2014 and 2015 Philadelphia Chapter of Pax Christi U.S.A.
Military Leadership in Context
3 part series
Most of my time with soldiers is problem focused. Psychiatrists and physicians are trained to identify and help solve problems. Occasionally I have the opportunity of just sitting back and watching interesting events unfold. Such was the situation recently with this very responsible field grade officer.
Janet did not occupy the leadership position she desired. Her initial complaints centered on not being promoted. She was working with people who “endlessly recycled unworkable solutions.” Her frustration and irritation were high. I suspected her of being an over-functioner – a person who does her share of work and the work of others. Clearly, she was a “take charge” person who was frustrated by being unable to do so in her current assignment.
Is Janet’s leadership typical of Army leadership? I do not know. I do know the Army is a hierarchical organization where leaders issue commands and soldiers unquestionably follow for the good of the group. One’s life depends on one’s brother (or sister) and his or her life depends on the other. It is a reciprocal agreement to protect another with your life; it is not negotiable. The loss of another is more drastic than the prospect of one’s own death.
She seemed pleased to vent her job frustration and I was sympathetic to the dilemmas presented. Is there a difference between being responsible to others rather than being responsible for others? Then came the big problem. Her sister who lived a thousand miles away was pregnant, unmarried, beyond the “safe age” for child bearing and hospitalized in a mental hospital. Their father with whom her sister lived had just died. She was in a behavioral regression and hearing voices.
Janet was distressed and uncertain how to proceed. Her leadership focus was always on taking responsibility no matter what the circumstances. Contact with her sister was not initially productive. Janet contacted the father of the child, a local handyman who wanted no part of the pregnancy. Efforts to communicate with her sister‘s mental health team ran up against HIPAA — those annoying federal guidelines that prevent even common sense communication between family and patient caregivers.
Janet travelled to visit her sister and settle their father’s estate, as well as sell the house where they both had lived. Her sister did not want an abortion but had limited ability to care for a child if and when she was discharged from the hospital. As the pregnancy progressed her sister was discharged and planned to place the child for adoption.
Janet discussed these developments for weeks and months. She became progressively convinced that she did not want to see her prospective niece or nephew (family) “lost” to the foster care or adoption system. She discussed her concerns with her sister with little resolution.
Eventually Janet’s sister gave birth to a daughter, my patient’s niece. The mother left the obstetrics hospital but the child did not. The staff did not believe the mother could properly care for the child. Months went by while social service and child protection teams debated the proper course of action. Social Services filed a petition to take the child away from the mother. Progressively upset by these actions or inactions my patient joined the court proceedings and filed for temporary custody of the child. The judge preferring that the girl stay within the family granted her petition. Knowing my patient worked full time I continued to ask if her spouse fully supported her action, and she assured me he did.
Janet was determined not to “lose” her niece in the foster care or adoption system. Her spouse agreed to help and they implemented a plan. I personally did not think it was the best idea - to take a child from her hospitalized sister and bring her home to their house. My patient worked full time and had adult children. Months went by and Janet realized that the niece was beginning to become quite attached to her while the baby’s birth mother remained hundreds of miles away in and out of the hospital “getting mental health treatment.”
My patient accomplished her goal but eventually decided the “victory” was a mixed blessing. She had assumed all the responsibility for the care of this child while her sister remained in treatment. The uncertainty of whether her sister would ever assume care for her child was disturbing to Janet, who was used to everything being in its proper place. Janet wondered if hearing voices created problems with being a parent. “Not necessarily,” I commented while noting that a number of people with schizophrenia were good parents.
Frustrated with her inability to communicate with her sister’s treatment team and get a timeline for reuniting mother and child, Janet made a bold proposal. She and her spouse would drive to this distant city, pick up her sister and move her to Janet’s home. There her sister would be offered a place to stay, assistance in raising her daughter and treatment by a local county mental health team. Janet put the pieces in place and discussed it with her sister who agreed to come.
