First person, singular.

,When I was a fellow one of the senior physicians at the children’s hospital where I trained approached me with a question:

“Dr. Callahan,” (she was always pretty formal). “Does your colleague Dr. Christopher have his own lab?”

“No ma’am” I replied (formal, too). “He works in the same labs we all do. Why do you ask?”

“Well in speaking with him he often refers to ‘his lab’ and I was just wondering whether the fellows actually had their own labs.”

We didn’t. I started to listen more carefully and noticed that Dr. Christopher (not his real name) had a tendency that afflicts many in leadership: the over-use of the first person (“I, me, my”). I acknowledge it is nowhere near as grating as referring to oneself in the third person (“Bo Jackson has to do what’s best for Bo Jackson”). But it is something I have noticed through the years, possibly a function of my own fear that I might sometimes lean in the same direction. Certainly positions of leadership can foster that way of thinking. People pay a great deal of attention to leaders wherever and whatever they are doing. They even notice and may comment on what the leader’s wearing (“Sir, I notice you wear Tom’s”). Perhaps that is why General George Patton said that leadership was theater. The leader is always on stage.

But it is too easy to succumb to the cult of the first person and increasingly cast our shadow over all we’re associated with: my team, my assistant, my hospital, my staff, my directorate, my lab. Pay attention to your own patterns of speech and see how many times you refer to yourself.

It would only be a bad habit if it weren’t for one thing. We may have bought into the traditional “heroic” model of leadership. The model is common in ancient literature. Leaders were known for their physical size, strength, or looks; individual personality traits or charisma. For example in Homer’s epic poem Achilles was a leader because of his demigod warrior status, Ajax as a result of his size and strength, and Hector because of his courage and dedication to his people. Early leadership theory focused on the leader and the leader’s persona.

Scottish writer Thomas Carlyle wrote in his book (the title is telling): On Heroes, Hero-worship, and the Heroic in history (1840), “For as I take it, Universal History, the history of what man has accomplished in this world, is at the bottom the History of the Great Men who have worked here.” His emphasis on the individual leader gave rise to the “Great Man” theory of leadership.

The problem is that we have entered an era of horizontal leadership where the best leaders are the best listeners; they are willing to relinquish power to accomplish goals, have the greatest ability to form and facilitate teams, and have the greatest emotional intelligence. The sun is setting on the great person theory (the traditional messianic or apocalyptic view we hold towards the occupant of the White House seems to be a persistent exception).

We should check ourselves. Excessive use of first person pronouns may reveal a tendency toward seeing ourselves in the “great man” or “great woman” spot light, to the potential detriment of our relationships with peers and subordinates who comprise the teams who really do the work.

The leader without a crowd following him; traveling and working with him, is simply taking a walk. We can too easily end up thinking “first person, singular” when we need the entire team – “first person, plural” – to get the job done.

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

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Lead from the back?

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/

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The sound of the guns

I probably shouldn’t look at social media during church. But honestly, I was just opening the Bible App on my phone (!) The local “Nextdoor” link on my email was a post from someone living nearby: “Neighborhood too dangerous.” The author wrote, “We were talking about how annoying it is that we cannot walk outside without fear of being held up at gunpoint and it might be time to move to a safer place…”

It has been something of a bad week for our neighborhood. Someone was held up and robbed on the street I walk to work and a young man was shot a few blocks from our home. But none of this is new to West Baltimore or to the city where more than three dozen people have been killed since New Years. Perhaps it was just a little too close to home.

The post made me think of our pastor.

He was born and raised in Baltimore and despite growing up in one of the city’s toughest neighborhoods in a single parent home he has a college degree and is among the best read men I know. He had every reason and every opportunity to move away from the conditions in a city that Hobbes would likely agree are “solitary, poor, nasty, brutish and short.”

But he didn’t leave. Instead he studied, trained and prayed and with his wife planted a church in West Baltimore within a mile of the highest density of gun violence in the city. He was with the line of pastors at the uprising after the events surrounding the death of Freddie Gray two years ago this spring. He leads by example in the city of his birth that he could easily and justifiable have left behind.

This morning I was stuck by what drew me to his leadership and to this church.

We spent thirty years in the Army where among the highest virtues was the willingness to run toward the sound of the guns.

Now we are serving with this leader and these brothers and sisters who have chosen to do the exact same thing – literally and figuratively – on some of our nation’s most dangerous streets.

A couple commented at a dinner recently that it is not uncommon in our neighborhood to hear gunshots at night. These men and women whose church meets in a local public school; who are led by a courageous pastor and his wife are far more familiar with the sound than we are.

Perhaps I am drawn to this leader by the same qualities I have long recognized in those with whom I served in uniform:

True leaders run toward the sound of the guns.

We have found a community and leaders who live this.

And it feels a lot like home.

