Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

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Full Text

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Leadership in the Army medical department October – December 2009 Perspective 1 MG Russell J. Czerw Leadership and Healthcare Perfection 5 COL Chuck Callahan Critical Leadership Attributes for Army Medical Department Officers 11 Jody R. Rogers, PhD An Exploratory Study of the Characteristics of an Admired Leader 14 MAJ Samantha Hinchman; LTJG Jeff Magone (USN); CPT John Marshall; Benita Stoddard Leadership Wisdom 17 COL Mark A. Melanson Leadership Math 21 COL Chuck Callahan; 1st Lt Timothy Callahan (USAF) Personality Type and Leadership 24 David K. Hagey, MS Dynamic Leadership: Essential for the 21st Century 27 MAJ D. Scott McIlwain Resonance, Dissonance, and Leadership 32 COL Chuck Callahan The Mentoring Spectrum 37 COL Mark A. Melanson Seasons of Army Mentorship and the Mentoring Staircase 40 COL Mark A. Melanson Qualities of the Ideal Protg 44 COL Mark A. Melanson The Personality, Passion, and Essence of a Leader 47 MSG Reginald K. Hall Legal Counsel: A Leadership Tool 54 MAJ Joseph B. Topinka 360 Assessment, an Easier Pill to Swallo w: Implementation of Peer Assessment 59 for Captain’s Career Course Students and Staff LTC Eric Sones ALSO IN THIS ISSUE Ultrasonography for Advanced Regional Anesthesia and 64 Acute Pain Management in a Combat Environment COL (Ret) Randall J. Malchow Cardiovascular Risk Factor Screening an d Follow-up in a Military Population 67 Aged 40 Years and Older COL Diane Flynn; MAJ Jeremy D. Johnson; Cathy J. Bailey, RN; CPT Jason T. Perry; et al

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LTG Eric B. Schoomaker The Surgeon General Commander, US Army Medical Command MG Russell J. Czerw Commanding General US Army Medical Department Center and School October – December 2009 The Army Medical Department Center & School PB 8-09-10/11/12 0932007 GEORGE W. CASEY, JR General, United States Army Chief of Staff DISTRIBUTION: Special Administrative Assistant to the Secretary of the Army By Order of the Secretary of the Army: Official: JOYCE E. MORROW Online issues of the AMEDD Journal are available at http://www.cs.amedd. army.mil/dasqaDocuments.aspx?type=1 A Professional Publication of the AMEDD Community The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for The Surgeon General by the US Army Medical Department Center & School, ATTN MCCS-DT, 2419 Hood St STE C, Fort Sam Houston, TX 78234-7584. CORRESPONDENCE: Manuscripts, photographs, offici al unit requests to receive copies, and unit address changes or deletions should be sent to the Journal at the above address. Telephone: (210) 221-6301, DSN 471-6301 DISCLAIMER: The Journal presents clinical and nonclinical professional information to expand knowledge of domestic & inte rnational military medical issues and technological advances; promote collaborative partnerships among Services, components, Corps, and specialties; conv ey clinical and health service support information; and provide a peer-reviewed, high quality, print medium to encourage dialogue concerning healthcare initiatives. Views expressed are those of the author(s) and do not necessarily reflect official US Army or US Army Medical Department posi tions, nor does the content change or supersede information in other Army Publications. The Journal reserves the right to edit all material submitted for publication (see inside back cover). CONTENT: Content of this publication is not co pyright protected. Material may be reprinted if credit is given to the author(s). OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical Department units and organizations, and other members of the medical community worldwide.

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October – December 2009 1 Leadership is a vital component to the success of any organizational enterprise. At the most basic levels, the practice of medicine is a team effort, with defined roles and responsibilities which, however, may overlap or merge somewhat in the turmoil of saving a life. At those moments, leaders must step in and direct the efforts toward the desired outcome. Otherwise, nondirected activity can be futile, and often deadly. This is especially true in the chaos of combat operations when medical resources can be overwhelmed in the crush of heavy casualties. Those leadership skills are developed, molded, and refined as military medical professionals move through their military careers, exercising ever-increasing levels of nonmedical responsibility and authority, all the while retaining, expanding, and practicing their medical skills. Military leadership skills have long been recognized for their value as military members leave active duty and move into civilian careers. Medicine is no different. Indeed, the many military medical professionals who are Reserve or National Guard naturally demonstrate their leadership skills and experience in positions of authority and influence in their civilian practices. This facet of professionalism sets them apart from their purely civilian contemporaries. The medical professional with military experience has long been considered to be a very desirable, extremely valuable asset by the medical community, not only for their incomparable medical skills and experience, but also for the irreplaceable leadersh ip skills that are a product of that military environment. Two years ago, the Army Medical Department (AMEDD) Journal published an issue focused on the development of leadership among AMEDD officers. In that excellent issue, the emphasis was on the resources and structure in place to develop and refine the leadership skills and t echniques of our officers throughout their military careers. Articles dealt with the formal training provided at the AMEDD Center and School, the continuing training and professional education provided to staff members at medical facilities, and various topics and elements which should be addressed in any leadership education. With this issue, I am pleased to present another collection of articles focused on leadership in the AMEDD. Most of these articles explore various aspects of the building blocks of leadership, the th eories, the practice, and the application, along with the experiences and observations of some of our long-tenured military medical professionals who share a strong dedication to the development and practice of leadership skills. One of those who writes frequently on the subject is COL Chuck Callahan, who opens this issue with another of his thought-provoking articles. In this case, he addresses the relationship between leadership and the quest for perfection in the delivery of healthcare. We all understand that, in the literal sense, true perfection is unachievable in most human undertakings. COL Callahan develops the perception of healthcare perfection within an evolving, historical framework, and demonstrates that leadership skills and actions are woven throughout its progress, and will be more vital to its success in the future. Although the demographics of patient populations may be dramatically different, the principles presented in this article are relevant throughout the practice of medicine, whether military or civilian. Throughout history, leadership has been extensively studied as we have attempted to define the what and why of successful leaders. Dr Jody Rogers has contributed an article which looks at personal attributes which seem to be necessary for successful leadership. He discusses 5 specific attributes that he Perspective Major General Russell J. Czerw

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2 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 Perspective calls critical for effectiv e leadership: character, competence, competitiveness, courage, and care. His approach is straightforward; an individual must prepare for positions of leadership by focusing on development of those 5 attributes, sooner rather than later. Dr Rogers develops each of the attributes from the perspectives of both the leader and those in his charge, making the case for each of them as a building block for effective, succ essful leadership. Military medicine depends on such leaders every single day to continue the high level medical care and services our Warriors deserve. MAJ Samantha Hinchman and her coauthors further explore personal attributes of successful leaders in their article describing a study among officer students attending the AMEDD CaptainÂ’s Career Course which examined their opinions of admired attributes of leaders. The survey used in the study was modeled on an extensive, worldwide study which involved over 75,000 people. They compiled the results of the surveys administered to the students and compared the results to the earlier, larger study to see if the targeted military officer group had a different perspective on leadership than the other, much more diverse respondent population. Indeed, a statistically significant difference was revealed in 13 of 20 of the proposed attributes. It is understood that the military attracts a segment of the population with certain outlooks, opinions, and expectati ons, therefore, this type of study should be considered a first step in exploring their attitudes about leadership throughout their careers. This exploratory study suggests that academic and scientific research studies of specific or general population groups regarding leadership may not be directly applicable for the military environment. Additional data may indicate that our training and literature should be reviewed and adjusted to address the unique nature of both new and experienced leaders within AMEDD. Another of AMEDDÂ’s more prolific contributors on various topics of leadership is COL Mark Melanson. I welcome him back to the pages of the AMEDD Journal with an article that effectively coalesces his 26 years of leadership experi ence and advocacy into 10 points that he calls tips for leaders at all stages of their careers. He explores each point from the perspective of his extensive research and experience, and presents them within the practical realities of real-world application. Such insight is invaluable for anyone involved in leadership, whether in practice or the development of training. Theories and academically developed methodologies obviously have their place in the molding of leaders. However, the most valuable of lessons are usually from those such as COL Melanson who have experienced what works and what does not as they themselves practice l eadership on a daily basis. COL Chuck Callahan returns with a unique authorship collaboration, his son, 1st Lt Timothy Callahan, USAF, to contribute an article that frames leadership dynamics in a mathematical construct. The initial reaction to that description may be skepticism, but the approach reveals a practical, easily understood description of 10 elements of leadership theories and practice with direct mathematical corollaries. It is an easy and enjoyable read that brings the challenge of leadership into a truly user-friendly format. Leadership development is a challenging, complex undertaking, especially since it involves disparate individuals and provides virtually no metrics. Mr David HageyÂ’s article discusses what may be the most basic of parameters to consider in an individualÂ’s development process, that personÂ’s personality type. He presents one of the most widely used tools in personality evaluation and definition, the MyersBriggs Type Indicator, and applies its criteria to the various leadership styles that are common among individuals. Since leadership depends on effective personal interactions a nd positive perceptions among all involved, Mr Hagey posits that the successful leader understands his or her personality type and preferences, and then tailors their skills to optimize the associated natural leadership style. This is another easy, enjoyable read that i nvites the reader to think about important aspects of their own personality and preferences, and evaluate their personal leadership effectiveness from that perspective. Following consideration of perhaps the most basic element of leadership development and practice, the individualÂ’s personality, MAJ Scott McIlwain presents us with a discussion of the largest factor, the demographics of the entire population from which the military draws its members. His article proposes that the changing character of that population will necessarily mandate adjustments in our approach to leadership at all levels. Such changes are required not only to guide those who are in the military, but also to adjust to those demographic shifts to continue

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October – December 2009 3 THE ARMY MEDICAL DEPARTMENT JOURNAL attracting the high quality individuals required by today’s military services. MAJ McIlwain explores the unrelenting changes in the racial makeup of the population, the changing character of ethnicities present in US society, the shifts in religious denominations and practices, and, finally, the everevolving generational shifts in attitudes and expectations. This article is a well-researched, absorbing presentation of the challenges that lay ahead for the military leadership of both today and tomorrow. After all of the elements examined in the articles discussed above have been addressed, a leader should be completely prepared to be successful and productive in application and practice; or perhaps not. COL Chuck Callahan’s last article in this issue discusses the situational and environmental factors which can either adversely or positively affect a leader’s effectiveness and the organization’s success. He presents the situational concepts of resonance and dissonance, and how these must be taken into account by leaders. While the concept may, on the surface, seem esoteric and perhaps academic, COL Callahan expertly develops them into real-world, everyday situations and scenarios that we all immediately recognize. Resonance and dissonance deal with the emotional environment within which we function. It can be reinforcing or destructive, and is the product of personalities and actions. Proper application of good leadership can correct a corrosive and destructive environment. Conversely, bad leadership can destroy a functioning, positive situation, sometimes beyond recovery. This is an important article, the premise of which should be carefully considered by those charged with leadership training and development. A longtime advocate of mentorship as a vehicle for professional development, COL Mark Melanson contributes 3 articles discussing different aspects of this very important tool. As in his first article, he draws upon his long experience in practicing the art of mentorship to develop these articles from an overview perspective. In the first article, he discusses the entire spectrum of the mentor’s roles in a long-term mentoring relationship. He ch arts the evolving nature of the mentor’s responsibility, starting as a role model, progressing through several other stages, until finally the mentor serves as the protg’s counselor as he or she moves into positions of greater responsibility and influence. In the second article, he expands this approach, presenting a look at the pattern of growth that is experienced by successful Army mentors throughout their careers. He uses the analogy of the seasons of the year to describe the evolution, from the spring as a protg, to the winter as a grand master mentor. He also charts the progression as a staircase coinciding with higher ranks and the incumbent increased responsibilities. These are illuminating and thoughtful articles that can be used as a barometer for all of us invested in the growth and success of those in our charge. In the third article, COL Melanson addresses the expectations a mentor should have in the protg. Since a mentoring relationship is a reciprocal arrangement, the protg’s attitude and commitment are important factors in success or failure. He describes 10 qualities a mentor should expect from an ideal protg, both initially and as the mentoring arrangement progresses. This article is an excellent, succinct presentation which could be used as a primer for a potential protg to understand what is expected from him or her. The next article provides a valuable opportunity to present a thoughtful, articulate discussion of leadership from a completely different perspective, that of a senior, noncommissioned officer who has been exposed to leaders and leadership development training throughout his career as an enlisted Soldier. MSG Reginald Hall does not attempt to parse leadership into descriptive adjectives or quantify those elements that lead to success or failure. His approach is from a more “macro” level, those innate characteristics, talents, and qualities, especially a set of strong, personal values, that must be present before the more specific tools and techniques can be successfully applied. He challenges the comfortable (and easy) assumptions about leadership as a function of training, longevity, position title, and image. Rather, his article discusses many of the intangibles—those actions, nonactions, reactions, a dherence to values, perceptions, and courage—that intelligent, competent people invariably look for in a leader. MSG Hall develops his presentation with obvious insight from experience, including that of being a leader himself, and education as he moved through his successful military career. As you read this article, you will recognize many things that you have seen or sensed in leaders (and followers), both in and out of the military environment. This is another article that should be carefully read and contemplated by everyone in

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4 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 leadership positions, and by those charged with preparing our Soldiers for those responsibilities. Obviously, leadership cannot be practiced in a vacuum. No one is omniscie nt and can address all of the facts and circumstances necessary for decisions and actions without informed advice. In our reality of statutes, regulations, directives, standards, and guidelines, no leader can improvise in areas that are so governed. MAJ Joseph TopinkaÂ’s article clearly and succinctly outlines a number of the many areas in which judge advocates are valuable resources for AMEDD leaders. From the routine decisions involving the obligation of funds, to the dynamic, reactive actions necessary in respon se to a declared public health emergency, the legal aspects and ramifications of many decisions must be understood, and addressed, always very early in the process. This article is a sobering synopsis of a few of the areas in the practice of military healthcare that are affected, either directly or peripherally, by importa nt legal considerations. MAJ TopinkaÂ’s article is a timely reminder that military legal counsel is an invaluable, readily available tool in an AMEDD leaderÂ’s decision process. It is a source of very specialized assistance and guidance that we cannot afford to overlook. As mentioned earlier, leadership development is especially challenging in that it involves disparate individuals and offers virtually no metrics. Reduced to the most basic of parameters, the success or failure of leadership is dependent on the response from those who are led. Consequently, one of the ways to evaluate a personÂ’s leadership potential is to ask those with whom that person interacts. Military schools and other training organizations often use peer evaluations to gauge each personÂ’s perceived capabilities and potential. In his interesting, detailed article, LTC Eric Sones, Chief of the AMEDD CaptainÂ’s Career Course, describes the development of a peer assessment tool to assist the Small Group Leaders on the staff to improve their leadership skills. It is obvious that the successful implementation of the assessments was due to the extensive planning that was involved. The use of the surveys has now been expande d to the students at the Course, and the results have proven to be a valuable learning tool for students and staff alike. I am pleased that we have the opportunity to include 2 additional articles in this is sue dealing with delivery of healthcare. Each of these articles, albeit brief, contain information which is timely and important to the health and well-being of our Warriors. In the first, retired COL Randall Malchow describes his experience implementing the first use of ultrasound guided advanced regional anesthesia at a combat support hospital (CSH), in this case, the 47th CSH in Mosul, Iraq, in 2006-2007. This technique, using high frequency ultrasonography to identify individual nerve trunks for direct application of anesthesia, had been used in medical facilities for several years, but it had never been attempted in a deployed combat environment. In a 3-month period, 44 such procedures were successfully performed at the 47th CSH, not only validating this application, but stimulating the use of ultrasonography in other treatment applications as well. This article is another excellent example of the resourcefulness, energy, and dedication to the welfare of our Soldiers that is the standard of our military medical professionals. Concerned about information from the Armed Forces Institute of Pathology in 2008 that cardiovascular disease is the second leading cause of death in Soldiers aged 40 or older, COL Diane Flynn and her team conducted a study of that population group at Fort Lewis to determine 2 things; identification of unmanaged cardiac risk factors in those Soldiers, and the extent to which those so identified would comply with instructions to follow-up with their primary care provider. Their article reports their findings, which, in conjunction with earlier, similar studies, should be of concern to all of us involved in the delivery of healthcare. As pointed out in the article, voluntary participation may have skewed the results upwards, but it is still troubling that about a quarter of those examined had unmanaged cardiac risk factors. Even more disturbing, however, is that only a quarter of those with detected risk factors complied with instructions to follow-up to address those potential problems. As COL Flynn et al recommend, AMEDD should consider policies which ensure that Soldiers found to have cardiac risk factors do in fact report for follow-up evaluation and indicated interventions. Considering the statistical evidence of the potential seriousness of the conditions, and the indications in repeated studies of the presence of cardiac risk factors among our older Soldiers, the involvement of a SoldierÂ’s command in follow-up examinations and care may be warranted. Perspective

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October – December 2009 5 Hospitals are the sinks of hu man life in the Army. They have robbed the United States of more citizens than the sword. Dr Benjamin Rush1 Healthcare used to be simp le. Three or four hundred years ago, people who were sick sought a provider to heal them of illnesses for which there was seldom any cure. If you needed a healthcare provider, the chances were that you were facing an inevitably fatal condition. The best “product” that the provider could offer was often palliative, and the best that the provider could hope for was to separate the patient’s presentation from his or her demise with enough time to avoid culpability. Healthcare was delivered in the home. Providers were summoned to the patient’s bedside. Diagnosis and treatment were rendered in the same room, and the family was responsible for continuing nursing care. All of the ownership of the processes to deliver “healthcare” belonged to the patient and his or her family. The provider often took away the “fee-forservice” on a leash or in a cage. Hospitals emerged for several reasons, including the need to cohort the sick to deliver more efficient care, or to quarantine them from society and minimize risk of contagion from poorly understood diseases. Hospitals also developed around the need to train more providers. In 1714, Herman Boerhaave incorporated clinical bedside teaching at Saint Cecaeilia’s Hospital in Leiden, modeled after that championed by Thomas Syndenham in England. Boerhaave’s system for training physicians became the model for Europe in the eighteenth and nineteenth centuries, and laid the foundation for American medical education. Medical students were trained to think of his system of training and practice as “perfect, complete and sufficient.”2 But what happened to healthcare? When patients were admitted to the hospital, they lost control of the healthcare processes they owned when their care was delivered at home. Providers also abdicated control of their patients who became cohorts in substandard facilities. They were turned over to a system that was poorly designed, and were surrendered to the care of attendants who had insufficient training and ill-defined duties and skill-sets. Medicine and healthcare delivery have not become any less complex since Boerhaave’s day. And yet there is no mo re consistent, clear ownership of the healthcare delivery personnel, processes and facilities today than there was 300 years ago. Today, healthcare is delivered in extraordinarily complex systems where routine activities are affected on high-risk patients and high-risk activities on routine patients. Hospitals are often places where insufficiently informed peopl e are exposed to highly dangerous situations inf licted by well-trained, generally well-meaning but overworked professionals who are too often unaware of each other’s capabilities and limitations. Each owns an individual link in the healthcare delivery chain. But no one owns it entirely. There is no question that healthcare will eventually return to the home. As it is now, despite having a “hospital-centric” approach to healthcare in our country, a strikingly small percentage of a population ever come anywhere near a hospital. White et al introduced the concept of “healthcare ecology” in a 1961 article.3 White reviewed and validated the concepts several decades later while additional researchers demonstrated the principles in a range of populations.4-6 Healthcare ecology is a model that helps to describe the health concerns of a population as well as the sources of care for that population. For example, Green et al determined that, based on data from a series of national surveys, “Of 1,000 men, women, and children in the United States, we estimated that on average each month, 800 experienced symptoms, 327 consider seeking medical care,….”5(p2023) Further, the study by Green et al showed that 217 of those 1,000 hypothetical patients visit a physician’s office, 65 visit an alternative or complementary practitioner, 21 are seen in a hospital clinic, and 13 are seen in an emergency room. Of these numbers, only 8 patients are hospitalized, of which one is admitted to Leadership and Healthcare Perfection COL Chuck Callahan, MC, USA

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6 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 an academic medical center.5(p2023) So, while 80% of the population has a medical question or concern for which they could use some information or insight, less than one third will seek help. Too often we use the term “access” to refer to a patient’s insurance coverage or the availability of patient appointments. Patients need answers to questions and concerns far more often than they require an intervention in the system. For the most part, these facets of care can be delivered at home. What kind of healthcare system will be robust enough to provide the depth of specialty and subspecialty care that is required for the most desperately ill in the population and will at the same time be agile, flexible and responsive enough to address patient’s healthcare concerns at home? Very simply put—a perfect one. We bristle at the term “perfection.” It could be because it was the standard to which we were held as children when we didn’t come home with “straight A s.” Or it could remind us of the excuse we used as kids when we failed to measure up: “Well, nobody’s perfect.” It may suggest a zero-defect, no-excuse, no-mistakestolerated climate where error or dissent is swept under the rug by smiling, well-dressed chief executive officers (CEO) or crisply starched commanding officers. But really, “perfect” is none of these things. The “absence of error” is only one definition for perfect. Perfect is better used as an adjective that means: “1. Lacking nothing essential to the whole; complete of its nature or kind. 2. Being without defect or blemish…. 3. Thoroughly skilled or talented in a certain field or area; proficient. 4. Completely suited for a particular purpose or situation…. 7. Pure….”7 The first definition, “…lack ing nothing essential to the whole…” suggests that perfect is much more the presence of integrity than the absence of error. Integrity, especially as it relates to perfection, has become a popular word in recent years. Most leadership discussions start with the notion of integrity. It is much less frequently applied to systems of healthcare. Integrity was the Merriam-Webster “Word of the Year” in 2005.8 While a more common, current definition of integrity implies “adherence to a code,” the traditional definition of integrity is very different. According to leadership gu ru Stratford Sherman, the principle definition of integrity in the original Oxford English Dictionary was, “The condition of having no part or element taken away or wanting; undivided or unbroken state; material wholeness, completeness, entirety.”9 The definition stresses completeness or consistency. The concept of consistency and incorruptibility remained fi rst listed among dictionary definitions through the 1950s when adherence to an external code became a more common definition. Integrity (or perfect) was a word used of people and of animals in the ancient Hebrew world. Both animals and people described as being perfect with the Hebrew word “tamiym” were without blemish, complete, perfect, blameless, having integrity. For an animal to be acceptable for its intended sacred purpose, it had to have tamiym. It had to be everything it was supposed to be (male, domestic animal, first born), nothing it was not supposed to be (imperfect, defective, blemished), consistent (wit hout spot or blemish from head to tail), and complete (has all its features, is missing nothing).10 Perfection (or integrity) was a blend of what was expected as well as what was intrinsically consistent; a combination of an external standard, but more importantly an internal completeness. This is in contrast to the modern definition of integrity, demonstrated by the 2005 definition where the first definition is a “firm adheren ce to a code of especially moral or artistic values: incorruptibility."8 No matter how extensive and exhaustive they may be, perfect healthcare cannot be defined exclusively by complete compliance with the standards of The Joint Commission* or any other agency. A healthcare system can embrace external standards completely and still lack the soul that defines it as “perfect.” For a healthcare system to be perfect, and to be capable of responding perfectly to the looming changes in American healthcare, its leaders must focus on the 3 pillars that define healthcare systems: people, processes, and the place where healthcare is delivered. PERFECT PEOPLE A number of different populations experience our healthcare systems on a daily basis. Patients and family members walk in and out of our hospitals and Joint Commission on Accreditation of He althcare Organizations, One Renaissance Blvd, Oakb rook Terrace, Illinois 60181. Leadership and Healthcare Perfection

