Leadership Lessons From History

Part 1

Title: "She Outranks Me"

During the American Civil War, the Union Army officers in charge of a particular military field hospital wanted a troublesome volunteer nurse removed from camp. In her zeal and enthusiasm to take care of the wounded soldiers, this female front-line health care worker routinely ignored standard military protocols. At times, she even was openly insubordinate to her superiors whenever they were not sufficiently supportive of her charges' care. Eventually, the officers appealed to their commander, General Sherman (of burning down Atlanta fame), for permission to get rid of her. Sherman put the officers back in place by telling them, "She outranks me!"

One of the most valuable, but difficult, lesson the best leaders learn is when to restrain their own power. Just because a person is officially in charge, that does not make it automatically right for he or she to exercise that power, especially over professionals who have more knowledge and experience on the subject. Prime Minister Winston Churchill would argue his particular viewpoint for hours with his cabinet members, but if any stood their ground and proposed a different course of action, he would support them.

And there is another lesson that health care professionals can learn from the above examples. Anything that benefits our patients' care only serves to strengthen us in the end. Anything that detracts from that position, only ends up hurting us. That is to say, when we participate in, or acquiesce, to policies or procedures that are not in our patients' best interests, we make ourselves and our associates more vulnerable to the intrusion and interference by others. As medical professionals, the first question we should ask ourselves is, "Does this help or hinder the care of our patients?" To the extent that such action does or does not, this should help guide our actions.

Leadership Lessons From History

Part 2

Title: "That Sinking Feeling"

The first article showed how effective leaders know the limits of their own authority and how healthcare providers can benefit from the goodwill that they have generated, via the care of their patients, in their dialogues with other non-medically-trained stakeholders in the healthcare industry. This example will focus on what happens when leaders ignore or overrule the opinions, greater experience, and knowledge of those directly responsible and in charge of the health, safety and well-being of others.

Much has been written about the circumstances surrounding the sinking of the Titanic on April 15, 1912. The great ship was the very embodiment of the arrogant attitudes of the great captains of industry that had sprung up at the turn of the century. But besides the multiple design and construction flaws that contributed to the disaster, there were two other events that are relevant to our topic.

Anxious to establish a new transatlantic speed record for a passenger vessel right at the start of her maiden voyage, the president of the White Star Line company ordered Captain E. J. Smith to sail full speed ahead. Captain Smith reluctantly followed his boss's order, even though he had received radio messages earlier from other ships in the area warning all vessels that they had spotted icebergs. What neither one knew was that, when they sailed from the English port of Southampton, a middle manager had pulled strings to get on board and had replaced one of the regular ship's officers. This officer vacated the ship so quickly that he failed to hand over the keys to the locked cabinet that held all the binoculars.

In summary, on that ill-fated night, the Titanic hit an iceberg because its perched lookouts did not have a single binocular among them to see the danger in time due to the fact the ship was sailing too fast for the overall conditions. Over a thousand lives were lost because of an event facilitated by the actions of two, non-marine leader-managers whose personal objectives were not tempered by the necessary training and experience to properly judge and balance the safety risks they were assuming.

Any further comment on this lesson would be superfluous, except to say that, after assessing the damage report, the designer of the ship concluded that the magnificent vessel's sinking to the ocean's floor "was inevitable." At the news, Captain Smith's heart certainly sank to the bottom of his pants, which, in all probability, were overflowing already!

Leadership Lessons From History

Part 3-A Title: "Healthcare Stakeholders Also are Patients"

(Or ... A guide to effectively working with an organization's behavioral equivalents to Elizabeth Kubler-Ross' "Five Stages of Grief")

Healthcare professionals have used Elizabeth Kubler-Ross' groundbreaking work on patients' psychological reactions to bad news to help guide patients into accepting having a severe medical or terminal diagnosis. What many physician leaders do not realize is that the same five stages also can be applied to healthcare businesses, corporations, and government offices and their personnel, especially when any of these entities face embarrassing news or difficult choices, as a result of any one of a number of negative disclosures or events.

Table 1: Psychological Reactions To "Bad News"

- Elizabeth Kubler-Ross' "Five Stages of Grief" also can be applied to government offices & businesses as well:

• Indicted political leaders and cover-ups

• Major product recalls (e.g. medical devices, pharmaceutical products and drugs)

• Accidents and disasters, their causes and responses

Table 2: Elizabeth Kubler-Ross' "Five Stages of Grief" are:

• Denial

• Anger

• Bargaining

• Depression

• Acceptance

Physician leaders can help guide non-clinical personnel and representatives through Elizabeth Kubler-Ross' "Five Stages of Grief" so that true solutions to healthcare problems are addressed in a timely and satisfactory manner. The same counseling strategies used to assist severely ill patients transition to the acceptance stage also can work with administrative personnel and leaders in other industries.

