How to Do No Harm

How leaders can minimize harm in health care, in other industries, and in all areas of life.

“How can we change this process to prevent this error from happening again?” the senior ward nurse asked the group. It is a common question, one that I have heard thousands of times from experienced and dedicated health care professionals of all stripes.

I have worked in health care for many years, serving in positions from volunteer to emergency medical technician to senior attending physician to chief of staff at a hospital to chief medical officer of a large network. In every position, “do no harm” is a fundamental theme. This famous statement from the writings of Hippocrates encapsulates quality improvement, patient safety, access to care, and many other goals in modern medicine.

“Do no harm” can be thought of as eliminating risks that could lead to a bad outcome, such as injury or death. Occupational and Environmental Medicine physicians learn that there are four ways to decrease risk in the workplace and in the environment:

  1. Eliminate the risk entirely. We have two inverter generators to use at home and church rather than traditional ones. They are quieter and generate less carbon monoxide, thus eliminating two risks. Taking the lead out of gasoline and paint decreases the chance of lead poisoning, and using nitrile rather than latex gloves helps avoid latex allergies.
  2. Separate the risk from the people. Modern automotive engineers have designed and built cars which nearly the whole car can be destroyed in a crash, but the passenger compartment can stay nearly intact, thus saving the people inside. Hospitals sometimes use devices that automatically retract used needles to avoid needlestick injuries.
  3. Develop administrative controls; processes to minimize risk. “Tickets to ride” ensure the patients are protected before patient transport and “time outs” before procedures minimize the chance of operating on the wrong site, or even on the wrong patient.  
  4. Use personal protective equipment (PPE). Lead aprons in radiology protect patients and staff from radiation exposure. Gloves and mask decrease the chance of infections. In the fire fighting world, bunker gear enables humans to survive and even work in otherwise fatal environments.

The surest way to “do not harm” is to engineer the risk out, and second is to separate people from risk. Neither of these methods require people to do anything, and therefore remove the single biggest point of failure in many safety processes…human error. Techniques 3 and 4 are less reliable precisely because people have to be trained to follow administrative controls and use PPE. Further, people have to follow these controls and use these practices every time and under every condition.

Manufacturing is far more amenable to engineering controls than health care. Producing tires or peanut butter can be broken down into a discrete series of steps which must be done in sequence and in which the production machinery, the rubber, the peanuts, and the other parts of the process can be trusted to behave in reliable ways. In health care, neither the staff nor the treatments nor the patients are equally predictable. That is why health care relies on administrative controls and personal protective equipment, and why we have so many failures…so much risk to patients and staff.

There is, however, another way to minimize the risk of harm, and that is to improve the people. If hazard is thought of as having three components – danger (what can do the damage, like a hepatitis A virus), person (who is at risk), and vector (food and water contaminated with hepatitis A), those who wish to minimize the risk of hepatitis A can attack at any of these points. The Smallpox Eradication Program of the World Health Organization in the 1960s and 1970s, and the modern polio eradication program are examples of attacking the pathogen directly. Purifying the food and water, which commonly transmit hepatitis A, eliminates the vector. Immunization strengthens the person, making them immune to the disease. Simple interventions such as improving diet, exercise, sleep, and mental health improve the person and make disease and injury less likely. Education helps leaders and workers know why they are doing something, and training helps them do it right again and again. Cognitive aids such as checklists minimize reliance on human memory and other sources of failure.

In summary, “do no harm” applies to medicine, but also applies to every other area of life. We can and should engineer harm away, for it is the most effective way to minimize risk to life and health. Vaccines may be considered as a means of engineering harm away. We will attack dangers, block vectors, and strengthen individuals. To “do no harm”, health care professionals will use every tool in the shed, and will use them in a comprehensive and coordinated system. Our patients and our staff depend on it.  

Your Permanent Record

A little boy couldn’t resist the urge to pull the hair of the girl sitting in front of him. Across the room, a little girl couldn’t help chatting with her friend while the teacher was talking. These incidents happen every day in thousands of classrooms across the United States. Modern teachers have a variety of new techniques for dealing with such infractions, but in bygone days teachers would often respond with the same threat: “if you do that again, I will write that in your permanent record.” The children would immediately stop, at least for the moment, because everyone feared bad reports in their permanent record.

As children grew and went to school to school, perceptive ones realized that these transgressions never actually appeared on their report cards. The few who were able to see their school records found that only the most egregious sins were documented. Parents didn’t seem to have a “permanent record”, unless it was a criminal one. By the time that school ended and the working world beckoned, the secret was out; there was no “permanent record.” Teachers had known it all along, and their pupils had taken 20 years to figure it out.

Over the years several of my children have told me that a school teacher had mentioned a child’s permanent record. I felt the familiar egoism of experience, the smug sense of skepticism, gained in decades of American schooling, and told my children – there is no permanent record.

Your Permanent Record – Body and Mind

Recently in my clinical practice I cared for a 14 year old girl with a torn anterior cruciate (knee) ligament from a soccer game. Several months earlier I counseled a 26 year old whose life had been overturned by rape. Years before I treated a 23 year old for cervical cancer; she had started sex at age 13. Some patients, especially boys, have been hooked on tobacco before they started high school.  One young boy had a head injury from a bicycle accident, putting him far behind his peers. In all of these cases, the decisions that these people made as children, or decisions that were imposed upon them, changed their lives forever. My experience as a physician belies my skepticism. There really is a permanent record, and it is found in our bodies and minds.

Another obvious example of your permanent record is memory. While we usually overcome the pain of past mistakes and experiences, we usually can’t erase the memory of them. Few people reach adulthood without carrying a bag of regret, and before middle age that bag grows into a knapsack. Over the years our knees buckle and backs stoop with the growing weight of the past. As we enter the winter of our lives, many people can think of little but summers past. Much of the psychological illness that I treat every day comes from my patients’ memories of what they did, didn’t do, or what someone else did to them.

