January 17, 2015 · 7:19 pm

Leadership Lessons from an ETU

I did not arrive to work in Sierra Leone in any kind of leadership capacity.

Prompted by the news and the conviction of Faith, in October I signed up with USAID and then with Partners In Health to serve as a clinician caring for patients with Ebola.  I was initially scheduled to go to Liberia but with the growing need in Sierra Leone I was rerouted a week or so before my travel date.  We arrived in Sierra Leone on Wednesday December 3rd, trained aggressively and began working in the Ebola Treatment Unit (ETU) in the Maforki Chiefdom of Port Loko by that weekend.   Providing care to these wonderful people in partnership with the courageous Sierra Leonean nationals and a cohort of exceptional international professionals was one of the true honors of my life.

Although I was not formally in a leadership role until I became ETU clinical lead the last week or so of my time there, I was aware of the challenges and I was very impressed with the leadership team assembled.  Applying the critical dyad of “attention and intention,” I discovered that in the ETU, as is usually the case, leadership lessons abound:  “If the spirit of the student is in you, the lessons will be there” (Sir William Osler).  Here are several of my observations.

Master Narratives and Names.  New expatriate staff arrived at Maforki regularly.  It would have been very easy for the “long-timers” (those who had already been there a week or two) to develop the kind of exclusivism that could disrupt team development and undermine the “changing class picture.”  One solution was to aggressively learn the new peoples’ names and stories and take the initiative to reinforce that knowledge by introducing them by name and “narrative” to the folks who were already there.  People won’t readily surrender personal identity to take on group or team identity until the former is at least acknowledged.  The same practice was an important part of getting to know the local national staff and to build the team with them.

We need to practice “intentional inclusivity.” This follows by purposefully including newcomers into existing rituals.  For us at Maforki this meant eating meals together and inviting new colleagues on the morning walk to the ETU through the town of Port Loko.  It was a tremendous opportunity to get to know one another and to reinforce our new, shared identity.   “Not good with names” is not a viable excuse in leadership.

Lead from the front.  Nicollo Machiavelli wrote “It is the duty of a good general to be the first man in the saddle and the last out of it.” One of the most difficult aspects of work in the ETU was learning to accomplish the clinical tasks while wearing the personal protective equipment (PPE). The outfit included a Tyvek suit, plastic apron, boots, mask, shield and multiple pairs of gloves (I always wore three).  The process of ritually removing these garments (“doffing”) took a good 20-30 minutes if done fastidiously.   You were always anxious to get on with the process so you could get out of the suit.  (On top of which there was no way to urinate while in PPE, which added an occasional sense of urgency!)   Still it was always a choice to allow the more junior people to leave first and to monitor them carefully for safety as they went through the process.  Who should get to get out of the saddle first?

Practice calm in chaos.  We all need to know our leadership style in comfort and in chaos.  I have long known that my style of comfort is characterized in Goleman’s model as “affiliative;” focusing on the importance of people and relationships.  I value the input of others and in chaos I have the tendency to oscillate from firing from the hip with too quick decisions that may lack the collective input to the relative paralysis of dialog that involves too much “thinking out loud.”  So what I try to do in chaotic moments is to be quiet (not natural for me) to listen, to decide, then to reinforce, move on and check back with the results of the decision.  It is a discipline that has taken practice and even after many years, still requires intentional reinforcement.

Ditch discouragement and disparagement.  “Bitching” (pardon the language) is a natural way of blowing off steam in stressful situations.  People and circumstances can be frustrating and the process of complaining and commiserating is therapeutic.  Unfortunately it can also be destructive if it degenerates into slander or gossip.  And it can be poison if it proceeds unchecked.  Discussions about an individual’s performance have no place in public unless you are talking about yourself and the anecdote ends with laughter(!) Similarly, habitual negativity can become a weight that drags everyone down.  There may be a time and a place for both, but the leader’s job is to redirect the discussion when necessary.

Resist retreat.  Everyone gets worn out.  I found that by about week three or so, my enthusiasm for going in to the red zone waned through the course of the day.  I noticed the same trend in some of my colleagues who seemed like me at times to look subconsciously for other tasks to be spared the arduous, intense physical and emotional work.  The first step is to acknowledge that the feeling is normal and may even be self-protective.  And then one has to consider again Machiavelli’s “rule of the saddle.”  Leaders should be the first in and the last out.  In some of these times it was helpful to have a trusted colleague with whom one could commiserate in private, and then together like Rocky Balboa, we would “get back in the ring.”

