Communication Conflicts

Assumptions, Emotions, Perceptions, Conditions, and Facts color our communication with ourselves and others. We must learn to manage them.

A wise man once said that the hardest thing about communication is the illusion that it has occurred. I have been involved in hundreds of medical, military, and public safety operations, and the after-action reviews of each one cite communication as a problem. Whether in business, relationships, or anywhere else, avalanches of academic papers and mountains of media articles bemoan our inability to effectively talk to each other, and propose ways of fixing it.

Several factors are present in every communication event, including assumptions, emotions, perceptions, conditions, and facts. They change the communication, often without the participants realizing it.

Assumptions

Assumptions are believed true but without proof. Each person, whether he considers himself religious, spiritual, philosophical, materialistic, or something else, makes metaphysical assumptions, assumptions about the fundamental questions of life. Suppose three college students, Mike, Sienna, and Jorge, are talking about their planned vacations. Mike, a Christian, believes that God created everything, that He is the center of existence, and that the purpose of every created thing, including people, is to glorify God and enjoy Him forever. Sienna, a secularist, believes that the universe is just one of many universes in a “multiverse”, that the human community is the center of existence, and that making oneself happy is the purpose of existence.  Jorge, a philosophical naturalist, agrees with Sienna on the origin of things, believes that each individual is the center of existence for that individual, and claims that the universe has no meaning or end at all. Mike plans to do a mission trip to Brazil for his spring break, Sienna is scheduled to take an eco- and poverty-tourist trip to Belize, and Jorge is going to the Caribbean for alcohol, parties, and women. Each is acting in accordance with their fundamental assumptions about life, but their discussion will probably be no deeper than “whatever works for you.”

Most people do not recognize their own assumptions, but have a smorgasbord mishmash drawn from religions, the media, popular culture, and those around them. Nonetheless, these assumptions color everything that we do – from who we marry to how we work and vote. When two people talk, the further apart their assumptions are, the harder it will be for them to communicate, and the less likely it will be for the conversation to go well. Keep in mind that we are talking about fundamental, important assumptions; beliefs about life, the nature of good and evil, and purpose.

Imagine that Asherah, an ancient Sumerian woman, were listening to the conversation between Mike, Sienna, and Jorge. Unfamiliar with any idea of universal religion, she would puzzle over why Mike was sailing over the ocean (she couldn’t conceive of flying) to bring his religion to another people, who already had their own gods. Scoffing at the idea that all people are created equal, she would be scandalized that Sienna was going anywhere without her father or brother, and that she should be care about poor at all. Even if our Sumerian maiden secretly admired Sienna’s independence, she would not admire her egalitarian leanings. Asherah would understand Jorge’s plans the best, and if Jorge were wealthy, might approve.

Lesser assumptions also impact communication. If a woman believes that black men are threatening, or that men in general are oppressive, she will have trouble understanding anything that a male is trying to say, no matter how he says it. If a man considers women little more than sexual prey, he will be equally impotent in understanding women. The same is true for other prejudices, no matter their basis (religion, culture, nation, etc.). That is why such attitudes are so toxic.

Emotions

I know the look. When I am talking with my oldest daughter, I am in trouble when she squints, tilts her head, and furrows her brow. At that point, I better start apologizing, because we have moved from (usually) rational discourse to emotional damage control. It is not that she is unusually irrational but that she, like all people, is a complex mix of intellect and emotion. Often the emotion leads. My daughter is helpful in that she signals when the switch has occurred – with others you may never know.

Emotions powerfully affect communication, sometimes blocking it entirely. When doctors give a patient a terminal diagnosis, the patient hears nothing else during that conversation, no matter how the doctor says it. When a judge announces a contest winner, the same thing happens. Excessive anger or fear can also stop the ears and close the mind. Stress hormones like epinephrine and cortisol surge in the body, and all the person can do is react.

Emotions color conversations. All else being equal, speaking with someone you love will always be better than speaking with someone that you do not like, or are neutral towards, even if the words are as tame as “Please pass the butter.” Newlyweds eating by candlelight might see that request with the rose hue of love, while feuding co-workers at a mandatory company dinner might see it with the red fire of anger or the blue ice of bitterness.

Talking with someone new may be exciting, but it also generates fear. The same is true of talking to a person of a different age, sex, religion, culture, nationality, race, or political persuasion. Discourse with those who are different from ourselves is imperative, but the emotions involved often make it more difficult.