Your Permanent Record – Habits and Emotions

One of the key concepts of physiology and psychology is that of practice; what we do becomes easier to do again. If we throw a ball, we can through the ball more easily the next time. If we think a thought, we can think that thought more easily the next time. Champions in sports and music are made because the body improves through practice. Neophytes in a field make two common mistakes. First, they expect practice to make huge improvements, then become disappointed and quit when it does not. Second, they believe that practice makes perfect. In truth, practice makes permanent; only perfect practice makes perfect.

When a person thinks, neurons fire and hormones flow in certain patterns. When someone moves, neurons fire, hormones flow, and muscles contract in certain patterns. Repeating those patterns thousands and even millions of times develops habits and skills in certain areas.  This is how champions are made.

It is also how people fail. Repeating the same negative thoughts, refusing to forgive and wallowing in bitterness will develop neural pathways and hormonal patterns just like more productive activities will. Lying makes it easier to lie just as kicking a ball makes it easier to kick. Using foul language makes it easier to use foul language just as smiling makes it easier to smile. There really is a permanent record, and it is found in our habits and emotions.

Your Permanent Record – How Others Perceive and Treat You

Just as people develop patterns within themselves, they develop patterns in their interactions with others. I was caring for one woman in clinic while her husband sat in the exam room berating her. They had only been married two years, but his habits were toxic to her, to him, and to their marriage. I asked him, “If you have committed yourself to this woman in marriage, why would you want to hurt her, and yourself, by chiding her so? You had better change your ways or she won’t be there when you need her.”

Our actions change how others treat us. If a child gets a reputation as a troublemaker early in the school year, others in the class will treat him as a troublemaker, even if he improves over the course of the year. Because others are not as interested in us as we are, they will take a long time to notice our actions and change their opinions of us. Sometimes they will not change their opinions no matter what we do, because changing an opinion is harder than keeping the same opinion.

Benedict Arnold has a terrible reputation in American history because he tried to betray his country. Few will change their opinion of him, even if they learn that he was one of very few successful admirals (Battle of Valcour Island) and generals (Battle of Saratoga) in world history. Arnold fought with wisdom and courage for the colonies, only succumbing to pride and ambition at the end of a noble career. Richard Nixon was another character whose decades of admirable service have been forgotten and only his late mistakes remembered. People refuse to change their opinions of others because they gain something by keeping the opinions that they have.   That is one reason that it is so hard to make changes in life. A person does something good, no one notices, and others will treat them the same way as before. There really is a permanent record, and it is found in how others perceive and treat us.

Conclusion

Thoughts, words and actions are self-reinforcing spirals, and the summation of all of those spirals makes a life.  There really is a permanent record, and that record is you. Nothing good or bad is ever lost, and every moment makes a lifetime. Use them well.

Medical Preparation for Humanitarian Missions

“Doctor, this will be a very long war if for every division I have facing the enemy, I must count on a second division in hospital with malaria and a third division convalescing from this debilitating disease.” General Douglas MacArthur to Colonel Paul F. Russell, US Army malaria consultant, May 1943.

Just like soldiers going to war, people on humanitarian missions anywhere in the world can fail to accomplish their mission due to illness or injury. Whether missionaries seeking to advance the gospel of Christ, secular humanitarians trying to dig a well and build a school in a rural African village, or a combination of both, medical problems can inactivate the best intentioned and most capable teams. This article is intended to help people medically prepare themselves to go overseas on humanitarian missions. You can also watch the video.

Your baseline health

While in college I attended a lecture about living overseas doing humanitarian and missions work. The talk was fascinating but what changed my attitude was when the speaker said “to be most effective you must be in good physical condition. It does little good being an expert in your field or having the highest hopes when you physically are unable to perform.” That very day I took up running and in the 30 years since have never stopped. The basic three components of good physical health are adequate sleep (7-9 hours per night), good nutrition, and plenty of exercise. Meals should be high in fruits and vegetables, moderate in dairy, grains, and nuts, and low in meats and sweets. Exercise has three components: flexibility training six days per week, aerobic exercise at least three days per week, and resistance exercise at least two days per week, totaling at least 150 minutes of exercise per week. 10,000 steps per day is a common benchmark for walkers. Someone who is unfit at home will not become magically fit overseas; they are more likely to become even more unfit.

Living conditions will not be as comfortable on mission as they are at home. Water in developing countries is often contaminated, and ice is contaminated and scarce. Air conditioning is unheard of in much of the world, and the neediest countries are frequently the hottest. Showers, laundry, and good toilet facilities are usually harder to find in the developing world, Transportation may be lacking or dangerous, and garbage is often ubiquitous. Expect to walk farther and work harder on humanitarian trips than you do at home. Conditions that would be a minor annoyance back home can be harder to overcome. Overall, be in the best possible health before you go on mission.

Your pre-trip medical evaluation

Having practiced medicine for over two decades, I have evaluated many people preparing to travel overseas for business or pleasure. Such a visit is vital for medical preparation because it accomplishes a lot:

  1. Getting travelers up to date on their standard (US) required vaccinations.
  2. Giving travelers the vaccinations that are required for their destination, considering the conditions they are likely to face. For example, a person shopping in Tokyo for a week is not likely to need the vaccine against Japanese Encephalitis virus (JEV), but someone on a humanitarian mission for six weeks in rural Vietnam definitely needs it.
  3. Giving travelers the prophylactic medications, such as antimalarials and antidiarrheals, that are required.
  4. Refilling key prescriptions that travelers need to manage their baseline health problems, such as blood pressure or diabetes medications.
  5. Counseling the traveler on risks common to their destination, including identifying what they plan to do and figuring out how to minimize the health risks they face if they do it. This can range from teaching people about mosquito protection (bed nets, DEET and permethrin) to giving them information on local medical facilities in case they have trouble.
  6. Discussing what to bring on the trip.
  7. Discussing what to do on return from the trip, and when to come in again.