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

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The problem with rice bowls

Rice Bowl

  1. A task performed by a specific individual or group in exchange for compensation.
  2. A protected job, project, program etc.

Reaching back a decade or so I remembered an episode that taught me about our tendency to defend our turf and our “rice bowls.”

When I was Chief Medical Officer earlier in my career, I received a late evening email from my CEO while I was away on a business trip. The message informed me that the discharge nurses who were busily working under “my” section of “Health, Plans and Operations” were going to be moved to a new discharge management cell that would be run under the Chief Nursing Officer. The cryptic part of the message was that they were to be combined with the Department of Hospital Social Work, to be run under the office of the Chief Nursing Officer. I replied by email that I was a bit confused.

“Did you mean to imply that you were moving social work as well?” Social work was a department that had been aligned under the Chief Medical Officer – “my job” – for decades. It seemed odd that my Boss would realign a whole department without even mentioning it to me.

I learned by email the next morning that was exactly what she meant.

My first response was visceral. This was a personal affront! To have one of my subordinate departments removed from me span of control without even letting me know ahead of time. Disrespect! The CEO and my peer to whom my subordinates were transferred must have had no regard for me and for my position.

Someone had reached into my rice bowl and extracted rice without the decency of even letting me know!

Moments later I realized I was being ridiculous.

First, I knew my Boss and my colleague. They were no more interested in affronting or insulting me than I would be them. Even if they hadn’t thought of it, how justified would my outrage be without even considering and understanding the circumstances? In terms of “extracted rice” it was not as though I had any shortage. The traditional organization of our hospital placed all clinical activities except nursing under the leadership of the Chief Medical Officer.

No, the problem with this rice bowl was not the rice.

It was much more the idea of someone else reaching into my bowl.

I had reacted to the thought that someone else would reach over and violate the boundaries of my rice bowl, especially without even the decency of asking me first.

What was the cure for this flood of inane emotions? First, I had to choose to give people I trusted the benefit of the doubt they had earned through our relationship together. I also had to remember that my Boss and colleague were in fact acting consistently with the way I knew that they always acted.  They were working on organizational improvement, efficiency and improved patient care.

Perhaps “forgiveness” is too strong a word for the response I needed. They did not mean to insult me. However, if I felt insulted I could certainly forgive them the unintentional affront. It might justify a conversation in the future to avoid this misunderstanding. But she was my boss, after all.

Finally I had to accept a willingness to share the rice as well as the access to my rice bowl. I know that I didn’t have the opportunity to talk about this ahead of time but for the life of me I could not think of any particular reason why it was a bad idea. The difference between “dialogue” and “discussion” is that with dialogue I am willing to consider the possibility that my preconceived notions are wrong. In discussion my intent is to convince you of the error of your ways. I had to approach this decision with the willingness for dialogue and not necessarily the effort to persuade.

There is plenty of rice and work to share. Feel free.

You might just let me know when you would like to reach over toward my rice bowl – if only so that I don’t bump your hand with my own.

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

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“So…”

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.”ellipsis crop 1

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/

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How we can tell that we’re still not patient centered

“The vein rolled.”

This is how the medical student summarized his efforts to place one of his very first intravenous lines in an elderly hospitalized patient. He was successful on the second attempt, but reached for this classic explanation for the first failure. We learn early how easy it is to blame patients when things don’t go the way we expect.  Perhaps it’s how we cope with work in such a high-stakes business. And lest you think we have crested the hill and are on the downhill of this particular thinking, consider the following language recently heard from a resident physician:

“The patient was non-compliant.”

Medicine began the general migration from this term more than a decade ago, but you still hear it frequently when a patient’s response to his or her treatment regimen differs from the provider’s instructions. “Compliance” suggests a matching of patient behavior to provider recommendations.  “Adherence” is the preferred term and implies a match between patient behavior and the agreed upon regimen developed by both the patient and the provider. Adherence suggests that a dialogue has taken place and a set of behaviors (e.g. exercise, diet-modifications, medication) were agreed upon. Even of the patent fails to follow the regimen, at least he was a part of the decision.

There are other ways we reveal the same bias in our thinking. Patients who do not come to their appointments are called “no-shows.”  If they go to the emergency room for care instead, and do so frequently they are called “frequent flyers” or even as I heard recently, “PAUers” (PAU = Potentially Avoidable Utilization).  Interestingly we also tend to villainize the emergency rooms where they get care and the providers who care for them in the ER instead of recognizing their key role in providing patients access to care.

When we objectify patients language like this becomes acceptable. We forget that these are people with stories and refer to them instead as “teaching material” or “fascinomas.” From a business perspective we talk about “market-share” when we really mean people; people who need surgery or hospice, women who deliver babies prematurely, men suffering from prostate cancer. When we agree to see a patient who has come to the appointment late we are “rewarding bad behavior,” with no particular insight into why they might be late.