Emotions amplify or deaden the importance of communication. When a rigorous teacher in an important class says, “the test is tomorrow”, students will color and amplify the statement based on their perceived readiness. Prepared students will feel satisfied in their work and a readiness to get the exam over with, and unprepared students will feel dread about their anticipated grade and shame for not working harder. The words “the test is tomorrow” will pound in the unready student’s head all day long, while the ready student will hardly give them a second thought.

Perceptions

I was standing near a military medical tent in Washington DC during Barak Obama’s second inauguration in 2013. The Presidential motorcade was approaching, and several black women were chattering wildly in anticipation of seeing America’s first black president. Their emotions were high, and from the tenor and text of their conversation, had been for days. It was hard to know which black limousine the President was in, and hard to see anyone inside the vehicles due to their dark, tinted windows. Nonetheless, everyone found him and in the few seconds that he passed by, studied his every move. One woman shouted, “he looked at me!” while another exclaimed “he smiled at me!” Watching the same scene, I could not be sure that the President had done either. He could have scowled, or more likely not noticed them at all given the tens of thousands of people on the parade route, but it didn’t matter. Those women will stick to their stories and tell them to their friends and family all of their lives.

Perceptions are mental impressions or intuitive insight. In day to day life, what we perceive is often more important to our understanding and our actions than the truth. A look, body position, or tone of voice perceived as threatening, unkind, or even uncaring will undo the best of words. Similarly, favorable perceptions can make the communicating parties feel better about themselves and each other. Regardless of what Barak Obama actually did, the perceptions of these women at the Inauguration made them like him more.

Conditions

Everyone who communicates does so to gain something:

  1. Money
  2. Self-esteem
  3. Esteem in the eyes of others
  4. A chance to do good, whether by advancing their business or some other cause
  5. Specific, personal goals

While everyone more or less shares general goals, communicators are not likely to share specific goals. A boss might want to get his employee to do a task, while the employee might want to shift that work to someone else. A politician may want each person in the audience to vote for her, while listeners might want free food, a good time, and a chance to have an interesting experience with an important person that they can share with their friends. A man may want a date, but the woman he is talking to may simply want to escape from a “creepy” situation.

Real communication will be much harder to achieve if the parties don’t know what motivates others. If they know what the other person is thinking, the boss might emphasize the benefits of doing this particular job, the politician might design a rally to provide an exciting experience, and the suitor might learn more about the object of his affection to avoid making her uncomfortable. If the boss knows that nothing he can do will make the employee do the work, if the politician has no chance of getting certain votes, and if the man’s amorous advances are dead in the water, each would drastically change their tactics, or give up communicating all together.

Facts

People generally believe that they are communicating in facts, those objective truths upon which life is based. Because each party feels that he is dealing only in irrefutable facts, he may have trouble understanding how anyone could disagree. When we are not careful, this opinion leads to dismissing other opinions as stupid, or even evil. We demonize those with whom we disagree, and they demonize us. Our assumptions, emotions, and perceptions align against our opponents, and our desired outcome is no longer understanding or compromise, it is victory. Crushing the hated enemy, not understanding each other and accomplishing mutual objectives, becomes the goal.

Actually, facts can be challenged, debated, and seen from different perspectives. Truths are still objective – a person with colon cancer has colon cancer regardless of what they, their friends, or all the doctors in the world think. But finding the objective truth can be extremely difficult – much harder than we assume. No one has a monopoly on truth, but some do understand reality better than others – at least in certain fields. By comparing facts, acknowledging other opinions, being humble enough to learn, and keeping all participants’ best interests at heart, we all can get closer to the truth, and closer to solving the problems that vex our world.

Conclusion

It is hard to communicate effectively. If communication is an iceberg, facts are the visible part above the waterline, and assumptions, emotions, perceptions, and conditions are the barely visible parts below the surface. Just as the Titanic never would have foundered if it had hit only the top of the iceberg, so communication rarely founders on the facts. Rather, it founders because the parties don’t understand and sometimes don’t trust each other. Anyone who wants to communicate will take the time to ponder the assumptions, emotions, perceptions, conditions, and facts of others. These people will communicate better and have success.