Visit your doctor at least four weeks before you leave for this evaluation. The Center for Disease Control and Prevention (CDC) provides useful information at their Traveler’s Health website. It is a good idea to visit the dentist before going since dental problems can be big and care may not be available. Patients with glasses may wish to get an updated prescription if they haven’t had one in the past year.

Insurance and Other Concerns

Most people going on humanitarian journeys will have medical insurance of some type, but you need to check the terms carefully. What benefits are available overseas? Is medical evacuation included? Do they require preapproval for visits, and is that possible at your destination? Will you need supplementary medical insurance? Trip interruption and cancelation insurance are also important. Such insurance can cost less than $10 per day.

The US State Department offers the Smart Traveler Enrollment Program (STEP). This free program allows US citizens and nationals to register their trip with the local embassy or consulate. The embassy will provide enrollees information about safety conditions in their destination countries, contact them in case of emergency, and provide a conduit for family and friends to get in touch if trouble strikes. Travelers who don’t mind the US government knowing about their trip may benefit.

The US Customs and Border Protection offers the Global Entry Program, in which pre-approved, low risk travelers get expedited clearance into the United States. The application process includes an online application, an interview, and a fee.

Your health packing list

Travelers on humanitarian trips must take the things that they need to stay healthy at home. These include:

  1. Enough prescription medications to last for the entire trip and two weeks afterward. These must be in their original containers and with original markings or they may be confiscated.
  2. One pair of glasses and one spare, or one pair of contact lenses and one spare pair of glasses.
  3. Other personal stuff such as extra batteries for a hearing aid, knee or ankle braces.
  4. Hand sanitizer, sunscreen and insect repellent.
  5. Ear plugs, since developing nations can be noisy, especially in vehicles.
  6. A pillow or neck pillow to improve sleep on planes and other vehicles and if you will be in primitive lodging.
  7. Eye covers (sleep masks) to improve sleep.
  8. Hygienic wipes to clean up when showers, or even water, are not available.
  9. Over the counter medicines – motion sickness, pain medications such as Tylenol and Motrin, decongestants, antacids, etc.
  10. If going on a medical missions trip, be sure to take personal protective equipment (PPE). This includes gloves and goggles in case you will be exposed to body fluids. For more serious risks of infection, such as responding to the current ebola outbreak, gowns and masks, or even face shields, are required. Gloves must be disposable, and everything else should at least be laundered daily after contact with patients. Adequate PPE may not be available at your destination.
  11. A basic first aid kit, including Bandaids for small wounds.
  12. Health documents such as copies of prescriptions, health insurance documents, and a contact card in case you are debilitated and colleagues need to reach the US Embassy or Consulate and someone back home.

Individual travelers will have other needs. Some may need a cane for walking, while others may need a back support to minimize their pain. Diabetics may need needles and syringes to self-treat their diabetes, and asthmatics may need inhalers. Again, people should take whatever they need to function at home, and a few other things tailored to the risks at their destination.

Healthy traveling

People going to places with poor toilet facilities often don’t drink enough clean water because they can’t find it, it is unappetizing (often warm), or they don’t want to use the toilet. This fact makes it even more important to be well hydrated (clear urine) before the trip. During the flight (or long drive), take off your shoes and stretch your feet and ankles. Stand and walk whenever you can, and sleep whenever you can, keeping a jacket or blanket nearby because planes can get cold. Keep medications, a change of clothes and raingear handy in case your luggage is lost.

Staying healthy on site

Drinking bottled water is important in all but the most developed countries, as is frequent hand washing, and using sunscreen and insect repellent. Missionary teams will likely be working with long term field workers and native staff and should take their cues from them. Non-faith based humanitarian teams should also have local support. I have seen troops in Iraq develop diarrheal disease from ice or even water on plates or soda cans so travelers must be careful. Motor vehicle accidents are the number one cause of death among travelers in the developing world and it is OK to ask local drivers to slow down.

Dietary suggestions are harder to give. The official recommendation is to eat only cooked foods and avoid salads or fresh vegetables. These recommendations are sound and can be followed by casual travelers but are harder in a missions context. Teams will often be invited into the homes of those they are working with and as such will be offered local food. As unappetizing as the food may look, it is probably the best that the host family has, and as such it would be a grave offense to reject it. There are no easy answers here, but eating small portions (never a bad plan) and staying with the food most thoroughly cooked is helpful. If you develop symptoms and make a return visit to your doctor after your trip, be sure to tell him about things like this.

Jet lag

The body operates on circadian rhythms which impact everything from hours of sleep to hormone levels. These rhythms are inherent and are influenced by light, drugs and other factors. Symptoms of jet lag include fatigue, slow mental processes, and poor sleep. Since most people don’t get enough sleep and have a baseline sleep deficit, they can minimize symptoms by getting as much sleep as possible before and during the trip. Once you are in the new time zone, stick as closely as possible to the new schedule, limiting yourself to no more than one nap of up to two hours duration per day.

Culture shock

When travelers first arrive in a new place they are often enamored by its newness. This “honeymoon” stage lasts up to a few weeks, by which time most casual travelers have returned home. Soon however, travelers who stay longer, as missionaries and humanitarian workers often do, start to dislike much of what they recently found so quaint, and they want to go home. Effectiveness plunges. Eventually they become acclimatized to the new culture just as they do to the new climate. Their function will improve and they will return to a new baseline. Culture shock happens when returning home as well.