Janet announced she would pick up her sister at noon on a specific day. She expected her to be packed and ready and asked for help from “friends who owed Janet favors.” She called and told them to get her sister “ready by the expected time.” Half way through the trip Janet called and said she was on the way. At 11:00 AM of the appointed day, Janet left a message saying she would be there at noon. At 11:58 she texted, “I am outside your house.” Janet told her sister that if she did not come with her and take responsibility for raising her daughter with assistance, their relationship was over.
Her sister now lives with Janet’s family. They talk at least one hour each day. Janet tells her sister’s voices to behave themselves. If they do not she “will kick them out of the house.” Asking me what I thought, I told her that it was a rather unique approach. I advised that when she met with her sister’s mental health team that she “be cautious” before confiding all that she was doing. Her leadership, this take charge posture, seemed a little unorthodox for the situation.
Months went by with almost every piece in place. Janet ponders the one piece that she cannot control – that her sister “does not seem to know how to be a mom.”
MISSION ACCOMPLISHED? We will see! There may be limits to what one can expect “military leadership” to accomplish! Not only in war, but in peace, foreign policy, and personal relationships.
Pt. II December 2014
Leadership is easier to think about than to execute. Everyone has an opinion on what leaders should do and the choices are myriad. The Army has its way based on loyalty and taking care of one’s buddy, a very hierarchical form of altruism. When I first began working with soldiers at The Walter Reed Army Medical Center, I was pretty impressed with the “trappings.” The flag, the uniforms, saluting one another, the discipline, the ceremonies and rituals—all contribute to the esprit d’ Corp and following the leader. Watching so many amputees negotiate the cafeteria on their own was truly inspiring.
I suspect my reaction was similar to that of the many young people who join the military. The singular focus of leaders, the patriotism, “fighting our enemies,” the glory and valor, and the strangely comforting identification with all of it can obscure vision. In retrospect I think the inspiration I experienced led to my overlooking some obvious problems in the leadership of our unit. I believe a similar process overtakes young soldiers. They may not really understand what they are getting into. I don’t think I did either, but there is a difference. I could walk away from a problematic leader, but they cannot. Their job is to follow a command without questioning.
Although their mission is organized around altruism, ironically the needs of individuals are not always considered by their leaders. Soldiers discover they cannot take vacations when they want, nor can they always attend the funerals of family members or even of their parents. The needs of the military prevail. Effective and understanding leaders are so critical to the functioning of a unit, but such leaders are not always available.
In the beginning, a rather charismatic leader led our group at Walter Reed and conveyed an ability to get things done. Our funds allegedly came directly from Congress, secure for years, and did not have to pass through the normal bureaucratic “checks and balances.” Our leader’s discussions were always “visionary,” but not necessarily logical, and often a little contradictory. We mental health professionals talked among ourselves about how nice it sounded, but how discomforting it seemed.
Soldiers do not have the luxury of questioning. They are not allowed to talk about the leader or question the directions. If they receive contradictory commands, as they often do, they literally do not know what to do. One young woman I saw came in with panic attacks. Her history involved not being issued proper equipment. Later she was ordered to operate her vehicle. She knew that not wearing proper equipment while operating a vehicle was a violation. But she was just obeying orders. Another part of the command filed a disciplinary action against her for operating her vehicle without proper equipment. She tried to explain but one does not “talk back to command.” Facing disciplinary proceedings in “this Catch- 22” situation gave her anxiety attacks.
We physicians could easily talk among ourselves about when our leader was not making sense. The soldier with panic attacks could not do the same. She required medication to deal with her leaders. Most readers are aware of the recent shooting at Fort Hood, when Ivan Lopez shot himself and nineteen others. There was an extensive investigation. Leaders genuinely want to know why these episodes happen. I wonder how much note will be made of the fact that his leaders did not allow him to attend his mother’s funeral. He undoubtedly “had feelings about not being able to attend.” Leaders influence how individuals express their feelings. Some people get anxious, some get violent. Most everyone needs to talk it out.