Getting People to Answer

A Navy Lieutenant Commander (LCDR) came into my office recently. “Sir, I have emailed Lt. Col X several times and she hasn’t answered yet. All I get is radio silence. Could you help?” This young officer was voicing a concern that I hear frequently; someone that they are trying to work with, or get something from, wasn’t answering. Or at least they weren’t answering fast enough to suit us at higher headquarters. When faced with such a problem, many junior staffers go to the Boss, hoping that he or she will contact the person and get immediate results. Sometimes if the issue is urgent that is the right approach. Sometimes even going directly to the boss of Lt. Col X is the best approach. Often, however, it is better for the junior staffer to get the information themselves, and there are many ways to do that. I have been faced with similar problems in the past and have learned the hard way that, unless the issue is urgent, I need to exhaust my options for resolving problems, such as radio silence from someone I am supposed to work with, before going further up the chain.

Make sure that you are asking for the right thing

Ultimately any request, whether for information or for a task to be done, must be right. The energy that it takes to do it must be worth the value that comes out of it. We have to ask the right person; it is no good asking the chief of patient administration to do something that the chief of neurosurgery should be doing. We have to be clear in our request and respectful in the delivery. We must only make ethical demands. In medicine our requests must be the right thing to do for our patients and other stakeholders.

Give a little time

Sometimes it is a little embarrassing to remember past mistakes. Several years ago our commander at William Beaumont Army Medical Center received a suggestion to cut imaging costs by preventing physicians’ assistants, nurse practitioners and primary care physicians from ordering expensive magnetic resonance imaging (MRI) scans. He asked me to get information from my department, primary care, and from other departments to address the question. In the flood of other tasks I quickly forgot until a few days before the information was due. A cold knot welled up in my stomach and a sent out a flood of emails to everyone involved so that I could at least shift the blame to them if I didn’t get the data in time. Or so I thought…

There are lots of good reasons why people don’t respond as quickly as we would like. Sometimes they just don’t get the message, whether because it is lost in cyberspace or because they are out of the office. Other times they get it but are so far behind on email that they don’t see it. The more emails I receive, the more I sympathize with this problem. Everyone is busy, and an issue that I consider urgent may not be urgent to someone else.  Sometimes requests are confusing and the recipient truly doesn’t know what they are being asked to do.  

Assume the best

Most people do not want to do the wrong thing. If your request is reasonable and you ask in a timely and friendly manner, most will want to honor it and will feel guilty if they don’t. We sometimes assume that we will act with wisdom and compassion while others act with foolishness and spite, assuming the best about ourselves but the worst about others. This arrogant attitude only makes it harder to get good things done.

Even in the worst of circumstances it is usually unhelpful to assume malice. Shortly after my father died my mother received an email from her health insurance provider stating that he had technically been off of her insurance during his last six months of life. Therefore they were going to bill her for his chemotherapy, radiation therapy and hospitalizations. Mom was panicky and my brother was furious, so she asked me what to do. I replied that in situations like this you will more often be correct if you assume laziness and incompetence rather than malice and villainy.  Calmed slightly, my mother called the insurance company. After getting referred a couple of levels up the management chain, she learned that a computer error, a policy change, and an unwillingness on the part of some of their staff to look deeper had combined to generate this misunderstanding. Everything was covered.

Flip the roles

In another instance we had asked our subordinate command to provide a report about a recent mock Joint Commission inspection. Rumor suggested that the results were not pretty, and they were dragging their feet. After many weeks and many entreaties our Quality Management shop turned to me for help. I contacted their chief of staff, listened while she explained their perspective and then clearly explained ours. Then I asked “if our roles were reversed, wouldn’t you and your commander want the same thing?” The report appeared in my inbox the same day.

Name drop

Every organization is conscious of rank and position, no matter how flat they are organizationally. The larger the organization, however, the more conscious of such things it tends to be. Nowhere is this more true than in the military. Sometimes stating that a request is from a colonel or Navy captain rather than from a lieutenant commander or major is enough to get results. Even better, sending an email that has the higher ranking officer on the courtesy copy list lets the recipient know that a boss is looking at the request. More than once this has made the difference between action and inaction.