Safety

Part of providing successful humanitarian aid is keeping team members safe. We have discussed medical issues and important threats such as motor vehicle accidents, but there are other things to keep in mind.

  1. Make copies of all travel documents, including passport, visa, plane tickets, and insurance. Keep a copy on the trip and leave a copy at home.
  2. Get good medical insurance, including evacuation insurance.
  3. Keep your passport and identification with you at all times.
  4. Avoid drawing attention to yourself, either with obnoxious behavior, ostentatious displays of wealth or immodest clothing. Avoid alcohol and drugs. You are there to serve others, not to display yourself.
  5. Do not walk or travel alone. Go in teams of at least two.
  6. Be sensitive to others and to the local culture.
  7. Do not identify yourself with issues likely to be controversial. Don’t wear obviously American or military clothing, or anything that may cause offense locally.
  8. Do not violate the trust or the security of the long term staff you are working with.

Team Leaders

It is your job to make sure that every member of your team is as ready as they can be. Consider an example from World War II:

“Good doctors are useless without good discipline. More than half the battle against disease is fought not by doctors, but by regimental officers. It is they who see that the daily dose of mepacrine is taken, that shorts are never worn, that shirts are put on and sleeves turned down before sunset… I therefore had surprise checks of whole units, every man being examined. If the overall result was less than 95% positive, I sacked the commanding officer. I only had to sack three; by then the rest had got my meaning.” General Slim, Burma Campaign, WW II (under General Slim, the malaria rate in troops decreased from 12/1000 per day to 1/1000 per day.

While team leaders in missionary and humanitarian endeavors do not have the same control over their teams as generals during war, the principles still apply. Leaders must do everything possible to help those working with them to succeed in whatever mission they face. The ultimate responsibility remains with the individual, but the leader has a vital role to play. Make sure that everyone knows what your team’s mission is, and that your team members have the right equipment and supplies to accomplish that mission.

Leaders should ensure that a first aid kit is available for the team. This should include larger quantities of medication and supplies than individuals are likely to bring.

  1. Over the counter (OTC) pain medications such as aspirin, acetaminophen and ibuprofen – at least 100 tablets of each
  2. OTC diarrhea medications such as Imodium.
  3. OTC motion sickness medications such as meclizine.
  4. Three and four inch elastic (ACE) wraps to wrap injured knees, ankles, wrists, and elbows. Be sure that someone knows how to use them.
  5. A large box of Band-Aids.
  6. Extra water bottles with water filter and purification tablets (if in a remote location).
  7. Large bottles of sunscreen and insect repellant.

Conclusion

It may seem that there is too much to do. It may seem like much of this preparation is not necessary. Both statements are false. First, humanitarian and missions work is vital, there are so many people with so much need that people who can should go. Second, every part of the preparation noted above must be done. To do otherwise is to compromise the effectiveness of each individual, and each team, in doing this important work.

For more information, please look at the section “Personal and Team Preparation for Humanitarian Response” under the Virtual Emergency Operations Center at MDHarrisMD.com.

Medical Lectures

From Hippocrates (460-377 BC) through Galen (130-200 AD) through Osler (1849-1919) and until the present day, medical knowledge has been handed down from teachers to students through the spoken and written word. The excellent physician wields the weapons of science, art, and craftsmanship in his unending battle against disease and injury in his patients. The medical lectures highlighted here have been given to medical students, residents, fellows, and many others to help them master the marvelous and mysterious practice of medicine.

Academic

Aerospace, Occupational and Environmental Medicine

Disaster Medicine

Ebola Preparation and Response

Family Medicine

Opioids – the Back Story

Preventive Medicine

Epidemiology & Biostats for Curious Clinicians

Preventive Medicine by Primary Care Physicians

Sports Medicine

Preventive Sports Medicine

Edutainment

The Ghost of Medicine Past

 

JTF Cap Med/NCR-MD Leadership Studies

Pursuant to the Base Realignment and Closure Law of 2005, the Joint Task Force National Capital Medicine (JTF Cap Med) was established in 2008. Its mission was to integrate military health care in the National Capital Region, including the merging of the Walter Reed Army Medical Center (WRAMC) and the National Naval Medical Center (NNMC), and the transition of the DeWitt Army Community Hospital (DACH) into the Fort Belvoir Community Hospital (FBCH). On 15 September 2011 WRAMC and NNMC united to become the Walter Reed National Military Medical Center (WRNNMC) in Bethesda and the billion-dollar FBCH opened its doors. To handle the myriad of issues involved in such a major transformation, the JTF Cap Med endured.   Having completed its mission, it was disestablished on 30 September 2013.

In March 2013 the Deputy Secretary of Defense, Ashton B. Carter, directed that the Defense Health Agency (DHA) and a subordinate organization, the National Capital Region Medical Directorate (NCR-MD) , be established on 1 October 2013. The purpose of the DHA was to integrate services that could be shared between Army, Navy and Air Force medicine such as information technology, logistics, education, research, and others. The purpose of the NCR-MD was to continue the work of the JTF Cap Med in integrating military health care in the Joint facilities, WRNMMC and FBCH) and optimize and integrate military medical care in the rest of the military health facilities in the National Capital Region market. This includes the Malcolm Grow Medical Clinic and Surgical Center (MGMCSC – Joint Base Andrews), the Kimbrough Army Community Clinic (KACC – Fort Meade), the Navy clinics at Quantico and Annapolis, the Joint Pathology Center, the National Center of Excellence for Traumatic Brain Injury, and their subordinate facilities.

I came to the National Capital Region (NCR) as Chief Medical Officer at the DACH in July 2007 and have been serving in military medicine in the NCR since. In January 2012 I took over as the Director for Clinical, Business and Warrior Operations at JTF Cap Med headquarters and I maintained that position through the transition to the NCR-MD. These experiences and others have provided many leadership lessons that I hope will be useful to my staff, my students, and others who have interest in these areas. I have assigned one to two readings per month to my teammates at the NCR-MD, and now make them available to all.

