre-World War II America as the nation mobilized for war and families settled near the military bases where young men were inducted into the uniformed services. After the war, thousands of American service members were stationed overseas and many either started families in the communities where they were stationed or brought their families with them. In 1956, the “Dependents Medical Care Act” became law and mandated the provision of medical care for all military dependents wherever they were stationed. Today there are 9.4 million Americans in the Military Health System (MHS) including 4.2 million family members cared for in scores of uniformed clinics, hospitals and medical centers around the globe as well as in the civilian TriCare network.

Pediatricians have served in a variety of roles in every major armed conflict since the Spanish–American War (Burnett. Pediatr 2012;129:S33). In the current wars in the Middle East, the longest conflicts fought by volunteers in our nation’s history, pediatricians are among the most frequently deployed specialists serving in roles from battalion surgeons to hospital and health system administrators. Between deployments, uniformed pediatricians serve alongside civilian government service and contracted colleagues in a health system with features that should serve as goals for American healthcare.

Military medicine is longitudinal. Between job changes and shopping for new insurance under the Affordable Care Act, nonmilitary managed care plans suffer a 10-20% turnover every year. For some plans turnover may be as high as 30%. While retired military service members and their families who are eligible for care in military facilities tend to be stable, active duty families move approximately every three years. However they usually move to another military site with the same health benefits. Since the hospitals are in general managed centrally, the different sites are similar in the way they operate and in the outcomes that they follow.

In the United States’ volunteer military, as many as 40% of military service members had parents in the military. So many received care in military treatment facilities while they were growing up. In a real sense the children of today’s military members will be the core of tomorrow’s military force. Population health interventions directed towards children and adolescents by uniformed pediatricians who uniquely understand the military family can positively impact the future health of the American armed services, and could potentially affect the health of those who will one day receive care from the Veteran’s Administration.

Military medicine is part of a worldwide integrated healthcare system. My daughter (mentioned with her permission) has a chronic medical condition that has required surgery in at least six military and civilian facilities from Hawaii to Washington D.C. Since a single electronic medical record was fielded by the Military Health System nearly 15 years ago, all of her records from across the country were available in one electronic location for access by her pediatricians, pediatric specialists and surgeons. For all its foibles, the Armed Forces Health Longitudinal Technology Application (AHLTA) has established something almost without precedent elsewhere in the United States. It provides the opportunity to coordinate the primary and specialty care of individual patients who frequently relocate and it gives unique insight into the health outcomes of specific, well-defined patient populations. With these data, decisions for the allocation of healthcare resources can be made based on population needs and outcomes rather than merely healthcare supply or market forces.

Military medicine is equitable. For more than a century researchers have noted that the infant mortality rate (IMR) of black infants in the United States was at least twice that of whites (Brosco.  Pediatr 1999;103:478). For example in our nation’s capital, the IMR in Ward 8 which is poor and predominately black is ten times that of the more affluent and predominantly white Ward 3. In 1992, Army neonatologists published a review of fifteen thousand births at an Army medical center between 1985 and 1990 and demonstrated no statistical difference between IMR for black and white infants despite an increased rate of premature birth and low-birth weight in black infants (Rawlings et al. Am J Dis Child 1992;146:313). While the experience with the military population (i.e. employed, housed, educated, with access to food and resources) may not be easily generalized to the American public, the infants in this review shared the same thing that children cared for across the MHS enjoy today: stable social determinants of health and equitable access to high quality, low cost or free maternal and pediatric healthcare.

Military pediatrics is approaching its sixtieth anniversary. In 1959, the American Academy of Pediatrics executive board voted to approve a section on military pediatrics to advocate for the unique needs of the military child and to address the needs of the uniformed pediatrician. The original section included 25 members. Today more than 900 pediatricians are members of the section. They continue to serve and advocate for the military family.

These uniformed clinicians, their adult-focused counterparts, civilian government service and contracted colleagues belong to a healthcare system that the Nation might do well to pay attention to; one that is longitudinal, integrated and equitable. It is a system that should serve as an example: This is how good American healthcare could really be.

Chuck Callahan Henry V 4.3 – Lead from the Front      https://henryv43.wordpress.com/

Remarks to the graduating residency class, Eisenhower Army Medical Center, Augusta Georgia, June 9, 2017. Some of the material will be familiar to regular readers but struck me as the most important thing I could share with these accomplished clinicians, officers and leaders. 

Thirty years ago this June I graduated from my pediatric residency at Walter Reed Army Medical Center in Washington. That was a while ago. For reference, it was the last years of Reagan’s second term, the year the first Simpson’s episode was aired, the year Tim Tebow and Zack Efron were born. It’s practically ancient history. Many of the residents graduating this June weren’t born yet.