Fingers, voice and feet

It is easy to send an email, and equally easy to miss or ignore an email. It is much harder to ignore a ringing phone, especially one that rings again and again. It is hardest of all to ignore a person sitting across from your desk or in the waiting room outside your office. If the target of your inquiry is not intentionally avoiding the issue, a phone call may be all that is needed to get results. Phone tag is not a bad thing if you are able to make headway. Further, emails can be confusing, clouding the picture more than clarifying it in many cases. This is especially true for complicated or contentious issues. Even if the target of your inquiry is intentionally avoiding you, a phone call or even a visit is vital. The communication motto for my staff is “friendly, but relentless.”

In the modern day of emails, texts and web posts it can be difficult and even threatening to have tense conversations over the phone or in person, but some things will never get done otherwise. People who can handle these situations well are like diamonds, scarce and precious.

Give something they want

Everyone wants something, and the person that you need information from is no exception. Sometimes they feel overwhelmed and want less to do so if you have asked them for three things and reduce that to only two, they may be happy enough to comply. Sometimes they want an encouraging word or even a complement about them to their boss. Sometimes they just want to be listened to, and if you spend five minutes listening to their challenges they will reward you with what you need. Sometimes they need help with what you are asking them to do; the Navy LCDR offered to help Lt Col X compile the data he requested.

People at lower headquarters need to know that their higher headquarters is doing something to benefit them. Staffers at higher levels can make their work easier by being value added for those at lower levels. Sometimes giving them “something they want” means protecting them from something that they don’t want.

Think outside the organization itself. Higher levels of command have more than just money and people to give to their subordinates. They have expertise and experience to share, and sometimes people at lower commands need and even want that expertise. They also have access to media outlets, whether a base newspaper or a local radio station, where they can spread the word about the good things that their subordinate command is doing.

Double team, diversely if possible

In the introductory story the Navy LCDR was trying to get information from Lt. Col X, and was getting the stiff arm. He had given it time, assumed the best, and dropped names. He had called and gotten nothing, so the next approach was to double team her. A young active duty Navy male had tried, so he enlisted an older civilian female.

Why try this, because two can apply more pressure than one, and can apply it in slightly different ways.  Who knows why Lt. Col X was resisting his entreaties? Perhaps this officer had a mannerism that she didn’t like, perhaps she interpreted his actions negatively, or his age, race, sex, service, or something else put her off. Discrimination based on these factors exists, and we must overcome it. As rational as we like to think we are, man is an inherently irrational creature. Man is also a tribal creature, with whom identity and identification matter. Perhaps involving someone who was more like Lt. Col X would influence her to provide the assistance needed.

The 360

Those we try to influence do not work alone; they have bosses, subordinates and peers. Since Lt. Col X outranked the Navy LCDR, another possibility was for him to approach her deputy, an Army major, and ask if Lt. Col X had been out of the office or had some other reason why she hadn’t replied. He then asked if he could do anything to help the major help his boss, Lt Col X.  

This technique is useful because everyone is influenced by those around them. Perhaps convincing a certain peer of Lt Col X that this task was important would be enough to get her to do it. Even a trusted subordinate could do the trick.

The Boss 

If the request for information or the task that needs to be done is urgent, sometimes lower level staffers have to go straight to their Boss, and he or she has to go straight to the other person’s Boss. Most requests, however, are routine. If a staff member has done everything that he or she can and still gets nowhere, the Boss must act. Senior leaders have various options, including all of the ones noted above. For example, I could go directly to Lt Col X’s boss or to her boss two levels up.

There is danger in doing this in the wrong way. Years ago when I was a young Army captain I was working in a clinic in Germany and my boss had made an unpopular decision and gone to lunch. A few minutes later a brigadier general came into the clinic. Since I was the ranking officer there at the time our near-panicky executive officer came to me and said “Dr. Harris, a general is at the front desk and wants to speak to you!” When I asked the general what I could do for him, he said “Dr. Harris, someone at this clinic made a decision a few minutes ago and I came in hoping that I could influence that decision.” He never said “I order you”, he never demanded, and he was never cross or even stern. Knowing that he had tremendous power, the general was very gentle in how he used it.  I never forgot the lesson.

There is also danger in doing this too much. Leaders and subordinates grow weary of leaders who seem to be throwing their weight around. Senior leaders are generally very busy and have little time to devote to non-senior-leader level things. Getting involved in staff level work too often impairs a leader’s own ability to get other work done.   