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October – December 2009 7 THE ARMY MEDICAL DEPARTMENT JOURNAL clinics. They also attempt to reach their providers by phone, on the web, and by e-mail. They wonder at home or work about new or nagging health concerns, but do not attempt to reach out for information or insight because of the chaos of their lives—or of our healthcare systems. Our staff and other guests also move in and out of the system each day, each bringing their own attitude and affect to each encounter, inevitably shaping and changing others through interaction. The potential of possible interactions is practically infinite. Fortunately, the actual number of interactions is not. One day in the autumn of 2008 I counted the number of times I interacted with other human beings in the course of a day. As a hospital commander (or “CEO”), I had a number of meetings or interactions which might not be afforded to other members of staff. I counted every time I spoke to someone in person or on the phone, every hallway conversation, every person at a meeting I attended or class that I taught, every email I received, and every text message between 4 AM and 10 PM. In 18 hours I had 283 interactions, one every 3 minutes or so, with the highest number being emails and people I encountered in meetings. The point is that the number of interactions we experience on any given day is finite, even for someone whose business is leading and interacting with people. Since the number is finite, there is a finite number of times that we must choose to define the kind of interaction we will ha ve and, to a very large degree, the kind of outcome we hope to achieve. Business models that focus on customer service are correctly applied to healthcare settings. They help define not only how our staff cares for patients and their family members, but perhaps even more importantly, how leadership cares for and about staff. We cannot expect our staff to treat patients any better than we treat them. Why should healthcare provide less service than Wal-Mart or Circuit City? As leaders we model the behavior we hope to see: provide what they need and exceed what th ey expect. It means that we will approach every human encounter the same way, but we will respond to every human encounter differently; based on the individual’s needs. In every case it is a choice to pay attention to intentionally make a conscious decision to consider the patient’s best interest and then a choice to act on their behalf. Imperfection th en, is not so much the presence of error as the absence of attention inten tion decision and action Perfection in this realm of healthcare has certain consistencies. The interaction in general is enjoyable, entertaining, empowering, educating, and elucidating. Patients and our staff who are looking for this perfection ask us the following: “talk to me, sit with me, make eye contact, look me in the eyes, greet me by name, use my title, get to know me, ask me about me, touch me, shake my hand, and please do not read your autobiography to me.” The essence of healthcare is human interaction. Between 2002 and 2005 our pediatric research group in Hawaii spent more than a million and a half dollars looking at internet solutions for asthma care in the home. One of the most striking findings of our research was the importance of the relationship of the patient with the care manager regardless of the technology employed. In the face of systems of healthcare that are inconsistently consistent and consistently inconsistent, emphasis of the human or “people” aspect of the system will assure that the journey toward perfection will be characterized both by the absence of error wher ever possible, but, more importantly, the presence of consistent effort. Patients recognize and appreciate effort. For 3 years in the late eighties, I worked as a pediatrician at the clinic at Fort Hood. Weekend and holiday clinics were conducted w ith one medic and 2 providers. One provider worked for 3 hours, and one for 6 hours. Patients were scheduled at 5-minute intervals, 3 every 15 minutes. On the 6-hour clinic shift we saw 72 patients or more using 6 exam rooms over 6 hours. We were the only show in town, and so we hustled to provide the very best care we could in pretty constrained environment. I cannot speak for my 9 colleagues since I was only a captain, but I was not aware of a single patient complaint. People recognized effort and intention, and embraced an attitude similar to my teenage son’s comment to me several years ago, “Dad, you don’t always get it right but I know that you are always trying.” Perfection in the people aspect of healthcare is the consistent presence of attention and intention. PERFECT PROCESSES Healthcare systems migrated from the home to the hospital primarily to protect the population from

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8 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 contagious diseases and to cohort patients for greater ease in medical education, in medieval Islam before medieval Europe. Patient preference, autonomy, and, unfortunately, patient safety were not the primary concerns. Once care migrated from the home to hospitals, those who were most invested in a favorable patient outcome were excluded from decision making, almost until the very present time. Leadership in perfect heal thcare systems has embraced and promoted the Patient and Family Centered Care movement, which has gained momentum in the last 2 decades. Patients and family members are now increasingly engaged not only in specific decisions regarding patient care, but also in the redesign of the very healthcare systems that care for them. Truly perfect processes will not be approached until patient care returns to the home or families, and patients become much more autonomous in decisions regarding hospital care. Perfect healthcare systems take the patient’s life and priorities into consideration. In these systems, the processes allow for patients empowered by medical information and insight to decide what they need themselves. Healthcare is convenient. Access is the window, wide open, between supply and demand. Access includes provider appointments, patient emails, text messages, nurse triage, and provider phone calls. Care is driven by demand, not supply. And demand goes both ways. Traditionally, access has b een used to describe healthcare insurance or the availability of provider visits. Perfect systems use a different definition of access. Patients and their families are busy. Healthcare is just one of the priorities they juggle. They see healthcare access differently Patients desire information (general health knowledge), insight (wise interpretation and application of specific healthcare knowledge), or intervention (a system encounter that leads to a diagnostic or therapeutic action). The system in return focuses on health promotion and disease prevention using the same model; “accessing” the population through the same windows. Patients need information (new recommendations for colon cancer or breast cancer screening), insight (interpretation of specific risk factors for cardiovascular disease), or intervention (pneumococcal vaccination for patients older than 65 years). The accessible, convenient healthcare system reaches back to them on email, telephone, or text messages, and invites them to consider their healthcare in the midst of the chaos and crises of life. Perfect healthcare systems and processes are also responsible. We have moved beyond the point where healthcare is a strictly personal issue. The healthcare covenant between patient and provider/system goes both ways. Each side of the covenant has obligations and responsibilities on the i ndividual and the level of the greater public. Personal decisions (I choose to smoke, I choose to drink, I choose to engage in unhealthy sexual practices) have social implications as the public increasingly bears the impact of these decisions. Freedom and responsib ility go hand-in-hand, so the choices to assume health risks should also imply accountability for the increased healthcare burden. These systems also recognize that there are business forces that contribute to ne gative public health implications, and the systems take them on. Our nation’s love affair with overeating calorie dense fast-food coupled with increasingly sedentary lifestyles has led to an obesity epidemic that is crushing our healthcare systems. It only makes sense that the leaders of healthcare systems should confront these challenges head-on, knowing that they may well be opposed by traditional corporate sponsors. For example, a general pediatrician in Korea worked with the on-post Department of Defense (D oD) schools to eliminate chips and fries from school lunches and soda machines from the cafeteria. Perfect systems will anticipate and address health care challenges at their roots. PERFECT PLACES While hospitals evolved for the charitable care of the destitute ill in both Europe and the Middle East, and the nursing care was provided by dedicated religious orders, the wards were desi gned for the convenience of staff and the training of the providers who worked in them. Strong public health pressures also promoted the isolation and quarantine of the ill during eras of plagues. Patient and family considerations were not addressed in either the design or utilization of healthcare facilities. The trend in the construction of healthcare facilities centers on the evolving science of evidence-based Leadership and Healthcare Perfection

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October – December 2009 9 THE ARMY MEDICAL DEPARTMENT JOURNAL design. In newly designed facilities, patient rooms and clinical spaces are designed to improve patient outcomes. The new Fort Belvoir Community Hospital which will open in the spring of 2011 has been developed and is being built based on the principles of evidence-based design. In 2007, architects, builders, healthcare professionals, and facility designers met with patients, family members, and community leaders in a “visioning” session to develop the themes that should be prominent in the new community hospital. The group stressed 4 major points: the notion of “caring for our own,” the symbolism of the eagle for Fort Belvoir (where there are numerous nesting eagle pairs), the importance of history and military medicine, and the healing influence of nature. The hospital planning process took these factors into account while embracing evidence-based design, as well as Leadership in Energy and Environmental Design (LEED)11 construction guidelines. The result is a 120 bed, 1.3 million sq ft facility comprised of 5 separate but linked buildings and 2 large parking garages, spread like fingers across a former golf course on Fort Belvoir. All the inpatient rooms are single and include patient, family, and staff spaces. There are 55 outpatient clinics with 430 examination rooms. Every clinic waiting area as well as every inpatient room has abundant glass and natural light, and looks out on gardens, trees, and nature scenes. The building is oriented on a north-south axis so that the front rooms have morning sun and the back face westward toward the sunset. Staff lounges and offices also have windows. The facility’s inpatient tower has a green roof. The heat and air-conditioning units on the 4 ambulatory clinics are hidden beneath large, distinctive, swooping roofs so that inpatient ro oms have pleasing views in every direction. The swooped roofs serve as prominent, aesthetic features, they collect rainwater into subterranean cisterns to water the landscape, and they give the facility the impression of an eagle rising in flight. The list of specific, cutting-edge features that will be incorporated into the facility is beyond the scope of this paper, but include patient lifts in each room, patient controlled temperature and lighting, “smartroom” technology that detects staff radio-frequency badges and identifies staff on plasma screens when they enter the room, subliminal color-based way finding, and design cues to promote hand washing. The curtains in examination rooms are designed so that providers can move in and out without touching them to cut down on the spread of infection. Clinic units are identical so that clinic function can be changed or modified in the future as medical missions change. The facility design is the prototype for future DoD hospitals and serves as the nation’s best “laboratory” to demonstrate and validate many principles of evidence-based design.12-14 Most importantly, it is a community hospital that is “the community’s hospital.” Military and civilian community leaders and laypeople have been involved in the design and are regularly briefed on its progress. When completed, the hospital will have 3,200 staff members, more than 3 times the staff of the current DeWitt Community Hospital on Fort Belvoir. With more than 100,000 enrolled patients as well as a robust “secondary” medical and surgical capability, it will be the hub for military healthcare for the 244,000 beneficiaries living in the southern aspect of the Joint Operating Area of the National Capital Medicine Joint Task Force. Leaders building future hea lthcare facilities must insist on the very best patient and family centered care as a reflection of our commitment to the community, while stressing the application of LEED principles as a reflection of our commitment to society. For those of us working in aging facilities, we can still apply the principles of evidence-based design by making common areas light, open, airy, and inviting. Use of nature themes in interior design, attention to landscaping visible from patient windows or waiting areas, and efforts to decrease ambient noise all work toward the same goal. In one clinic of our 50-year old facility, the Muzak and overhead paging was so loud that providers had to rais e their voices to be heard. There are many steps that can be taken to embrace these principles before our new facilities are ready. Dr Benjamin Rush’s criticism of the hospitals caring for soldiers during the Revolutionary War cost him his friendship with Washington. Writing about those Revolutionary War hospitals, he called them “sinks of human life.”1 In the centuries following the war, the American hospital and the healthcare systems that ran them both played key roles in ushering in the era of modern medicine we now enjoy—almost complete freedom from the diseases that plagued Washington’s

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10 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 Army and frustrated Dr Rush’s attempts to deliver healthcare. Today, there are new challenges for American’s health and the delivery of healthcare. There has been an emergence of a customer-focused culture that stresses the importance of service standards in these systems with an emphasis on the human, covenantal aspect of care delivery. Systems are being overhauled to make access seamless and to eliminate both systematic and random errors that have b een tolerated in America’s healthcare system. Facilities are being designed to improve patient outcomes and to serve as models of energy and environmental efficiency. The military healthcare system is the model for a national integrated healthcare delivery system with international reach that is patient focused, efficient, and effective, while surpassing the very highest standards for quality and cost-effective care. Setting and exceeding the national standard will require leadership, decisiveness, and teamwork. Americans are awakening to the danger and the challenges in healthcare, and will not long tolerate nor endure the burdens of an inaccessible, inconvenient, inconsistent system. As inevitable changes come, will we be the leaders or the led? REFERENCES 1. Bayne-Jones S, ed. The Evolution of Preventive Medicine in the United States Army, 1607-1939 Washington, DC: Office of The Surgeon Genera l, US Dept of the Army; 1968:67. Available at: http://history.amedd.army.mil/books docs/misc/evprev/ch4.htm. Accessed April 11, 2009. 2. Magner L. A History of Medicine New York, NY: Marcel Dekker Publishers; 1992:226-227. 3. White KL, Williams TF, Greenberg BG. The ecology of healthcare. N Engl J Med 1961;265:885-892. 4. White KL. The ecology of healthcare: origins and implications for population-ba sed healthcare research. Health Serv Res 1997;31:11-21. 5. Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of healthcare revisited. N Engl J Med 2001; 344:2021-2024. 6. Dovey S, Weitzman M, Fryer G, Green L, Yawn B, Lanier D, Phillips R. The ecology of healthcare for children in the United States. Pediatrics 2003;111:1024-1029. 7. The American Heritage Di ctionary of the English Language 4th ed. Boston, MA: Houghton Mifflin Company; 2000. 8. Merriam-Webster Online. Available at: http://www.mer riam-webster.com/info/pr/2005-words-of-year.htm. Accessed September 22, 2009. 9. Sherman S. Rethinking integrity. Leader Leader 2003;28: 39-45. Available at: http: //www.leaderto leader.org/ knowledgecenter/journal.aspx?ArticleID=132 Accessed March 3, 2009. 10. Word search for tamiym (Strong's 8549). Blue Letter Bible web site. Available at: http://www.bluele tterbible.org/lang/ lexicon/lexicon.cfm?Str ongs=H8549&t=NASB>. Accessed April 11, 2009. 11. Intro – What LEED Is. US Green Building Council web site. Available at: http:// www.usgbc.org/DisplayPage.aspx? CMSPageID=1988. Accessed September 23, 2009. 12. McCarty M. Healthy design. Lancet 2004;364:405-406. 13. Urich RS, Zimring CM, Zhu X, Dubose J, Seo H, Choi Y, et al. A review of the literature on evidence-based healthcare design. Health Environ Res Des J 2008;1:61-125. 14. Zimring CM, Malone E, Sa dler BL. Implem enting healthcare excellence. The vital role of the CEO in evidencebased design. Health Environ Res Des J 2008;1:1-18. AUTHOR COL Callahan is the Commander, Dewitt Army Hospital and Health Care Network, Fort Belvoir, Virginia. Leadership and Healthcare Perfection

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October – December 2009 11 Critical Leadership Attributes for Army Medical Department Officers Jody R. Rogers, PhD “If leadership is so simple, why is it so hard?” What a great question! This question was asked of me after I finished a presentation to 400 Reserve Captains Career Course officers. When speaking, I try diligently to demystify leadership as a way of motivating inexperienced and uncertain officers that they can enhance their leadership effectiveness by consistently applying relatively simple, common sense behaviors with their colleagues. It seems that too many people think leadership is the sole responsibility of a chosen few who are empowered by circumstance or position to do great things. In reality, leadership is everyone’s business and although only a few people may actually be assigned to formal leadership positions, it is everyone’s job to be a leader.1 The Army Medical Department (AMEDD) can meet its mission only if everyone does their best to enhance their leadership effectiveness, regardless of position. If the AMEDD relied only on the leadership acumen of our senior executives to be successful, it would, in fact, not meet its organizational missions. Th is is not to denigrate the wonderfully effective senior leaders within the AMEDD today. God only knows how hard they are working to meet mission. They are doing the very best they can. My point is simple; in order to be successful, the AMEDD must have more leaders located throughout every level of the AMEDD. In reality, leadership is not that difficult. Leadership is nothing more than the consistent application of relatively common sense behaviors. There is no silver bullet, no quick fix to being seen as a more effective leader. The most effective leaders behave in a consistent manner that focuses on the development and well-being of their followers. Behaviors such as expressing a caring attitude, teaching/mentoring/coaching whenever possible with the focus on developing their followers, establishing and articulating a clear vision, establishing and maintaining challenging but achievable standards, and inspiring followers to meet/exceed organizational goals are but a few of the relatively simple things effective leaders do. Peter Luongo2 writes about the need for effective leaders to hire good people. He lists several attributes that are mandatory in all his new hires. Two of the attributes are character and competitiveness. As I read his discussion, I came to the conclusion that many of the same attributes he looks for in his new hires are also critical for leadership effectiveness. The attributes critical for effective leadership are shown in the Figure. They include, in this order, character, competence, competitiveness, cour age, and caring. It all starts with character and ends with a caring attitude. All are important with the attributes at the foundation of the pyramid being the most important. CHARACTER Leadership effectiveness begins with character. A person of character is someone who has the values, integrity, morals, and ethics to earn the trust of colleagues. Character defines the “who” of the leader. The line, “It ain’t about who you are or what you are, it’s about what you do with what you’ve got” is inaccurate and sends a wrong message about organizational success.2(p31) What you accomplish as a leader is transitory if it is not accomplished in an ethical or moral manner. Great leaders know what they stand for, what they will tolerate, what they value, and how they want to be seen by their fellow employees. Leaders of character realize that who they truly are is more important than how they are perceived. Leaders of character know that the only person best able to judge their true character is the “person in the mirror.” That person can never be fooled. Any cracks in CHARACTER COMPETENCE COMPETITIVENESS COURAGE CARE Personal attributes essential to the exercise of effective leadership

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12 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 this foundational attribute will affect the stability and viability of every other attribute discussed below. What are some ways leaders can demonstrate their character? Once again, simplicity rules. Leaders can demonstrate character by always telling the truth regardless of how painful, by writing down their values and conducting a daily values review to ensure they are living their values in deed and word, by never humiliating or talking behind others’ backs, by ensuring they build and not destroy employee self-esteem, by being seen as optimistic realists, and by being respectful of everyone regard less of position or power.3 Character is nonnegotiable. As you strive to improve your leadership effectiveness, start by conducting a self-review of your character. Are your behaviors ethical and moral, and do you demonstrate integrity in all your actions? What are your values and have you shared them with your colleagues? Do you respect all with whom you work? Analyzing your character may seem simple, but it rarely is easy to do because once you start asking these questions of yourself, you risk not liking the answers. COMPETENCE The very best leaders are also competent in their field. They may not be the smartest or most experienced person, but they are competent enough to be credible. Effective leaders also know they must continue to learn and refine their skills in order to maintain credibility with their employees. The concept of life-long learning is essential to effective leadership, simply because it is critical to establishing credibility. In his presentation to the AMEDD Executive Skills course students, Lieutenant General Weightman frequently talked about the fact that the leader may very well not be the oldest, most experienced, or most knowledgeable within a section; but he or she must demonstrate a baseline of knowledge and, more importantly, a strong desire to learn in order to enhance their skill level.4 Effective leaders must also be sufficiently selfconfident to willingly acknowledge their lack of expertise or knowledge so as to not try to fool employees into thinking they are smarter or more competent then they really ar e. This issue falls back to the character issue. You cannot “fool the troops,” as they will quickly determine your true competence on their own. If you attempt to embellish your level of competence so as to not lose credibility, you will actually be compromising your character—that is always fatal as a leader. Always work hard to attain and maintain your competence. Your colleagues will appreciate your integrity if you willingly acknowledge your deficiencies but demonstrate your willingness to learn. COMPETITIVENESS The first time I read about this attribute in Luongo’s book,2 I was somewhat taken aback. I initially considered competitiveness to be an attribute that could destroy teamwork and relationships in an organization if employees attempt to beat their colleagues by withholding information or not being a good team member to look good at a colleague’s expense. That is not what he meant by being competitive. I like to use the word ambitious as a way of explaining what I think competiveness means to me. Leaders should be ambitious. They should never be satisfied by the status quo and should always look for ways to improve the organization. They should set high standards and then lead the organization to accomplish them. The following profound insight is attributed to Michelangelo: The greater danger for most of us lies not in setting our aim too high and falling short, but in setting our aim too low, and achieving our mark.5 I believe we have a tendenc y to set our goals too low and then wonder why our organizations do not change as much as we would like when we accomplish those goals. I am convinced our people like to be challenged as long as the challenges are reasonable. They would prefer to do meaningful work that is challenging rather than waste the day away doing less challenging work that is perceived as unimportant. A leader’s ambition or competitiveness should be outwardly focused with the goal of making the organization and its employees more successful. Ambition to make you better educated or more competitive for a promotion or greater responsibility should never come at the expense of others in the organization. Perceived selfishness is a quick way to destroy a leader’s integrity or character in the eyes of his or her followers. Remember, character is nonnegotiable. COURAGE What makes leadership difficult for most people is the realization that, in order to improve, leaders must do things that most people lack the courage to do. This is the primary reason why leadership is so hard for many people. It takes great courage to openly demonstrate a Critical Leadership Attributes for Army Medical Department Officers

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October – December 2009 13 THE ARMY MEDICAL DEPARTMENT JOURNAL caring attitude. It takes great courage to think long and hard about what your values are, what motivates you to greatness, who is important to you, what is important to you, and for what are you willing to suffer. It then takes even gr eater courage to share your thoughts, your professional desires/wants, your vision, and the answers to the previous questions with your colleagues. When was the l ast time you actually asked for feedback on how you are doing as a leader? Is it because you did not think that information would be important? Or, is it because you thought you may not like the answers you would receive. If you truly want to improve your leadership effectiveness, you must generate the courage to ask how you are doing and then to learn from the an swers received. The best leaders tend to be very courageous and are comfortable in the answers they receive when they ask the tough questions. They are courageous enough to know it is not about them but about improving the organization. CARING If I were to ask one of your employees, “Does (your name) care about you, I mean really care about you,” what do you think the answer would be? I believe all leaders think they care about their colleagues, but if you were to ask those colleagues, you may receive a different answer. The problem is demonstrating a caring attitude. Just showi ng up for work and handing out assignments is not enough. Openly demonstrating a caring attitude requires courage. As leaders, we often fear that being perceived as a caring individual is a sign of weakness. Nothing could be further from the truth. Someone who cares about their employees does not waste their time by giving them easy and/or meaningless work. Being a caring leader means giving your employees a clear, compelling vision of the future that is challenging and will require all their resources and knowledge to achieve. Being a caring leader means setting clear and ambitious standards of how the work is to be accomplished. There is nothing easy or soft about any of these things. Demonstrating a caring attitude also means treating people as human beings and not as functional employees, taking a personal interest in them so you can help them accomplish their professional and personal goals, and showing them that you are as committed as you want them to be. It is working hard to catch your employees doing great work and then recognizing/rewarding them for their efforts. One thing that is definitely required for most leaders to demonstrate they care is the courage to do so. Remember, everyone, regardless of rank, position, age, or experience wants to know someone cares about them and what they do. As a leader, you must have the courage to demonstrate you care about your people. It sounds simple, but is rarely easy. CONCLUSION The very best leaders have character, are competent, are competitive, have courage, and are openly caring individuals. My “5 Cs” of leadership appear simple at first blush, but are rarely easy for most beginning leaders. They may not be easy but they are not impossible to the leader with the desire to improve their effectiveness. These attributes cannot be mastered overnight. Do not wait until you are promoted or assigned to a position requiring leadership. It is simply too late to start thinking about your leadership effectiveness at that time. You must start now to improve your leadership effectiveness. Work on enhancing your character, attain/maintain a high level of competency, always remain competitive with the focus on the improvement of your organization, develop the courage to take on the tough challenges facing leaders today, and never forget that your people want to know you care about them. I know it sounds simple, but for most of us it is hardly easy. REFERENCES 1. Kouzes JM, Posner BZ. The Leadership Challenge 4th ed. San Francisco, CA: Jossey-Bass; 2007. 2. Luongo PA. 10 Truths About Leadership Cincinnati, OH: Clerisy Press; 2007. 3. Cockerell L. Creati ng leadership magic. Leader Leader 2009;53:31-36. 4. Weightman G. Presentation at: Army Medical Department Executive Skills Course; April 2007; Fort Sam Houston, TX. 5. Michelangelo Quotes. Thinkexist.com web site. Available at: http://thinkexist.com/quotes/ michelangelo/. Accessed September 22, 2009. AUTHOR Dr Rogers is a Visiting Professor in the Graduate Program in Healthcare Administration, Trinity University, San Antonio, Texas. He also works in the AMEDD Executive Skills Program, Leader Traini ng Center, AMEDD Center and School, Fort Sam Houston, Texas.