Leaders also influence the effectiveness of the followers. Our mission was to provide behavioral health services over a secure internet. Our leader’s charisma could build a service—we went from five to 75 people in a short time. Keeping the service logical, organized, and well maintained, however, was not part of his vision.
In our organization, there always seemed to be a technology crisis. Our unlimited funding apparently allowed him “to throw money at problems.” For every type of technology failure, there seemed to be a member of the bureaucracy hired to assist. There was an information technology person for computers, several who worked on electronic medical records, another who did passwords, another on scheduling, and there was always an 800- number to call for more “advanced” problems. There were also employees who were in charge of contracts, re- search, property, and equipment. There was money to pay all these people.
Soldiers do not have the same benefits. Agree with it or not, our society has asked them to fight our wars. Their mission is to kill the enemy. They do not always have proper equipment, adequate supplies, or sufficient protection. Their military leaders cannot throw money at the problems. Their funding is limited by political leaders. In fact when our soldiers return with “problems,” there is insufficient money “thrown their way” to treat them medically, provide for their disability, and to reeducate them. Maybe our society needs a little more imagination regarding what is happening to our soldiers and how to be helpful.
Soldiers are always talking about waiting for orders: for reassignment, temporary training, disbanding a unit or even discharge. The worst seems to be waiting for a disciplinary action. They become tense, anxious, and bored with the waiting. The leader’s reassignment inefficiency seems a waste of time and personnel.
Our unit recently had a similar reassignment experience. The “old” Walter Reed Hospital where we worked was closing and moving to a new location. The original plans allowed for our initial five-member staff to have offices in the new location. The rumor was that our charismatic leader, with his own special stream of funding from Congress, had not alerted the planners of our growth. We were twelve times as big as when we started, and there was no room.
We could not go just anywhere. It had to be a secure Defense Department authorized location with a maze of electronic and physical protection. Finally, the day arrived, and the Walter Reed Hospital moved. We did not. We wondered if we would have an office that was open or closed? Where would it be? Mostly, we wondered, is this the way soldiers were treated? Did they often wait for deployment to one place, but then the battle plan changed and so they were sent elsewhere? We were tense and anxious.
Later, as the fiscal year closed, our contracts were also ending. Our leader assured us that all the appropriate planning and preparation was in place. We should expect a seamless transition to a new contract. Despite full schedules of patients, no contract appeared. Days then weeks went by. Younger professionals who were supporting families needed work and took other jobs. Those of us with other jobs just waited. My fellow psychiatrists talked about whether the “real” Army operated this way. What would it be like in a foxhole with chaos around you, not knowing if you could depend on others? We were not in danger but we certainly operated within chaos.
Finally we returned to work. The explanations for what transpired were too numerous to count. Who really knows what the leader either did or did not do? And then one day our visionary leader and his assistants disappeared, escorted out of their offices by uniformed service members. Then uniformed military people occupied offices throughout our building. We were about to experience the type of hierarchical structured leadership that service members experience. Had our leader experienced a better leader himself, this might not have happened?
I like working with soldiers. Their stories are fascinating and inspiring, and I know I can be helpful. But I also know that, unlike them, I can and they cannot, walk away from the “chaos” that seems to surround their work. Even
more, I can think about and question the leadership and talk about it with my colleagues. I think it makes me a better follower. But, it might not make a soldier a more effective one.
Physicians have many qualities. Being a natural leader is not always one of them. My experience with the Army has really opened my eyes on this leadership issue. The past medical leader of our unit was full of great ideas, but lacking focus, efficiency, and a cooperative spirit led to fragmented care and demoralized staff.
When our medical leader “disappeared,” the Army bureaucracy moved in and took over. Regulations appeared everywhere. There were sign-in and sign-out sheets, multiple time sheets, protocols and treatment plans. Once “the new rules” were in place, a high-ranking enlisted man was assigned to be our administrative leader. He was the NCOIC, or the noncommissioned officer in charge. I remembered NCOICs from my Army experience. They are trained to be leaders and he was arriving to lead us. I decided to watch, listen, and ask questions.