Conclusion

Poor communication and cooperation at every level is, and always has been, a problem in and between organizations. Staffers must do everything they can to fix this problem, including asking for the right thing, allowing time and assuming the best. They can flip the roles, drop names, and use fingers, voice and feet to accomplish their mission, always being ready to give a little in order to get a little. They enlist other people to help them. If all else fails or if time is short, they ask their boss for assistance. Ultimately the mission is what matters, and everyone at every level must accomplish it.  

Learning Many Ways to Communicate

(- …. . .. — .–. — .-. – .- -. -.-. . — ..-. .-.. . .- .-. -. .. -. –. — .- -. -.– .– .- -.– … – — -.-. — — — ..- -. .. -.-. .- – .)

In the popular movie Star Wars, the protocol droid C3PO boasts that he is programmed with over six million forms of communication. His skills come in handy for Luke Skywalker, Han Solo, Princess Leia, and the other characters trying to save the galaxy from the evil Empire. From Ewoks to Jabba the Hut, C3PO plays a major role in the final outcome.

In real life we often assume that communication is easy and we consider ourselves masters at it. In truth, however, communication is fraught with opportunities for misunderstanding. We often assume that our language, written and spoken, is the best and the others should learn it. In fact, each language is stronger for some tasks and weaker for others, just like people. Further most others will not learn our language, whatever its virtues. If we wish to speak with these people, we will need to learn how to communicate with them. This article will discuss ways of communicating with others, and the importance of doing so.

Cultural anthropologists tell us that there are 12 “signal” ways that we communicate. These include:

  1. Language/verbal – The spoken word, typically provided in person. When the speaker is present, this is the most powerful single means of communication in most cultures.
  2. Written – Text in any form, whether prose, poetry, law, history, fiction, or some other genre.
  3. Numeric – On roads and highways throughout the world, numbers on Speed Limit signs communicate important facts; so do bank statements and balance sheets.
  4. Pictorial – Pictures are worth a thousand words, but pictures may speak different things to people of different cultures.
  5. Colors – Warm colors such as pink or red and cool ones such as blue or green communicate powerfully and differently in restaurants, offices, or bedrooms.
  6. Sounds and silence – The same sound may signify a gun shot or a car engine backfire in different situations.
  7. Kinesthetics (Facial expression, hand gestures) – Smiles and frowns are more or less universal, but hand gestures vary by culture.
  8. Optical (Light) – A dark space might communicate intimacy or foreboding, while a light one might suggest openness or sterility.
  9. Tactile (Touch, Feel) – A hand shake can be cold and limp or warm and strong. It can be perfunctory or fully engaged. Each type communicates vastly different things.
  10. Social distance – How much space do you allow between yourself and others and in what circumstances? In day to day interactions, people from Western cultures prefer more space than those from Eastern cultures.
  11. Use of time – In Mexico start times for meetings tend to be more flexible than in Manhattan.
  12. Smell – Realtors sometimes tell home sellers to bake cookies just before an open house, so that the inviting smell draws people in. Restauranteurs and other retailers use smell for the same reasons.

The best communicators will use all of these ways to share their message with their audience.

The most obvious way to communicate is through spoken language. Mandarin Chinese, English, Hindi, and Spanish are some of the most widely spoken languages in the world. Soldiers, statesmen, businessmen, travelers and ministers are often required to learn another language. There are many sublanguages; one way that a person identifies himself as part of a certain group is through his use of their common language. Doctors speak like doctors to one another, using a different vocabulary and patterns of speech than non-physicians do. For example, when discussing a patient, they use a certain format, beginning with age and sex, progressing through the history, physical exam, laboratory and radiology studies, and assessment and plan. A typical presentation may sound like this:

Patient X is a 63 year old male with a history of angina pectoris status post single vessel stenting who complains today of crushing chest pain, 6/10 severity, radiating to the jaw and left shoulder, which began 30 minutes ago. Past medical and surgical history are otherwise unremarkable. He has no drug allergies and his current medications include aspirin, atenolol, and nitroglycerin as needed. He is alert and oriented to person, place and time and his physical exam is notable for diaphoresis and shortness of breath. His EKG demonstrates 3 mm ST elevation in the precordial leads and his troponin levels are elevated. Our assessment is acute myocardial infarction and he will be admitted for cardiac catheterization and revascularization.

Lawyers and other professionals do the same. Using the language of the profession is a requirement if you wish to be an accepted part of it.