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14 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 The Army Medical Department operates an Executive Skills Program within the Leader Training Center with the goal of developing leadership training programs for junior and senior officers. A survey was created by Dr Jody Rogers of the Center and administered to students in the CaptainÂ’s Career Courses from January to March 2008 to identify the 7 most admired leadership characteristics. The survey tool was based on the extensive research conducted by Kouzes and Posner. Their 2007 book, The Leadership Challenge ,1 is the source for all discussion of their studies and findings throughout this article. Kouzes and Posner cite additional research that identifies the characteristics an individual looks for in an admired leader. They further define admired leaders as individuals whom subordinates would be willing to follow. The qualitative exploratory research study identified 20 leadership characteristics. Respondents were asked to select 7 of 20 characteristics they most admired in a leader. The study was repeated over the course of 20 years in 6 continents. Their research revealed that the 4 characteristics most commonly selected were honest, forward-looking, inspiring, and competent. RESEARCH QUESTION Our study was interested in answering the following question: Is there a statistically significant difference between the selected characteristics of an admired leader from the students in the surveyed Captains Career Course (CCC) and the data from Kouzes and Posner1 of respondents from 6 continents? To investigate this research question, we obtained data from the Army Medical De partment Executive Skills Center and compared it to their data. The Army Medical Depart ment Executive Skills Center maintains a database with information from the students who have attended the CCC. Our research was an exploratory study of 272 surveys from this database (survey data collected January-March 2008). Of the 32 available data fields on each survey, only 20 were included. Participation in this survey was voluntary and all survey results were anonymous. The survey was replicated from the Kouzes and Posner study that administered su rveys to more than 75,000 people around the world. The military students were asked to select 7 out of 20 characteristics that they found in an admired leader. Of the 272 surveys provided, 5 were excluded from the study due to missing data, leaving n = 267 for our study. The 5 excluded surveys accounted for 1.8% of the total survey population. Another 11 surveys (less than 5% of the data collected) had some discrepancies as the subjects chose either more or less than 7 characteristics. However, the data was compiled twice, once using those 7 surveys and once excluding them. Since there were no differences in the results, the surveys were included in our study. METHODOLOGY The categorical variables in our study were the following 20 characteristics of an admired leader: ambitious, broad-minded, caring, competent, cooperative, courageous, dependa ble, determined, fairminded, forward-looking, honest, imaginative, independent, inspiring, intelligent, loyal, mature, selfcontrolled, straightforward, and supportive. The data was coded into 1 if selected and 0 if not selected. Since the variables from the CCC are categorical in nature, we did a general frequency analysis for the 20 characteristics (Table 1). After obtaining the frequencies for each characteristic from the CCC data, we ran a hypothesis test to compare our results to the Kouzes and Posner1 research results for the percentage of respondents selecting each criteria over 4 time periods (2007, 2002, 1995, and 1987). Our results were used as the hypothesized value for each of the 20 An Exploratory Study of the Characteristics of an Admired Leader MAJ Samantha Hinchman, MS, USA LTJG Jeff Magone, MSC, USN CPT John Marshall, MS, USA Benita Stoddard, LMSW

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October – December 2009 15 characteristics of admired leaders to run a hypothesized test at the significance level (alpha) of 0.05 (Table 2). RESULTS AND FINDINGS There were statistically significant differences between the hypothesized value (from the CCC survey) and the mean (from Kouzes and Posner) for the characteristics of ambitious, caring, competent, cooperative, dependable, fair-minded, forward-looking, honest, imaginative, inspiring, loyal, selfcontrolled, and straightforward. There were no statistically significant differences for the characteristics of broad-minded, courageous, determined, independent, intelligent, mature, and supportive. The following 4 characteristics led responses in the Kouzes and Posner surveys: honest (87%), forward-looking (69.75%), competent (66%), and inspiring (65%). However, the CCC results were led by honest (78.3%), competent (71.5%), inspiring (56.2%), and dependable (53.9%). Only 33.7% of CCC respondents selected forward-looking as compared to 69.7% from the Kouzes and Posner study. Conversely, only 33% of the Kouzes and Posner respondents selected th e characteristic of dependable, whereas the CCC result was 53.9%. Our CCC research showed statistically significant differences from the Kouzes and Posner data in 13 of the 20 surveyed characteristics of an admired leader. The most dramatic of these is the difference found in the characteristic of forwardlooking. Kouzes and Posner report that this is “what sets leaders apart from other credible individuals.”1(p37) The reason for the difference may be in the maturity and experience of the surveyed students in the CCC. Their view on leadership (at the rank of captain) is more limited to their experiences at the managerial level, rather than that of a more senior officer who has also had command and staff experience. Table 1. Captain’s Career Course categorical variable frequency table for survey responses. Characteristic Code* Frequency Percentage Valid Percentage Cumulative Percentage Ambitious 0 205 76.8 76.8 76.8 1 62 23.2 23.2 100 Broadminded 0 168 62.9 62.9 62.9 1 99 37.1 37.1 100 Caring 0 148 55.4 55.4 55.4 1 119 44.6 44.6 100 Competent 0 76 28.5 28.5 28.5 1 191 71.5 71.5 100 Cooperative 0 213 79.8 79.8 79.8 1 54 20.2 20.2 100 Courageous 0 203 76 76 76 1 64 24 24 100 Dependable 0 123 46.1 46.1 46.1 1 144 53.9 53.9 100 Determined 0 215 80.5 80.5 80.5 1 52 19.5 19.5 100 Fair-minded 0 169 63.3 63.3 63.3 1 98 36.7 36.7 100 Forward-looking 0 177 66.3 66.3 66.3 1 90 33.7 33.7 100 Honest 0 58 21.7 21.7 21.7 1 209 78.3 78.3 100.0 Imaginative 0 246 92.1 92.1 92.1 1 21 7.9 7.9 100.0 Independent 0 246 92.1 92.1 92.1 1 21 7.9 7.9 100.0 Inspiring 0 117 43.8 43.8 43.8 1 150 56.2 56.2 100.0 Intelligent 0 147 55.1 55.1 55.1 1 120 44.9 44.9 100.0 Loyal 0 172 64.4 64.4 64.4 1 95 35.6 35.6 100.0 Mature 0 212 79.4 79.4 79.4 1 55 20.6 20.6 100.0 Self-controlled 0 229 85.8 85.8 85.8 1 38 14.2 14.2 100.0 Straightforward 0 183 68.5 68.5 68.5 1 84 31.5 31.5 100.0 Supportive 0 168 62.9 62.9 62.9 1 99 37.1 37.1 100.0 *Code: 0 Characteristic NOT selected 1 Characteristic WAS selected

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16 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 LIMITATIONS AND FUTURE WORK We recognize that this study is exploratory in nature from secondary data and, as a result, the data is limited. In the future, the su rvey instrument should be indexed by the CCC class number and dates of the class to ensure reliability and validity, as well as to increase the sample size for hypothesis tests. Additional research should also be conducted to include surveys from entry level leaders attending Officer Basic Course to senior leaders attending the Army War College, in order to further explore the characteristics of an admired leader at various stages of a Soldier's military career and maturity. CONCLUSION Using a hypothesis test to compare our results to the results from the research by Kouzes and Posner, we found statistically significant differences in 13 characteristics (ambitious, caring, competent, cooperative, dependable, fair-minded, forwardlooking, honest, imaginative, inspiring, loyal, selfcontrolled, and straightforward). After further review, one of the top 4 characteristics, forward-looking, which Kouzes and Posner identified as the discernable characteristic of an admired leader, was not selected by the CCC cohort. Based upon this, the CCC faculty should consider modifications to the leadership course in order to explore this characteristic and its importance with their students. REFERENCE 1. Kouzes J, Posner B. The Leadership Challenge. San Francisco: Jossey-Bass; 2007. AUTHORS MAJ Hinchman, LTJG Magone, and CPT Marshall are resident students in the Army-Baylor University Graduate Program in Health and Business Administration at Fort Sam Houston, Texas. Ms Stoddard is also a st udent in the Army-Baylor University Graduate Program. She is a Health System Specialist with the Dept of Veterans Affairs Heart of Texas Health Care Network. An Exploratory Study of the Characteristics of an Admired Leader Characteristic Hypothesized Value Mean Data Std Dev Std Error n Z P value (alpha = 0.05) Ambitious 23.2 16.75 3.304 1.652 4 -3.90 *0.0001 Broadminded 37.1 38 2.449 1.225 4 0.73 0.4624 Caring 44.6 22.75 2.5 1.25 4 -17.48 *0 Competent 71.5 66 2.16 1.08 4 5.09 *0.000000354 Cooperative 20.2 26.5 1.732 0.866 4 7.27 *0.000000000000347 Courageous 24 25.25 3.862 1.931 4 0.65 0.5174 Dependable 53.9 33 0.816 0.408 4 -51.19 *0 Determined 19.5 20.5 4.123 2.062 4 0.49 0.6276 Fair-minded 36.7 42.5 4.509 2.255 4 2.57 *0.0101 Forward-looking 33.7 69.75 5.5 2.75 4 13.11 *0 Honest 78.3 87 2.708 1.354 4 6.43 *0.000000000132 Imaginative 7.9 25.5 7.234 3.617 4 4.87 *0.00000114 Independent 7.9 6.25 2.63 1.315 4 -1.25 0.2096 Inspiring 56.2 65 4.967 2.483 4 3.54 *0.0004 Intelligent 44.9 44.5 3.697 1.848 4 -0.22 0.8287 Loyal 35.6 13.5 3.317 1.658 4 -13.33 *0 Mature 20.6 18 4.761 2.38 4 -1.09 0.2747 Self-controlled 14.2 9 3.367 1.683 4 -3.09 *0.002 Straightforward 31.5 34.25 1.258 0.629 4 4.37 *0.0000124 Supportive 37.1 35.75 3.775 1.887 4 -0.72 0.4745 *Results are statistically significant, P < 0.05 Table 2. Hypothesis test: me an vs hypothesized value

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October – December 2009 17 The purpose of this article is to share some leadership insights that I have discovered during my career as an Army Medical Department (AMEDD) leader. While this is not an exhaustive treatise on the vast subject of leadership, it is a crisp list of 10 practical tidbits that I learned for myself through leadership research and practice, and from observing other skilled leaders. My hope is that leaders of all kinds, young and old, new and seasoned, will find these tips both practical and beneficial, and pass them on to others. START WITH LEADING YOURSELF Although it may appear obvious, it is worth clearly stating that in order to effectively lead others, you must ultimately begin with properly leading yourself. The very first step in doing this is ensuring that you have a balanced, healthy degr ee of self-discipline; this includes your conduct both on and off duty. Any reckless behavior in your personal life will most certainly detract from your professionalism as a leader. In the end, if you cannot lead yourself, both in and out of uniform, you will be unable to effectively lead others. Next, you must de velop and maintain a program of self-development. To me, selfdevelopment is one of the 4 essential pillars of Army leader development, along with professional schooling (both military and civilian), developmental assignments, and mentoring from others. For me, I have found it best to establish a set time to carve out some uninterrupted period for my personal selfdevelopment (I have been asked many times how I find the time to do this; I respond that I do not find the time to do this, I make the time to do this!). For some of my assignments, this occurred early in the morning before I began the day’s duties. For other jobs, I took time during the weekends to work on my own professional growth. Currently, I use the time that I commute by train to read and reflect on my own personal leadership developmen t. Luckily, I am able to “tune out” the background noise of the multiple conversations around me and make the most use of this precious time for my personal and professional benefit. Another useful tip is to always carry along something of a professional nature to read (such as a book or an article) when you go to appointments. As it turns out, I spend considerable time each week waiting for appointments or meetings to begin. By bringing along professional development reading materials, I can readily capitalize on this otherwise “dead time” for brief, focused self-development. BE A GOOD FOLLOWER After being able to lead yourself, the most important thing for a leader is to be a good follower. Each of us, whether we are a newly commissioned officer or a senior AMEDD leader, has a boss. Given that, it is incumbent upon all of us to always strive to be good subordinates. We can best do that by understanding our leaders one and 2 echelons above us, and do our utmost to make them successful. This includes using our time with our raters and sen ior raters to get a better sense of who these officers are and what are their leadership preferences. Therefore, the counseling which is the centerpiece of the officer evaluation system is also a two-way dialogue that lets us learn about those we follow and how we can best support them. Other ways to be a good follower is to keep our leaders informed about what we are doing, not going behind their backs to accomplish the mission, letting them know what is going right and what is going wrong, and never undermining their authority by criticizing or disparaging their orders or their leadership in public or in private. CHANGE CAN BE THE ILLUSION OF PROGRESS The central premise of Darwin’s seminal work, The Origin of Species ,1 is that the key to survival in biological evolution is the ability of a species to adapt. A species that does not adapt perishes, ultimately becoming extinct. The same can be said of the Army. When I first came in the Army, two and a half decades ago, I immediately struck by a tremendous cultural inertia that resisted critical change. Procedures were institutionalized and were out of step with the then current reality and external forces demanding that the Army evolve. Now, sadly I fear the opposite may have become true. With all of the dramatic and widespread change that I see all around me, I often wonder if perhaps the pendulum has shifted too far the other way Leadership Wisdom COL Mark A. Melanson, MS, USA

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18 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 and we have gone from change averse to change addicted. Now, I am not saying that we should never change things; however, we need to make sure we truly understand the status quo and determine if the situation has truly changed and warrants adaptation to ensure our continued effectiveness. That is why I make it a practice when I take on a new assignment or assume a new duty position, I hold off making any substantial changes for a set period of time (In my current assignment, I did not make any major changes for a period of 6 months). Instead, I focus on learning my new job and its current intricacies and nuances to be sure that I thoroughly understand it. Then, I discover my boss’s intent, and in what direction he or she intends to lead. Combin ing this with a realistic appraisal of the current situation and where I want to head, puts me in a much better position to properly design and effectively im plement any needed, but measured change. DON’T DROP THE GLASS BALLS An excellent metaphor for leadership is juggling. All of us have more on our plates than we can possibly hope to accomplish; that’s just the way it is. We cannot ever hope to do it all. Each day we start with a finite, known list of tasks that we strive to complete before we go home for the day. Unfortunately, throughout the day, we receive more and more tasks. I liken this situation to juggl ing balls. Some of the balls we juggle are what I designate as “tennis balls.” They are things that we or others want done but are not really critical. So, if you drop them (don’t do them or do them in time), they bounce on the floor and do not break (that is, there are no serious consequences). People may get angry or disappointed if we drop them, but it is not a disaster if we do so. Often, you can pick the tennis balls up later and resume juggling them with no serious penalty, pe rsonal or professional. Conversely, some balls I la bel as “glass balls;” these are things that are important and there will be real and serious consequences if we drop them; they will metaphorically “shatter” if dropped. Examples of glass balls include most tasks given to us by our superiors. Other examples of glass balls are compliance with Army regulations or command policies. Some not-soobvious glass balls include re laxing, spending quality time with our families, pursuing our treasured hobbies, and maintaining our own personal health, fitness, and well-being. Each of us has a certain limit in the number of balls we can actual juggle at any given time. This juggling limit also changes from day to day and can be affected by how well rested we are and whether or not we are sick. To further complicate things, some of the balls that we juggle may start out as either glass balls or tennis balls, and they may then unexpected ly change into to the other type of ball in midair. So, we need to be constantly evaluating all of the many balls we are currently juggling, determini ng whether or not they are made of glass or not, and assessing new balls that others throw to us to determine if we need to attempt to juggling them or let them fall to the floor (and hopefully they will bounce). Of course, one of the most effective ways to resolve this dilemma is to delegate the juggling of some of these balls to others so that they can begin handling them instead of us. However, we must be mindful and be sure not to give our subordinates too many balls to juggle, and we must always keep track of the glass balls to be sure that they remain in the air and are not lying behind us in shattered pieces on the floor. LEAD FROM THE FRONT This advice has been a long time leadership maxim. Your Soldiers need to see you out and among them. They need to know that you are with them and out front leading the way. This is the military version of “Management by Walking Around” cited in the classic leadership book, In Search of Excellence .2 In a deployed setting, this means leaving your command post and going out to where the danger is. In the hospital setting, this means making the rounds to where the day-to-day activiti es are occurring, such as surgeries, procedures, appointments, etc. When a major problem or crisis arises, you should go directly to the scene, determine first-hand what is happening, and personally take charge. Once you have a handle on what is happening, you can then confidently step back and delegate others to im plement your solutions. A leader who only leads from the rear is at best operationally blind with no real situational awareness, or at worst becomes loathed and resented by those whom he or she leads. NEVER LEAD ANGRILY Each of us is human. When things go wrong or people do not do what we want them to, we can get angry. That being said, it is imperative that, as leaders, we do Leadership Wisdom

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October – December 2009 19 THE ARMY MEDICAL DEPARTMENT JOURNAL not lose our tempers. For me, when something happens that sets me off, I seek to immediately disengage from the situation so I can “blo w my stack” quietly and in private. This can be accomplished by asking others to leave the room or by retreating into your office and closing the door (please note that yelling behind closed doors does not count). In my opinion, leaders that rant and rave in front of their subordinates are just bad leaders, plain and simple. I have no tolerance or respect whatsoever for these most toxic of leaders. The higher the rank, the more this is true. Senior leaders must master the vital skill of defusing their anger and maintaining their composure. Never make important decisions, give an order, counsel a subordinate, leave a voicemail message, or send a text or an email when you are angry. Once you do, you can never take it back and the results can be disastrous, even career ending. You need to experience your feelings, but not let them hijack your reason and distort your judgment. I know for me this is one of the most difficult things to do, and I am not always successful in doing so, even despite my best efforts. USE THE RIGHT TOOL FOR THE RIGHT JOB My father is the ultimate “Mr. Fix-It,” and he taught me from a very young age to always use the right tool for the right job. This means knowing both your tools and the problem that you are trying to fix. Interestingly enough, effective leadership is like a toolbox. It is filled with many tools that a leader can use to motivate his or her followers to accomplish the mission: encouraging words, rewards, inspirational quotes or examples, recognition, shame, and the threat of punishment (if used both sparingly and gingerly), to name but a few. Unfortunately, there is not only one way to lead Soldiers, civilians, and contractors. Before you reach for a leadership tool, you need to know your subordinates and the proper leadership tool which is needed for that individual at that time. Some subordinates need to be clearly told what is expected of them and exactly how they should complete their duties. Others need to only be told to “take that hill” and they will make it happen. While everyone needs praise and encouragement, some individuals need more of it. Nonperformers need to be confronted early and in private when they are not performing properly, and continually held to task and to standard. In the end, all of this really boils down getting to genuinely know your people and how they each need to be lead. Hence, leadership is indeed very personal. CHECK WITH NAPOLEON’S CORPORAL The French Emperor Napoleon Bonaparte had a corporal who shined his boots and helped maintain his uniforms. As the story goes, this corporal was always present when Napoleon met with his general staff. Before any major campaign decisions, the Emperor would turn to his corporal and ask what the man thought of the plan currently on the table. If the corporal understood the tactic and thought it made sense, Napoleon implemented the strategy; if he did not, Napoleon sent the staff back to the drawing board. Used properly and judiciously, I think this is invaluable leadership advice. While I do not vet all of my leadership decisions through my own Napoleon’s Corporal, I have used this method with large, complex, and very important matters. I have also seen one former Army Surgeon General use another version of this approach by asking the opinion of the most junior Soldier present in the room (someone other than the general’s aide) as a sanity check on a given course of action being proposed. BELIEVE IN YOUR SUBORDINATES In my opinion, one the best kept secrets to being a highly successful leader is to truly and deeply believe in your subordinates. Regrettably, I have seen leaders who were wary or distrustful of their subordinates, and consequently became doomed to a career of micromanagement, or became overwhelmed and paralyzed by their inability to delegate. While holding too tightly to the leadersh ip reins may work for a junior leader early on in his or her career, eventually it becomes impossible for one to succeed, except through one’s subordinates. Fortunately for us leaders, there is a wonderful phenomenon called the Pygmalion Effect. Pygmalion was a sculptor in ancient Greek Mythology who falls in love with a female statue that he carves out of ivory. His vision of her literally brings her to life from within the ivory block. In the Pygmalion Effect, people literally become what we expect them to be. In education, this is also referred to as the Rosenthal Effect, where student achievement is directly related to the teacher’s a priori expectation of how the students will perform. Luckily for those of us who lead, this phenomenon applies to those being led, they tend to rise or fall based upon our opinions of them, expressed or unexpressed. Soldiers who sense that their leadership has no confidence in them or does not trust them, will act accordingly. Conversely,

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20 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 Soldiers who feel that their leadership believes in them and trusts them will often exceed the expectations of their leaders, and can move mountains. MINE THE DIAMONDS IN THE ROUGH I end this essay on leadership with what I think is one of the most important bits of advice for leaders, passionately embrace mentorship. As leaders we have a sacred obligation to develop our subordinates and it is one of our greatest responsibilities as commanders, raters, and supervisors. We must make it our ongoing mission to assess the Soldiers we lead and discover those with the greatest potential, the diamonds in the rough. Once we identify them, we must make the time to mentor and groom these future senior leaders to assume the mantles of lead ership years or decades down the road. As we all know, the Army grows its leaders from within. Hence, the future senior leaders of our Army Medical Department are our lieutenants and captains of today. Part of effective talent management is nurturing these rising stars so that we retain them and help them to grow into the future leaders that they are destined to become, and our Army will one day so desperately need. SUMMARY Becoming a good leader starts with effectively leading yourself. Good leadership flows from good followership. While leaders n eed to be adaptive, they need to make sure that change is actually necessary and not merely the illusi on of progress. Effective juggling of leadership responsibilities requires identifying the glass balls and making sure that they do not drop. Leaders need to be visible and be out front, especially when things get rough or when they are the most perilous. Anger should never be allowed to reign and cloud a leader’s judgment. Leadership is not “one size fits all,” those being led are unique and, consequently, different approaches will be necessary to properly motivate followers. When considering important leadership decisions, it is advisable to seek out your own Napoleon’s Corporal to be sure that your plan is sound and those who will implement it do in fact fully understand it. Genuine belief in your Soldiers is the most powerful and lasting thing that you can express as a leader. Lastly, mentoring is a solemn responsibility of leaders that must never be eclipsed by the many literal and figurative battles of the day. REFERENCES 1. Darwin C. The Origin of Species Baltimore, MD: Penguin Books; 1968. 2. Peters TJ, Waterman RH Jr. In Search of Excellence New York, NY: Warner Books, Inc; 1984. AUTHOR COL Melanson is Chief of the Health Physics Office, Walter Reed Army Medical Center, Washington, DC, and Radiological Hygiene Consultant to The Surgeon General. Leadership Wisdom

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October – December 2009 21 Leadership is a lot like grade school. The basics are very similar. A good leader devotes him or herself to the 3 Rs, reading, writing, and arithmetic, plus one — rhetoric. The first two are obvious. Leaders do not advance if they do not learn. And they do not learn if they do not read and communicate in writing. A leader must also be able to articulate his or her thoughts to others—the capacity for rhetoric. Leadership arithmetic is a little tougher to grasp at first. But, in many ways becoming the new leader to an organization is like encountering a complex mathematical equation. It conjures up memories of calculus as we attempt to influence the change of attitude, behavior and culture over change in time (da/dt). Or we grapple with trigonometry as we attempt to identify and solve for the group’s angles. There are some basic mathematical rules that can help us to be more effective leaders. 1. Read the instructions first. Know what you are trying to solve before you launch into the problem. There are a lot of variables for you to consider and you could work on any number of them. But you need to understand the keys to the equation and the desired results before you set to work on it. 2. Consider the whole equation. Take the time to look at both sides of the equation and all of the variables before you attempt to solve any aspect of it. The first weeks and months in any new organization should be devoted to understanding as much about it as possible. Only then can you begin to identify which aspects of the problem should be taken on first. 3. Account for existing values and variables. It is too tempting, especially early in a new leadership position, to jump into the equation without thinking through what has already b een worked on and solved. Understanding the work of your predecessor is crucial to keep you from fruitlessly hammering at the same variables, or undoing something that has already been solved. 4. Do not do addition without subtraction. A new leader has lots of new ideas. They will be added to the equation early on in an effort to effect change and solve what appear to be the key variables. If you find yourself baffled as to why the things you are adding are not being factored into the equation, remember that you cannot really add without also subtracting. Time, energy, and focus are all finite factors for your subordinates. Anything you add must have an equal and opposite investment in time, energy, and focus subtracted from the equation. Balance must be maintained if there is to be any productive result at the end of the day. 5. Do not miss the exponents. The organizational chart should serve the needs of the organization and should cha nge to match the mission and the individuals available to help meet the mission. There are talented individuals scattered across any organization whose attitudes and influence are exponential. They are the power factors in the equation. Remember that you cannot change the equation without taking their influence into consideration. Challenge them with meaningful opportunities for leadership. They will surprise you, and themselves. 6. Factor out the negatives. There are folks in any equation whose bent will be negative, no matter the subject under discussion. These are difficult individuals, regardless of your approach to the problem. You must engage them early, get them on your side, or remove them from the equation if you have any hope of solving it. It only takes a single negative individual to change a positive organization for the worse. 7. Find the common denominators. Solving conflict is ofte n a matter of reducing a discussion to what both sides have in common. In practice, we remind ourselves what drew us into the equation in the first place, the care of Warriors and their Families, for example. It puts the differences into Leadership Math COL Chuck Callahan, MC, USA 1st Lt Timothy Callahan, USAF

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22 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 context and provides a common framework to solve the problem. 8. Simplify both sides of the equation. Active listening allows the leader to identify and recount the key factors on both sides of a problem. When people on either side hear their leader identify and articulate the essence of their disagreement, they know that someone has listened to them. 9. Do not forget to account for units. Everyone in the organization brings their background and experience to the equation. It is too easy to lose visibility of these aspects of each variable when you are attempting to work through things. But, if you keep the units in mind, it will help you to understand the differences and you can use shared units and experiences to help solve problems. 10. Check your work frequently. Devoting regular time to step back from the problems and take stock of the progress is a key aspect of leadership. There is no one else in the organization who can be counted on to make sure that crucial aspects of the equation are being addressed. Stop at regular intervals, review the initiatives and projects, and make sure that they make sense in light of the organization’s overall strategy. Leaders are not born, they are made. They make themselves by attending to basics as leader-learners, just as they did in school: reading, writing, arithmetic and rhetoric. Retired General Tom Hill asked me at a cocktail party once what I was reading. It was in that conversation that he challe nged me to read Manchester’s books on Winston Churchill1,2 and Ambrose’s book on Lewis and Clark, Undaunted Courage .3 He told me that sometimes he asked young officers what they were reading, and he got the answer “Sir, I can’t afford the time to read.” He would bellow, “Son, you can’t afford the time not to read.” Reading is a leadership fundamental. So much of fundamental communication is writing – modern leaders and commanders must use writing to communicate their message to their troops. There are simply too many of them to depend on one-on-one conversation. The battlefield is so fluid that a conversation held last week is out of date and devoid of importance a week later. I have developed the habit of re-reading emails before I send them out, and having my public affairs officer check every email I intend to send out to “all users” before I punch “send.” I also keep a file of written “missives” and other articles on the shared drive which includes my leadership philosophy, philosophy on OER rating, and others. Effective leaders have to be effective communicators. And in the 21st century of electronic mail, “Facebook,” and blogging, we must be able to write things that others will want to read. I am constantly amazed at how often I am called on as a leader to speak in public, whether at morning report as a department chief, to residents as a program director, medical staff as deputy command of clinical services, or any number of forums as commander. Recently, as I was standing outside the hospital’s conference room, my Sergeant Ma jor asked me to come in and address his meeting of 60 or so Soldiers who were up for reenlistment. Before I had time to protest (or think) he called the room to attention and I was on the stage. It happens frequently. Public speaking is something that can be learned through practice and coaching. Rhetoric (the use of language to persuade) is a skill taught to preachers and salesmen. It is something that a leader can always sh arpen. Record (video and audio) your next speech and have someone whose public speaking skills you respect watch it with you. Like arithmetic, leadership is a skill set that can be learned. I am embarrassed to admit that my approach to algebra one in 8th grade was to copy Jane’s homework each morning, and then wonder why my performance was so poor on the tests. Leadership can be imitated, but not copied. Like math, it takes practice, patience, and persistence. Patience may be the most difficult part of the puzzle, because it means that results of your labor may not become apparent in the commander’s or leader’s brief tenure. I recently received an email from a civilian employee in my organization which included: “I believe that you will be able to plant the seed for change. The change will not happen today or tomorrow and may not happen in the next two years, but it will change…” That kind of command “delayed gratification” will require patience and will provide lots of opportunity for practice. What is true in math is true in leadership. Remember the 3 Rs plus one — keys to being and becoming an effective leader. Leadership Math

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October – December 2009 23 THE ARMY MEDICAL DEPARTMENT JOURNAL REFERENCES 1. Manchester W. The Last Lion: Winston Spencer Churchill: Visions of Glory, 1874-1932 Boston, MA: Little, Brown, and Company; 1983. 2. Manchester W. The Last Lion: Winston Spencer Churchill: Alone, 1932-1940 Boston, MA: Little, Brown, and Company; 1988. 3. Ambrose SE. Undaunted Courage New York, NY: Simon & Schuster, Inc; 1977. AUTHORS COL Callahan is the Commander, Dewitt Army Hospital an d Health Care Network, Fort Belvoir, Virginia. 1st Lt Callahan is a Project Engineer with the 355th Civil Engineer Squadron, Davis-Monthan Air Force Base, Tucson, Arizona.