Leadership Lessons From History

Part 3-B

Title: "Five Stages of a Product Recall"

(Continuing Part of: Health Care Stakeholders Also Are Patients Or ... A guide to effectively working with an organization's behavioral equivalents to a Elizabeth Kubler-Ross' "Five Stages of Grief" for individuals)

Let's assume a major manufacturing defect was suspected in a part or a device by the users here in the United States. Let's also assume that a review of the available data showed insufficient cause to alert the appropriate regulatory body, or that the agency's preliminary review failed to detect anything wrong. Nonetheless, your group is still concerned enough to request a meeting with the manufacturer. What might a person expect as a result of the meeting?

Accepting the hypothesis that any organization is capable of responding according to Kubler-Ross' Five Stages of Grief, over a time frame of months to years, the leaders or representatives of the manufacturing company could exhibit one or more of the below behaviors:

DENIAL, ANGER, BARGAINING, DEPRESSION, ACCEPTANCE

Of course, it is also possible for an organization to exhibit multiple behaviors or stages simultaneously. For instance, one part of an organization could be in denial while another part is seeking to gag those whom it perceives as pursuing unfounded claims; an organization also may vehemently deny all allegations in public while vigorously pursuing a private or governmental settlement without actually admitting any wrongdoing. For an organization, the stage of "Depression" may be reflected in a dramatic drop in its revenues or stock prices, or from a major change in its leadership, or from a regulatory agency and/or court decision not in their favor. Still, even at that point, their representatives may pursue multiple strategies; e.g., outwardly decrying the "unfair" judgment while negotiating a reduction in penalties in exchange for withdrawing all appeals.

The next part in this series will focus on the denial aspect to such organizational behavior.

Leadership Lessons From History

Part 3-C

Title: "Denial: The First Stage of a Product Recall"

Or ..."If a tree falls in the forest, but no one wants to listen, then what?(A Continuing Part of: Healthcare Stakeholders Also Are Patients. Or, ... A guide to effectively working with an organization's behavioral equivalents to Elizabeth Kubler-Ross' "Five Stages of Grief")

Initially, denial is the defense mechanism most likely to be invoked at any encounter with representatives from a company facing possible "bad news" about a device defect (Table 1). "Unconfirmed" information is likely to be suppressed, or not revealed fully to higher leaders in their organization, in the interest of not generating any undue alarm with the stockholders.

Table 1: DENIAL: Expected organizational responses during the initial phase

• "This does not happen to OUR products!"

• "These only are ISOLATED incidences"

• "It only happens in EXTREME circumstances to a few"

• "The number of events has not reached STATISTICAL significance"

• "The data is FAULTY"

• "Proportionally, the numbers are still small... or smaller than (another example)"

These responses may be frustrating to physician leaders. A good analogy of such organizational responses is the "Dead Parrot" skit from the famous British comedy show, "Monty Python's Flying Circus." In the show, the store owner informs the customer that the recently purchased dead parrot was just sleeping. Yet, in examining the past, whether or not it is a potentially defective product, or a new drug with previously unrealized and severe side effects, the "Dead Parrot" skit is repeatedly played out by different players.

An effective strategy to use for such organizational resistance is to point out that, in healthcare, and for the good and the overall best concern of the patients, not acting until there is absolute proof may do more harm than good. The question should be, "Is it safe?" and not "Do we have evidence that it is unsafe." The two statements represent opposite perspectives. The Space Shuttle Challenger disaster happened, in part, because the focus was not on demonstrating that the defective "O" rings were safe, but, rather, because the responsibility to prove that the "O" rings were unsafe was placed on the skeptics. Another way of stating the same question is to remind everyone that the prime medical ethic is, and always shall be this: "First, do no harm."

Leadership Lessons From History

Part 3-D

Title: "The Other Stages of Grief"

Physician leaders can help guide non-clinical personnel and representatives through Elizabeth Kubler-Ross' "Five Stages of Grief" so that true solutions to healthcare problems are addressed in a timely and satisfactory manner.

In the previous discussion, "Denial" was shown to be the first defense mechanism typically used by many leaders of organizations facing bad news. Subsequent to that, anger, bargaining, depression and then, finally, the stage of acceptance is reached, but not before potential obstacles are resolved.