Computer languages enable people to communicate with computers. The language of music is a powerful way to share profound thoughts and emotions. Prisoners in solitary confinement from Colditz Castle to the Hanoi Hilton have used Morse code to communicate between themselves, but because it is difficult to make dashes with taps, more often use the Tap (or Knock) code. It uses the Polybius Square of Ancient Greece.

To be most effective in whatever they do, people need to master at least one form of communication, their native language, and most would do well to be proficient in others. Even though it can be difficult to learn another language, the effort to learn and practice even a few words is well worth it, for it shows concern for others. After the USS Tang (SS-306) was sunk by its own torpedo on 24 October 1944, the commanding officer LCDR Richard O’Kane and eight crewmen escaped and survived. They were picked up by a Japanese patrol boat the following day. While being interrogated, a Japanese officer said to Kane “I have learned English, but you have not learned even one word of my language. How can we understand each other’s’ problems? How can there be peace?” (Kershaw, Escape from the Deep)

Americans abroad will discover that those they meet often speak English far better than those Americans speak the local language. While shopping in Germany I struggled with my order until the cashier said “Wouldn’t you rather do this in English?” In that case, with a line forming behind me I agreed, but in others I refused. My German improved as a result.

The US Foreign Service Institute has developed a rating scale for language proficiency.

  1. Level 0 – no speaking ability in the language.
  2. Level 0+ – you can use at least 50 words in the appropriate context.
  3. Level 1 – Elementary speaking proficiency. You can communicate well enough to travel using the language.
  4. Level 1+ – More than level one, but you are limited to fairly familiar material.
  5. Level 2 – Limited working proficiency. You are no longer limited to a range of memorized texts and you can give simple instructions, explanations and descriptions. You still get lost with more complicated material.
  6. Level 2+ – Rate of speech and fluency are increasing
  7. Level 3 – Minimal professional proficiency. You can handle all social and work requirements but still have an accent.
  8. Level 3+ – You are able to understand idiomatic speech as well as routine conversation.
  9. Level 4- Full professional proficiency. You can correct errors that you make in the language.
  10. Level 4+ – You speak almost as well as a native and have a deep understanding of the culture as well.
  11. Level 5 – Native speaker proficiency.

In conclusion, learning new languages is useful and can be fun. Native speakers will generally help you. There are lots of ways to communicate besides just languages, and excellent communicators should use them all way.

Si usted quiere aprender una nueva idioma, buena suerte. Wenn sie wollen eine neue sprache zu lernen, viel Gluck. And finally, .. ..-. -.– — ..- .– .- -. – – — .-.. . .- .-. -. .- -. . .– .-.. .- -. –. ..- .- –. .

–. — — -.. .-.. ..- -.-. -.-

These sentences can be translated, “if you want to learn a new language, good luck.”

Afterward

While preparing this paper I asked my son, a Civil War buff, to review the Morse code. Here is his “tongue in cheek” assessment:

.-/-./-..//.—/..-/…/-//…/—//-.–/—/..-//-.-/-./—/.–//–/-.–//..-./.-/-/…././.-.//-../—/./…//-./—/-//-.-/-./—/.–//–/—/.-./…/.//-.-./—/-.././//…./../…//…/—/-.//-../—/./…///

Deciphered – “And just so you know, my father does not know Morse code. His son does.”

Communication in and between Military Organizations

The Chairman of the Joint Chiefs of Staff, Army General Martin Dempsey, wrote in his Mission Command White Paper (3 April 12) “In the Joint Force 2020, operations will move at the speed of trust.” Good communication is one of the most important ways that people and organizations build trust. My purpose in this paper is to provide guidelines to help military medicine better communicate and improve trust.

Communication between individuals appears simple, but it is not. The communicator has a thought to express and someone to whom she wants to express it. However, the communicator must first put her thought into words or other symbols, then transmit those words or symbols in a way that the receiver can understand. The receiver must be able to hear and understand those words or symbols and decipher the communicator’s thought. The process is fraught with potential for misunderstanding. For example, if a woman wants to invite a friend to lunch, she must first have the idea, then ask the friend in a language both understand and in a way that will be appealing to her friend. The friend has to be able to hear (or read) and understand the woman’s intent.