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24 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 Leadership is expected from everyone in the Army regardless of designated authority or recognized position of responsibility.1 We are all leaders, even though we might not have a designated leadership position on an authorization document. As leaders, we need to understand those we work with and ourselves. In our work relationships, we find that people have different interests, varied skills, occasional difficulties communicating what they mean, and they choose to live life in their own way. So how do we appreciate and reconcile the differences in people in order to build and develop strong, successful teams? One of the tools available to us is the Myers-Briggs Type Indicator (MBTI) (CPP Inc, Mountain View, CA). Developed by Katherine Briggs and Isabel Briggs Myers2,3 based on the work of Carl Jung,4 this highly regarded and widely used tool can assist us in identifying what Jung called “preferences.” The MBTI does not attempt to stereotype or compartmentalize anyone. It tries to help us better understand ourselves, make us aware of what motivates us, allow us to recognize our natural strengths, and permit us to realize our potential for growth. Our personalities are a culmination of many things like genetics, family life, life circumstances outside the family, society's expectations and requirements, and many l earned traits. Psychological or personality type is just one aspect of personality. The MBTI attempts to identify self-reported patterns to help us look at others and ourselves. The MBTI uses 2 opposing behavioral divisions on 4 scales to produce a “personality type” or preference. First, how do we prefer to direct our attention or our energy? Second, how do we prefer to take in information? Third, how do we prefer to make decisions? Fourth, how do we orient ourselves to the outer world or the kind of lifestyle that we have adopted? Our results from the MBTI instrument may change depending on our frame of reference and/or our environment when taking the MBTI instrument. Remember, the MBTI results identify valuable differences between normal people. No bad types exist within the MBTI results, only differences in people. To clarify what preference means, try a quick experiment. Take a moment and sign your name on a piece of paper. That would indicate your preference for signing your name. Now, switch the writing instrument to the other hand and sign your name again. Most of us are able to do this, although it may require increased effort and concentration to do it with the nondominant hand; we may find it uncomfortable. This exercise shows that, given a particular circumstance or situation, we can operate through the full spectrum of an MBTI scal e, but we generally find a particular section on the scale more comfortable than the rest. This result is our preference. THE 4 SCALES AND 8 PREFERENCES OF THE MBTI Extraverts and Introverts If you get energy from being around people and process information externally then you are classified as an extravert. When “ E s” have a problem to solve, they typically pick up the phone and call someone, go and visit family or friends, or find some other way to connect with people. E s find small group work and open forums very helpful as it allows them to talk out loud (externally processing) and use the energy from others to recharge and solve their problems (leadership style: interactive). If you get energy by being alone and process information internally, then you are classified as an introvert. When “ I s” have a problem, they need to be alone so that they can think about the situation and come up with a solution through introspection. Personality Type and Leadership David K. Hagey, MS

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October – December 2009 25 Introverts find support through self-help books, movies, and other resources that allow them the time to process the informa tion (leadership style: reflective). Example from work: Your boss is an I and you are an E You both come into work early. As an E you are there to socialize and talk with others. The boss is there to focus on the work at hand. You see him walk into the office area and greet him with a big “Hey!” He goes into his office without responding. What do you do? Introverts and Extraverts working together must respect their differences and find ways to accommodate the needs of both personality types. Sensors and Intuitives A Sensor (“ S ”) is someone who is very detail oriented. Sensors see minor flaws as major flaws. Sensors notice the fine details when asked to describe something. Sensors prefer practical solutions to theories and call themselves realists. Sensors live in the present. If Sensors are looking for solutions to problems, they will put more value in experience over a hunch. Sensors excel when asked to use tried and true methods that draws on their existing skill set (leadership style: administrative). Intuitives (“ N s”) are big picture thinkers. Intuitives look to the future and can see all the possibilities. Intuitives dream big. N s are the idea people and admire others who are creative thinkers. Intuitives notice what is new and different and comment on the overall feel and look of things. N s are the inventors—they see how problems can be solved with a new invention or process. Intuitives consider th e future when they process information. They sometimes make “random leaps of thought” during this process. N s trust their gut. Intuitives like to spend time analyzing and considering the possibilities (leadership style: visionary). Example from work: The colonel ( N ) needs to know where the department could hold a conference. He calls in one of the captains ( S ) and asks him to develop a list of hotels in the local area where they could hold a conference. The captain comes back later and hands the colonel a list of hotels. The colonel eyes the list and asks, “But where are the telephone numbers for points of contact, and how many people will the rooms hold, what about refreshments and maps that show distance from our facility?” The captain replies, “But sir, all you asked for was a list of hotels.” Sensors and Intuitives must understand the differences in the ways they process info rmation to work together in harmony. Thinkers and Feelers If you are a “ T ” (a Thinker), you will base your decision-making around practical, objective criteria. Thinkers appear cold and reserved often seen as antisocial at a conference or meeting, as Thinkers are more interested in finding practical solutions to problems—that is why they came in the first place. Thinkers like to be thought of as realists (leadership style: logical). As a Feeler (“ F ”), you base your decision-making around your values and emotional clues. Feelers trust their gut and care about how actions make them feel or others feel. F s exercise compassion and empathy, and look for harmony. Feelers are easy to spot due to their warm and friendly nature; th ey are often labeled as people persons (leadership style: harmonious). Example from work: The Company Commander ( T ) and the First Sergeant ( F ) find out two of their personnel have been arrested for shoplifti ng in the Post Exchange. As they discuss the issue, the Commander is ready to impose maximum punishment under the Uniform Code of Military Justice.* The First Sergeant mentions that one of the Soldiers is married and lives off-post with his family, while the other Soldier is single and lives in the barracks. He states that it is not fair to punish them with the same penalties. Feelers like to work in ha rmony where feelings and personal values are regarded as important. Thinkers *The Uniform Code of Military Justice, a federal law,5 is the judicial code which pertains to members of the United States military.

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26 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 focus on practicality and impersonal, analytical problem solving. Judgers and Perceivers Judgers require a very structured, ordered, and predictable environment to be happy. If “ J s” are working in an unorganized environment, they will either try to organize it or they will constantly complain that things are a mess, nothing is in its place, or that the disorganized workplace environment affects their productivity. Judgers thrive in highly regulated environments. J s work first and play later (leadership style: planful). Perceivers like a more laid-back approach. “ P s” focus on the experience and they prefer things to unfold as they will. Perceivers do not like to limit options, and thrive in dynamic, ever-changing workplace environments. P s can work in a mess, in fact, they prefer to work in chaos as it stimulates creative thinking when predictability is removed. Perceivers seek employers that offer flexible working arrangements. P s love to play. If work is lighthearted and not terribly regimented, they are content (leadership style: flexible). Example from work: As a J do you keep a to-do list? When you accomplish something on the list, do you mark it off? As a J when you do something not on the list, do you add it to the list and then mark it off to show it was completed? Have you ever turned-in a project by the due date, even when you needed more time to research? As a P do you keep a to-do list? How often do you write things down and how often do things on the list change? Have you occasionally called to extend a deadline in order to develop more/better data? The Judger prefers a highly structured work environment, whereas the Perceiver enjoys a more relaxed climate for work. Some of us may think that the MBTI is a “touchyfeely” tool. If used correctly and ethically by a qualified practitioner, the Myers-Briggs Type Indicator increases self-understandi ng and appreciation of personal differences in or der to improve one-on-one interactions and team success. Information about the MBTI is available from a myriad of sources, including the following websites: www.mbticomplete.com (MBTI Complete (CPP)) www.aptinternational.org (Association for Psychological Type International) www.keirsey.com (Keirsey Temperament Sorter) REFERENCES 1. Field Manual 6-22: Army Leadership; Competent, Confident, and Agile Washington, DC: US Dept of the Army; October 12, 2006: p3-11. 2. Saunders FW. Katherine and Isabel: Mother’s Light, Daughter’s Journey Palo Alto, CA: Consulting Psychologists Press; 1996. 3. Myers IB. Gifts Differing: Understanding Personality Type 2nd ed. Palo Alto, CA: Consulting Psychologists Press, Inc; 1995. 4. Jung CG. Psychological types. In: Hull RFC, transed. The Collected Works of C. G. Jung Vol 6. Princeton, NJ: Princeton University Press; 1976. 5. Uniform Code of Military Justice, 64 Stat. 109, 10 USC, ch 47. AUTHOR Mr Hagey is a Training Instructor, Oral and Written Communications, at the Leader Training Center, Army Medical Department Center and School, Fort Sam Houston, Texas. Mr Hagey is certified as an MBTI practitioner by the Association for Psychological Type International (http://www.aptinternational.org). Personality Type and Leadership

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October – December 2009 27 CROSSROADS Convergence Sigmund Freud’s Convergence Theory holds that crowd behavior is not a product of the crowd itself, but is brought to the crowd by particular individuals. Thus, crowds amount to a convergence of like-minded individuals. Therefore, people who wish to act in a certain way come together to form crowds. For instance, Soldiers with common job skills, badges, patches, or even a favorite football team may band together within the Army with overt intentions. Convergence theory also asserts that crowd behavior itself is not irrational, but rather, people in crowds express existing beliefs and values so that the group reaction is the product of widespread popular feeling. Properly directed, this feeling can be esprit de corp s. In some instances, this leads to parochialism and pontification within an organization. However, the chain of command in the Army is, by design, the common denominator for all Soldiers and employees and therefore responsible for controlling the many degrees of freedom within the units. Since leadership is situational, a single article can not address the different levels of leadership, much less different types of leadership requirements of different types of units (eg, sniper platoon vs preventive medicine detachment). However, discussing social reality within the context of the Army in contemporary America may be the key to the recruitment and retention of high quality Soldiers. A Young Democracy In the 1923 case of United States v Bhagat Singh Thind ,1 a naturalized citizen, the US Supreme Court ruled Asian-born persons could not become citizens. Bhagat was stripped of his citizenship based on a 1790 statute that declared Indians to be Asians and Asians to be “not white,” and therefore ineligible for US citizenship. By 1924, the Johnson-Reed Act2 set strict quotas on immigration by origin. However, the scope of the exclusion expanded over the years to include Japanese, Koreans, and other “Asiatics.” Paradoxically, Jesus would not have been allowed citizenship and the majority religion of the country was Christianity. Fortunately, the Civil Rights Act3 was passed in 1964 and paved the way for the 1965 Immigration and Nationality Act.4 For the first time since 1924, people from all over the world could come to America and become citizens. Figure 1 shows how the trend of foreign-born US citizens was affected by legislation, with a distinct drop in foreign-born population after the Johnson Reed Act followed by a recovery increase after the Immigration and Naturalization Act. Certainly there were global circumstances that instilled fear among many Americans and caused such legislative knee-jerk reactions, but one must remember that policy is meant to be created, changed, a nd/or abolished to suite contemporary circumstances. Dynamic Leadership: Essential for the 21 st Century MAJ D. Scott McIlwain, MS, USA Uniform \'y-n -frm\ consistent in conduct or opinion, from Latin uniformis (one form). Ethnic \'eth-nik\ of or relating to large groups of people classed according to common racial, national, tribal, religious, linguistic, or cultural origin or background, from Latin ethnicus (nation, people). Religion \ri-'li-j n\ a personal set or institutionalized system of attitudes, beliefs, and practices, from Latin religio (constraint). Generation \je-n -'r -sh n\ a body of living beings constituting a single step in the line of descent from an ancestor. Source: Merriam-Webster Online Dictionary. Availa ble at: http://www.merriam-webster.com/.

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28 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 Change There are 192 member states in the United Nations.7 Each one is represented in the US Census. The United States is the most diverse nation on earth. This growth is a result of our nation’s birthrate rising faster than the mortality rate. When these 2 factors combine with immigration and mixed ethnicity marriages, a faster growth of minority ethnicities is created. Even the US Census Bureau has changed its data collection methods to more accurately reflect the diversity of the United States. In 1977, the Office of Management and Budget (OMB) issued Statistical Policy Directive Number 15.8 In this new government policy, only 4 races were options. A review of the Directive by an interagency committee in the mid-1990s resulted in recommendations for change, the most notable of which was the ability for respondents to select one or more race on surveys.8 For example, the selections “White” and “Asian” can be simultaneously selected by a respondent with biracial parents. Tiger Woods even light-heartedly comments that he is “Cablinasian” when asked about his ethnicity, which represents his mix of Caucasian, Black, Indian, and Asian heritage. In October 1997, the OMB announced that these revised standards for federal data on race and ethnicity would be utilized by all governmental agencies beginning in January 2003.9 THE NEW FACE OF AMERICA Ethnicity Different cultures came with our nation’s immigrants Although the cultures were present, they were not readily visible because expression of uniqueness was not the norm in American culture until recent decades. For instance, study groups for a particular religion would not openly advertise or meet in public venues. Over the years, as the minority populations have grown, their cultures make their way out of the basements of houses and into mainstream America.10 The national paradigm is rapidly shifting from a “melting pot” to a “mixed salad.” Rather than the dissolution of immigrant cultures into our society, unique cultures now stand out as individual parts. Today, the fastest growing groups in the United States are Hispanics and Asians. Each is nearly as large as the black population. By 2050, Caucasians are predicted to no longer be the majority in the United States.11 Many immigrants are maintaining ties with their homeland with telecommunication and the internet. The local newspaper can easily be accessed in most cases allowing immigrants to keep abreast of community events. Globalization of communication is allowing immigrants to be a part of their homeland on a continuous basis rather than shedding their past to conform to a new society. Religion The founding fathers of our nation wrote a religionfree constitution. Therefore, no religious belief would be considered privileged in the public eye. Even so, Christianity was still the dominant religion of our fledgling country. This led to spirited competition among congregations since they had no support from government. This free market of religion became a unique characteristic of America that exists today. In the past 3 decades, the majority religions in the United States were Catholic, Protestant, and Jewish. Now, the fastest growing religion in the United States is the Muslim faith. In the United States, there are more Muslims than Episcopalians or Presbyterians and approximately the same number of Jews. This trend is followed closely by Mormonism, Hinduism, Buddhism, and Sikhism. In 1997, there were over Dynamic Leadership: Essential for the 21 st Century Figure 1. Foreign-born percentage of total US population for each year, 1850 through 2000. Sources: Gibson and Lennon5; Census Brief 2000 6 Hart Celler Immigration Act Expansion of Racial Quotas and Exclusions Chinese Exclusion Act Percentage

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October – December 2009 29 THE ARMY MEDICAL DEPARTMENT JOURNAL 1,000 Muslim mosques in the United States. In 1960, there were none.10 The religions of the world share one important feature. They all aspire toward a spir itual goal, whether it is the union with a supreme being or the realization of a higher spiritual state. Although there are many faith traditions in the world, similarities in their moral code are striking. Believers are inspired to pursue their faith's moral code as closely as possible. Aside from teaching religious ceremony and ritual, religions teach people to respect each other and help others in need. Moral codes have inspired nonprofit organizations such as the Muslim Red Crescent, Christian Red Cross, and nondenominational Habitat for Humanity. It is apparent in public politics that multiculturalism is recognized, but religion is foreshadowed. Religions shape every aspect of our daily life, from laws regarding marriage and divorce to the details of food preparation. Both nations and individuals describe themselves in religious terms. Religion provides people with hope for the future and comforts them in times of anguish. Therefore, it cannot be ignored by leaders. Generation Disconnect The term “generation gap” refers to a 15-year period (1965 – 1980) where birth rates sharply declined after the post World War II “baby boom.”12,13 Once the children of the baby boomers began having families of their own, the birth rate once again started to rise. However, children born in this dip, or gap, are referred to as generation X. The title is representative of the disproportionately small growth of this age group that was “lost in the gap.” The growth following the gap is the grandchildren of the baby boomers known as generation Y, or millennials. The rise in the birth rate is noticeable in this group, but not as pronounced as the baby boom. After generation Y, is another marked “echo” gap resulting from the smaller generation X starting families (Figure 2). The attitudes and behaviors of each generation are studied by sociologists because of the impact their interactions have on society, and moreover the workplace. There is no magic age that makes you one generation or the next, nor does being labeled a particular generation make you predisposed to certain characteristics. What makes these generational gr oups have different mind sets are their experiences. Figure 3 identifies the percentage each generation contributes to the Army’s population and a few identifiable characteristics. With approximately 80 million peers and having parents from the “greatest generation,” baby boomers tend to be highly competitive and will readily work long hours and sacrifice to remain competitive. Unfortunately, this also correlates with a high divorce rate and clashes with other generations in the work place. This group is credited with shaping today’s corporate culture that has made the United States a dominant figure in agriculture, medicine, business, and manufacturing. The high divorce rates from the baby boom generation and the recession of the 1980s shapes the mindset of generation X. Watching sacrificial hard work be rewarded with layoffs and personal hardship, generation X is particularly untrusting when it comes to employers. Between divorce and dual career parents, this generation is often referred to as the “latchkey” generation. This is a reference to children who would go home after school to an empty house because their parent(s) were still at work. This created a sense of independence among this group that carries over into the work place. This group does not believe in the career ladder and w ill change jobs without a second thought. Gen Y 1977 1998 75 million Gen Z 2002 to Present Baby Boom 1946 1964 76 million Gen X 1965 1976 51 million Birth Rate Figure 2. The US birth rate (live births per 1,000 population) for the years 1940 through 2005. Sources: Vital Statistics of the United States, 1994 14; Hamilton, Martin, and Ventura15

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30 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 Generation Y is just beginning to show up in the work force. Growing up in a thriving economy, this generation is the most optimis tic of all generations in the work place. They ar e accustomed to being involved in decision making, are technologically savvy, and have high expectations from their employers.12 This generation constitutes the bulk of the Army and our future. CONCLUSION Convergence of religion, ethnicity, and generations are shaping our future and mandates the development of dynamic leaders. Keeping abreast of these issues through education will allow leadership to maintain a proactive stance on change and the diversity within the United States. Acknowledging that differences exist, even in an organization that is driven by uniformity, can facilitate a collegial atmosphere and ultimately a more productive organization. REFERENCES 1. United States v Bhagat Singh Thind 261 US 204 (1923). 2. Immigration Act of 1924, 43 Stat. 153; 8 USC 201 (1924). 3. Civil Rights Act of 1964, Pub L 88-352, 78 Stat. 241 (1964). 4. Immigration and Nationality Act of 1965, Pub L 89236, 79 Stat. 911. 5. Gibson CJ, Lennon E. Historical Census Statistics on the Foreign-born Population of the United States: 1850-1990 Washington, DC: US Bureau of the Census; February 1999. Population Division Working Paper No. 29. Available at: http://www.census.gov/ population/www/documentation/twps0029/ twps0029.html. Accessed October 5, 2009. 6. US Bureau of the Census. Census Brief 2000 Washington DC: US Bureau of the Census; August 2000. Available at: http://www.census.gov/ prod/2000pubs/cenbr002.pdf. Accessed October 5, 2009. 7. Press Release ORG/1469: United Nations Member States. United Nations Website. July 3, 2006. Available at: http://www.un.org/News/Press/docs/2006/ org1469.doc.htm. Accessed March 31, 2008. 8. Directive No. 15: Race and Ethnic Standards for Federal Statistics and Administrative Reporting. Washington, DC: Office of Management and Budget; May 12, 1977. Available at: http:// www.whitehouse.gov/omb/fedreg_directive_15/. Accessed September 24, 2009. 9. Race Data. US Census Bu reau Website. Available at: http://www.census.gov/population/www/socdemo/ race/racefactcb.html. Accessed March 18, 2008. 10. Eck DL. A New Religious America San Francisco, CA: Harper Collins; 2001. 11. Bernstein R, Edwards T. An older and more diverse nation by midcentury [press release]. Washington DC: US Census Bureau; August 14, 2008. Available at: http://www.census.gov/Pr ess-Release/www/releas es/archives/population/012496.html. Accessed October 5, 2009. 12. Cheung E. Baby Boomers, Generation X, and Social Cycles Vol 1. Toronto, Canada: Long Wave Press; 2007. 13. Bennis WG, Thomas RJ. Geeks and Geezers: How Era, Values and Defining Moments Shape Leaders Boston, MA: Harvard Business Publishing; 2002. 14. National Center for Health Statistics. Vital Statistics of the United States, 1994, Volume 1, Natality Atlanta, GA: US Centers for Disease Control and Prevention; 1994: Table 1-7. Available at: http:// www.cdc.gov/nchs/data/statab/natfinal 1995annvol1_07%20.pdf. Accessed October 5, 2009. 15. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2007. National Vital Statistics Reports Vol 57 No 12. Atlanta GA: US Centers for Disease Control and Prevention, National Center for Health Statistics; March 18, 2009. Dynamic Leadership: Essential for the 21 st Century 4% of the Army Work defines life High divorce rate “Breadwinners” 12% of the Army Works to live Very untrusting Dual career family 83% of the Army “Connected” High expectations Telecommuting Figure 3. The proportion of the “generations” across the US Army Soldier population. Sources: Cheung12; Bennis and Thomas13; Maxfield16; Wong17

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October – December 2009 31 THE ARMY MEDICAL DEPARTMENT JOURNAL 16. Maxfield BD. Army Profile 2005 Washington, DC: Office of Army Demographics, US Dept of the Army; September 30, 2005. Available at: http:// www.armyg1.army.mil/HR/docs/demographics/ FY05%20Army%20Profile.pdf. Accessed October 5, 2009. 17. Wong L. Generations Apart. Xers and Boomers in the Officer Corps Carlisle, PA: Strategic Studies Institute, US Army War College; October 1, 2000. Available at: http://www.st rategicstudiesinstitute .army.mil/pubs/display.cfm?pubID=281. Accessed October 5, 2009. AUTHOR MAJ McIlwain is the Director, Otolaryngology Technologist Program, Academy of Health Sciences, US Army Medical Department Center & School, Fort Sam Houston, Texas. No matter the generational niche, throughout history members of the US military have unfailingly displayed cour age and dedication in defense of fr eedom and our way of life. Moreover, in so doing they also have reflected the inhere nt decency and generosity of the people of the United States, whenever and wherever they serve.