After bringing up a particularly difficult issue, physicians may encounter push-back, or even threats to their careers, including legal actions, if they continue to pursue an unpalatable or uncomfortable question or situation, especially if it involves a potential reduction in the organization's finances. Even when confronted with reasonable proof, confirming a physician's suspicion, the organization's leaders often minimize or explain away (bargain down) the impact. In the past, a medical product was re-designed while still selling or utilizing older models and fixing the potentially defective models only if problems developed in people. More recently, a major auto company essentially did the same with a car part.

A decade ago, a major manufacturer of computer chips explained away their corporate decision, not to replace the defective computer chips sold in their consumers' computers, as the chips' discovered mathematical miscalculations occurred only during complex computations, computations that were unlikely to be utilized by the average consumer! The ensuing consumer backlash made them reconsider that position.

Physician leaders can assist other leaders avoid such flawed reasoning by pointing out that, historically, such information is eventually revealed and that the damage to their corporate reputation and goodwill, never mind the legal recoveries, is likely to exceed any short-term monetary setback.

Additionally, and depending on the situation and their position, physician leaders should seek out champions within and outside of the organization who can take up the issue for them. Other than that, physician leaders should document all that they have done and their discussions to resolve such issues or problems.

Leadership Lessons From History

Part 3-E, Statements

Title: "Applying Elizabeth Kubler-Ross' Stages"

Healthcare professionals can learn from Elizabeth Kubler-Ross' groundbreaking work on a patient's psychological reactions to "bad health news" to successfully interact with other leaders in or outside the medical profession, especially when those other leaders are facing embarrassing news or financially difficult choices or actions. The following represents typical leadership statements that illustrate those stages.

Table 1: DENIAL: Typical organizational statements made during the initial phase of a product recall

• "This does not happen to OUR products!"

• "These only are ISOLATED incidences"

• "It only happens in EXTREME circumstances to a few"

• "The number of events has not reached STATISTICAL significance"

• "The data was FAULTY"

• "Proportionally, the numbers are still small... or smaller than (another example)"

Table 2: ANGER (Blame, Protest & Frustration)

• "It's the CUSTOMER'S fault!"

• "The INSTALLATION was faulty"

• "The MAINTENANCE was faulty"

• "It's the SUPPLIER'S fault!"

• "What is YOUR hidden agenda in making these unsupported allegations?"

• "We will take legal action against anyone or any institution harming the reputation of our product, or business/corporation, or its leaders, by making these false and deleterious accusations."

Table 3: BARGAINING (Positioning)

This includes all lobbying, PAC efforts and legal maneuvering meant to circumnavigate present laws or regulations. This also includes any efforts to thwart official investigations into the subject in order to mitigate or cancel any potential official requests for a recall.

• Recall a product, but call it a "mislabeling"

• Recall only some of the product

• Recall, but keep it quiet

• Recall, only if others are blamed

• Recall, only if the company can obtain concessions

• Recall, but with obstacles to compliance

• Stretch out the recall over an extended time period

• Recall, but only if the company and its leaders can get legal protection

• Recall, but only after the annual stockholders' meeting

• STALL! STALL! STALL!

Table 4: DEPRESSION (Confession)

• "The problem was underestimated"

• "Once known, everything reasonable was done"

• "Others have done worse"

• "Previous directives no longer are operational (e.g., Watergate)"

• "We are confident that once everything is settled, that the company's stock price will return to its previously high levels."

Table 5: ACCEPTANCE (Resignation)

• "We will take responsibility, but we were not responsible"

• "Changes already were underway long before the issue became public"

• "Our people were the first to detect and report it"

• "We will fully cooperate with...."

• "We will support legislation to...."

• "Those responsible no longer are with us" • "Steps have been taken to ensure that this will never happen again in our company!" (Repeated several times over the course of many incidences spanning decades.)

Leadership Lessons From History

Part 4

Title: "Alexander's Greatness"

Our West Point Military Academy's instructors teach its young cadets that the most difficult of all battle maneuvers to accomplish successfully is to attack a prepared enemy force from across a river. During his lifetime, Alexander the Great did this twice. At the Battle of Issus, circa 333 [up arrow]B.C., Darius, the King of Persia, not only managed to maneuver his much larger army behind Alexander's smaller Greek forces, but also had his soldiers dig in behind strong, fixed, fortified positions across a river that separated his army from Alexander's men. The disparaging Greek officers had all but given up hope, when Alexander calmly informed them that they would win a great battle that day. And they did.

How often in Medicine do we ignore the obvious, or fail to use all of our faculties and senses in addressing our patients' medical problems? How often do we first consider the psychological position of our patients, our co-workers, or our administrators before acting or speaking? How often do we fall into a rut, treating the same patients with the same medical conditions the same way, over and over again, until we become numbed by the experience? Have you ever felt as if you were sleep-walking through your whole day? Just like Alexander's officers, could you be missing something obvious?