The ceremony was held on the great lawn in front of the main entrance of a building that has since been closed and abandoned. I was one of several hundred graduates and the highlight of my memories from the day are the few minutes in the crowd of graduates standing around at the veranda after the ceremony drinking punch and eating cake when we were briefly separated from our three year old son. We found him as quickly as we realized he was gone as we saw one after another of the men standing nearby startle and look down as someone tugged at their green polyester, black striped pant-legs and a little blond haired boy looked up and asked: “Daddy?”  “Daddy?”  “Daddy?”

I am certain that there was a speaker at my graduation ceremony. And I suspect that he probably gave a speech. But for the life of me I can’t remember who it was or what he said.  So I know what I’m up against. I also know the competition. I watched Will Farrell on YouTube as he give the graduation speech at USC this year. Three years ago when my daughter graduated from nursing school at the University of Miami Jimmy Buffett gave a great graduation speech. I wish I could remember what either of them said.

I do remember they made three or four points and I planned to do the same. But I thought about the risk of the audience remembering any of them let alone me remembering as I tried to speak without notes. Instead I decided to leave you with one. One point I’d like you to consider; something I don’t remember anyone mentioning to me when I was in medical school or residency but something that proved pivotal when I was practicing primary care, specialty care, as a hospital leader and also as father of seven, grandfather of four (almost five) and husband of 37 years this summer.

One early morning while I was working at the Ft. Belvoir hospital my daughter called me from Miami where she was attending nursing school. She was riding her bike (without a helmet I am sure) in the predawn darkness on her way to the train station. Her pediatrician father wasn’t happy about the circumstances. But she was heading to her first day of clinical rotations and had a question for me: “Dad, what advice do you have for me on my first day with patients?”

It caught me off guard, in part because I was a little worried about her on her bike in the dark on the phone. But it didn’t take me long to come up with an answer:

“Remember to look into their eyes.”

As a general pediatrician at Ft. Hood Texas in the late eighties (before the days of computers and electronic medical records) we were scheduled for acute patients every five minutes. A typical morning or afternoon seeing patients with acute problems included 36 encounters in three hours. The clinic was open every day of the year. Weekends and holidays one pediatrician worked for six hours and saw 72 patients and the other saw 36. There wasn’t much time to establish rapport.

Somehow – I think because of Grace as prayer was a part of my patient care – I realized that if I sat down in every visit, leaned forward, made eye contact and then mirrored the parent’s face with my own the patient’s perception of the visit was more positive and they were more satisfied that they had been heard. I also found it was a discipline to help me to really listen. I have since become aware of the research confirming all of these but especially the relationship of eye contact during a physician encounter.

Direct eye contact or intentional gaze is positively related to the patient’s assessment of the clinician’s empathy. Eye contact is significantly related to patient perceptions of clinician attributes, such as connectedness and liking. The shorter the visit, the more the percentage of eye contact time is an important indicator for the patient’s perception of empathy (Montague E, et al. Nonverbal interpersonal interactions in clinical encounters and patient perceptions of empathy. J Participat Med. 2013 Aug 14; 5:e33). Lots more could be said about the importance of eye contact with patients and families in the intensive care unit as well as the impact of the electronic record on our ability to make and maintain eye contact. And even when I was in West Africa caring for patients with Ebola where there was little language in common there was eye contact and touch – through three layers of gloves – to communicate empathy and compassion in the face of tragedy and loss.

As a pediatric department chief I also found eye contact to be critically helpful. I think the most important thing about morning report or morning huddle for a leader is that it gives you regular, repeated time to look into the eyes of your peers and subordinates and to become sensitive to subtle changes in affect or mood. One morning report one of the residents teased another of her peers in the audience during a presentation. After the laughter subsided, I glanced back and looking into the affected resident’s eyes I saw she was fighting back tears. I quietly picked up the phone on the wall next to me and paged her out of the meeting, then met her out in the hallway to allow her time to compose herself (which she did quickly). It meant a lot to me and must have meant a lot to her. I heard about the event from a friend of hers a decade and a half later.

As hospital CEO I found that looking into the eyes of patients, families and subordinates was an important part of the culture we were trying to create. We had a rotating “Focus Five” that our leadership team worked on and for a long time we concentrated on getting staff to only use their iPhones or Blackberries when they were “off stage” and not with patients. Specifically staff was encouraged not to look at their phones when they were moving through the organization or working at reception areas but to greet patients and peers and make eye contact instead.

Rushing to a meeting with a few deputies one morning we passed a young mother pushing her baby in a stroller. She was an acquaintance of my wife’s whom I had met once or twice before. Eye contact told me that something wasn’t right. “How’s it going?” I asked her. She said “Fine” but I could tell it wasn’t. I asked the “second question” (the one we don’t always take time to ask): “You don’t seem fine…?” Tears followed. Her husband was hospitalized and she was worried about him. We spent time together and I was late for the meeting I had been rushing to. It was time well spent.