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32 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 When I was 11 years old, my friend Mike and I formed the Lafayette Escadrille (LE). It was a club based on riding around on bikes looking for noble deeds to accomplish. As I remember, there were precious few noble deeds to occupy preadolescent boys in the New Jersey suburbs of the sixties. But we had an elaborate system of ranks, emblems, laws, maps and notebooks along, with about a half-dozen kids who were, to a one, far less enthusiastic a bout the LE than we were. I was, as I recall, the leader. Leadership has been a lifelong study for me. I believe that leaders (those who end up in positions of responsibility and authority) should be students of leadership (the ability to motivate a group of people toward a common goal). To be a lifelong student means that one has never quite arrived at the level of leadership expert. There are always more lessons to learn. I am also convinced that lead ership is life. The lessons that one learns as a leader and in the practice of leadership forge principles which are also essential for success in marriage, parenthood, business partnerships, friendships and all scope and manner of human relationship. The opposite is also often true, although we seldom make the observation. For example, if I can figure out how to successfully parent a child through 2 decades of development, I can also learn to adapt my leadership style to different situations and individuals within an organization. Leadership in an individual is a product of nature, nurture, and “knocks.” Clearly there are certain personality types that are more common in leaders. For example, in a study of 270 senior officers at the Army War College, Herbert Barber determined that 71.1% of the students indicated preferences that fit into one of the 4 Myers-Briggs Personality Types* that include thinking and judging: ISTJ Introverted Sensing Thinking Judging ESTJ Extroverted Sens ing Thinking Judging INTJ Introverted Intuitive Thinking Judging ENTJ Extroverted Sensing Thinking Judging These traits suggest a distin ction in how leaders make decisions; thinking (whether one values impersonal logic) vs feeling (using personal feelings in processing information or making decisions). They suggest a distinction in the way a person encounters the world; judging (one analyzes and judges the external environment) vs perceiving (reacting to it with flexibility and spontaneity).2 Strong nurturing environments also promote the development of leadership. There are numerous examples of leaders whose childhood was supporting and nurturing. Someone puts the idea in a child’s head that he or she can be more, do more, accomplish more than imagined. World renowned neurosurgeon Ben Carson points to the influence of his mother and family,3 as does President Obama. General Douglass MacArthur’s mother “Pinky” followed him to West Point and lived in the hotel off post while he was a cadet.4 But leadership is also a matter or responding to knocks—the knocks of opport unity or the knocks of life. British Prime Minister Benjamin Disraeli said “The secret of success in life is for a man to be ready for his time when it comes.”5 When an opportunity to lead presents itself, leaders step up. Similarly, when trials or difficulties come—the knocks of life—the true leader separates himself or herself from the pack by demonstrating courage, perseverance, and purpose. The practice of leadership is based on a leader’s principles. Principles define the “who” of a person; what they stand for, how they are defined. Integrity, humility, honor, and faith are examples of principles that define who we are. Values describe “how” we live. They are the way we work out principles in the practice of our lives. Justice, mercy, loyalty, veracity, service, courage, and wisdom all represent values we *The Myers-Briggs Type In dicator (CPP Inc, Mountain View, CA) is a personal ity questionnaire designed to identify certain psychological differences according to the typological theories of Carl Gustav Jung as published in his book Psychological Types .1 See related article on page 24. Resonance, Dissonance, and Leadership COL Chuck Callahan, MC, USA

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October – December 2009 33 use to negotiate life. The last of these, wisdom, may in some ways be the most important. Wisdom knows the right thing to do or say in the right circumstance. It is based on intuition, which in itself is a combination of instinct (feelings or emotions) and intellect (cognition and knowledge). Crucial then for wisdom is an understanding of one’s feelings and emotions as well as the feelings and emotions of others. Emotional intelligence describes a person’s ability to be aware of and responsible for the management of his own feelings, as well as being able to be sensitive and respond appropriately to the feelings of others. In his 2002 book,6 Daniel Goleman summed up his research on emotional intelligence in the workplace. He described 6 types of leadership styles (visionary, coaching, affiliative, democratic, pacesetting, and commanding), 4 domains of emotional intelligence (self-awareness, self-management, social awareness, and relationship management), and the steps leaders could take to learn these leadership skills. The result of successfully considering emotional intelligence in any setting was what he called “resonance.”6(p55) The notion of resonance and resonant leadership is based on a principle of physics that describes the generation of sound of musical instruments. Instruments all have natural frequencies at which they are capable of vibrating if they are struck, strummed, or blown at the appropriate frequency (think about the appropriate “buzzing” of the lips for those who play brass instruments or reed vibration for woodwind players). When one object vibrating at the same natural frequency of a second sets the second into vibrational motion, you have resonance. And you get music. The sound of the sea you hear when you listen to a seashell is also due to resonance. Even an apparently quiet room is filled with sound waves with a range of frequencies. These sounds are mostly not heard because of their low intensity. This background noise fills the seashell, causing vibrations within the seashell. The seashell has a set of natural frequencies at which it will vibrate. If one of the frequencies in the room forces air within the seashell to vibrate at the shell’s natural frequency, a resonance situation is created and the “sound of the ocean” is loud enough to be heard. Emotional resonance is similar. When, through paying attention and being intentional, I allow my emotional state to reflect yours, or when I am able to influence your emotional state in a positive way, I create resonance. Humor and laughter (that is not at the expense or hurt of another) are good examples of emotional resonance. They can be amplified as they are shared and can create resonance. All of us can recall a tense or uncomfortable situation that was instantly transformed by a shared laugh or smile. The best indicator of the morale or “timbre” of an organization—its resonance—is the presence of laughter. Dissonance is the opposite. It is the creation of negative emotions through my inability or unwillingness to appreciate your emotional state. Or is it a negative influence that I generate through my own ill-humor, or ill-treatment of others. Goleman and his associates recognized that cer tain leadership styles were more likely to create resonance in the workplace (visionary, coaching, affiliative, democratic) and others were more likely to create dissonance (pacesetting and commanding).6(pp71-80) This is not really sophisticated stuff. I think that most of us understand intuitivel y the difference between resonance and dissonance. You meet someone at a party and strike up a conversation. You find that you share similar interests and some similar experiences. You share a brief anecdote about a serious or challenging aspect of your life. You laugh together. When you walk away from the encounter, you say to yourself, “What a great guy! We have to get together again.” When you share the same ideas or concepts, you have cognitive resonance. When you find yourself sharing the same feelings, you have established emotional resonance. You also probably know what dissonance looks like. Or you know someone like this at work or in the family. Whenever he is around, things are tense. He seems to be unable to appreciate (or care!) when you are stressed or struggling with your job or personal issues. His attempts at humor are unappreciated or, even worse, mean-spirited. People shake their heads when he walks away and find themselves saying things about him such as: “He is so out of touch,” “He just doesn’t get it,” “He doesn’t listen,” or “He is not on the same sheet of music with us.” This is also the guy who seems to always be thinking of what he is going to say while you are still talking,

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34 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 and doesn’t let you finish your sentences. He will cut off the conversation before you are sure he understands your concerns, or he will change the subject (often using a personal anecdote) and force the conversation in another dir ection. This person creates cognitive dissonance by centering on discussion (where he attempts to “help” you see the error of your ways) instead of dialogue (where both parties are willing to confer and concede on specific points). Emotional dissonance is also created by his unwillingness to consider how you feel. We find that cognitive and emotional dissonance play themselves out in 3 different settings that can be broadly grouped as “love” (our close, personal relationships), “life” (our professional relationships), and “leadership” (the way we relate to groups of individuals). In each case, there are unique risks and benefits to working toward resonance and away from dissonance. LOVE My wife and I lost our first baby. Her pregnancy after a year of marriage had been the answer to our dreams. She had a miscarriage at about 12 weeks in July 1981, and we felt as though our lives were shattered. People close to us said things like “You’re still young,” or “You’ll have another.” I know that they meant well, but we didn’t want anothe r baby. We had already bonded with this child. We had already named him. I remember thinking through my tears, “We would have played ball together….” In the next decades, we were blessed with 7 children and a number of foster children, and I have played ball with and been soundly beaten by more than one of them. But I remember how distant I felt from friends and family—emotional dissonance. More importantly, my wife and I grieved at a different pace. I was “over” it well before she was, and dove into my second year of medical school studies to distract me from the loss. My wife wrestled with the loss of the baby longer than I did, and she struggled with questions the whole experience raised about God and faith. We learned that for us to experience what I now know to be emotional resonance, we had to learn to listen to each other, to appreciate where we were in the emotional recovery process, and to give each other space where it was needed. We were blessed to bring home our oldest son a year later. There are scores of examples of the same kinds of emotional dissonance and resonance in raising children and staying married for nearly 3 decades. I believe that the longer you work at being married and parenting, the more time you spend working toward both cognitive and emotional resonance. A key that I learned from Steven Covey is one of his “Seven Habits”: listen first to understand, then to be understood.7 Active listening is the key to establishing emotional resonance with those whom we love. LIFE A wise family practitioner once told me, “Whenever you are with a patient and you feel anything, ask yourself what’s happening.” He used it as an opportunity to teach his young medical students about situations that ranged from patients evoking anger in us by frustrating conversations, to picking up on patients making sexual advances toward us. His insight was invaluable in my first job as a pediatrician. Our acute or same-day appointments were scheduled at 5 minute intervals, 36 appointments per half day, 72 in a 6-hour weekend clinic. In a 5minute appointment, there is not a lot of time to explore the subtle nuances of emotion and cognitive resonance. I found very quickly that if I sat down (I used the trash can in the ex am room), leaned forward, made eye contact, and disciplined myself to try to mirror the patient’s level of concern with my own facial features, we were often able to establish emotional resonance. I heard many times, “Dr Callahan really listens to me.” I wish I was always as confident that I was listening. But what the parent was usually trying to say was that we were able to establish emotional resonance, even within a 5-minute visit. Patients and our peers more often than not merely want to be understood. They want to know that someone is willing to consider what they are feeling, and is willing to try to understa nd their perspective. An unwillingness to feel and to understand leads to dissonance. The discipline requires that we approach every encounter in life with attention (what are the needs of the person with whom I am speaking?), intention (what can I do to connect and to understand?), decision (will I choose to take the initiative to establish or deepen this relationship?), and action (will I take the necessary steps to make this connection?). Resonance, Dissonance, and Leadership

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October – December 2009 35 THE ARMY MEDICAL DEPARTMENT JOURNAL LEADERSHIP Sometimes I am accused of trying to reduce life to a series of 2 2 tables. It may be true, but, especially in leadership, I think sometimes that simple observations can be made. Interactions between a leader and his or her subordinates can either create resonance or dissonance. (Interactions can also be neutral, in which case the relationship remains unchanged, shaped by previous resonance or dissonance.) Leaders create resonance or dissonance either on purpose (resolute) or by accident (dissolute). Some leaders, whether through their innate leadership style or their personality, create resonance on purpose: resolute resonance. These are leaders who talk about the importance of their people, and then demonstrate it with their actions. In the 1954 movie White Christmas (Paramount Pictures, Hollywood, CA), starring Bing Crosby, Danny Kaye, and Rosemary Clooney, the men describe their old World War II general (MG Thomas Waverly played by Dean Jagger) by saying, “we ate then he ate, we slept then he slept…” and sang “We’ll follow the old man wherever he wants to go….” By his intentional and “attentiona l” actions on behalf of his men, the fictional MG Waverly demonstrated resolute resonance. (There are certainly scores of examples of nonfictional leaders who have demonstrated the same ability to create resolute resonance.) Sometimes you have to shake things up. It is common when taking over an organization that needs a turnaround starting at the very top. Michael Watkins’ book, The First 90 Days,8 is a must read for every new commander and leader. He makes the point that new leaders in struggling organizations may need an outsider to come in and “break some eggs,” shattering pat solutions and shaking up an established, but unsuccessful corporate culture.8(pp61-62) Such a leader can be considered to be practicing resolute dissonance; creating organizational dissonance for a specific reason. In the book, Band of Brothers ,9 Steven Ambrose describes the soldiers of E asy Company of the 506th Infantry Regiment, 101st Division, as being united in their hatred of their first company commander, CPT Herbert Sobel, whose leadership style could at best be considered narcissistic. He did not take the unit into combat, but as his soldiers shared a common hatred of him, they united as a team.9(p25) Thus, CPT Sobel’s leadership created resonance he did not intend, dissolute resonance. Finally, there are leaders whose style is simply degrading and discouraging for those with whom they work. One Army commander is given to angry tirades, demeaning his staff in front of others. Another commander works every night until midnight and expects all his staff members to do the same. A hospital department chief sows dissent by talking to staff members about other members of the staff behind their backs. The actions of these leaders result in dissolute dissonance. The workplace climate they create is one of dissonance, but they have no idea that they are doing it, nor would they necessarily care. What disciplined practices w ill help us to be aware of the principles of emotional intelligence and to practice an awareness of our emoti ons and the emotions of others as we move through the chaos and crisis of day to day living and leading? GET UP ON THE BALCONY Getting above what is happening or what we are feeling must become a continual process for leaders. Every time we get angry, annoyed, or perplexed— something is happening. Every time we feel happy, satisfied, or fulfilled—something is also happening. Understanding what led to these feelings and taking the opportunity to respond rather than react depends on our ability to pause and look down on what is occurring. We need a regular seat on the balcony. LISTEN TO LANGUAGE From this balcony view we can also be aware of the feelings and reactions of others. When we say something that makes someone else annoyed or impatient, we can often tell by their body language and posturing. Their “natural language” communicates without them saying a word. ALWAYS ASK WHY? Understanding what is going on with those whom we lead is crucial. There may be little we can do to mitigate others’ emotional responses to what we say or do, but we need to understand them. People follow managers with their heads. They follow leaders with

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36 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 their hearts and emotions. It is crucial that we be sensitive, then, to the very things that will motivate them to either follow, or not. SHOOT AN AZIMUTH Compare the way you are feeling or the feelings you observe in others with yo ur overarching goals. Weigh actions carefully—will this accomplish what I am really after? If I react angrily or speak sharply, will that make my people more likely to accomplish what I think are our shared objectives and goals? Will it accomplish my own, personal, professional, or leadership goals? Having a good sense of our “azimuth” will keep us out of trouble. CHOOSE ACTIONS This follows naturally. Feelings are amoral, they are neither good nor bad. What we do with them most certainly can be. What separates humans from other animals is, in part, our ability to choose how we respond to our feelings or the feelings of others rather than just reacting. Many adults and, in fact, many leaders never quite reach th is level of evolution. Life is complex. There is a messy unpredictability to it. Philosopher G.K. Chesterton captured this notion in a 1924 work, The real trouble with this world of ours is not that it is an unreasonable world, nor ev en that it is a reasonable one. The commonest kind of trouble is that it is nearly reasonable, but not quite. Life is not an illogicality; yet it is a trap for logicians. It looks just a little more mathematical and regular than it is; its exactitude is obvious, but its inexactitude is hidden; its wildness lies in wait.10 We are in the business of navigating that very wildness, between the logic of reason and the inexactitude of emotion. It is an unpredictable and somewhat dangerous course. – But that is what leadership is for – REFERENCES 1. Jung CG. Psychological types. In: Hull RFC, transed. The Collected Works of C. G. Jung. Vol 6 Princeton, NJ: Princeton University Press; 1976. 2. Barber HF. Some persona lity characteristics of senior military officers. In: Cl ark KE, Clark MB, eds. Measures of Leadership West Orange, NJ: Leadership Library of Amer ica, Inc; 1990:441-448. 3. Clarrissimeaux A. Never give up – how to live a meaningful life. Success October 2008. Available at: http://www.thefreelibrary.com/Never+give+up: +Dr.+Ben+Carson%27s+only+childhood+advantage: +his...-a0206255463. Accessed 23 September, 2009. 4. Perret G. Old Soldiers Never Die: The Life of Douglas MacArthur Holbrook MA: Adams Media Corporation; 1996:29. 5. Maxwell JC. The 360-Degree Leader: Developing Your Influence From Anywhere in the World Nashville, TN: Thomas Nelson, Inc; 2005:128. 6. Goleman D, Boyatzis R, McKee A. Primal Leadership. Realizing the Power of Emotional Intelligence Boston, MA: Harvard Business School Press; 2002. 7. Covey S. The Seven Habits of Highly Effective People New York, NY: Simon and Schuster; 1989:239-241. 8. Watkins M. The First 90 Days Boston MA: Harvard Business School Press; 2003. 9. Ambrose S. Band of Brothers New York, NY: Simon and Schuster; 1992. 10. Chesterton GK, Dooley D. G.K. Chesterton Collected Works, Volume 1: Heretic s Orthodoxy The Blatchford Controversies San Francisco CA: Ignatius Press; 1986:285. AUTHOR COL Callahan is the Commander, Dewitt Army Hospital and Health Care Network, Fort Belvoir, Virginia. Resonance, Dissonance, and Leadership

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October – December 2009 37 INTRODUCTION In a traditional mentoring relationship, the mentor guides the protg and shares wisdom gained from his or her career. Each mentor ing relationship is unique, a direct result of the individual personalities of the two participants. While some me ntoring relationships are very brief, perhaps only the duration of a project (or deployment), others can last an entire career, or even longer. The purpose of this paper is to present a model, the Mentoring Spectrum, to describe the broad range of mentoring relationships that can exist between a mentor and a protg. It starts with the simplest relationship, the Role Model, and continues with deeper and more complex relationships until it reaches the epitome of mentorship, the Counselor. The goal of this article is to present the continuum of mentoring relationships so that mentors and protgs can better understand the various options for mentoring partnerships that are available to them. ROLE MODEL The Role Model is the first type of mentoring relationship in the Mentoring Spectrum and is the simplest. In this relationshi p, the senior officer serves as an example for the junior officer to follow. By observing the mentor, the protg learns what is proper personal and professional behavi or. While this form of mentoring relationship is more passive than the others that will be described, it is still an active form of mentoring. In some cases, the mentor may not even know that a particular subordinate is watching and modeling the superior officer ’s pattern of behavior. Regardless, the seasoned leader knows that he or she is being watched and could be serving as a role model for junior officers to follow. So, senior officers need to remember that they are always “on stage” and are potentially mentoring through their daily “performances.” PRECEPTOR Unlike the Role Model, the Preceptor is a much more active and engaged form of mentoring. The term preceptor is borrowed from examples in medicine, where a new physician is paired with a more experienced clinician who serves as a teacher and is expected to instruct the neophyte on what he or she needs to know clinically. Therefore, this type of mentoring relationship usually occurs in the early phases of a junior officer’s career. In the case of the Preceptor, both the mentor and the protg are aware of each other and their relationship. The mentoring focus is strictly technical, on the development of specific skills. Typically, the relationship only lasts until the protg has mastered the requisite skills and has therefore completed the preceptorship. However, in some cases, a bond may be formed that can blossom into a deeper mentoring relationship. I know this was true for me; my longtime mentor started out by teaching me how to perform physics testing of medical x-ray systems when I was a brand new second lieutenant. But his genuine interest in my technical development and the rapport that developed between us set the stage for the growth of a much deeper mentoring relationship that continues to this day. COACH The next role in the Mentoring Spectrum is the Coach. Unlike the Preceptor, the Coach is focused on the overall job performance of the protg, not just the mastering of an individual task or skill. So, the Coach is concerned with mission accomplishment and how the protg functions within the unit or organization. Supervisors typically mentor their subordinates by being Coaches. Because the mentoring focus is on job performance (and the Coach may also be personally accountable for the success or failure of the protg), there may be some limitations to the depth of this relationship. For example, the protg may be reluctant to share doubts or weaknesses with the mentor for fear of receiving a bad rating. Also, if the senior leader supervises more than one junior officer, the cautious mentor might be concerned about the appearance of favoritism by providing more mentoring to one subordinate over another. As a result, the level of trust between mentor and protg may be limited when the mentoring relationship is one of coaching. The Mentoring Spectrum COL Mark A. Melanson, MS, USA

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38 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 ADVISOR While an Advisor is also concerned with protg job performance, this mentor is also focused on the junior officer’s career and professional development. Hence, the Advisor often becomes i nvolved in issues such as future duty assignments and pursuing advanced civilian and military schooling. Career or specialty consultants usually have an Advisor-like mentoring relationship with the junior officers in their Area of Concentration (AOC). Hence, these mentors also delve into more personal matters, such as family issues pertaining to a proposed permanent change of station (having a child in his or her senior year of high school) or a deployment (having a brand new baby on the way). However, since the consultant literally holds the protg’s career in the palm of his or her hand, the wary protg may be reluctant to share everything with the Advisor (such as doubts about continuing an Army career or thoughts about transferring to another AOC). CONFIDANT After sufficient trust has developed between the mentor and protg, then the mentoring relationship can deepen with the mentor becoming a Confidant. The Confidant is more trusted and fully capable of dealing with personal issues that the protg may have (for example, marital problems, uncertainty about continuing an Army career, or the decision about whether or not to retire). Since the protg deeply trusts the mentor, he or she is not reluctant to discuss sensitive topics such as personality conflicts with other senior officers or dissatisfaction with AOC leadership. For the protg, the Confidant serves as a sounding board for ideas and helps to brainstorm solutions to problems of both a personal and professional nature. COUNSELOR The Counselor is the pinnacle of the mentoring spectrum and is the fullest and deepest expression of the mentoring relationship. He or she is an avatar of the personae Mentor, in Homer’s Odyssey With a Counselor, a protg can discuss any topic and will seek guidance from the mentor in either personal or professional matters. As a result, the Counselor remains an enduring influence on the protg and the relationship can last for decades. It is important to note that it normally takes a long time to reach this depth of mentoring. In my case, it took approximately 10 years before my mentoring relationship deepened to the level where my mentor became my Counselor. THE MENTORING SPECTRUM The previous discussion outlined the 6 different mentoring relationships that can exist between mentors and protgs. The Figure shows these relationships as a part of the Mentoring Spectrum. In the Figure, the xaxis is labeled as “Trust” (referring to the protg’s trust) and the y-axis is labeled as “Influence” (or the mentor’s influence). As the graph depicts, as a protg’s trust increases, so does the mentor’s influence. So, a Counselor has more trust and more influence than a Confidant, who has more trust and more influence than an Advisor, etc. Within the graph there is a dividing line near the center. To left of this dividing line is a region labeled as “Professional Trust” and to the right of this dividing line is a region labeled as “Personal Trust.” This line of demarcation reflects the transition from a protg only sharing work or career related issues (demonstrating professional trust) to ultimately opening up and including personal matters (demonstrating personal trust). In most cases, this transition tends to occur at the point when a mentor becomes an Advisor, although the actual transition point will vary for each individual mentor–protg pairing. SUMMARY The purpose of this paper is to discuss the Mentoring Spectrum, a model which helps to explain the various mentoring relationships that can occur between a mentor and a protg. First, a senior leader can be a Role Model, setting the example for known and The Mentoring Spectrum Professional Trust Personal Trust Role Model Preceptor Coach Confidant Counselor Advisor TRUST INFLUENCE Graphical depiction of the Mentoring Spectrum.

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October – December 2009 39 THE ARMY MEDICAL DEPARTMENT JOURNAL unknown protgs alike. Next, a superior officer can become a Preceptor and teach the protg a specific skill or task. When mentors are Coaches, they are focused on improving the overall quality of duty performance and may also have a personal stake in the protg’s success. As an Advisor, a mentor has a longer perspective in mind and guides the protg towards career development and professional growth. After personal trust is earned, a mentor can become a Confidant and be a sounding board for more sensitive and personal matters. Finally, a mentor can reach the summit of mentoring and become a Counselor, providing the entire range of guidance typically associated with the mentor archetype. As the Mentoring Spectrum illustrates, when the mentor gains more and more trust, he or she has more and more influence over the protg, to include ultimately matters of a highly personal nature. It is hoped that by understanding these different mentoring relationships, mentors and protg can select the type of partnership that is the best fit for them. AUTHOR COL Melanson is the Chief of Health Physics at Walter Reed Army Medical Center Washington, DC, and the Radiological Hygiene Consultant to The Army Surgeon General.