Month

Article

January

Fighting for Health – The Future of the Military Health System

http://mdharrismd.com/2013/06/13/fighting-for-health-the-future-of-the-military-health-system/

Encouragement When Nothing Seems Right

http://mdharrismd.com/2013/05/13/encouragement-when-nothing-seems-right/

February

Getting Things Done in Military Medicine

http://mdharrismd.com/2013/03/31/getting-things-done-in-military-medicine/

March

Communication in and Between Military and Military Medical Organizations

http://mdharrismd.com/2013/03/31/communication-in-and-between-military-and-military-medical-organizations/

The British Campaign in Afghanistan 1839-1842

http://mdharrismd.com/2013/03/31/the-british-campaign-in-afghanistan-1839-1842/

April

Using the Military Decision Making Process in Civilian Organizations

http://mdharrismd.com/2013/03/31/using-the-military-decision-making-process-in-civilian-organizations/

May

Bridging Strategic Thinking with Tactical Operations

http://mdharrismd.com/2013/03/31/bridging-strategic-thinking-with-tactical-operations/

Jonathan Potts – American Revolutionary Physician

http://mdharrismd.com/2013/06/07/jonathan-potts-american-revolutionary-physician/

June

Briefing Senior Leaders

http://mdharrismd.com/2013/04/20/briefing-senior-leaders/

The Informative Brief

http://mdharrismd.com/2013/11/22/the-informative-brief/

July

In Praise of the Battle Rhythm

http://mdharrismd.com/2013/03/31/in-praise-of-the-battle-rhythm/

Making Meetings Matter

http://mdharrismd.com/2013/03/31/making-meetings-matter/

August

The Dance of the Headquarters

http://mdharrismd.com/2013/03/31/the-dance-of-the-headquarters/

September

Awards and Recognition Ceremonies – Are They Really All About You?

http://mdharrismd.com/2013/03/31/awards-and-recognition-ceremonies-are-they-really-all-about-you/

October

The Importance of Learning Many Ways to Communicate

http://mdharrismd.com/2013/03/31/the-importance-of-learning-many-ways-to-communicate/

Formal Business Visits and Town Halls

http://mdharrismd.com/2013/10/12/formal-business-visits-and-town-halls/

November

A Sense of Time and Place

http://mdharrismd.com/2013/03/31/a-sense-of-time-and-place/

Getting People to Answer

http://mdharrismd.com/2013/11/01/getting-people-to-answer/

December

DOTMLPF-P Analysis and Military Medicine

http://mdharrismd.com/2013/11/09/dotmlpf-p-analysis-and-military-medicine/

Taking Intelligence Threats Seriously

http://mdharrismd.com/2013/03/31/taking-intelligence-threats-seriously/

 

The Future of the Military Health System

Introduction

In the book Retribution: The Battle for Japan, 1944-1945, Max Hastings described how ships’ crews took on the characteristics of their commanders. One captain was not well liked but was respected because “he had a mind like a slide rule.” Most good commanders took care of their sailors.

One characteristic of all effective commanders was that they communicated all that they knew about the strategic situation to their crews. In December 1944 the US Navy had 1100 warships and 5000 support ships. Most sailors never saw the big battles and instead spent the war shipping cargo between ports. For example, it is 5100 nautical miles from Honolulu, Hawaii to Darwin, Australia. Cargo ships took 21 days each way to make the trip. Temperatures in these all-metal ships reached 110 degrees, the odor of fuel and sweat was ubiquitous, and the noise was deafening. Men swabbed, repaired, ate, slept and repeated the process endlessly. They saw nothing but the sea, the sky, their ship, and each other. Few knew how their part, no matter how small, fit into the overall plan for victory.

How many of you feel like one of these sailors, endlessly repeating the same tasks with no idea of the impact of your labors?

Good sea captains in the Pacific in World War II told their sailors how their ship, their section, and their own work contributed to winning the war. The leaders in the Military Health System, (MHS), including the JTF Cap Med, are dedicated to telling our warriors and civilians how your work contributes to our mission.

The Problem

The MHS consumes $50 billion dollars per year, 10% of the entire defense budget of the United States. In 2001 the MHS consumed $18B, 5.9% of the defense budget. These skyrocketing costs are unsustainable. The United States must find a less expensive way to provide health care, and a system for health, to its military beneficiaries and others.

The key question before Congress, the White House, and the American people is: “Is the Nation’s commitment to the Warriors and their families a military health care system or a health insurance plan for the military?” If the latter, there is little reason not to contract out beneficiary direct care services. If the former, then military medicine must better align under the Joint Strategic Capabilities Plan (JSCP) and take its military duties very seriously. The MHS’ mission under the JSCP includes provided beneficiary care, with active duty as first priority. It also includes defense against Chemical, Biological, Nuclear, Radiological, and high Explosive threats (CBRNE), whether intentional or not. Finally, the JSCP mission for the MHS includes Defense Support of Civil Authorities (DSCA), Stability Operations and Humanitarian Assistance.

Of that $50B about $32B is spent providing garrison patient care (not including salaries for active duty medical personnel, field medical care, etc.). Of that $32B, over $16B is spent on purchasing care from the private sector and the other $16B is spent for direct care in the MHS. Civilian medical providers in the national capital region and throughout the country would love to get more of the $16B spent on direct care in our area. That will happen if we have no space for our patients, or if they choose civilian care instead of choosing military care.

Many patients were forced out of the MHS by the needs of war wounded and are not coming back. Some cannot get military health care because of inefficiencies in our own system. Others leave because of inability to get appointments, poor customer service, too long a drive from home, or no parking.