One of my good friends, Colonel Mark Thompson reminded me a decade ago,”You don’t really have to be good to be a leader… you just have to be present and positive.”  I would expand to this degree: the definition of a good leader may well be the one who is both present and positive, whether he or she is in a formal leader position or not.

And so effective leadership often boils down to this: showing up and looking up.

 

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

 

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December 21, 2014 · 3:29 pm

Litter and Lists: the forest from the trees

This Christmas season I am learning my leadership lessons at an Ebola Treatment Unit (ETU) in Sierra Leone.  It has been a privilege to be caring for wonderful people with brave national medical staff and a cadre of international health care professionals.  It is a horrible disease and the medical system in this nation has been strained as any health care system would be.  For those of us who have joined the fight it has been an exercise in delivering care in crisis.

The ETU where I work is a relatively new center as are most of the facilities caring for patients with Ebola in this country.  There was no care delivery center here two months ago. The site was developed and staffed rapidly and patients began coming right away.  Although there are limited resources available, the pocesses and procedures are evolving even as the center cares for increasing numbers of patients.

It has been an exercise in examining our natural response to crisis.

These thoughts came to me as I was picking up trash.

Trash in the hospital or on the hospital grounds is an obsession for me.  Even today when I visit hospitals I find myself picking up litter from the ground. My wife reminds me quietly, “This is not your hospital” but it seems that I can’t help myself.  I notice it.  What is on the ground to me is a reflection of what the hospital staff think about themselves and what they do.  It is one of the “cultural indicators” that I have adopted for assessing a new organization.  When I arrived in Sierra Leone at the ETU one of the first things that I noticed was litter.  And my need to address is led to an observation about myself.

My reflection came in the context of noticing that a significant number of my new colleagues began making patient lists on their computers.  There are several score patients in the unit but none of us are responsible for all of them.  Still, a number of staff members generate complete computerized lists and update them daily.  One colleague poured himself into a policy on standardizing an emergency procedure.  Another worked hard on specific nursing policy.  Each effort represents a tactical exercise; a task we can do and feel that we have completed something.  Medical professionals are inherently tactical by nature: we tend to see our practice one patient, one hospital or operating room bed, on examination room at a time.

It struck me that we naturally revert to our tactical natures when we attempt to exercise leadership in crisis.  It is not necessarily bad.  As soldiers we were taught to enhance our fighting positions (aka “foxholes”) continually.  And frankly the only fight that we really needed to pay attention to was the one that took place right in front of us.

But leadership requires us to be aware of a bigger picture.  Our tendency to “be tactical” will trump our need to see and operate strategically.  If as leaders we don’t think and plan strategy it won’t get done.  I have seen that too many times.

Emerging from our foxholes may start with a general recognition of the battle beyond them.  In medicine, each patient has a family, the family is a part of a “clan” or extended family that is in turn a part of a community.  The patient also has a professional or social “clan,” a network of unrelated contacts. Together they represent regional and even global populations all potentially touched by the decisions we make about an individual patient.  This is very clearly true in the battle against this epidemic disease in Africa. But it is just as true in our hospitals and health care systems at home.

The absence of strategy is a strategy.  “Strategy abhors a vacuum.  If strategic function is lacking, strategic effect will be generated by the casual accumulation of tactical and operational outcomes” (Colin Gray). We will have a strategy in every endevour.  It is only a matter of whether we shape the strategy, or it shapes us.

Strategy begins with the regular discipline of looking beyond mere litter and lists.

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

 

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November 7, 2014 · 1:40 pm

Parsing the verb “to hear.”

Recently my wife traveled with a team to an orphanage in China to meet some of the children and to help to build relationships.  One of the things I was reminded of when she was gone was how well she listens.  And I realized that after nearly four decades of marriage and dating, my ability to make sense of the events of my life has become inexorably interwoven with her intentional and “attentional” listening to me.  So I missed her.  But it caused me on several long, quiet drives to think again about listening and the verb “to hear.”

“To parse” is to analyze, or to examine closely.  In closely examining my own ability to hear I know that I have been influenced by those from whom I have learned to listen.  But in leadership there is a point beyond listening that I have too often neglected.  There are four aspects in parsing the verb “to hear” as it pertains to our relationships with others.