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40 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 INTRODUCTION Although mentoring is an inhe rent responsibility of all Army leaders, not all mentors will have the same degree of success or experience the same depth of mentor development. While some officers will thrive and grow as mentors, others will never quite get the hang of it. Despite this natural disparity in individual mentoring potential and ability, I have come to believe that there is a clear pattern of growth unfolding throughout the careers of effective Army mentors. The purpose of this paper is to share the seasonal-like aspects of mentoring I have witnessed in my own career and the discovery of a model, the Mentoring Staircase, which accurately reflects and charts my own personal growth, as a protg and mentor, over the past 26 years, and into the future. Throughout this paper, I will use as an example the mentoring development of a due course officer (commissioned as a second lieutenant with no constructive credit, peaking at the rank of colonel, and retiring after 30 years), the situation with which I am most familiar. However, I think sufficient parallels exist for those who are commissioned at higher ranks and receive constructive credit, the timelines need merely be adjusted accordingly. Despite this small degree of timeline variability, I hope that all students of Army mentoring will find this discussion relevant and will benefit from this critical, introspective analysis. SEASONS OF ARMY MENTORSHIP While the metaphor of life being a series of 4 consecutive seasons is not a new concept, I am not aware of it being used to describe Army mentoring. However, the seasonal analogy does make perfect sense. A newly commissioned officer is “planted” in the fertile soil of the Army and then he or she is (hopefully) nurtured and helped to grow. Having grown, the mid-career officer takes his or her place as an Army leader and, in turn helps others to learn and grow. As eligibility for retirement approaches, the officer begins to think about the remaining time that is left and what will be his or her legacy. Finally, the senior officer enters the last stage of his or her career, tying up loose ends, and ultimately retiring. So are the seasons of Army mentorship, from spring to winter, from beginning to end. SPRING: BEING MENTORED Spring is the first season in Army mentorship and is a time of profound personal and professional growth. The primary goal during this initial period is for our new officer to become fully competent in his or her career field. Typically, this early season encompasses the company grade ranks of second lieutenant through captain. The fact that this initial developmental interval lasts roughly 10 years is not arbitrary. According to researchers who study experts and expertise, it normally takes about 10 years for one to truly master one’s craft and become an expert. This decade of mastery is often referred to in the professional literature on expertise as the “Ten Year Rule.”1 It consistently applies across all domains of human expertise: chess, athletics, music, and, in my opinion, mentoring. During this initial phase, our newly minted officer is focused on learning his or her various duties and what it means to be a commissioned Army officer. Hopefully, competent senior officers are actively mentoring the young officer. Additionally, the company grade officer is also growing through selfstudy and self-reflection. Given these facts, our junior officer is identified as a Protg. Now, that is not to say that the young officer is not in some limited way mentoring others. For example, he or she may be guiding enlisted personnel or conducting peer mentoring, like showing a fellow junior officer how to perform a specific task. But, the Protg has not fully matured and is not yet prepared to mentor other officers in full scope and depth of mentorship, such as career development, maintaining competitiveness for Seasons of Army Mentorship and the Mentoring Staircase COL Mark A. Melanson, MS, USA

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October – December 2009 41 promotion, balancing career and family, etc. Simply put, one cannot expect to fully and properly mentor what one has not yet personally experienced and consequently mastered. SUMMER: BECOMING A MENTOR After the completion of his or her first 10 years, our young field grade officer has reached many important milestones. First, he or she has been promoted 3 times, thereby demonstrating both past success and future potential. Additionally, this officer has successfully tackled 3 or 4 different assignments and acquired a modicum of experience. In some cases, the officer has earned a graduate degree and achieved specialty board certification. With regards to making the Army a career, this officer has passed the critical halfway point to 20 years, and has usually committed to the Army for at least another decade. All of these factors combine to make the young major ripe and ready to don the role of a Mentor, one who guides and develops company grade officers. On top of his or her game in terms of technical expertise and having a burning desire to share what he or she knows, our young Mentor makes the first serious attempts to deeply mentor junior officers. If the new Mentor has been properly groomed by others, he or she will seek to learn from and emulate the mentoring behavior of those personal mentors (sometimes successfully, sometimes unsuccessfully). Officers who were not mentored strive to give others the important guidance and direction that they were denied and had to learn for themselves, often the hard way. In both cases, the fledgling Mentors will have to learn by trial and error. Hence, this aspiring Mentor will again follow the Ten Year Rule and spend the next decade perfecting his or her mentoring skills and developing a unique, individual style of mentorship. At the end of this important decade of mentoring growth, our striving Mentor will emerge as a fully competent mentor of young protgs. AUTUMN: BECOMING A MASTER MENTOR Another major milestone in any Army career is hitting the highly coveted 20-year mark. For some, it is the time to retire and open the next chapter of life. For others, they are still climbing the ladder of Army success with “stars in their eyes” and no apparent end in sight. However, for a select few, it is a time of great introspection with thoughts shifting towards what they want to accomplish before retirement, whenever that will inevitably occur. Regard less of their situation, these fully vested senior officers have ideally perfected their skills as mentors, developing many junior officers and teaching them how to be competent junior Army leaders. Many of the younger officers that they have mentored over the years are now entering the “summer” of their own careers and are starting to take on protgs of their own. Hence, the mentoring focus for our senior field grade officer shifts to teaching their long-time protgs, as well as others, how to mentor. In order to denote this important passage into a new, deeper level of mentoring, I choose to designate this senior field grade officer as a Master Mentor, or mentor of mentors. Hopefully, this Master Mentor has had the benefit of quality mentoring during his or her early protg years and has spent another decade learning how to mentor young protgs. In this later season of Autumn, our Master Mentor is now sharing with the mentor-intraining the essential skills for mentoring another officer. As in the previous two seasons, this development period can last as long as 10 years. Although, for some Master Mentors it may be shorter, depending upon when they retire or whether or not they reach the next and final plateau of mentoring (discussed below). Instinctiv ely, this senior officer seeks guidance from his or her own mentors, most, if not all of whom have retired In addition to reflecting upon personal experiences, Master Mentors often conduct independent research into the field of mentoring in order to further grasp its fullest dimensions. He or she also actively seeks out other master mentors to share experiences and learn from these sagacious peers. For some, such as me, mentoring becomes a deep passion and one of the primary reasons that these dedicated officers remain on active duty and defer their retirement, often despite the “Sirens’ song” of lu crative career opportunities beyond the Army. WINTER: THE LEGACY OF THE GRAND MASTER MENTOR As in nature, the final season of Army mentoring is Winter. The Winter of Army mentoring is marked by both the impending finality of retirement and the deep compelling desire to leave some lasting legacy. For those very few officers that reach this highest plane of mentoring, this season is marked by a rare ability to rise above their role as a Master Mentor and reflect

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42 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 about how to mentor other master mentors. In essence, the Grand Master Mentor is a mentor of mentors of mentors. The epitome of the Grand Master Mentor is the wise and humble character of Yoda, in the Star Wars movie saga. Like Yoda, our Grand Master Mentor fully understands the entire mentoring process and how all of the seasons fit together into an overall lifecycle of mentoring. Within the Army Medical Department, many consultants, assistant corps chiefs, and corps chiefs are able to successfully ascend to the role of Grand Master Mentor. For some, their ultimate goal is to establish a culture of selfperpetuating mentoring for all of their officers and maximize the overall effectiveness of each season of the Army mentoring lifecycle. Given that, our Grand Master Mentor has the unique opportunity to make profound and lasting changes in his or her Area of Concentration (AOC) and, perhaps, even beyond. THE MENTORING STAIRCASE In addition to viewing the growth of a mentor in terms of successive seasons, it is also useful to look at mentoring development as ascending steps, each building upon the previous ones, like a staircase. Figure 1 depicts the Mentoring Staircase, a model which shows how each mentoring step builds upon what is learned in the previous stages. In the first phase, the Protg step, the officer is engaged in selfdevelopment while receiving guidance from a Mentor. As previously discussed, this time period lasts about 10 years until promotion to major for due course officers. Eventually, the newly promoted field grade takes the next step, placing a junior company grade officer under his or her wing and proceeding to show the young protg the ropes. During this second decade, the Mentor further develops and hones skills in mentoring company grade officers. (Also, the Mentor continues to self-develop while receiving mentoring from a Master Mentor). After the 20-year mark is passed, presuming the officer does not retire, there is an opportunity for a deepening of the mentoring role with this Mentor stepping up to becoming a Master Mentor and developing midcareer protgs in the fine art of becoming Mentors themselves. (Ideally, there is a senior officer mentoring him or her in addition to this officer engaged in self-development). Lastly, our “crusty, old” mentor takes the final step up the Mentoring Staircase and becomes a Grand Master Mentor, guiding Master Mentors on how to effect lasting change and growth. COMBINING THE MODELS: A PERSONAL EXPERIENCE — THE EAGLE IN WINTER Finally, it is possible to combine both models, the Seasons of Army Mentorship with the Mentoring Staircase. Figure 2 illustrates this superimposition of models with regard to my own Army career. The journey began with my commissioning in 1983 and will ultimately end with my mandatory retirement date in 2013. During the Spring, the first decade of my career, I was at the Protg step, blessed to have an outstanding Mentor who really taught me what it meant to be an Army officer. I spent this first season relentlessly pursuing personal development and excellence. With promotion to major, I entered the Summer of my career, becoming a Mentor and guiding several company grade officers by sharing what I had learned over the previous decade. In 2003, I hit my 20year mark and the Autumn of my career, becoming a Master Mentor and beginning to share with wider audiences, in lectures and in writings, what I had learned about mentoring.2-4 On the occasion of my quarter century in the Army, I was nominated and appointed by the Army Surgeon General as the AOC Seasons of Army Mentorship and the Mentoring Staircase Figure 1. The Mentoring Staircase. 30 Years 25 Years 20 Years 10 Years Master Mentor Mentor Protg Grand Master Mentor mentors mentors mentors self development General Officers

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October – December 2009 43 THE ARMY MEDICAL DEPARTMENT JOURNAL Consultant for my career field, taking the final step to become a Grand Master Mentor and guiding others on how to set up mentoring programs and develop mentors.5 In fact, this very article is but another affirmation of my own passage from Master Mentor to Grand Master Mentor and entrance into the Winter of my career. SUMMARY The purpose of this paper is to share 2 complimentary models for the growth and development of Army mentors, the Seasons of Army Mentorship model and the Mentoring Staircase model. During the first phase of development, Spring, a young officer starts out on the first step as a Protg, receives mentoring, and learns selfmastery. After a decade of learning and promotion to field grade, the more experienced officer enters the Summer of his or her career and steps up to become a Mentor, mentoring protgs. With the arrival of retirement eligibility, those Autumnal officers who do not retire can take an additional step and evolve into Master Mentors who teach others how to effectively mentor. Lastly, in the twilight years of Winter, those who reach the highest level of Army mentoring can take the final step and become Grand Master Mentors, establishing a long lasting culture of mentoring that will be a fitting legacy to their leadership and example. To close, I sincerely hope that those reading this article are inspired by this discourse and strive to make the most out of their own mentor journey and reach their greatest mentoring potential, whatever that may be. I know for me personally, it has become the most satisfying accomplishment of my Army career. REFERENCES 1. Simonton, DK, Historiometric Methods, The Cambridge Handbook of Expertise and Expert Performance New York, NY: Cambridge University Press; 2006:327. 2. Melanson, MA, Winstead AD. Officer professional development: a case study in officer mentorship. Army Med Dept J January–March 2003:7-10. 3. Melanson, MA. Mentor and protgs: simple rules for success. Army Med Dept J July–September 2006:50-58. 4. Melanson, MA. Evolving Roles of highly successful mentors. Army Med Dept J October–December 2007:37-39. 5. Melanson, MA. Mentoring in the Army Medical Department: Advice for Senior Leaders. Army Med Dept J October–December 2007:26-28. AUTHOR COL Melanson is the Chief of Health Physics at Walter Reed Army Medi cal Center, Washington, DC, and the Radiological Hygiene Consultant to The Army Surgeon General. 1983 Master Mentor Mentor Protg Grand Master Mentor 1993 2003 2008 2013 Winter (5 years) Autumn (5 years) Summer (10 years) Spring (10 years) Figure 2. Seasons of an Army Career and the Mentoring Staircase.

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44 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 INTRODUCTION A vital responsibility of senio r leaders is to mentor junior officers so that they can one day step forward and lead the Army Medical Department. One of the key things that a good mentor looks for when selecting a protg is whether or not a particular junior officer has potential. Then, there is the natural question: what exactly is potential? Ultimately, potential manifests itself as the ability to one day, through growth, study, and practice, become a fully developed and highly competent Army officer. So, what does potential actually look like? For me, there are certain unique traits that I look for as evidence of true potential in a prospective protg. This short list of qualities is based upon nearly a decade of research on the subject of mentoring, observing the junior officers that I have mentored over the years (both successfully and unsuccessfully), and an assessment of my own strengths and weaknesses as a protg. It is hoped that by identifying and developing these qualities, junior officers who have mentors or are seeking mentorship will experience the deepest and fullest benefits of mentoring. LOVE OF LEARNING The first important quality of an ideal protg is to be a true lover of learning. This is not surprising since the entire mentoring relationship revolves around the conveyance of knowledge and wisdom from mentor to protg. (Coincidently, the quality of being a consummate student is also a key trait in highly successful mentors.1) Therefore, in order for this partnership to work, the protg must truly want to learn. For the ideal protg, the mentoring experience is a journey towards deep personal and professional growth. By finding a revered and trusted mentor, the junior officer is fully engaged in the process of growing and learning under the tutelage of that seasoned senior officer. This special relationship can be very short or last an entire career, or even longer. SELF-STARTER For me, an ideal protg is a true self-starter. This protg knows that he or she is the one primarily responsible for his or her career being successful. Therefore, this young leader does not sit around waiting to be told what to do and takes charge of his or her own development. By being proactive, the ideal protg is constantly assessing his or her strengths and weaknesses and how to improve and grow. Likewise, when the chance to learn pr esents itself, this junior officer is the first one to stand up and seize the opportunity. While remaining a full mentoring partner with his or her mentor, the junior officer is also doing a lot of self-development work on his or her own. When it is all said and done, the self-starting protg actually leads the mentoring experience, with the mentor coming along for the ride and providing needed help and guidance. CONFIDENCE In order to be successful as a protg (and an Army leader for that matter), one must be confident. I know personally that this can be particularly hard, especially when one is first commissioned and does not yet know very much about being an Army officer. But, with time, experience, and patience, a junior officer will learn and acquire the skills necessary to succeed. It is important to note that this confidence is measured; it is not arrogance or cockiness. That being said, an officer always knows his or her own limitations. So, if you are getting into a situation where you are in over your head, you must quickly recognize this and promptly seek assistance from your mentor. Failure to do this has often been the root cause for ending many an officerÂ’s career, regardless of rank. RISK TAKER Despite the real perils mentioned in the previous paragraph, the ability to take risks is a very important trait of the ideal protg. TodayÂ’s Army desperately needs officers at all levels who are willing and able to take risks and do what needs to be done to accomplish the mission, often in the absence of guidance. Now, I am not advocating irresponsible or careless risk taking. Rather, I am referring to the ability to assess a situation, understand the mission, and then develop and implement new and innovative courses of actions. Qualities of the Ideal Protg COL Mark A. Melanson, MS, USA

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October – December 2009 45 It all boils down to the ability to overcome the fear of doing something new or untested and squarely face the threat of failure. Unfortunately, there is no other way to grow; without taking risks you cannot reach your fullest potential. RESILIENCY If a protg is going to take risks, then sometimes the outcome will be unsuccessful. Hence, mistakes will be made and failures will occur. No one likes to fail, especially hard-charging junior officers (and crusty old colonels like me!). But, the ideal protg accepts complete responsibility for all mistakes or failures and seeks to fully understand what went wrong and why. This officer does not engage in a blame game or make excuses. Rather, the ideal protg is reflective and studies personal defeats in order to learn from them, often referred to as failing forward.2 Then, the junior officer gets up, dusts his or herself off, and tries again. The key to resiliency is to truly accept that no one is perfect, to believe that we can learn from our mistakes, and to realize that it is often from our setbacks and failures that we learn our greatest lessons in life. Therefore, in order to stay the course, a protg must be resilient. ENTHUSIASM For a mentor, one of the most refreshing traits of a desirable protg is genuine enthusiasm. It is this clear and palpable excitement fo r the mentoring partnership that continually stokes the fire of this important relationship. As for me personally, it is one of the primary reasons that I enjoy being a mentor. A protg’s enthusiasm is contagious and can jump-start and revitalize the mentoring experience. It also helps the protg find the energy and maintain the focus required to do the hard work that so often accompanies personal and professional growth. So, be excited about being a protg and embarking on the unique journey of self-discovery that is mentoring. OPEN-MINDED Being open minded to a mentor’s advice is not difficult when one is a new junior officer and knows very little about Army officership. However, as one grows in knowledge and experience, it can become easy for a protg to assume th at he or she has all of the answers and needs no help. The ideal protg remembers that the mentor has vastly more experience and precious wisdom to share. Hence, the protg listens to advice given and carefully considers it, rather than disregarding it out of hand. This includes constructive feedback that may seem negative and may be difficult to hear. By being open-minded to new and different ways of looking at situations and approaching problem solving, the ideal protg is more able to experience the full spectrum of mentoring. COMMITMENT Commitment is the glue that keeps the mentoring relationship together. Without it, the mentorship will inevitably die a quiet death. To avoid this, the ideal protg is deeply committed to being mentored. This means that the protg faithfully attends mentoring sessions, completes assigned homework, and keeps promises that are made. While the Protg’ s commitment is first and foremost to the mentor, it is also a commitment to one’s self and to reaping the fullest benefits of the mentoring experience. From my observations over the years, the most committed protgs usually end up as the most successful. LOYALTY Without trust, there is no mentoring relationship. It is within this safe environment that the mentor and protg can be open and honest. For the protg, it is the chance to ask potentially embarrassing questions. Likewise, the mentor can also share past blunders and failures that have important lessons to teach the protg. In order for this candid dialogue to occur and continue, both members must maintain confidences. All of this simply comes down to loyalty. The protg must be loyal to the mentor and not divulge anything confidential without the mentor’s blessing. Always remember, trust is hard to earn and can be lost so very easily. GRATITUDE The final quality of the ideal protg is gratitude and it is the most important. The ideal protg is always grateful to his or her mentor The mentor is taking time out of the busy duty day (and often during off-duty time) solely for the purpose of helping the protg develop and grow. As mentioned above, the mentor is also sharing personal mistakes and setbacks so that the protg can learn from them. Given that, the protg must be appreciative of this gift of mentoring. In my opinion, the best way to sincerely show gratitude is for you to take what you have learned and share it with others. In order to do this, you must be willing to “pay

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46 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 it forward” and ultimately become a mentor yourself. This is how I have chosen to repay the superb officers that have mentored me and are mentoring me still. Indeed, the astute reader will quickly recognize that this very article is but another example of my humbly paying it forward. SUMMARY The purpose of this paper is to share what I view as 10 important qualities of an ideal protg. First, protgs must have a deep-seated love of learning that drives them to make the most out of the mentoring partnership. Next, protgs must be self-starters who take personal charge of their mentoring. Confidence is vital so that the junior officer can face the many challenges that lay ahead in any Army career. Careful risk taking is necessary so that the protg can reach his or her greatest potential. Bouncing back from mistakes and failures is crucial for protgs, so they must be resilient. Ongoing enthusiasm is the fuel that sustains the mentoring relationship over time. By being open-minded, a protg carefully considers all advice, including constructive criticism, that the mentor shares along the uphill path to wisdom. Remember that commitment is the very glue holding the mentoring relationship together. Also, protgs remain loyal to their mentors by always maintaining confidences. Most important, an ideal protg is truly grateful for all the things that the mentor has done and repays that debt by also becoming a mentor. In closing, it is hoped that by developing these qualities, present and future protgs will get the most out of their mentoring partnerships and keep the age-old spirit of mentorship alive. REFERENCE 1. Melanson MA. Evolving roles of highly successful mentors. Army Med Dept J October–December 2007: 37-39. 2. Maxwell JC. Failing Forward Corning, CA: Nelson Books; 2000:191-192. AUTHOR COL Melanson is the Chief of Health Physics at Walter Reed Army Medical Center Washington, DC, and the Radiological Hygiene Consultant to The Army Surgeon General. Qualities of the Ideal Protg

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October – December 2009 47 INTRODUCTION In military environments and cultures of urbanized societies, the word “leader ” is as common as the word “ I .” Such a comparison might have never been considered, but take time and seriously consider it. Conceptualize how often the word I is used in a world that statistically grows more egocentric each day. “I don’t like that; I refuse to sit there; I wish I had something like that; I need one of those; or I got mine, so that’s all that matters.” Reflection might reveal that I is an almost completely worn-out word. Now examine the effectiveness of the word leader in an environment where it is used frequently and injudiciously—almost as much as the word I How often at a military school, briefing, formation, or professional forum does the facilitator begin by saying “good morning leaders,” or “welcome leaders”? Does anyone not believe that mo st military personnel are automatically considered and addressed as leaders based solely on their rank? Should everyone in the military beyond the grade of E-4* be recognized as a leader? Does this not weaken the word’s value and wrongfully associate those who are leaders with the likes of those who are not? Is wearing a rank or holding a managerial position enough to be validated as a leader? These inaccuracies should be carefully considered. The arbitrary and unmerited practice of addressing large groups as leaders vastly diminishes the culture of leadership. Unless individuals demonstrate the personality, passion, essence, and other key traits (enthusiasm, confidence, mental toughness, compassion, emotional stability, etc) that undoubtedly distinguish them in an objectively positive manner, they should not be deemed a leader. With so many ways that personalities can be analyzed, described, and categorized, it is interesting to consider whether there is a personality type that can be truly identified among the world’s greatest leaders. If so, imagine reading descriptions of personality types and, by description alone, selecting an individual who matches a personality type that will lead you in life, relationships, business, finances, religion, politics, values, peace, and even war from that day forward. Does personality have anything to do with being a leader, leading, and displaying leadership? Is leadership a byproduct of certain personality types? Think, conclude, and share. Passion is a very strong word, so strong that there’s even passion in the word passion, so strong that it is extremely difficult to say the word passion without somewhat changing your tone or demeanor to demonstrate some degree of its definition, and yet so strong that the thought of passion is almost always inspiring. Are leaders inspiring? Do leaders make people change their tone and demeanor? Do leaders have passion; do all leaders have passion; and is passion a prerequisite for being a leader or by concept, leading? Maybe it is; maybe it is not. If passion is a trait that a leader must possess, embrace, and demonstrate, then at what level should a leader’s passion be? Ruminate, decide, and internalize your thoughts. Essence is the quality with which something is identified, the most important feature or idealized form of something. What is the essence of a leader? What is a leader’s most important feature? Are leaders idealized? If yes, then why? Is it their essence? What makes one person willing to idealize, admire, or model another? Admiration sometimes comes very easy— simply by having a single trait or skill that another person does not. Are you one of those leaders whom others idealize and look to as a role model? If not, then why, and if you know why, are you willing to become what others need and hope to look up to? Without a doubt, you can be one of the world’s greatest leaders, but maybe you have never reached inside your soul, made a strong base of your values, and built upon the appropriate traits and features. Would you believe that there are millions of people The Personality, Passion, and Essence of a Leader MSG Reginald K. Hall, USA *Army and Marine corporal; Navy petty officer 3rd class; Air Force sergeant

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48 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 wandering through life having renounced the hope of finding someone to look up to? Perhaps there are also millions of people so bemused by life that they are clueless of their own desire to have someone to look up to, until they find that “magnetic” force to which they quickly attach. Often, that attraction is leadership. Consider the power of leadership and decide if the following statements support reality. Animals often look for masters who will lead them. Children build and embrace relationships more quickly with adults who will lead them. Some of the world’s strongest female leaders hope passionately for husbands who will lead them and their households. Men will normally only submit to someone who has proven capable of leading them. Nations select politicians who they feel will lead them. Church members elect pastors who they trust will lead them. There are infinite propositions such as those, so leadership is inevitably important. It separates men and women from the majority, and it supports the fundamentals of life. FORMING A LEADER Some people tend to think that leaders are born with some kind of remarkable trait that makes them stand out in a crowd, exude confidence, or take charge of situations as opposed to a llowing themselves to be bystanders of situations gone wrong. Who knows? These theories may be correct, but, if so, why do so many organizations spend large amounts of money and invest substantial amounts of time trying to develop and grow leaders? In the abstract, if leaders are born as such, would not it be more practical to find those people who are seemingly born as natural leaders and pay them to multiply, rather than risk wasting money and training on people w ho will never prove to be great leaders? There might be a need for a new investment strategy, or perhaps the need for a completely new outlook on leadership. The majority of people who attend leadership courses are not really premier candidates. Are the investments that organizations make for leadership training practical and cost-effective strategies for the vast majority of people who attend? How often has someone attended a leadership course and recognized an individual who is absolutely not an obvious leader, example, or role model, as far as can be seen to their left and right? This happens often. Perhaps if such a situation is not noticed, it is a sign of one’s own blurred judgment. Is the idea of only placing specific qualifying personnel in specific types of schools or training a wrongful approach? Some people would say “send those who are not good leaders to leadership training to make them good leaders.” Any logical person might laugh at that statement or that kind of thinking because it has been proven historically and repetitively that opportunity does not always lead to success. More realistically, it rarely leads to success. It is more logical to understand that the more opportunities that one is given to find success, there’s higher likelihood that they will be unsuccessful. Therefore, wasting opportunities wastes time and resources; wasting time and resources is an obvious and significant waste of money. Simply said, leaders are formed around personal values, hopes, and commitment. Standing out in a crowd does not make someone a leader; it more logically means that a person has a unique quality that most likely has little to do with leadership. The critical thinker knows that anyone who witnesses another person presenting a stronger demeanor than their own could falsely (as is commonly done) classify the other as a leader. Think about this. How many of the people who are said to be leaders have justifiably proven themselves as such? Also, exuding confidence does not make someone a leader, though this is undoubtedly a quality that a good leader should have. Exuding confidence could simply mean that a person hides their flaws well, is a great actor, or has a very poor sense of self-evaluation which falsely allows him to feel confident. There are droves of people who appear confident, but have no clue of the ignorance of things they say, or the possible harm they could cause. Maybe they are unaware of the inappropriateness or ineffectiveness of things th ey do. Even taking charge is not an absolute sign of leadership. Action without a good plan is just action. Taking charge could simply be a sign of impatience or intolerance. Being the first person to say “let’s go” or “let’s do this” does not indicate that the initiator is a leader by any sense of the The Personality, Passion, and Essence of a Leader

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October – December 2009 49 THE ARMY MEDICAL DEPARTMENT JOURNAL word. So many leaders “by virtue of school” and “by virtue of position” carelessly and hastily make these claims. Again, leaders are formed from personal values, hopes, and commitment. Just like great performers, athletes, or strategists, leaders are very similar. They are who they are because they commit to being who they are; they value what they represent, and often aspire to be better or improve upon the person that they have become. This is a very simple concept, so why are so many people falsely glorified as leaders. What are a leader’s values? Why do leaders hope and work to be leaders? Why do leaders commit themselves to such stringent actions, habits of thinking, and results? Why? Those who are leaders know these answers, plus answers to any other questions concerning their commitment and why they consider themselves to be leaders. Those who are not true leaders (thus not convincingly committed by personal values, hopes, and actions) will think and ponder over these simple questions, showing evidence that they have not thought and rethought these questions with every value they demonstrated, task they performed, and encounter they shared. Great performers can always articulate why they do what they do, why they commit so determinedly, and why they value what they do. Athletes and strategists can do the same. Why would leaders be any different? They are not. THE HIERARCHY OF DISCIPLINE Of all the traits and elements of a leader, discipline reigns supreme. Previous Army leadership doctrine defined discipline as “prompt obedience to orders.” This is a powerful definition. The same doctrine also defined discipline as “doing wh at’s right even when no one is looking,” and more current editions include “doing what’s right rega rdless of who’s looking.” These are value-driven definitions. The first definition illustrates a person’s (more so, a leader’s) commitment and actions. To execute any action promptly upon orders demonstrates the commitment and discipline to do so. To demonstrate obedience in any regard proves the commitment of values and selflessness which overpower rebellion and hesitation and creates consistency. To be a true leader, one must demonstrate values, function selflessly, deter rebellion, eliminate hesitation, and be consiste nt in all things. Again, discipline is prompt obedience to orders. Disciplined people and leaders (those having discipline and so much more) “do what’s right even when no one is looking” because the eyes that control and shame them are the eyes within their souls. These same individuals “do what’s right regardless of who is looking” because their objective is not to satisfy anyone, but to prove to themselves and others the value of living with honor and being committed to those things that reflect values. Discipline reigns supreme. Which is more important, discipline or one’s conscience? Which is more powerful? Which is a greater contributor to leadership? Without a doubt, discipline reigns supreme. Discipline is more important, more powerful, and contributes more to the ideals of leadership. Having a conscience is simply having enough character to be concerned about something that is a violation of a personal value. Discipline is having the commitment to always support one’s values, regardless of external pressures. Having a conscience is powerful because very often when something wrongful or unsubstantial is internalized, the underlying value will cause a change in action or behavior and create a positive or satisfying result. Discipline is far more powerful because it is much simpler. With discipline, if something is right, it is supported consistently in be haviors and actions. When something is wrongful or unsubstantial, it is not supported and is often corrected. Consistency and discipline tie firmly together There is never one without the other. A person cannot be considered disciplined if he* occasionally abandons his personal values and standards. A person might sometimes be considered to have discipline, but is not disciplined. If a person does anything the same way all the time (consistency), he demonstrates discipline, and is justifiably considered to be disciplined in that regard. If a person has no consistency in what he does or what he says, the root cause can be easily traced to a lack of discipline. In the same regard, a person is not a strong leader if he is not consistent, and he is not a leader if he is not disciplined. Discipline reigns supreme. In so many situations that life presents, leaders must always show discipline. There are infinite ways to take shortcuts. There are also infinite ways to achieve marginal or satisfactory results. Having discipline means having the willingness to duplicate what is valued on a consistent basis to ensure a consistent result. In all things that a leader does, discipline must always reign supreme. *Throughout this article, the use of “he” is a nongender-specific convention for simplification and readability.