We have a duty to our service members and their families. We are honor-bound to fulfill the promise of Abraham Lincoln when he said “With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”

The MHS is not fulfilling this duty, or even competing successfully for our patients. It is increasingly difficult to get care in the military system, and many recent investigations suggest that our quality is average. We do well at public health, combat casualty care, and medical evacuation. However we struggle at the basics of low cost, high access, and high quality.

What if the MHS shrinks, or even goes away?

If America loses the MHS, we lose:

  1. A vital combat force multiplier

Consider the history-making survival rates among wounded warriors in Iraq and Afghanistan. No civilian organization (or other military) can come close to the MHS in saving and restoring our wounded, ill and injured service members.

  1. A source of soft national power

When serving as vice Chief of Naval Operations (VCNO), ADM William J. “Fox” Fallon suggested that the Navy get rid of hospital ships because they cost too much money. When later serving as PACOM commander and coordinating US relief efforts after the 2004 Southeast Asia tsunami, he noted that “in the Global War on Terrorism, a hospital ship is more cost effective than a carrier task force.” Carrier task forces can rain terrible destruction, but medical care can win the hearts and minds of the people. The response to the Ebola outbreak in Western Africa has demonstrated the successful use of medicine, as well as engineering, as an element of national power.

  1. Education and research

Other institutions can train doctors, nurses and medics, but only the MHS can train these professionals to be leaders and warriors as well. America needs civilian trained clinicians, but it also needs outstanding medical professionals who are also excellent in military skills.

No civilian or other academic institutions can duplicate the research of the MHS. Combat injuries are often significantly different than civilian trauma, and the MHS is located in areas with high concentrations of these patients. Further, civilian facilities often do research on diseases Americans care about (such as cancer) but not on diseases that are not common at home (such as malaria, schistosomiasis, and African sleeping sickness).

  1. America’s ability to respond to manmade and natural disasters and national security special events (NSSE) with military-unique medical resources.

No one in the world has the deployable medical capability of the military health system. Medical warriors have responded to civil wars, terrorist attacks, earthquakes, tornados, and a host of other disasters and NSSEs with resources and expertise that no one else could. Countless lives have been saved and suffering averted by the men and women of military medicine.

What must the MHS do?

The Military Health System is already getting smaller, and that is probably a good thing. We have demonstrated that we cannot consistently provide better access, higher quality and lower price for routine medical care than our civilian colleagues. Should we choose to, we could compete better, but often we don’t choose to. Many of our patients are going to civilian health care, and that means that many of our jobs will be going to the civilian sector as well. If that is the best for our patients, our families, and our nation, so be it.

The MHS must focus on what we can do well, and maintain a good infrastructure to support the nation in the future. This should include:

  1. Institute a unified medical command, US Medical Command, which will align and provide command and control to the entire MHS, regardless of service affiliation. The Defense Health Agency is duplicative and would be made obsolete.
  2. Close organizational and planning alignment of military medicine with their parent service.
  3. A single major military medical center in the main metropolitan areas of Washington DC, the Tidewater area, San Antonio, Puget Sound, Hawaii, and Landstuhl.
  4. Moderate sized hospitals in areas of large troop concentrations, including San Diego, Fort Bragg, and Fort Bliss.
  5. Outpatient clinics, including primary care, behavioral health care, and public health, in all other areas when significant numbers of troops are present.
  6. Military medical education and research facilities including the Center and School in San Antonio, the Walter Reed Institute of Research.

To improve military medicine, we must do the following:

  1. Each person in military medicine must be convinced of the indispensable work of caring for warriors and their families.
  2. Each worker in military medicine must understand our vital role as individuals and as teams.
  3. Each of us must do our part to the best of our abilities and top of our competencies.
  4. Each of us must hold ourselves and others accountable for excellence.
  5. Each of us must place our primary focus on the needs of the patients, met within resource limitations.
  6. We must work together, escaping every snare that entangles and divides us and laying aside every weight that slows us.

Together we must move from a health care system to a system for health, including implementing certain programs such as patient centered medical homes, behavioral health, public health, and others.

Conclusion

From the days when Dr. Jonathan Potts cared for Washington’s patients at Valley Forge, military medicine has served our warriors and our nation. Our private sector colleagues will take care of more and more of our military patients and their families. Current leaders in the MHS must position military medicine to move into the future. It is a challenge, but no more than that faced by Dr. James Thacher at Saratoga, or Dr. Jonathan Letterman at Antietam.

America owes its warriors and their families a military health plan, but also a powerful military health system. Nothing less can provide the quality and scope of care, and of health, that America and the world needs. It must be excellent, be available to all of our beneficiaries, be an agile element of national power, and be affordable to our nation. The task falls to the professionals of military medicine to make this happen.

How to Pick Your Fitness Goals

For the past two weeks many Americans have enjoyed the Olympic Games.  Watching the fastest runners and swimmers, the finest gymnasts, and the best teams in the world is both an inspiration and a thrill.  It stirs the heart to see the athletic prowess that these young stars can reach.  So moved, many people commit to improve their own physical fitness and set goals to achieve that end.

To get fit, people need first to decide what their goals are.  The first goal is rehabilitation.  Injured athletes, and even injured couch potatoes who wish they were athletes, need to have healthy and normally functioning muscles, bones and nerves, not to mention organs such as heart and lungs, to be fit. How many of us sprain our ankle, strain our back, or bruise our muscles, and when the pain goes away think that we have fully rehabilitated?  Some people exercise despite having a bad cold, the stomach flu, or a headache.  You might say that the first goal in fitness is to move from abnormal health to normal health.