If communication can be difficult between individuals, communication is harder between individuals in organizations. In addition to the normal communication obstacles between individuals as noted above, each organization acquires its own personality that must be considered. A salesman at Apple Inc. works in a different environment than a buyer at Caterpillar Inc. and each will come from a different culture. The larger the organization, the more bureaucratic it must become to manage itself. Communication in a five person local restaurant will be very different than that at McDonald’s headquarters. People in older, larger, wealthier organizations sometimes see themselves as better than those in younger, smaller, less wealthy ones. The converse can also be true. Each individual’s position in the organization also affects their ability to communicate. A mail room clerk is unlikely to email or telephone the Chief Executive Officer in most organizations.

Military organizations are some of the oldest, largest, and wealthiest in the world. They are, by nature and by necessity, hierarchical and complicated. Militaries are affected by not only organizational politics but also national politics. The rank structure is very clear and communications between individuals is heavily influenced or even determined by rank. It would be unusual for a seaman to even address his skipper aboard ship; he would be expected to use his chain of command – the hierarchy of sailors and officers above him – to speak his mind.

Service cultures are powerful and color most interactions between services. Historically Army units fought alongside one another and in the presence of their higher headquarters. They could be destroyed by enemy action but generally not by weather. Disease and starvation were usually more manageable threats on land than at sea. Navy ships, on the other hand, were often patrolling alone or in small groups far from any support. The enemy was a threat, but even in peacetime all hands aboard could perish from a sudden storm. Due to the close quarters aboard ship, epidemic disease was common. Some fatal diseases were inevitable if the cruise was long enough; between 1500 and 1800 an estimated two million sailors died of scurvy. Can we wonder why the Army and Navy cultures are different, and affect communication between them?

To overcome these difficulties as much as is possible, the US military has developed processes to assist communication between organizations. They can be divided into two categories; communication between commanders through chains of command, and communication between the staffs of those commands. Commanders regularly communicate to other commands through informal means, but may formally communicate to subordinates through orders such as task orders, operations orders, warning orders, fragmentary orders, and the like. They communicate to subordinates, peers and superiors through requests for assistance, requests for information, requests for forces, and others, depending on the situation.

Staffs communicate informally. Since staffers are not commanders, they have no authority to tell other organizations what to do. However, since they advise commanders and prepare the documents noted above, they have great influence. Knowing this, staff members at subordinate commands often defer to staff members at higher commands. Staffers at higher commands, therefore, must be very careful about how and what they ask subordinate command staffers to do.

The Army, Navy, Air Force, and other uniformed services have hundreds of documents explaining command, chain of command, and the roles and responsibilities of staff. Those will not be summarized here. Command and staff channels of communication are both necessary. It would be impossible to get anything done between organizations if commanders had to do all of the communicating. However, subordinate commands need formal communications in many circumstances to account for their people and maintain order in their organization.

Taskers to military medical units are fast and furious. Dozens of committee meetings, work groups, medical support missions, and educational activities, developed internally and by every level of command, compete for the time of doctors, nurses, and other personnel. Task requests and orders to other organizations are no different. Subordinate headquarters must know what they are being asked to do and be able to coordinate their response, including saying no when they can no longer support a mission.

As a commander and as a senior staff officer I have been asked for guidance on when to use each channel of communication. The following are guidelines which have proven useful:

When to use an informal request (staff level communication)
1.Requests for information when the information should be quick and easy to obtain. Less than one hour is a good rule of thumb.
2.Tasks that require less than one hour to do.
3.Requests for personnel support when the need is for a single local meeting or series of local meetings but the time commitment is low.
4.Requests are generated locally, such as when the local command (military medicine in the National Capitol Region NCR, the JTF Cap Med) needs to bring together subject matter experts (SMEs) to create a working group for a certain area.
5.When the request can be expected to be readily accepted by its recipients.
6.Urgent requests that have a very short suspense should be informal at the beginning and be written into an order ASAP.

How to use an informal request (staff level communication)
1.Email and verbal request to appropriate staff level communication point of contact (POC). Email is important to document request and clarify the suspense.
2.Ensure that the request does not come across as an order and that it is done in the most collegial manner.
3.Track request to ensure that the request is addressed on time.
4.If request is not honored by the suspense, refer to higher level and re-request or commence an order.