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50 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 ACCEPTING AND ENDURING SACRIFICE Being a leader takes great sacrifice, moving beyond the comfort zone and giving more than what is natural, all for the greater benefit of others. Sacrifice is sometimes easy, but often, not so easy. For those who sacrifice little or seldom, what is given might seem as no big deal or appear to have almost no adverse impact on life. Being committed to personal sacrifice, and sacrificing repeatedly is a much different circumstance. Because a leader always has many things to do, recognizes more that needs to be done, and has more people asking for assistance (as they trust his judgment, perspective, work, and counsel), time is always very critical. Time is the one element of life that cannot be reproduced or regained, at least not in the physical sense. Ironically, more time is also the one luxury on almost everyone's wish list. Imagine sacrificing your time (just your time) any and every time that someone asks. Calls for assistance, obvious signs of confusion, desperate cries for attention, on-the-spot interruptions to vent or chat, and many other similar circumstances really take a toll on a leader’s time. Because a leader recognizes that everyone needs or will need something at one time or another as an antidote to make it through the day and get back on track with life, sacrifices are made and time is given. There is a huge reward for what is given; a feeling of personal satisfaction gained by enabling someone to move beyond an issue or roadblock and continue life with a less stress, more focus, and a lot more empowerment. Leaders make great sacrifices. Often, the need for phenomenal patience comes with sacrifice. Many people are egocentric (all about themselves) and somewhat inconsiderate as to what they ask for and how often they ask. They might ask things of a leader that they would not ask of a close relative, and also repetitively ask for time and attention. People today are often very egocentric in balancing their requests with a leader’s sacrifice. For example, someone with a serious need might deem it more important (really more self-satisfying) to risk arriving late to be helped and have the leader wait, rather than opting to be early and feeling inconvenienced by waiting. A leader might also find it very common to have others be unacceptably disorganized when articulating needs or presenting problems, thus vastly wasting the precious commodity of time. It can be very frustrating to refrain from making tempered comments when it is obvious that sacrifices and time are taken for granted, or when understanding that the pace of the average person is rarely comparable to your own (the leader). In these situations, a leader sacrifices many things: time, patience, a measure of sanity, and adherence to personal values. There are some occasions when such sacrifice is not wise. These are the times when a specific sacrifice does not support the most good for the most people, does not support personal growth of those capable of sustaining on their own, or when personal strength will be diminished, causing the leader to be a broken source for the numerous individuals he miraculously supports. A leader who neglectfully allows personal matters to become chaotic and unmanaged is of little use in helping others manage their issues and concerns. With age comes wisdom. As leaders mature, they realize that not everyone can be helped simultaneously, or continuously. When necessary and feasible, these are times when leaders offer short, clear, and specific guidance as a first course of action until more time is available. Sometimes leaders must simply employ other capable but less experienced individuals who can assist, while also benefiting from the increased opportunities to mentor. Visionary leaders always look ahead and can often preview an issue before it becomes an issue. This is when “pearls of wisdom” might be offered to prevent unwanted results and exhaust the need for more serious attention in the future. Most commonly, leaders rarely say “no,” but learn that saying “yes” does not always have to be a self-crippling effort. Leaders grow and share wisdom. Because of the compassion in a leader’s heart, he gives eagerly and often. Sacrificing as a leader means that there will be numerous occasions when the burden of sustaining one’s own professional and personal responsibilities will seem monotonous because of the time spent investing in others. Sacrifice hardly ever comes easily or conveniently, however, it often comes with great reward, but only when managed wisely. FALSE HYPOTHESES OF LEADERSHIP More than anything, individuals must embrace the concept of leadership a nd ask themselves what it means to be a leader, what is the value of being a leader, and what it takes to become a leader? These are The Personality, Passion, and Essence of a Leader

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October – December 2009 51 THE ARMY MEDICAL DEPARTMENT JOURNAL very serious questions that are rarely acknowledged by many who think they are leaders or by others that people often mistake as leaders. Being in a leadership position does not make an individual a leader. A leadership position should inspire an individual to commit to becoming a good leader and demonstrate strong leadership attributes (enthusiasm, confidence, mental toughness, compassion, emotional stability, etc) to live up to the expectations of such a key position. Ironically, leadership positions often hinder growth because an individual sometimes selfishly and unconsciously becomes crippled by the fact that he has the right to give orders. The common response is personal gratification and the thrill of empowerment which normally drive individuals to become self-serving. A more responsible and appr opriate response would be the cautious and meticulous execution of tasks and decisions to consistently ensure a logical, productive, and honorable example. Being in a leadership position should inspire leaders to lead. Wearing a leader’s rank or being assigned to a leader’s office does not make someone a leader. In the military (depending upon specific branches of service), corporals through generals wear leaders’ ranks, but can you honestly say that all or even most of them embrace the responsibility of leadership? Many careless thinkers might automatically believe and say that senior noncommissioned and commissioned officers have to be leaders. Critical thinkers would probably say that every noncommissioned or commissioned officer should be a leader or be made to embrace and demonstrate leadership and the principles thereof. Other careless thinkers might say noncommissioned and commissioned officers are forced to be leaders. Critical thinkers would more appropriately say only that these individuals are for ced to be in leadership positions. However, the few individuals truly committed to being leaders would articulate their opinions even more discriminately. It is distressing to acknowledge that many people, by virtue of their careless nature, often tend to become lazier and less attentive to leadership re sponsibilities as they achieve higher ranks and offices. Though many senior level individuals often perform the technical responsibilities of their positions well, a significant proportion seldom embrace those critical leadership attributes that are more common among young, energetic populations. This leads to the next simple truth, but remember, rank does not justify leadership. A stellar job performance or demonstration of competence does not make an individual a leader. A person might do a great job or consistently perform many tasks without visible flaws, but there might be no leadership shown in the way that the tasks are performed, or in the attention given to teach others to perform them. Some of the smartest people will admit that they are not good leaders. This can be demonstrated by assembling a group of stellar performers and asking them to work together to complete moderately simple tasks to the highest standard possible. Often those who are not good leaders will much rather work through problems and situations on their own because they find it much easier. It might be a psychologically painful experience for some independent thinkers and doers to have to work in groups, deal with alternative opinions, have personal suggestions critiqued, execute a plan with which they disagree, and be submissive to the direction of others appointed to be in charge. When faced with similar situations, regardless of personal preference, strong leaders humble themselves, appropriately invest time to allow everyone to express opinions as to how things should be done, form a plan based on the best ideas from every individual, and normally complete what is required with better results than they have previously experienced. It takes a humbled and disciplined thinker to become such a doer who will discover the fruition of humbled and disciplined efforts. Neither competence nor job performance is the same as strong leadership. The presence of people who are willing to follow one’s actions or thinking does not make an individual a leader. Having followers means only one thing, there are people willing to follow. Often, regardless of person, actions, ideas, cause, or objectives, there will always be someone willing to follow someone else. It is an observable truism that many people wander through life simply looking for someone or something to whom or which they can attach. Many others simply look for an opportunity to be considered a part of something, but not necessarily a part of something greater than themselves. Emerging from a sense of desperation, being a part of something brings peace to the lonely. There are also populations of people who look for opportunities to be in the spotlight and,

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52 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 tragically, being in the spotlight or being seen by others brings more satisfaction than the purpose for which they are spotlighted. These few of many similar truths demonstrate that having followers often has little or nothing to do with being a leader. Logically, there is credibility shared for what resembles leadership. Perhaps appropri ate descriptors of a person with followers would be “t hat person is influential,” “that person has gained a group of followers,” and/or “that person has given someone a purpose for which to unite.” Likewise, what is commonly verbalized by noncritical thinkers and alle gers (without a measured criterion) is inappropriate. They tend to automatically say “that person is a leader” or worse, “that person is a good leader” or “…strong leader.” Even when liberally (but logically) granting credit, having followers might mean people have enough trust in another to follow that individual, but it does not measure up to the wholeness of leadership. With hundreds of distinct reasons why one person might follow another, we must absolutely break the trend of falsely honoring people as leaders simply because they have followers. This is equally but more distinctly true when considering self. True leaders lead consistently, consciously, and cautiously because they know that everything that is done, can and will be duplicated, but, trustingly, not to the detriment of others. Having followers only means that others are following you, not necessarily for good or positive reasons. Copying a leader’s actions makes no one a leader. Some people feel that they will be good leaders if they copy what was done by someone whom they considered to be a good leader. In a narrow scope of thinking, such justifications might suffice, but actually such thoughts are misleading when it comes to leadership. Following anyone while doing anything makes one a follower. Though anyone is capable of learning from the past, great leaders know that actions, behaviors, and decisions are pertinent to specific times, locations, circumstances, groups, personalities, and more. What may have been a great plan in 2003 could be a terrible plan in 2037, based on the exact conditions but with different people. The personalities, experiences, attitudes, motivations, and values could not only make the plan from 2003 not fitting for current strategy, but might make the plan a bad fit for the future, thus becoming a terrible plan in its entirety. It must be understood that people respond differently depending on their values, perspectives, morale, discipline, attitudes, and more. It must also be understood that people resp ond differently from person to person based on all the aforementioned factors, plus others such as appearance, demeanor, tone, and style. It is more logical to say that great plans from leaders of the past can always be considered, but modified to complement the personnel, circumstances, mission and goals at hand. With so many logical justifications, it should be clear that following good leaders does not make someone a good leader and duplicating good plans does not make a current plan a good one. Additionally, great leaders (normally passionate in their values and actions) rarely want the same result as other leaders. That sense of “settling” is not what leaders desire. It is very reasonable to want better results given the kick start of a plan that once proved positive. Consider that anyone who begins planning with the feeling that there is not much to think about or consider because the plan is already in place is destined to fail or reap marginal results. If plans and actions are not results of critical thinking, doers have failed to consider human fact ors, risks, conditions, and potential outcomes that could lead to detrimental results. These are reasons why strong leaders never “cookie-cut” their leadership styles and actions. Going beyond what is historical or traditional, leaders approach planning calmly, logically, and critically, anticipating distractions and chaos but implementing checks and balances to ensure optimal results. Finding good in others and their actions, extracting ideas or methodologies from the past and our own experiences, and then modernizing all to be nefit current situations is a far more logical approach than copying past leaders in hopes of being a good leader today. Being the senior person involved does not make an individual a leader. Some people feel that they have the “right to lead” by virtue of seniority. Do you agree? What gives a person the right to lead? Does anything? Experiences, rsum, positions, and other such factors, help people earn the right to serve in leadership positions. There is no true right to lead when the complexity of human interaction is considered. From a values perspective, there are mutual competing satisfactions in a person desiring to lead as there are with followers “choosing to be led.” There are a large number of humans who, by virtue of their own intellect, arrogance, and cautions, will not allow just anyone to lead them. Humans desire the personal The Personality, Passion, and Essence of a Leader

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October – December 2009 53 THE ARMY MEDICAL DEPARTMENT JOURNAL satisfaction of feeling comfortable with those who lead them, those they allow to lead them, and those they choose to follow. Therefore, seniority does not convey the right to be a leader. The right to lead is earned through a person’s proven willingness, commitment, and humbleness to lead cautiously. There are many invalid perceptions and false idols of leadership. Regardless of the situation, circumstance, position, role, level of authority, or any other factor, identification of leaders should not be falsely hypothesized. The best and most accurate way to identify a leader is to sacrifice, commit, and become a leader. THE POWER OF LEADERSHIP One of the greatest and most powerful gifts that one person can give another, ter tiary to life and love, is leadership. In the midst of discouragement, hard times, mental distress, and many other negative influences, strong leaders radiate a sense of hope. In the presence of strong leaders, people tend to know that resolution will appear, and, in regards to their personal matters, leaders will take the time needed to offer meaningful guidance or direction that will somehow make things better. Even without persona l conversations, the hope that stems from a leader opens the mind and allows flowering buds of discovery to bloom with new ideas, clearer thinking, and foreseeable resolutions. Within days or even hours of being around strong leaders, the once foreseeable forecast of hope floods the mind with inspiration until faith settles the dust of pessimism. Strong leaders might be seen as the dawn of a new day. Leadership is very powerful. Association with strong leaders is one of the most comforting experiences that a person can witness. Despite only knowing a strong leader for a very short time, a person might immediately feel a calming sensation and reassurance that things will be okay, even in a crisis. People love feeling comforted. For most people, there is a remarkable satisfaction that comes with knowing that there is someone who will figure things out, develop a plan, look out for everyone’s best interest, take nothing for granted, and always work diligently for the best result possible. Perhaps these are the factors that bring quiet in the midst of a storm, and compel others to gravitate toward strong leaders. Leadership is comforting. Even those who feel threaten ed by strong leaders often end up appreciating the aura of positivity that somehow evolves from their presence. Have you ever witnessed how people respond in the presence of such leaders? Some automatically sense that they must step up their game, stand a little taller, sharpen their attitudes, and enhance their performance. Often without words, these things happen. Why is that? It is the power of strong leadership. Being around strong leaders might cause those individuals identified as “weak links” in the chain to feel anxious in one breath and reassured in the next. They tend to somehow sen se that adjustments will be uncompromised, know that adaptation will force them beyond their comfort zones, but also understand that their bad or relaxed hab its should be changed. Ultimately they trust that through it all and regardless of the conditions, they will be treated fairly without being wrongfully singled out so that they will eventually blend in with all others. How can so many emotions be stirred simply by someone’s presence? How can so many truths be interpreted strictly by witnessing a person’s demeanor? How can so much understanding occur without even asking one question? It is the power of strong leadership. CLOSING THOUGHT The most powerful person on earth is not the one who has the most money. The most powerful person in the world is not the one who brings the most fear. The most powerful people, alive or dead, are perhaps those who have demonstrated the willingness, commitment, and humility to lead cautiously, with the ultimate, sincere goal of taking care of people while producing outstanding results. That within itself is powerful. A true leader has the right personality, passion, and essence. Do you? AUTHOR MSG Hall is the provisional Sergeant Major for the Center for Health Educatio n and Training, Academy of Health Sciences, Army Medical Department Center and School, Fort Sam Houston, Texas.

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54 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 BACKGROUND As the Army Medical Department (AMEDD) undergoes significant transformation and faces numerous challenges in fulfilling its mission to provide world-class healthcare to Soldiers, their Families, retirees, and other beneficiaries, AMEDD leaders should be aware that they are not alone in their decision-making, especially in terms of legal support. There are numerous judge advocates, civilian attorneys, military paralega ls, and civilian paralegals providing legal support throughout the AMEDD at the 8 medical centers and numerous hospitals, clinics, and facilities throughout the Army. They provide valueadded advice and support, possess a unique macro and micro perspective, and have access to legal channels which can be beneficial to the leader and his or her organization. A critical leadership skill for AMEDD leaders is the ability and willingness to make prudent decisions even without having full information. Leaders quickly realize they can never get all the pertinent information to make fully informed decisions. They develop confidence in knowing they have enough information to make the best decision in a timely manner. Leaders also realize that the best way to gain well-timed information is to create a team of subject matter experts capable of providing prompt, accurate information. One of the key members of this team should be the legal counsel in the organization. AMEDD leaders should utilize their legal counsel in traditional and innovative ways and include them as a member of the team as they deal with issues that span a spectrum of subjects. The following is an array of subjects for which legal counsel are currently providing support to leaders throughout the AMEDD. MILITARY SUPPORT TO DECLARED PUBLIC HEALTH EMERGENCIES The AMEDD provides support to declared public health emergencies arising from disease, such as pandemic influenza. Following such a declaration, the President may direct any federal agency to use its authorities and resources in support of state and local assistance efforts. The Department of Defense (DoD) and the Department of th e Army have developed response plans, in coordination with the Department of Health and Human Services and the Centers for Disease Control and Prevention, in the event of such an outbreak of disease. Current strategy for an avian flu pandemic may involve is olation and quarantine. Isolation refers to the separation and the restriction of movement of people who have a specific infectious illness from healthy people in order to stop the spread of that illness. Quarantine refers to the separation and restriction of movement of people who are not yet ill, but who have been exposed to an infectious agent and are therefore potentially infectious. Legal counsel are critical advisors to the public health emergency officers and their staff who are planning when, where, and to what extent the military role will be in such an event. HUMAN SUBJECT RESEARCH The Surgeon General of the Army oversees all human subject research within the Army. Legal counsel advise local Institutional Review Boards which oversee research projects at the regional medical commands and medical centers. Legal counsel are ever vigilant of the rights of patient subjects, consent forms that are difficult to understand for participants, and protocols which violate bioethical standards. STANDARDS OF ETHICAL CONDUCT Ethics counselors in the Army are required to be attorneys. In the AMEDD, legal counsel help leaders to avoid violating Titles 5a, 18b, and 31c of the United States Code (USC) and the Joint Ethics Regulation .1 Within the AMEDD, frequent ethics issues facing personnel are gifts, postgovernment employment, offduty employment, relationships with contractors, and travel payments under 13 31 USC §1353.2 Legal Counsel: A Leadership Tool MAJ Joseph B. Topinka, USA aGovernment Organization and Employees, 5 USC bCrimes and Criminal Procedure, 18 USC cMoney and Finance, 31 USC

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October – December 2009 55 PERSONAL HEALTH INFORMATION Legal counsel advise AMEDD leaders on the rules for protecting patient confidentiality under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).3 HIPAA requires everyone in the Military Health System to safeguard and keep confidential the health information of patients (personal health information (PHI)). A patient’s healthcare information is confidential and will be not released to anyone without an authorization from the patient or an exception to HIPAA. While commanders and their designees have a specific exception to receive health information that others do not, it is limited and they do not have unrestricted access to a Soldier’s PHI. This can sometimes cause misunderstanding and a phone call to the supporting attorney may be in order. QUALITY ASSURANCE Documents and information produced by or pertaining to activities carried out by the DoD as part of a medical quality assurance (QA) program are confidential and privileged.4,5 A QA program is any activity by or for the DoD to assess the quality of medical care. This includes activities such as privileging, infection control, patient care assessment, medical records review, health resources management review, and identification and prevention of medical or dental incidents and risks (risk management, patient safety, and incident reports). Only The Surgeon General may authorize release of QA documents or information outside of DoD. Legal counsel are critical in providing advice to leaders and staff on QA activities and appropriate handling of QA documents and information, especially with regard to procedures involving health provider misconduct and malpractice that affect the privileges of physicians, dentists, nurses, and other healthcare practitioners. PHYSICAL DISABILITY EVALUATION SYSTEM The US Army Physical Disability Agency, under the operational control of the Commander, Human Resources Command, operates the Physical Disability Evaluation System (PDES) and executes Secretary of the Army decision-making authority as directed by Congress.6-11 The Physical Disability Evaluation Boards (PEBs) meet at 3 locations: Walter Reed, Washington, DC; Fort Sam Houston, TX; and Fort Lewis, WA. In light of the increase in personnel processing through the PDES, the Army, through the Army Medical Command (MEDCOM), mobilized 18 Judge Advocates and para legals in 2007 and has continued a cycle of mobili zations of legal personnel to assist Warriors in Trans ition Soldiers as Soldiers Counsel (Office of Soldiers’ Counsel (OSC)) before the PEBs at the 3 PEB sites, plus locations at Fort Carson, CO; Tripler Army Medical Center, HI; and Landstuhl Army Medical Center in Germany. These attorneys provide the advo cacy for Soldiers facing disability determinations that will impact the rest of their lives. MEDICAL EVALUATION BOARDS In 2008, the Army, through the MEDCOM, hired Medical Evaluation Board (MEB) outreach attorneys and paralegals for 19 Warrior Transition Unit battalions to handle regional MEB outreach needs. The posts that have the MEB outreach teams include: Walter Reed Army Medical Center, Washington, DC Fort Polk, Louisiana Tripler Army Medical Center, Hawaii Fort Gordon, Georgia Fort Benning, Georgia Fort Stewart, Georgia Fort Riley, Kansas Fort Campbell, Kentucky Fort Knox, Kentucky Fort Drum, New York Fort Bragg, North Carolina Fort Sam Houston, Texas Fort Hood, Texas Fort Bliss, Texas Fort Lewis, Washington Fort Richardson, Alaska Heidelberg, Germany These positions were established to ensure that Soldiers obtain the legal counseling they need to make the appropriate decisions early in the review process. They supplement the specially trained OSC physical disability attorneys at a local level. They also provide Soldiers in the MEB process with general legal assistance to help resolve personal legal matters, other than criminal actions.

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56 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 RESOURCE SHARING Since federal agencies have had the ability to costshare for years under the Economy Act, the sharing of resources between DoD and the Department of Veterans Affairs (DVA) is not a new concept. However, since 1982 when Congress passed the Veterans Administration a nd Department of Defense Health Resources and Emergency Operations Act,12 the Secretary of the DVA and the secretaries of the military departments may enter into healthcare resource sharing agreements pursuant to guidelines established jointly by the Secretary of the DVA and the Secretary of Defense. Under these guidelines, heads of individual medical facilities can enter into local agreements and such agreements require the finesse and review by counsel who have an understanding of the applicable law.* TRAINING AGREEMENTS Military treatment facilities (MTFs) operate professional education programs to train military healthcare professionals in various areas of expertise.14 The MTFs often enter into gratuitous training and affiliation agreements with civilian healthcare institutions under the authority of 10 USC §4301.15 The primary legal issue for these training agreements is liability coverage for the healthcare provider. The Department of Justice (DoJ) requires MTFs to use language in the training agreement that would either require the civilian training institutions to provide liability coverage for the DoD provider, or include language that would imply the provider is a barrowed servant of the institution. More recently, civilian training institutions are rejecting the DoJ language and insisting that DoD carry liability for their providers. Legal counsel must see these agreements and often have to coordinate with the DoJ to ensure that the signed agreement will ensure that AMEDD providers are appropriately covered for liability. INTERAGENCY AGREEMENTS Interagency agreements co me in a number of forms ranging from recordings of mutual understandings to multiple year, multiple million dollar acquisitions of goods and services. An agreement involving acquisition of goods and services from other federal agencies is generally prohibited absent a statute specifically authorizing it. While there are several statutes that provide such exceptions, each has different requirements and is applicable in different circumstances. Within the DoD, various statutory authorities authorize agreements in specific circumstances. Similarly, a variety of regulatory and policy directives prescribe procedures that differ, for example, in acquisitions ( a ) from DoD agencies rather than other federal agencies; ( b ) involving contract support from other agencies rather than noncontract support; ( c ) involving DoD contracting activities rather than non-DoD contracting activities; and ( d ) involving one-time requirements versus recurring support. Advice from legal counsel on the specific circumstances can assist AMEDD commanders to identify the correct authority and form of agreement most supportive of their mission requirements. OBLIGATION AND EXPENDITURE OF APPROPRIATED FUNDS Activities across the AMEDD run the gamut from the most regular and mundane, to the most unusual and arcane. One thing most of these activities have in common is that they involve the obligation and expenditure of funds appropriated by Congress and allocated for AMEDD use. The funds come in various “colors” and various periods of “availability” for new obligations. Depending on the activity the commander wants to undertake, the funds required to do so may vary depending on the nature and structure of the activity, the authority for the activity, the magnitude of the activity, the timing of the activity, and the actions previously taken by others with regard to the activity. Only one color can be correct. Some funding actions raise little or no issue, while color, timing, and availability of funds may make others problematic. Legal counsel can help the commander sort through these issues by identifying the fiscal rules applicable to the activity and the funding the commander proposes. UNAUTHORIZED COMMITMENTS As AMEDD becomes increasingly more dependent on contracts to provide services, the need for a better understanding of contracts is ever more critical. This is especially the case when ch anges are required in the contract and leaders or management personnel decide Legal Counsel: A Leadership Tool *Only those VA/DoD Resource Sharing Agreements between Do D and the VA entered into pursuant to Public Law 97-174 12 and 38 USC §8111 13 can be accurately termed as “Resource Sharing Ag reements.” All other sharing agreements are more accurately termed “Interagency Agreements.”