Ignore.  “Wait, what?”  This is our most basic response to hearing.  We don’t.  In a world full of distractions we walk down the halls of our institutions with Blackberry or smart phone in hand, checking a few text messages while we’re on the elevator or scanning emails while we sit through board-room briefings. So when we should hear and listen we miss the opportunity because we are not present.  “Be there” lion-tamer Gunther Gabel-Williams advised his son as he took over the family business and stepped into the lion cage. Continue reading →

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October 12, 2014 · 9:16 am

“Tri-Focal” Leadership

A couple of years ago I noticed that I needed to slide my glasses down my nose to read. The optometrist I spoke with told me that I was going to run out of nose before this normal process of aging ended (“presbyopia” comes from Greek, “presbus” and “op” or literally “old man’s eyes”).  As I left the Army, I was fitted with bifocals. They made it easier to look through the otoscope and to read the Kindle, but the middle distance was still blurry (e.g. looking at the computer screen).  The next time I ran into an optometrist I asked whether I needed tri-focals.   With age I have noticed the need for a “tri-focal” approach to leadership as well.

If we are paying attention, the first thing we learn in leading is judgment.  We begin to recognize patterns in the behavior of superiors, peers and subordinates and we develop sets of responses to those patterns that have the probability of a favorable outcome.  Bad judgment is almost always retrospective.  Good judgment is the product of perception, understanding, knowledge and experience combined with flexibility and agility in crafting a response.  The first step in the evolution of effective leadership is knowing what needs to be done.

The second step is execution.  I used to tell new staff members that what I was looking for was people who have the ability to finish what they started.  At the lower (tactical) level it takes an ability to prioritize, not to over-commit, to persevere, and to follow-through.  With more senior positions (operational) it takes an ability to coordinate with different teams for tasks that cannot be accomplished alone.  At the highest levels (strategic) it requires delegation, clear group goal-setting, and the ability to hold subordinates and peers (even harder) accountable to accomplish their tasks.  This second step often distinguishes truly effective leaders.  It is the ability to get things done.

Leaders with judgment and the ability to execute act in ways that affect others.  The more senior the leader the more critical it is that he or she takes into account the perceptions of others.  They must demonstrate cognizance: the ability to know, to notice and to be aware.  Actions have second, third (tenth…?) orders of effect on all “stakeholders” and leaders must learn to be cognizant of how actions affect and are perceived by others.   This includes individual leader actions (e.g. enjoying the perks of senior leadership and discounting the perception of subordinates) as well as organizational actions (e.g. shifting a group’s mission and ignoring the effects on one group of customers).

In April 2003, when LTC Chris Hughes and his soldiers were confronted by an angry mob in the holy city of Najaf, Iraq, he ordered his men to take a knee and point their weapons toward the ground.  The situation was diffused, the crowd calmed and he was able to safely withdraw his men without compromising his mission (which was to maintain peace and establish presence).   He demonstrated judgment, execution and importantly cognizance in the situation; keys to effective “tri-focal” leadership.

By the way, the optometrist I spoke with told me that the lenses I needed weren’t called “tri-focals.”
They’re called “progressive.”

It’s an apt description.

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

 

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August 29, 2014 · 6:09 am

Toxic II: Heavy Metal Poisoning

I consider myself fortunate never to have worked for overtly toxic leader.  Perhaps it is because I have spent much of my professional career with pediatricians, who tend to be a relatively patient and easy-going bunch.  While I know toxic leaders are out there, looking back over three decades I cannot think of a single one of my senior leaders whom I would consider toxic.

I have unfortunately, had subordinate leaders who were described as toxic by their teams and have had to address the problem as a leader.  The angry, abusive leaders were easy to recognize.  But there is another subtle form of leader toxicity that is ultimately just as deadly and may be even more prevalent.  From what I recall learning in school, the two remind me of heavy metal poisoning.

“Mercurialism” comes from mercury toxicity and like any heavy metal poisoning it has acute and chronic forms.  I liken this form of poisoning to what we typically consider when we think of a toxic leader: unpredictable angry outbursts, inflammatory, derisive, demeaning comments, foul language and aggressive behaviors.  Mercury poisoning can cause clinical symptoms of sensory impairment, difficulties hearing and speech, disturbed sensation, lack of coordination, atrophy, loss of visual acuity and loss of strength in an affected individual.  Mercurial leaders have the same effect on their organization.   The organization is weakened, has poor internal coordination and communication, and becomes insensitive to customers, internal and external.  Ultimately the organization can lose its vision.