We could spend hours talking about the importance of this principle to our families, especially in the age of iPhones. One of the most profound lessons I have learned in my life was taught to me by my three year old daughter when she was trying to talk to me while I was distracted doing something; reading the paper or some computer screen.  She took my face in her little hands, turned it towards her, made eye contact and said, “Daddy, wisten to me!” She knew if she had my eyes, she had my ears and my attention.

There is a phrase from the Northern Natal region of South Africa that I first read in a book by business guru Peter Senge.

“Sawubono” – “Sikhona”

“I see you” is the greeting. “I am here” is the reply.

I see you. I am here.

I have to tell you that being present with our patients and peers has never been more important. But I wouldn’t have stayed in military medicine, wouldn’t still be a patient in the system and wouldn’t support it if I didn’t believe that there was something unique about it. There is something our patients need that can be found in military medicine that may not be a part of the way our civilian colleagues think. It’s not what they normally see.

On any given day there is a woman on the labor and delivery unit of your military hospital having her second or third child, trying to raise her children while her husband recovers from his third or fourth deployment. He did not come back the man she knew and she wonders if he ever will.

If you pause for a moment and look into her eyes you will see something that our civilian colleagues might miss because you have seen it before. You have been there yourself. She needs something more than her baby delivered: “I see you. I am here.”

There is a soldier in our military orthopedics clinic with a painful knee that has seen far too much for his 28 years. He has lost his brothers in battle and he has lost a part of himself. If you look up from his knee for a moment and you look into his eyes you will see something that our civilian colleagues might miss because you have seen it before. You have been there yourself. He needs something more than his knee taken care of: I see you I am here.

Perhaps the most important thing we can take away from this day, from this graduation celebration at the end of one life-phase and the beginning of another is this commitment that will make us better physicians, better friends, better bosses, parents, spouses – for our patients, our peers, our family members and to those we will have the privilege to lead:

I see you. I am here.

Best to you always. To my military colleagues: Take care of our Army, our military.

Take care of our Warriors and their families.

Chuck Callahan Henry V 4.3 – Lead from the Front      https://henryv43.wordpress.com/

It was one of the most profound leader-lessons I’d heard in months and I am certain she didn’t mean it to be.  My colleague and I were paired off in an exercise to talk about our personal vision and goals as part of a fellowship in civic leadership I’m attending. She is the leader of a non-profit that focuses on caring for Latino families in our area. She knew that it was critical for her organization to be led by members of the community she was serving, and so she concluded that this was a time when she had to “lead from the back.”

I was nearly dumbstruck (not something that happens to me very often). For someone raised with the Army Infantry motto “Lead, follow, or get the heck* out of the way” and for whom “Lead from the Front” is this blog-site subtitle, her observation about leadership and practice were both profound and timely. We moved to Baltimore with the hope that we might in some way contribute to the community with very little idea what we could do or how.

My wife proposed before we moved that my leadership ethos “Ducere, Docere, Deservire” (to lead, to teach, to serve) might be better considered “Discere et Deservire” (to learn and to serve) during this period of our lives. But I am pretty sure that I was not completely buying it. And when I was honest I had to admit that I chafed at times at not being “in charge.” It had been a difficult transition from hospital director (where people always answered my emails) to hospital contractor (where amazingly my emails were not answered as quickly).

But there are seasons and reasons why leadership from the back of the room is important and I think my colleague’s comments were an awakening. One could argue that the most influential leader in Disney’s movie “The Lion King” was the crazy old baboon Rafiki rather than the brave, sagacious Mufasa or the impulsive, heroic lion Simba. Rafiki led from the back. There are advantages.

You can see the whole room unobserved. While everyone’s attention is focused on the leader, the speaker, or the problem at hand, if we pay attention we can watch the dynamics in the room from the back. We can see who is listening and who is on their iPhone; watch the body language and facial expressions. It is probably a better perspective to appreciate the context than the pressured position of the podium.

You are not responsible for the clock. In fact, the clock is probably behind you and the pressure of Robert’s rules and the timeliness of the agenda are someone else’s problem. (It’s especially relieving to an Myers-Briggs ENFJ for whom timeliness in meetings is a continual challenge anyway.) Instead of focusing on process the observer can notice interaction and outcome in ways you couldn’t from the head of the table or the dais.

