On Having Knight Vision

The Holy Grail seems at times a more reasonable quest.

The standard for behavior and rhetoric has become intolerance and abuse. New allegations of harassment and assault are so numbingly common in the continuous news cycle that we can’t remember which actor, which athlete, which politician provided the last denial or tears of reptilian remorse. No one is entitled to their own opinion nor do we “agree to disagree” (whatever that meant anyway). People who see things differently are “idiots” treated with a level of disdain we used to reserve to trot out seasonally for the fans of rival sports teams.

“A man never hurts a woman” my mother scolded after I beaned my big sister in the head with a stone thrown carelessly over my shoulder in her direction. “Walk her to the door!” my dad hissed as I sat passively in the back seat of the station wagon while my date made her way up the sidewalk after a ride home from a high school band party. Offer your seat. Hold the door. Don’t be unkind. Offer it up. Think of others. Do your best.

It seems like a vision from a different world.
But perhaps these days it’s a world worth remembering; one worth fighting for again.

My mother gave me the gift of knight vision.
Not the ability to see in the dark but the desire to push against it. Continue reading

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Military Medicine: How Good American Healthcare Could Be

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

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

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

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

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

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

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

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

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

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

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

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

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

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Population Health: Capital and Lower Case “P”

The term “population health” entered my vernacular in the late nineties when I was a new pediatric department chief and our hospital director of quality introduced me to the term. Like most clinicians I was a pretty good medical “tactician” in the ICU, the clinic, and on the hospital ward. But I didn’t consider the bigger “strategic” outcomes of groups of patients often enough. This changed.

The department and hospital took on pediatric asthma in our population and saw the hospitalization rate for our patients drop by two thirds. (In fairness, it was also the beginning of the era of “asthma control” so there were more tools available.) We championed telemedicine systems that provided pediatric subspecialty consultation for children six time zones and thousands of miles away and monitored children with asthma in their homes over the relatively new Internet. After helping to run health care facilities and systems for the Army and working in a few health care systems overseas, I was fortunate to begin work as a hospital executive focused on population health in an urban medical center.

These past two years I have been mentored by health care and community leaders regarding the impact of the social determinants of health (e.g. housing, education, food security, jobs, transportation) on the health and well-being of those living in the communities surrounding our hospital. These social determinants comprise up to 80% of the factors influencing health outcomes. In many cases the journey to ill-health in adulthood began for our adult patients in infancy or even earlier with insufficient or absent prenatal care.

Infant mortality for babies born in one neighborhood a half-mile from our hospital is ten times what it is five miles away in another part of town. Life expectancy is nearly twenty years shorter. Efforts to affect the long-term outcome of the two-dozen or so babies born in our city every day over the course of their lifetime include addressing their health care access and quality and the disparities that drive these outcomes. Even more importantly, efforts must address the social determinants that impact their health: Population Health with a capital “P.”Pop Health Triangle 15 Oct 17 b

But in my new position I soon became aware of a tension in the understanding of population health. Early in my tenure someone referred to the patients frequenting the ER and hospital wards as “PAUers,” (“potentially avoidable utilization”). Other names that I continue to hear for these patients include “high-utilizers,” “frequent-flyers,” and even very recently “train-wrecks.” There is no question that health care facilities, payers and practices must address the high health care utilization of these patients who struggle with a tremendous burden of complex, chronic disease. By some estimates, 5% of our population consume 50% of health care resources.

What has become clear is that many discussions of population health in healthcare facilities center almost exclusively on the peak of the risk/care consumption pyramid: population health with a lower case “p.” While the health of these individuals is as important as that of anyone else on the pyramid, a focus on small “p” population health can sometimes become centered on how this population affects the healthcare institution. In this case solutions are driven by investments in the healthcare system and tend towards short-term goals and short-cycle return on investment. Small “p” population health is generally seen through the healthcare system lens and its effectiveness is measured using system-based interventions and metrics (e.g. readmission rates, ER utilization, etc.)

In contrast, Population Health with a capital “P” focuses on the base of the risk or utilization pyramid where people are not accessing health care but where they are making decisions that will ultimately impact their health. At the base of the pyramid the focus should be on how healthcare organizations – particularly those that serve as anchor institutions in urban or rural settings – can through intervention and influence positively affect the health & well-being of the population.