“Plumbism” is the name for lead poisoning (from the Latin “plumbum” for lead, source of the element’s atomic symbol “Pb”). Plumbism may also be acute or chronic, but in the latter case symptoms include depression, loss of appetite, pain, nausea, malaise, fatigue, and disturbed sleep.  The “leaden” leader also has a toxic effect on an organization, but the effect may be more subtle. Teams function, but at a depressed level compared to their capability.  Members experience loss of passion and weariness. There’s organizational malaise.  This toxic leader, though well-meaning, wears them down. Continue reading →

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July 25, 2014 · 8:27 am

Leadership Quote of the Day: “QV QD”

The surgeon had several 3×5 cards taped to the file cabinet in his office.  The typed quote on one card struck me: “Never sacrifice family on the altar of medicine.”  I was an impressionable 27 year old intern.  Like all Walter Reed house staff, I was dazzled with this remarkable pediatric surgeon who labored to maintain balance in his life despite his tremendous work ethic. I scribbled the words on my notes, then wrote them on a 3×5 card and posted it on my desk when I got home. It was the beginning of my quote collection.

Around the same time, I began to read with a pencil and scratch paper in hand, and jotted things down things that were insightful or inspiring.  I typed them into my old Apple IIe computer in 1989.  The practice and the collection continues (>100 pages!) and has become one element of a lifelong study of truth, of life and of leadership.

Sharing the quotes began after my final deployment to JRTC at Ft. Polk in February 1999.  LTC (later Brigadier General) Becky Halstead, the Battalion Commander of the 325 FSB, 25th Infantry Division, wrote a quote every day on a white board outside the mess tent.  I borrowed the idea and when I got back started a “quote of the day” (qd or quaque die) on our white board at Tripler Pediatrics morning report. When I was on leave or out of town, staff and residents continued the tradition (although with good-humored irreverence!)  At the annual awards dinner in June, each graduating resident was honored with a specifically selected quote.  I later learned that the residents looked forward each year to see which quote I would choose and read for them.

The tradition continued with a white board outside my office door when I was a new hospital commander and then as daily e-mails while serving as Chief of Staff at Walter Reed Bethesda and in my final tour as Commander of the Fort Belvoir Community Hospital.  Members of the team have often provided feedback on the quotes and have used them in other settings themselves.  As it turns out, I am not alone this pursuit of truth.

Today I find that many of the quotes speak like old friends whispering from the shadows of my memory; reminders of books or lectures, lessons learned in times of pain and times of joy. They are some of the voices that have shaped me as a leader and that motivate me to continue as a student.

For several years I used the Latin medical phrase “qd” (quaque die) or “every day” for the practice of sharing the quotes.  It was also conveniently short for “Quote of the Day.”  Unfortunately but with good reason, “qd” became one of The Joint Commission’s banned abbreviations several years back.  So it has been used with some trepidation.

In light of the ban (wanting to be a good example of TJC standards adherence!) and since these quotes are not quite daily on Twitter anyway, the name “qv: quaecumque vera” is probably better (Motto of the University of Alberta and reference to Philippians 4:8).  It reflects our responsibility to regularly and with discipline pursue truth as leaders on behalf of those we have the honor of leading.  And it reminds us that we have much to learn from others and from the voices of history regarding “quaecumque vera:” “Whatever is true.”

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

Start your own quote collection. Follow @HenryV4_3 on Twitter.

 

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April 18, 2014 · 11:15 am

The Machine: Alterity vs. Automation

“It’s nothing personal, it’s just business.”

There is a tension in leadership between attending to the person and to the operation of “the machine.”  Automation is a system of operating a process by highly automatic means that reduces human intervention to a minimum.  Complex systems like healthcare require the efficiency and lack of variation of automation in order to insure the highest predictability and the best outcomes.  Unfortunately, the most important cogs in the machine and the most critical consideration in the outcomes of any business are people.

Alterity is a philosophical term that means “otherness” (from the “other of two,” in Latin “alter”). The word implies the ability to distinguish between self and not-self, and consequently to assume the existence of an alternative viewpoint on a given subject.   Leaders demonstrate alterity when they are willing to look beyond the “machinery” of their organization and consider its individual members with empathy.