He was young—almost half the age of our “seasoned” medical staff members. He was upbeat and enthusiastic. We surmised he knew little about behavioral health and psychiatry. We were correct but he was willing to learn. He thought physicians were poorly prepared to be leaders in the military and he did not mind expressing his viewpoint. I admit I was “put off” if not offended by this viewpoint. I asked questions, and he was eager to discuss. I learned that he had grown up in a difficult inner city environment. He knew about surviving in “gangs.” Deployment in war was safer than being in his neighborhood. He understood how to get individuals to work together. That got my attention.
I knew that competing with one another to get into medical school, surviving the rigors of a medical curriculum, working 120 hours a week during residency might foster an illusion in us that we physicians can accomplish what- ever we determine to tackle. Certainly it creates a sense of self-determination and autonomy. Being in charge of and responsible for oneself, however, is not the same as being in charge of and responsible for others.
“So why aren’t physicians good leaders in the Army,” I asked.
“It starts with the selection process,” the NCOIC said. (Hereafter referred to as our leader) “Being curious about biology, thinking in a very reductionist manner, and memorizing reams of data is not training for leadership. It might get you through medical school.” I acknowledged so much studying and clinical training was competitive and implemented within a fairly sheltered lifestyle.
The leader went on to compare the training of soldiers and physician officers. By the time a physician officer in the Army is a field grade officer, Major or above, he or she has just completed his residency training. Then they are given the command of a unit. Hence they rise to a command level with no leadership experience. Comparatively, by the time a regularly commissioned officer becomes a Major, he or she has had at least two prior combat command positions and passed several performance reviews. Interesting point! I started to pay more attention.
The leader continued, “the law even fosters poor physician leadership.” “What did you mean by that?” I asked. Previously he had been in charge of a unit in which he was unable to terminate a physician who was performing in
an incompetent manner. Physicians whose medical training is paid by the military owe the military future time in service for their prior training. Congress passed a law saying that physicians who are paying back their time cannot be terminated from their jobs. How did this young leader deal with that problem? He discovered the physician was writing narcotic prescriptions for prostitutes in exchange for services. He could not legally terminate the physician but he could report illegal behavior. The incompetent physician was no longer a problem for his unit. Good leaders can work around even Congressional obstacles, I learned.
I also learned that this leader was not just expressing his own opinion about physicians being unprepared for effective leadership in the military. It is a viewpoint widely held. An unclassified Officer Leader Development Study, published in 2013, reported that physicians accounted for 21% of all Army officers. The report’s findings showed that this unintended consequence came from the way physicians were recruited and trained in the military. Physician officers are not, the report stated, “adequately inspired, or motivated upon entry into the Army Profession, … or adequately developed as leaders through military education, … [as their training is] focused more on managing the business of the healthcare system” than leadership.
“So what if all physicians are not good leaders?” I asked. Our leader spoke directly to the Fort Hood shootings by physician, Major Nidal Hasan. (Speaking of unintended consequences!) Stating this was just his opinion of course, he outlined how the prior medical command did not deal with Hasan’s obvious problems in his prior assignment. He made the case for the failure of medical leadership being a factor in the Fort Hood shootings. It made me think of the Hippocratic Oath.
So has the leadership of our new NCOIC made a difference for our psychiatrists? Unquestionably yes. We are clear about what we are doing, we know how to do it, and we can rely on one another. And soldiers can rely on us. Our NCOIC’s leadership has made a difference because of the way he facilitated how we do what we know how to do.
Our leader was so good that a higher-level command ordered him to go elsewhere for another leadership position. We are technically leaderless, but his lingering effects are such that we are doing rather well without a leader. Isn’t that the sign of a good leader? Seems a testimony to him, and even more, a “medical benefit” to soldiers.
Ted Beal
Ted Beal, MD, a psychiatrist with the Department of the Army is also a member of the Georgetown Medical School faculty.