You can observe the leader in context and provide feedback when solicited. One of the most valuable assets in leader development is having a “second chair on the balcony;” being able to look down on a set of circumstances with a trusted colleague and with the additional perspective, attempt to better understand sets of feelings or actions. Of course such feedback should in most cases be solicited, and if unsolicited is best left to positive, noncritical comments until more candor and critique is requested.

You can support the leader when the need arises. At ROTC summer camp in the late seventies the cadet physical training leader faltered on a relatively complicated 8-count exercise that I believe was called “the lunger.” I stepped in briefly shouting out the correct count until the leader got back on track and the platoon didn’t miss a beat. The supervising officer highlighted that event in my evaluation that day and I have since recognized it was an opportunity to support organizational success by stepping in briefly to lead from the back.

Finally there is an even greater opportunity nested in this philosophy, especially when I consider our current geographic location. For far too long, leadership in almost every setting has been assumed by people who look like me. Too often men with my “demographic” assume leader roles at the exclusion of women and members of other ethnic or racial groups.

In our West Baltimore neighborhood we are newcomers. And we are the minority. As much as I might think I know about leadership, I do not understand this context or the way the challenges have been shaped by the city systems and circumstances. While I bring perspective, I will never understand it as well as someone raised here. And perhaps there is a question of even greater importance: could my leadership discourage those in the community from leading because they don’t look like me and they don’t see any leaders who do? My role for now is to build and support. “The first duty of a leader is to create more leaders” (General Bill Creech).

I think I am going to have to become comfortable with leading from the back; to become more Rafiki than Mufasa. It is not natural for me, though at least the crazy part comes easy.

Chuck Callahan Henry V 4.3 – Lead from the Front      https://henryv43.wordpress.com/

First, I noticed it in conversations a year or two ago. Then I noticed it more, especially over the past several months. And then to my horror, I noticed I was doing it myself. Now I catch myself saying it often and I frequently try in vain to reel the little conjunction back, hearing echoes of the neonatology attending who once said to me after I made a particularly dumb comment on rounds, “Did you ever say something that you wish you could get back?” I nearly always regret starting a sentence this way:

“So…”

I am not the only one making these observations, and there seems to be a fair amount of heat being generated by the over-use of the word “so;” a little verbal pause before the answer to a question or response to another’s statement.

Another trend that seems to be happening with increased frequency in public discourse was pointed out to me by a colleague recently: the up-talk epidemic. It is the tendency to end sentences with an upward voice inflection as though asking a question, which according to one pundit is a decade old tendency that has now become so common in speech that it goes without notice.

It is a challenge these days for student-clinicians who often have to learn to use more definitive language in talking to patients about life and death matters: “Well, we think you have cancer?” It impacts other disciplines as well. Consider the financial advisor speaking to a client, “I think that this might be a solid basis for your financial plan?” the corporate leader providing feedback, “We think that you’re not meeting the standard?” or the combat leader speaking to his (or her) soldiers “I want you to take that hill?”

We teach leaders to attend to their inflection (pitch), amplitude and rhythm when speaking in public. And specifically to pay attention to verbal ticks or habit words, like “like” or “um.” The conjunction “so” has  come seemingly out of nowhere and now presses to overcome the habit-word pack in frequency as well as annoyance. And the unconscious tendency to up-talk undermines the leader’s ability to communicate definitively and with confidence.

Both of these trends reflect a fundamental change in the way we communicate with others. They are the spoken equivalents of the three little blinking dots on the iPhone text-message screen; a conversational manifestation of the tyrannical “iPhone ellipsis.”

When you’re in the middle of a text message “conversation,” and you see those three dots, you know that the person with whom you are communicating has something more to say. The verbal equivalent of this ellipsis is the word “so.” It is an inoffensive conjunction that merely communicates that more is coming. I now have the floor and you should wait for me to finish my next comment.

Up-talk, or the upward inflection of my voice at the end of a sentence is the rhetorical equivalent of the three blinking dots. The upward tone of my voice implies that I am not finished speaking and you interrupt at your own risk; there is more to follow and you may miss something interesting.

According to a 2014 Gallup poll, texting far outranks phone calls as the dominant form of communication among millennials (18-29 year olds) with 68% saying that they texted “a lot” in the previous day.  Among 18 -24 year-olds texting more than doubled between 2008 and 2010, from 600 to over 1,400 texts a month.

We should not be surprised that such a pervasive, newly ingrained cultural habit like texting should affect the way we communicate with one another. Texting was essentially unknown to communication prior to 2000 and only surpassed the number of phone calls per month within the last decade. We are only beginning to realize the impact of texting and the “short message service” (SMS) on our culture and organizations.

So… how do we coach our leaders – young and old – that these new habits might not be the ideal way to get across what they’re trying to say …?

Chuck Callahan Henry V 4.3 – Lead from the Front      https://henryv43.wordpress.com/