People are the least predictable part of the machinery of production and the most variable part of the product.  They have bad days, bad weeks, bad moods, bad weekends that spill into bad Mondays and so they hurt, are distracted, are grumpy at the very times when we need them to be focused, selfless, responsive and loyal. Employees want the efficiency of the machine when it comes to the processing of their pay, leave and vacation requests.  Customers want service efficiency.  But both groups resent being treated like they are cogs in a machine when they are hurting, frustrated, angry and need to be heard. Continue reading →

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January 29, 2014 · 12:52 pm

The Officer as a Gentleman. Toxic antidote?

We have been talking about this for a decade now, at least since Colonel George Reed published his paper on toxic leadership in Military Review, an article that has fueled innumerable leadership journal clubs in and out of the military.  It happens that in the ensuing years the military has been embroiled in a series of increasingly unpopular wars that have asked much of leaders at every level.  It is very likely as General Martin Dempsey, Chairman of the Joint Chiefs said, that our system has favored “competence over character.”  The need for short term results (within the two years or less of a short command tour) instead of an investment in the long term – including leader development – may be an unanticipated consequence.  Regardless, senior military leaders are increasingly characterized in the press as toxic and displaying poor moral judgment.

Toxins are poisons.  Toxic leaders poison those around them, particularly subordinates.  One colleague of mine characterized a toxic leader he knew as an “equal opportunity yeller” who “used to spit and slobber” as he yelled at you.  This is not a new trend.  Fifteen years ago in his monograph on generational challenges in the officer corps, Dr. Leonard Wong referred to a common theme among young leaders, “They have lost faith with the senior leadership of the Army. They believe they [senior leaders] are either out of touch with reality or liars. We’re losing a generation of good leaders.”  That was before 9/11.

An antidote is a substance which can counteract poisoning.  The term derives from the Greek αντιδιδοναι (“antididonai,” “given against.”)    The Good Book teaches “He who is faithful in a very little thing is faithful also in much; and he who is unrighteous in a very little thing is unrighteous also in much” (Luke 16:10). Phillips Brooks, a nineteenth century American clergyman said, “Character is made in the small moments of our lives.” Continue reading →

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January 22, 2014 · 8:08 pm

The Decision to Lead

(Remarks presented at the Transfer of Authority Ceremony,
Ft. Belvoir Virginia, January 17, 2014)

This month marked the end of my tenure as Commander/Director of the Fort Belvoir Community Hospital (FBCH) and concluded eight years serving with the executive committees of four different military hospitals in the National Capital Region (NCR). The transfer of authority ceremony marked the true end of the 2005 NCR BRAC (Base Realignment and Closure Act) as the last of the dinosaurs shuffled off towards La Brea and a new generation of leaders with fresh perspective move medicine in the NCR “enhanced multi-service market” to even greater levels of access, service and excellence! 

There is no question that our hospital and health care system leaders will continue to embrace the words of General Douglass MacArthur, “A good soldier, whether he leads a platoon or an army, is expected to look backward as well as forward; but he must think only forward.”

The health care team at Fort Belvoir Community Hospital has logged some remarkable accomplishments in the past several years.  Prior to the summer of 2011, it didn’t exist as an organization.  Since the opening, the move, the merger, standing up a range of new care-services, the hospital achieved its first ever Joint Commission accreditation and quickly established itself as the most recommended hospital in the Military Health System (MHS). Continue reading →

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December 29, 2013 · 3:36 pm

Mentor and Coach: Right Brain, Left Brain?

     For though ye have ten thousand tutors (paidagōgos) … ye have not many fathers…”
          Letter from Paul to the Church at Corinth (1 Corinthians 4:15)

The business of becoming a grandfather over the past few months has given me pause.  First I have to get over the sense that am far too young.  I think of grandfathers as old.  I couldn’t possibly be at that point…

Assuming that it is possible (and that seems to be the case) and acknowledging that age is at least in part a way of thinking, one characteristic of being more senior is that you are also more circumspect.  While I blundered into parenthood three decades ago without a whole lot of thought or worry that I might not get it right (“How hard can it be?”) this major life change comes with a bit more thought; perhaps even angst.

My wife made an observation recently that I have found myself contemplating: maybe this business of being a grandfather is more about being a mentor than a coach.  And maybe that means that it will take more of my right brain. Continue reading →

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