The second goal in fitness is to optimize health.  Many people have normally functioning bodies but still are not in good physical condition. The American College of Sports Medicine recommends 30 minutes of moderate cardiovascular exercise five days per week, resistance exercise two days per week, and flexibility exercises three days per week.  Such a routine will not produce Olympic champions, or even local tennis club champions, but will provide a good level of fitness for day to day life in most people.

The third goal in fitness is performance.  Long distance runners run 50 or more miles per week, in addition to other exercises, to be the best in their sport.  Swimmers, cyclists, gymnasts, and other athletes spend hours more practicing to perform at whatever level they need to be competitive.  To most military members, “performance” may be limited to successfully doing their jobs, keeping up on unit runs and passing physical fitness tests.  To competitive athletes, “performance” may mean practicing their sport 8 hours per day, five or six days per week.  Olympians may work at that intensity for decades.

Keep in mind that sometimes high performance impairs fitness.  Swimmers who specialize in the butterfly stroke and baseball pitchers can develop shoulder instability.  Long distance runners burn so many calories that if their food intake doesn’t increase enough, they can get muscle wasting and brittle bones.  One of the most important goals in sports medicine is to help athletes achieve their performance goals without compromising their overall fitness.

While you sit on the couch and watch sports after the Games, think about how to change your lifestyle to improve your personal fitness.  Do you have an ankle or knee that has never been quite right since that injury a few years back?  Get it checked out and get a personalized rehabilitation plan.  Are you pretty normal but just don’t get out and move?  Figure out how to change your schedule to make time for exercise and good fitness.  Then get with a friend and go for it. Do you want to be an Olympian, or at least champion of next month’s golf tournament at your local course?  Talk to a local trainer and sports medicine professional to get a personalized performance plan.

Fitness and prevention are two of the most important topics any of us can learn for our health.

Who is Responsible?

I was at a Preventive Medicine conference in February of 2011 and the speaker was discussing unhealthy lifestyle choices.  Her theme was that people really weren’t responsible for smoking cigarettes, being overweight or sedentary, or any other unhealthy choice.  Instead, they were victims of their genetics and their environment.

At a conference on Emergency Medicine in January of 2011 another speaker had a similar theme; most people who do not do as the doctor recommends are not responsible for their decisions.  Instead, certain individuals, the medical community and the overall environment are responsible for what other people do.

The Patient Protection and Affordable Care Act of 2010, better known as Obamacare, has a provision encouraging employers to provide incentives to their employees for achieving health milestones.  For example, an employer might have a program giving employees a discount on their health insurance if they stop smoking.  However, the law stipulates that since some people may not be able to reach the health milestone, the employer must not discriminate against them.  Rather, employers must provide the same incentive for those who try to stop smoking but fail as for those who actually succeed.  According to a contact at the Center for Medicare and Medicaid Services, unions representing minorities approached a senator from New Jersey, who inserted this provision into the bill.

In the political campaigns surrounding the mortgage related financial crisis of 2008, candidates bent over backward to blame greedy lenders for manipulating hapless people into purchasing houses that they couldn’t afford.  This was indeed a problem.  However, few suggested that the borrowers themselves bore any responsibility for getting themselves into such debt.  Many borrowers demanded government relief for debts that they incurred, while rejecting the possibility that they bore any responsibility for their predicament.

What has happened to people being responsible for themselves?

The Bible is clear that while people are to help one another, each person is ultimately responsible for his or her own thoughts, words and actions.  Deuteronomy 24:16 states that each person should pay the penalty for their own sins, not for the sins of others.  Ezekiel 18:20 teaches that the righteousness of the righteous will be on himself, as will the wickedness of the wicked.  Galatians 6:5 states that each person should carry his own load.  2 Thessalonians 3:10 instructs “if anyone will not work, neither let him eat.”  Scripture teaches that every one of us is an independent moral agent, capable of obeying or disobeying God, and that we will bear the consequences for our actions (Romans 6:23, 1 Corinthians 10:13).  

The concept that people are independent moral agents capable of freely deciding between alternatives comes from the idea that God is a person, an independent moral agent capable of freely deciding between alternatives.  Since man is created in the image of God (Genesis 1:27), man also has these basic characteristics. 

Increasingly in America, it seems that people believe that “god” is merely an impersonal force generated by some or all living things in the universe.  While Obi Wan Kenobe might have Luke Skywalker believe this, the inescapable conclusion is that if god is not an independent moral agent capable of freely deciding between alternatives, neither are we.  If “god” is merely a summation of life forces that exist, each controlled by the combination of forces that affect them, as river banks control the flow of a river, then humans are also a summation of life forces controlled by influences around us.  Even for those who might reply that the river also influences the river bank, the forces are still impersonal, devoid of conscious action and therefore devoid of responsibility.

If God is a sentient and independent moral creature, we are sentient, independent moral creatures.  If our god is a combination of impersonal life forces somehow generated by the universe, neither sentient nor independent, neither are we.  Thus our underlying construct of the world influences or determines our opinions on human freedom and responsibility.

The Bible teaches that man is composed of two parts, a material part (body) and an immaterial part (spirit or soul).  As a material object, man is forced to do certain things by physical laws.  A man who steps off a cliff will fall; he has no more choice about whether or not to fall than a rock does. Only in this sense can a man claim to have been forced to do something.

The immaterial part of man is not constrained by physical laws.  Gravity does not affect the spirit, and even physical death does not end its existence (Matthew 10:28).  No one can claim to have been forced to behave in a certain way; even those threatened at gunpoint have the option of choosing to be shot.  Throughout history, persecuted Christians in similar situations have chosen death over denying Christ.