When to use an order (command level communication)
1.Requests for information when the information will be difficult and time consuming. More than several hours is a good rule of thumb.
2.Tasks that require more than several hours to do.
3.Requests for personnel support when the need is for many meetings and the time commitment is high.
4.Requests are generated from other entities, such as when higher headquarters (in the NCR, TRICARE Management Agency or the Department of Defense) needs to bring together SMEs to create a working group for a certain area.
5.When the request can be expected to incite resistance in its recipients (These should be informally staffed beforehand to evaluate the resistance and identify the cause – they probably have good reasons for not wanting to do it).
6.Urgent requests that have a very short suspense should be informal at the beginning and be written into an order ASAP.

How to use an order (command level communication)
1.The SME must write the substance of the order.
2.Work with operations (JTF Cap Med – J3A) for formatting.
3.Let the Joint Staff (J-code, such as J4, J5, etc) director know what is going on so he can brief the commander, the deputy commander, or the chief of staff.
4.Review the final order.
5.Ensure that it makes it through J-code and upper level reviews.
6.Track when it is signed by the CDR.
7.Contact your POCs at the subordinate MTF to ensure receipt.
8.Help ensure that it is done on time. Subordinate commands sometimes view higher commands as work generators and information parasites. Higher commands need to work hard to be value added.

Readers will notice that these guidelines do not cover many of the situations which arise. They are not intended to, since each situation is unique and must be handled as such. Here are two guidelines for things that “fall in the middle”:
1.Send a courtesy copy of the request to whoever in the leadership wants it at the receiving command. For example, sometimes chiefs of staff of subordinate commands want to be copied on all significant informal requests.
2.Send a courtesy copy to the proper level at the J-code so that no one at the higher command is blindsided if the request generates anxiety at the receiving command.

Guideline two mentions sending courtesy copies “at the proper level”. While we as Americans are taught that “all men are created equal”, we as humans have a tendency to believe that we are a little more equal than everyone else. Thus the senior staffer in the subordinate headquarters might take offense if he or she is asked to do something by a junior staffer in a higher command. Even if they do not take offense, everyone has limited time, energy, focus and talent, and the senior staffer is often a lot busier than the junior one. Therefore it is generally good for staff level communication to occur between roughly equivalent levels. Rough equivalents US Federal service:

Military Officer Grade General Schedule (GS) and Senior Executive (SES) DoD Civilian Military Equivalency Rate (DoD   Financial Management Regulation 2/98) These tables are primarily used for comparing pay   between military and federal service. They do not reflect the importance of   the positions. In terms of communication and authority the senior enlisted   ranks (E7-E9) align better with the senior military officer grades (O5-O6)   and senior civilian grades (GS 13-15). The middle enlisted ranks (E5-E6)   align better with the middle military officer grades (O3-O4) and middle   civilian grades (GS 10-12).
General/Admiral SES SES
O-6 GS-15 GS-15
O-5 GS-14/13 GS-14
O-4 GS-12 GS-13
O-3 GS-11/10 GS-12
O-2 GS-9 GS-11
W-3/W-4 GS-8 GS 11-12
W-1/W-2/O-1 GS-7 GS-9
E7-E9 GS-6 GS 6-8
E5-E6 GS-5 GS-5
E4 GS-4 GS-4
E1-E3 GS 1-3 GS 1-3

Rough equivalents by position in a military compared to a civilian medical organization:

Military Medical Equivalent Civilian Medical Equivalent
Commander, Med Group Commander (AF) Chief Executive Officer or President
Deputy Commander, Chief of Staff, Staff Directors, Squadron Commander   (AF) Chief Medical (Nursing, Operations, Financial, etc) Officer
Department Chief, Flight Commander (AF) Department Chief
Service Chief, Element Chief (AF) Service Chief
Clinic Chief Clinic Chief

Generally, in hierarchical organizations such as the military, routine communication should occur between people at the same level, one level up or one level down. Therefore department chiefs routinely communicate with department chiefs, service chiefs and staff directors, while chiefs of staff typically interact with commanders, deputy commanders, and department chiefs. Some communication occurs between levels but in non-emergency situations, routine communication usually follows this rule. Nothing written here is intended to stifle positive communication, but rather to enhance it.

These guidelines have been useful in the past and hopefully will be useful in the future. Our success or failure as a nation has much to do with the success or failure of organizations within it. Our success or failure as a military has much to do with the success or failure of military medicine. Our success or failure in military medicine has much to do with how well we communicate with each other and with the most important members of our team; our patients.