The expectation is a strategy that affects multiple generations over multiple generations; long-term goals and long-cycle return on investment that require community leadership and prioritization. With efforts seen through the lens of the health care recipient rather than the system, it is measured by the effectiveness of community-based interventions and metrics. And where small “p” population health tends toward blaming the patient and being pejorative, capital “P” Population Health with its focus and resources invested in the community has the potential to be restorative.

There is no doubt that American healthcare must address both small “p” and capital “P” population health. But we must be careful not to allow the economic urgency of the peak of the utilization pyramid to hijack our opportunity to invest in the health and well-being of those who are yet at the pyramid’s base.

They may not remain at the base of the pyramid.
But for their sake, for our communities and for our health care systems, we must do all we can to see that they do.

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

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Learning Leadership in the City

Ten TwelveOn a clear, breezy summer Saturday morning in the Sandtown-Winchester neighborhood of Baltimore, 10:12 Sports Director Jeff Thompson speaks to a young player about character in the context of a flag-football game. In the background, the Ravens and the Bengals play the fifth game of their season.

In this neighborhood, 60% children live below the poverty level, 80% of households with children under 18 are female-headed, unemployment is 17% and a quarter of kids never finish high school. The field where the young men play is half a mile from the scene of the uprising and violence surrounding the death of Freddie Gray in 2015.

This is the neighborhood where Jeff Thompson and his volunteers work with young men teaching the fundamentals of character and leadership from a Christian perspective. The lessons are framed against the backdrop of a flag-football league that also employees local youth on weekends as referees, linesmen, and statisticians.

Character is the foundation of almost any leadership model. The ability to “lead self” is crucial before one can attempt to apply almost any other leader competency. There’s much that a developing leader can read about the importance of character and no shortage of books on the subject. But no book can teach what we learn from credible mentors who serve as examples and who listen to understand.

Albert Schweitzer said, “Example is not the main thing in influencing others, it is the only thing.” Leadership guru Michael Useem took that same idea one step further: “Leadership is best learned from example and best communicated through example.”

Still a relative newcomer to Baltimore, I have joined the search for the magic, missing ingredients that once applied will cure the city’s woes. I know already that there isn’t any single thing. But on this Saturday morning these young men – in the context of a community who loves and cares for them and who holds them accountable for their actions – were experiencing the closest thing I have found to a foundational first step.

“Leadership is character in motion” (Les Csorba).

For these young men on any given Saturday there is more in motion than the football and the players on the field.

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

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“Remember to look into their eyes”

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

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

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

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

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

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

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

“Remember to look into their eyes.”

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

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

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

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

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

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

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

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

“Sawubono” – “Sikhona”

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

I see you. I am here.

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

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

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

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

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

I see you. I am here.

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

Take care of our Warriors and their families.

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

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Reflection: The Leader’s Gift – Presence

If the currency of the economy of relationship is trust, the currency of leadership is presence. To “be there” at the critical moment for an individual, a team or an organization is the essence of a leader’s effectiveness. Presence requires of the leader attention and intention. Good leadership is always intentional and “attentional.”

When I was helping to lead a community hospital in Virginia a decade or so ago I decided to count through the course of day every single human interaction I had – in person, in the hallway, in an executive or hospital meeting; by phone, email or text. I carried a 3×5 card and made little pencil tick-marks throughout the day. At the end of the 18 hours or so of measurement I counted 283 pencil marks: 283 encounters. The requirement for me as the leader to be present, attentional and intentional was not daunting or infinite. It was in fact finite and consisted of scores of opportunities to be present, to be listening, to be attentive – to “be there.”

The Egyptian philosopher Ptahhotep wrote in the 24th century BC, “Those who must listen to the pleas and cries of their people should do so patiently, because the people want attention to what they say even more than the accomplishing for which they came.”

Being there is a privilege bestowed on the leader never to be taken for granted.

There is a greeting among the people of Northern Natal in Africa when they meet someone, make eye contact and resolve to be present: “Sawu Bona – I see you.”

The reply is an equal commitment to attention and intention: “Sikhona – I am here.”

I see you. I am here.

These are perhaps the most important words we can live by for the men and women we have the privilege to lead.

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

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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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