“They just don’t care” is something I heard recently from a provider. It is a troubling value judgment. And it may be the thought that is most concerning because it reveals how disconnected we have become from our patients’ lives.

American medicine in the mid nineteenth century was provided by practitioners who lived in the community with their patients. Healthcare was delivered in the home. In 1873 there were fewer than 400 hundred hospitals in the entire nation.  The transition to twentieth century medicine was fueled by gasoline. The introduction of the automobile allowed the physician to dramatically increase his productivity and efficiency. The transition was also accelerated by the invention and proliferation of the telephone. According to Professor Paul Starr (The Social Transformation of American Medicine, 1982) the first telephone exchange in the United States was established in 1877 to connect the Capital Area Drugstore  in Hartford Connecticut with 21 local doctors, so patients could contact the doctors and coordinate their visits. Provider efficiency increased but so did revenue, driving an even greater need for efficiency.

The transition has come at a cost and we continue to experience the repercussions.  Again from Professor Starr:

“The doctor of the nineteenth century was a local traveler who knew the interior of his patients’ homes and private lives more deeply than did others in the community. By the early twentieth century, many physicians went to work at hospitals or offices and had little contact with the homes or living conditions of the patients they treated. This radical change in the ecology of medical practice enabled physician to squeeze unproductive time out of their day.”

Unfortunately it also created a distance between patients, providers and health care systems that exists to this day. When patients in our inner city community talk about what they are looking for from their health care system they talk about trust.

The economy of medicine is ultimately relationship, and the currency of that economy is trust.

The vein may well have rolled. But the operator on the other end of the IV catheter is the one with the responsibility to explain why and then to attempt it again. If we can’t get the line we will find someone else who can.

There is a person and a people at the end of the IV needle.

And I suspect they are getting tired of being stuck.

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

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The difference between tumid and true

Tumid.

I stumbled across this gem of a word recently while I was looking at an old translation of the Hebrew word for “proud” (`aphal) from a passage in the biblical writings of the prophet Habakkuk (2:4). When used anatomically, tumid means “swollen, distended, of a bulging shape or protuberant” from the Latin word “tumidus” derived from ”tumēre,” “to swell.” The Latin root is also the source of our word “tumor.” When used to refer to speech the word means inflated, pompous, or bombastic. How about “orotund” for another related beauty from the Latin word “ore,” or “mouth,” and “rotundo”  “to make round.”  It’s a good facial expression if you’re singing. Probably a bit pretentious if you’re not. These words have become illustrative of the current state of American politics.

Faith is one of the cardinal principles of leadership. The leader must be able to cast a vision and believe in something he or she cannot see; something that’s bigger than self or an organization. In addition to believing, the leader must also be believable so that others will see and believe the vision as well. This is where truth comes in.

Vision requires a balance between faith and the senses; between hope and the stark reality of the way things really are. One of the earliest lessons I learned in the practice of medicine was the tension between realism and optimism. It was reinforced repeatedly over decades in the practice of pediatric intensive care. The job of the clinician is to find the balance between hope and reality; to be honest about the risks and potential negative outcomes in a patient’s course but at the same time to recognize that there are almost always reasons for hope. Both are true and both are needed.

Leaders face the same dilemma, a tension that author Jim Collins called “The Stockdale Paradox,” based on lessons Medal of Honor awardee Admiral James Stockdale learned as a prisoner of war in Vietnam.  “This is a very important lesson.” Stockdale told Collins in an interview for the book Good to Great. “You must never confuse faith that you will prevail in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality, whatever they might be.“ He told Collins, “I never lost faith in the end of the story. I never doubted not only that I would get out, but also that I would prevail in the end and turn the experience into the defining event of my life, which, in retrospect, I would not trade.”

The leader must seek and believe truth while balancing optimism and realism. As an example, when I helped lead a federal medical facility during the 2013 Sequestration our message was to acknowledge the awful betrayal these public servants felt toward the government and the potential impact on their lives of losing 20% of their income.  At the same time we tried in every meeting to recognize the incredible sacrifices they made for our patients. We told them we believed the crisis would see a prompt end because of their commitment and the relationship they shared with the families they served . We were right. It ended quickly.

But what if I had lied? What if I had told them something that I knew was untrue or something that they could easily ave confirmed as disingenuous? How would my words of praise or promise have been interpreted then? I suppose that out of loyalty they might have ignored the lies, or convinced themselves of the truth of something that any objective person could confirm was untrue. But thinking people would have seen through it. They would have known that what I was saying in my weekly town hall gatherings and frequent emails was tumid: bombast, hot air, empty promises without substance.

We must be thinking people; sensitive to the difference tumid and true when evaluating our leaders or when considering those whom we would chose to lead us, just as we do in our own leadership practice.

For the leader, neither volume nor verbosity can replace veracity.

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

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