There is no evidence that genetics and environment force specific actions; people with genetic and environmental predispositions to alcoholism, for example, often do not become alcoholics.  In her speech, my preventive medicine colleague said that she might be tempted to drink a Starbucks mocha ten times during the day and resist nine times.  She used to idea to argue that she really had no choice because eventually she would give in.  What she may not have realized is that her example undercut her argument; the fact that she was able to resist nine times proved that she was capable of resisting.  In fact, teaching that people are incapable of controlling themselves and are therefore not responsible for their actions destroys much of what medicine tries to do when encouraging healthy behavior change.

In the Emergency Medicine conference, the speaker suggested that some people are responsible for their actions but others are not.  The obvious question is “When do people become responsible?”  Is it at a certain age? A certain education level? A certain socioeconomic class? A certain race?  A certain sex? A certain mental capacity? Many people would argue that the very young and the severely mentally challenged are not responsible for their actions, but identifying an education level, class or race that makes people responsible smacks of elitism, sexism and even racism.  Did she really want to go there?

Another problem with denying responsibility is that it cuts both ways.  If a person does not have to take responsibility for the bad things that they do, they cannot take responsibility for the good things that they do.  A man cannot escape responsibility for driving drunk by saying that he was forced to do so by his genetics and environment, and then later claim responsibility for beating his alcohol problem through his own efforts.  If forces outside ourselves control our bad actions, they also control our good actions.  The physicians in Preventive Medicine and Emergency Medicine who spoke in the conferences mentioned above were highly successful and respected women; leaders in their fields.  If they really believed that people are not responsible for their actions, then they were not responsible either. If they deserved no censure for their failings, they deserved no respect for their accomplishments.

Is there no place for helping others?

When God created Adam and Eve in the Garden of Eden, He did nothing to protect them from eating the forbidden fruit except commanding them to avoid it.  He did not make the fruit ugly and bad tasting; He created it beautiful and good.  He did not place the tree in the far corner of the garden, surrounded by thorn bushes; He put it in the center of the garden in easy view and reach.  God takes human responsibility seriously.

However, our fallen and sinful nature inclines us to sin in a way that Adam and Eve, in their perfect state, were not.  Therefore it is reasonable for us to build safeguards into our lives to avoid sin. It is also reasonable for us to build safeguards into our lives to avoid poor choices of many varieties.

Parents, teachers, and ministers bear the primary responsibility for teaching children that they are responsible for their choices and how to identify wise choices.  Children can disregard the soundest training, but it is undeniable that good training and good examples are better than bad training and bad examples when rearing little ones.  Individuals, including children, suffer the worst consequences from their own choices, but those entrusted with training them will suffer the consequences for their failure to do so.

Similarly, it is reasonable for institutions, public and private, to help people make good decisions and build safeguards against them making bad ones.  Nutrition information on food packaging can be a benefit.  Medical devices that help patients to use them safely are a good idea.  Warnings against smoking and other unhealthy habits can discourage bad choices.  Honest lending practices, enforced by watchful regulators, are important.  Banked highways and seatbelts can prevent injuries in accidents. People in medicine, public health and many fields should be involved in finding ways to help themselves and their fellow Americans make the best choices. 

Since we are responsible for our actions, how do we make better choices, and ultimately do better actions, in the long run?

The New Year is supposed to be a time when people make resolutions to improve their lives, reducing the bad and increasing the good.  Common knowledge suggests that people decide to change and manage to do so until February, when they lose their will power and relapse into their former lifestyle.  The problem, of course, is that people vow to change for the rest of their lives, which is impossible to do since people live moment by moment.  No 30 year old can make healthy choices for 40 years at a time, but he doesn’t have to.  He only has to make healthy choices for the next moment, and the next, and the next.  If he keeps it up, he will have changed his life, and maintained that good change for 40 years, or more.    

My patients sometimes come to me wanting to change a habit such as overeating.  Many come to the appointment in a stew of emotion, making grand promises to reform their lives.  They equate intensity of emotion with willpower and likelihood of success.  Other patients come in seeking ways to make changes, sometimes small and sometimes big, which are sustainable moment by moment, in healthy directions.  The latter group, regardless of the intensity of their emotion, usually succeeds.   I tell them, “The key to changing your life is not to decide hard, with a maximum of emotional fume and fret, but to decide long, with the quiet determination to succeed this moment, and the next, and the next.

One last note.  Everyone will make good choices, and everyone will make bad choices.  Everyone will reap the rewards when they choose well, and everyone will bear the burdens when they choose poorly.  This is a heavy burden to bear.  Some people make one wrong choice and suffer from it for the rest of their lives.   I have taken care of patients whose only sexual liaison ended up in a lifelong sexually transmitted disease like herpes or HIV.  Other patients drank too much, drove home, and killed someone else or paralyzed themselves. The Gospel of Jesus Christ is good news because He is the only One who can make even our bad choices turn out OK, either in this world or the next.  Those who trust in Him can be assured that He will make both their successes and failures work together for His perfect will and their ultimate good (Romans 8:28).

Conclusion

It is vital to help one another, whether in the family, community, or society, but ultimately the responsibility for each person’s thoughts, words and actions falls on that individual.  The man who smokes, is overweight, or buys a house that he cannot afford is responsible for his actions, and he must suffer the consequences.  The man who works hard, earns a good living, and gains respect from his actions and accomplishments deserves credit for his good choices.  Others may contribute to his poor choices, and they bear responsibility for their poor choices.  Others may help a man choose well, but either way, each man is responsible for himself. To teach otherwise is an offense to him as an independent moral creature equal to others.  Teaching that man does not bear responsibility for his actions is also a disincentive to overcome vexing problems, and robs him of the satisfaction of his accomplishments.  Finally, it devalues him as a child of the independent, moral and responsible God.

Hope is not lost for those who feel trapped by their bad choices.  The power of Almighty God as manifest in the Son, Jesus Christ, will make all things, even bad choices, work out to the good for those who love Him and are called according to His purpose.