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October – December 2009 57 THE ARMY MEDICAL DEPARTMENT JOURNAL to make those changes without the advice of legal counsel or without contacting the contract officer or the contracting officer representative. These changes can result in unauthorized commitments. Such commitments must be investigated and ultimately approved for ratification. If they are not ratified, individual liability may result. Ratification is not automatic and the advice of legal counsel is often required when a decision on ratification is being made. DISCIPLINE AMEDD commanders have options available for the resolution of disciplinary problems for military personnel. In summary, they can determine that no action is necessary; initiate administrative action, dispose of the offense with nonjudicial punishment, or dispose of the offenses by court-martial. Whatever the decision, advice of legal counsel is key. Recently, a great deal of attention has been paid by the media to nonjudicial punishment so some additional details about that option are important to note. Nonjudical punishment under Article 15 of the Uniform Code of Military Justice* is a means of handling minor offenses requiring immediate, corrective action. Nonjudicial punishment hearings are nonadversarial. They are not a “mini-trial” with questioning by opposing sides. The commander conducts the hearing. A Soldier may request an open or closed hearing, speak with a defense attorney about his or her case, have a spokesperson, and present witnesses. The commander conducting the hearing must be convinced that the Soldier committed the offense in order to impose punishment. A Soldier has a right to appeal nonjudicial punishment to the next-higher commander. AMEDD commanders and leaders also have options available for the resolution of disciplinary problems with civilian personnel. Op tions include counseling, reprimands, suspensions, a nd termination. Advice by legal counsel who serve as labor attorneys in conjunction with the local civilian personnel offices is a must, especially as the rules and laws in terms of civilian personnel discipline are complex and often can involve local labor unions. CONCLUSION While the aforementioned subjects are not meant to represent a comprehensive list, they provide a sense of the spectrum of legal issues facing leaders in the AMEDD for which legal counsel are there to support and advise. It is a team effort and the legal counsel of the AMEDD team are important players whose training and experience can be invaluable to the solutions of both legal and nonlegal problems. Most of all, legal counsel can help the leader focus on the big picture and its interaction with the law.17 ACKNOWLEDGEMENT I thank Charles Orck, Maurice Deaver, and Rosalind Gagliano for their assistance in the preparation and review of this article. REFERENCES 1. Department of Defense 5500.7-R: Joint Ethics Regulation Washington, DC: US Dept of Defense; August 1993 [ch 6 March 23, 2006]. 2. Acceptance of Travel an d Related Expenses from Non-Federal Sources, 31 USC §1353 (2003). 3. Public Law 104-191 Health Insurance Portability And Accountability Act Of 1996. August 21, 1996. 4. Department of Defense 6025.18-R: DoD Health Information Privacy Regulation Washington, DC: US Dept of Defense; January 24, 2003. 5. 10 USC §1102 (2004). 6. Retirement or Separation for Physical Disability, 10 USC §61 (2008). 7. Department of Defense Directive 1332.18: Separation or Retirement for Physical Disability. Washington, DC: US Dept of Defense; November 4, 1996. 8. Department of Defense Instruction 1332.38, Physical Disability Evaluation. Washington, DC: US Dept of Defense; November 14, 1996 [ch 1 July 10,2006]. 9. Department of Defense Instruction 1332.39: Application of the Veterans Administration Schedule for Rating Disabilities. Washington, DC: US Dept of Defense; November 14, 1996. 10. Army Regulation 40-501: Standards of Medical Fitness. Washington, DC; US Dept of the Army; December 14, 2007 [revise d September 10, 2008]. *The Uniform Code of Military Justice (UCMJ), a federal law,16 is the judicial code which pertains to members of the United States military. Under the UCMJ, military personnel can be charged, tried, and convicted of a range of crimes, including both common-law crimes (eg, arson) and military-specific crimes (eg, desertion).

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58 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 11. Army Regulation 635-40: Physical Evaluation for Retention, Retirement, or Separation. Washington, DC: US Dept of the Army; February 8, 2006. 12. The Veterans Administration and Department of Defense Health Resources and Emergency Operations Act, Public L No. 97-174. 13. Sharing of Department of Veterans Affairs and Department of Defense Health Care Resources, 38 USC §8111. 14. Army Regulation 351-3: Professional Education and Training Programs of the Army Medical Department. Washington, DC: US Dept of Army; October 15, 2007. 15. Members of Army: detail as students, observers, and investigators at educational institutions, industrial plants, and hospitals, 10 USC §4301. 16. Uniform Code of Military Justice, 64 Stat. 109, 10 USC, ch 47. 17. Chanen, JS. The Strategic Lawyer, ABA Journal [serial online]. July 2005 Available at: http://www. abajournal.com/magazine/th e_strategic_lawyer1/. Accessed August 4, 2009. AUTHOR MAJ Topinka is Deputy Staff Judge Advocate, Office of the Staff Judge Advo cate, US Army Medical Command, Fort Sam Houston, Texas. Legal Counsel: A Leadership Tool

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October – December 2009 59 Would you be a better leader today if, while you were a junior leader, there had been a formal pathway to receive constructive feedback from peers, subordinates, and supervisors? The 360 feedback assessment is an appraisal tool with which individuals (self-assessment), subordinates, peers, and supervisors within an organization provi de constructive feedback to each other, with the goal of improving the leadership development process. As Chief of the Captain’s Career Course (CCC) Branch at the Army Medical Department (AMEDD) Center and School, my mission is delineated in Department of the Army Pamphlet 600-4 : …to train officers to lead company or equivalent-sized organizations and serve successfully in U.S. Army staff positions. Graduates of the AMEDD CCC are prepared for subsequent assignments by learning the leader, tactical, and technical task s, including the supporting knowledge and skills necess ary to support the Joint Team across the full spectru m of military medical operations.1 In taking this mission and defining leadership development, I continually come back to the fact that good leaders are self-aware. This is a key tenant in leadership development. Understanding yourself (self-awareness) through selfdevelopment is essential to effective leadership. According to Kouzes and Posner, Leadership development is self-development….The quest for leadership is first an inner quest to discover who you are. Through self-development comes the confidence needed to lead. Self-confidence is really awareness of faith in your own powers. These powers become clear and strong as you work to identify and develop them.2 Receiving honest and constructive feedback from your peers, subordinates, and supervisors can be a helpful exercise in building confid ence, as well as self-development. Senior Army leadership will acknowledge that leadership is an ongoing process. I can definitely attest to this. After 18 years of service, I am still learning and developing my leadership style. With this in mind, together with the help of my Small Group Leaders (SGLs), we developed a process of using the 360 assessment tool for assisting us in molding our leadership development. Although familiar with the Army’s internet (Army Knowledge Online) based 360degree assessment (Multi-Source Assessment and Feedback Program) and Kouzes and Posner’s Leadership Practices Inventory,3 we chose to develop an assessment tool which would directly address the leader development process in an academic environment, specifically, the Captain’s Career Course. BACKGROUND Although I thought I understood the gravity of Army values, during a recent assignment I saw first-hand the devastation that follows when a junior officer in both personal and professional conduct disregards the Army values of integrity and honor After this incident, I considered for the first time whether peer assessments could be used with junior officers to develop or enhance Army core values to prevent incidents such as this from ever happening again. In 1992, during Ranger School as a second lieutenant, I was exposed to my first peer evaluation. At the end of each of the 4 phases of Ranger School, the platoon conducted peer evaluations. This evaluation was very effective in the field environment because it gave each of us (Ranger students) a voice on who was pulling their weight during missions. In addition, it provided the Ranger Instructors a clearer assessment of the students in the platoon. The peer evaluation process surfaced “Spotlight Rangers” who would only shine when the instructors were watching. Each student would rank order every platoon member (ie, 1 to 30, 360 Assessment, an Easier Pill to Swallow: Implementation of Peer Assessment for Captain’s Career Course Students and Staff LTC Eric Sones, MS, USA

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60 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 30 being the worst), and, as a result, the bottom quarter of the class automatically recycled to the beginning of that particular phase. This type of ranking system is what some may consider as the “hard pill to swallow.” Being labeled at the bottom of your peer group by your peers, without an explanation of why or how to improve, could potentially cause a loss of interest in leader development by some individuals who might have benefited otherwise. This factor led to the development of the CCC 360 assessment tool that seeks to improve all who participate, rather than exclude those who are not seen as stellar performers by their peers, subordinates, or supervisors. THE PROCESS My initial intent was to use our specifically designed self/peer instructor-based assessment concept with the CCC’s 14 SGLs. Refining this new assessment process would be a challenge in an educational environment, but would ultimately be beneficial to all who participated. With initial consultation and input from COL Jeffery Haun, Director of AMEDD Leader Training Center; Dr Jody Rogers, Director of the AMEDD Executive Skills Program; and Dr Robert Leeds, CCC Future Operations, the Leadership Survey was created and administered to the SGLs on July 31, 2008. Each SGL had to complete an initial self-survey, shown as Figure 1. The self-survey listed 12 different categories, focusing on specific leadership attributes that pertained to each individual’s responsibilities as an instructor. Each category has a point value from Strongly Disagree (1) to Strongly Agree (6). Each SGL checks the point value to match each category based on a self-assessment. The lowest category marked for improvement requires the SGL to enter at least one comment focused on improvement. The highest marked category on success requires the SGL to enter at least one “sustain” comment. In addition to addressing the highest and lowest category, each SGL then listed the top 3 personal values that they see in themselves, further building on the success comment. After completing the self-survey, the SGLs moved to the peer survey. The same process as the self-survey was followed, as each SGL completed a peer survey on each of their colleagues. As Course Chief, I completed a supervisor survey on each SGL, and, in turn, each of them completed a subordinate’s survey on me. Finally, the CCC students completed a student survey on their SGL. Except for the omission of categories 11 and 12, the student survey was identical in structure to the self-survey, as shown in Figure 2. All surveys were collected in a self-sealing folder, signed on the back by each party, collected by a disinterested person, and then delivered to the AMEDD Executive Skills Program office for analysis. The results of the analysis for each SGL were then incorporated into an individual graph, illustrated in Figure 3, which was a consolidation of self, peer, student, and supervisor ev aluations. Each graph had different data points matching the weighted criteria for each question answered. In addition to the graph, a sustain/improve comment sheet was provided. The comment sheets filled in the gaps that the graph was unable to explain. Each SGL’s graph and comment sheet were placed in a sealed folder which was signed by the Executive Skills Program office representative and delivered to the SGL. Next, each SGL was required to meet with 360 Assessment, An Easier Pill to Swallow: Implementation of Peer Assessment For Captain’s Career Course Students and Staff Figure 1. The initial self-survey administered to the Small Group Leaders of the Captain’s Career Course. Category 1(SD) 2 3(D) 4(A) 5 6(SA) 1 I always display honesty, integrity, and trustworthiness. 2 I make decisions...and do not shy away from the tough ones. 3 I communicate often and clearly...with everyone. 4 I mentor, empower, and develop my subordinates...a consummate team player. 5 I hold everyone accountable, including myself. 6 I have strong control over my emotions. 7 I excel in pressure situations. 8 I have the compassion to listen to others. 9 I know the material that I teach/ instruct and can lead any discussion in my small group. 10 I have a positive attitude and am passionate about what I do. 11 I am a team player. 12 I am a catalyst for and manager of change Provide one Sustain and one Improve comment Sustain Overall Score_________ 1) Improve 1) Top three values you see in yourself 1) __________________ 2) ____________________ 3) _____________________ Leadership (Self) Survey

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October – December 2009 61 THE ARMY MEDICAL DEPARTMENT JOURNAL Dr Rogers, who provided some professional trend analysis on the graph and comment sheets as part of their initial assessment. RISK AND MITIGATION As I planned to introduce this new concept/process to my SGLs, I knew that with potential benefits came some potential risks. Below are some potential risks with this process and the subsequent mitigation I found useful. Risk: Unconstructive Feedback. Using the 360-degree approach may give some SGLs an opportunity to share feedback that is unconstructive and hurtful, thereby disrupting the teamwork and cohesiveness of our group. Mitigation. Set grounds rules early. Emphasize that comments (sustain/improve) should be centered on categories, based on constructive thoughts, not be emotionally based, and should focus on ideas and behavior, rather than individuals. Show an example of a constructive thought in the survey process. Try not to assume that everyone has the same vision you may have. It is important to have a source trusted by all to review the comment sheets, ensuring all comments are constructive. If the trusted source finds some comments offensive, he/she can approach the recommender to refine the comment in terms that are more diplomatic and still allow for feedback. Risk: Old Dog, New Tricks. Sometimes participants tend to voice lack of interest in the process due to their habitual comfort in their style and approach. This lack of enthusiasm could potentially spread to other participants. Mitigation. Lack of enthusiasm is hard to mitigate. The process should be emphasized as a tool that may be useful to some and maybe not others. This instantly allows the skeptics to place themselves in whichever category is suitable. Deemphasizing it as a “silver bullet” to leader development will take away the skeptic’s negative response to the process. Once the initial assessment is complete skeptics at least have information on which they can choose to take action or ignore. The majority of my SGLs knew some of their own strengths and weaknesses, however, having others (peers) recognize these challenges may entice each SGL to make a change in leadership behavior. This Leadership (Student) Survey Category 1(SD) 2 3(D) 4(A) 5 6(SA) 1 This person always displays honesty, integrity, and trustworthiness. 2 This person makes decisions...and does not shy away from the tough ones. 3 This person communicates often and clearly...with everyone. 4 This person mentors, empowers, and develops subordinates...a consummate team player. 5 This person holds everyone accountable, including himself/herself. 6 This person has strong control over his/ her emotions. 7 This person appears to excel in pressure situations. 8 This person has the compassion to listen to others. 9 This person knows the material they instruct and can lead any discussion. 10 This person exudes a positive attitude and is passionate about what he/she does. Provide one Sustain an d one Improve comment Sustain Overall Score_________ 1) Improve 1) Top three values you see in the Instructor 1) __________________ 2) ____________________ 3) _____________________ Figure 2. The survey used by students at the end of the Captain’s Career Course to ev aluate each student’s Small Group Leader. 0 1 2 3 4 5 6 7Q1 Q 2 Q3 Q4 Q5 Q 6 Q7 Q8 Q9 Q 1 0 Q11 Q12Weighted Criteria Student Self Peer SupervisorSurvey Question Figure 3. An example of the plot of the consolidated, weighted scores from the 4 surveys that is prepared for each Small Group Leader as part of his or her individual assessment for each Captain’s Career Course class.

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62 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 360-degree process challenged some of the negative group dynamics, broke down mental barriers, and focused on the fact that this assessment was an opportunity to learn and grow. Initially, my SGLs did not wa nt to participate in the evaluations. Little trust existed in the process, in my ability and willingness to use the information constructively, and in the ability of their fellow officers to evaluate each other in a compassionate and helpful way. As a result, I acted first in evaluating myself and in asking my SGLS to evaluate me. I then used their input to demonstrate what I was looking for, and the importance of their evaluations of me. I believe giving them the opportunity to evaluate me was very helpful in allaying some of the concerns they had of this evaluation. They saw firsthand how I planned to use the information to improve my leadership abilities. Once th ey saw the process unfold, they were more willing to participate in the evaluation. Risk: Evaluation Influence. The 360-degree assessment could indirectly influence evaluation criteria on each SGL’s Officer Efficiency Report. Mitigation. In consultation with immediate leadership, the consensus was the outcome would prove more effective for the SGLs if the supervisor was not involved in the survey collection. Therefore, a disinterested party, in this case the Executive Skills Office, became part of the collection and analysis process. Taking the supervisor out of the collection and analysis of the survey assessments helped the SGLs grow personally and professionally which was the primary intent behind the 360-degree assessment process. Risk: Leading by Example for Group Buy-In. Sharing your comments in an open forum is helpful, but caution must be exercised. Some comments were hurtful to some of the officers. My SGLs learned that giving constructive feedback is just as important as receiving constructive feedback. Feedback seen as cruel and vindictive is not beneficial to helping a fellow officer grow. Learning how to give constructive feedback in a nonthreatening manner is a critical leadership mentoring/coachin g tool that my officers learned through this process. Going first in this process proved very instructive to me. I was learning as my SGLs were observing the process that they would soon be undertaking. After receiving my survey feedback during the meeting, an open discussion followed concerning each point. In an effort to lead by example, this forum allowed me to emphasize how important this new tool was to our organization and how I would address the constructive feedback shared in their assessment of my leadership at CCC. Mitigation. As the leader, you must be willing to go through the process yourself and show how the comments will lead you down a path to self-improvement. However, reemphasizing the constructive format, and having a disinterested party participate in “filtering” these comments is essentia l, especially when the results were discussed openly with the group. ADDITIONAL LESSONS LEARNED 1. All sustain and improve comments need elaboration. A one-word comment, like “communication” in the improve column does not provide adequate detail for the process to begin. This comment leaves it up to the rated individual to decipher how he or she should improve on communication. For example, is the rated individual talking too much or too little, difficult to read, or do nonverbal cues need to be improved, etc? 2. Sharing one or 2 overarching theme(s) for sustain and improve areas in an open forum can be effective. Sharing in front of others shows an outward commitment to thei r peers that they will work on specific sustains and improvements. Start with the crawl phase in the process and make realistic goals. Make periodic status checks each quarter to verify personal progress. 3. Give individuals completing surveys adequate time to do so. If possible, provide a few days to allow each participant to consider the individual they are assessing. It is obvious that the more thought and consideration given to each individual survey will make it more valuable in the assessment process. 4. Use an outside, unbiased source to consolidate comments, mentor, and share thoughts with each individual’s assessment. If one is not available, at the very least provide guidance through an officer professional development session on how to read the graphs. 360 Assessment, An Easier Pill to Swallow: Implementation of Peer Assessment For Captain’s Career Course Students and Staff

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October – December 2009 63 THE ARMY MEDICAL DEPARTMENT JOURNAL 5. Administer the self, peer, and supervisor 360-degree assessment to newly assigned SGLs around their 6-month anniversary of arrival so others can properly assess and answer each category comfortably. FUTURE STEPS/SUMMARY Would you be a better leader today, if, when a junior leader, there had been a formal pathway for you to receive constructive feedback from peers, subordinates, and supervisors? I know for me, the answer is, without a doubt, yes. Whether it is returning a lost wallet or obeying a commander’s policy completely, as Army leaders each one of us is tested each day. These daily tests refine our values as leaders. Rather than simply relying on these daily challenges to develop our officers, it is our hope at CCC that the 360-degree tool will make leadership development deliberate and intentional in an educational setting. The CCC-designed SGL self, peer, and supervisor assessment surveys are now conducted twice a year, and the student surveys completed at the end of each graduating class (4 times per year). The current survey forms were refined to adopt the 10 rating criteria from Kouzes and Posner’s Leadership Practices Inventory.3 The new SGL self-survey is shown in Figure 4. Each time the survey is conducted, data is compiled so individual SGLs can see the trend analysis over time. Since benefits of the 360-degree process were indisputably evident, we have implemented the 360degree assessment within our CCC student population as well, in an effort to cr eate a mentorship experience for our entire student body. Overall, the 360-degree assessment process has been an eye-opening experience for our team. The 360degree effort, while labor-intensive at times, has created an environment for leadership development that is unparalleled in its effectiveness and has opened new doors for self-development within our organization. REFERENCES 1. Department of the Army Pamphlet 600-4: Army Medical Department O fficer Development and Career Management Washington, DC: US Dept of the Army; June 27, 2007: 13. 2. Kouzes JM, Posner BZ. The Leadership Challenge 4th ed. San Francisco, CA: Jossey-Bass; 2007:344. 3. Kouzes JM, Posner BZ. The Leadership Challenge Workbook 3rd ed. San Francisco, CA: Jossey-Bass; 2006:14. AUTHOR LTC Sones is Chief of the Captain’s Career Course, AMEDD Center and School, Fort Sam Houston, Texas. Figure 4. The current SGL self-survey form used by the CCC. The 10 rating criteria (detailed below), were adopted from Kouz es and Posner’s Leadership Practices Inventory3 and are also used in the current student survey. Leadership (SGL Self) Survey Category 1(AN) 2(R) 3(S) 4(OW) 5(O) 6(ST) 7(FO) 8(U) 9(VF) 10(AA) 1 I always display honesty, integrity, and trustworthiness. 2 I make decisions...and do not shy away from the tough ones. 3 I communicate often and clearly...with everyone. 4 I mentor, empower, and develop my subordinates...a consummate team player. 5 I hold everyone accountable, including myself. 6 I have strong control over my emotions. 7 I excel in pressure situations. 8 I have the compassion to listen to others. 9 I know the material that I teach/ instruct and can lead any discussion in my small group. 10 I have a positive attitude and am passionate about what I do. 11 I am a team player. 12 I am a catalyst for and manager of change Provide one Sustain an d one Improve comment Sustain Overall Score_________ 1) Improve 1) Top three values you see in yourself 1) ________________ 2) __________________ 3) ___________________ Key to Criteria: (AN) Almost never (R) Rarely (S) Seldom (OW) Once in a while (O) Occasionally (ST) Sometimes (FO) Fairly often (U) Usually (VF) Very frequently (AA) Almost always

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64 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 Ultrasonography for Advanced Regional Anesthesia and Acute Pain Management in a Combat Environment COL (Ret) Randall J. Malchow, MC, USA *The Military Advanced Regional Anesthesia and Analgesia Initiative was established in 2005 to develop consensus recommendation s from the Army, Air Force, and Navy anesthesia services for the implementati on of improvements in medical practice and technology that wi ll promote regional anesthesia and analgesia in the care of military beneficiaries. It also serves as an advisory board to the individual service anesthesia consultants to the surgeons general. INTRODUCTION Ultrasonography has revolutionized modern medicine empowering physicians to offer an increasing number of diagnostic and therapeutic procedures using ultrasound guidance. These a dvances have expanded their use on the battlefield in Operation Enduring Freedom and Operation Iraqi Freedom by radiologists, general surgeons, urologis ts, emergency medicine physicians, and gynecologists.1,2 Anesthesiologists have also utilized ultrasonography as early as 1978 when ultrasound was used to aid in the identification of vascular structures for the supraclavicular brachial plexus block,3 while more recent higher frequency probes have allowed anesthesiologists to identify individual nerve trunks and thus provide peripheral nerve blockage under direct visualization. Military anesthesiologists have also advanced acute pain control of Soldiers with extremity injury beyond the exclusive use of opioids. The placement of the first continuous peripheral nerve block (CPNB) in a wounded Soldier in Iraq on October 3, 2003, opened the door to pain control never experienced previously in a combat environment.4 Since that time, numerous Soldiers have benefited from the growing use of CPNB catheters that can accompany them through the echelons of military trauma care until they arrive at medical facilities in the United States. This case series reports the first use of ultrasound in a military deployed environment for the specific use of providing advanced regional anesthesia and acute pain management. OBSERVATION Upon notification of my pending deployment to Iraq in early 2006, I contacted the Military Advanced Regional Anesthesia and Analgesia Initiative* to explore the concept of applying ultrasonography to advanced regional anesthesia in a combat environment. In support of our efforts, GE Healthcare Systems (Waukesha, Wisconsin) offered to provide one of their high resolution systems, and shipped a new GE Voluson i ultrasound system (with all accessories) to the 47th Combat Support Hospital (CSH) in Mosul, Iraq. Most anesthetics at the 47th CSH were conducted with a balanced general anesthesia with morphine as needed for postoperative pain on the surgical ward. With the arrival of the GE Voluson i ultrasound system with 2 ultrasound probes (a 12L (12 MHz linear) probe and a 4C (4 MHz curved) probe), a plan was implemented to use ultrasound guided advanced regional anesthesia techniques as part of the perioperative anesthesia and analgesia plan for wounded, polytrauma patients. RESULTS Forty-four ultrasound-guided regional anesthetics were performed by the same anesthesiologist experienced in regional anesthesia for a variety of upper and lower extremity trauma over a 3-month period, as outlined in the Table. The 12L probe was used in the short axis view for most blocks with excellent resolution, while the 4C probe was used for the deep Distribution of upper and lower extremity nerve blocks using ultrasound. CPNB Single Shot Total Interscalene 4 1 5 Supraclavicular 5 4 9 Infraclavicular 0 2 2 Axillary 5 0 5 Subtotal 14 7 21 Lower Extremity Femoral 6 5 11 Sciatic 2 4 6 Popliteal 5 0 5 Other 1 0 1 Subtotal 14 9 23 Total Regional Anesthetics: 44 Upper Extremity

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October – December 2009 65 penetration often required for infraclavicular and sciatic blocks, for example. Color flow doppler was particularly useful in confirming the location and orientation of vascular structures. Proximal nerves (eg, interscalene, supraclavicular, sciatic, and popliteal) were clearly seen as hypoechoic structures surrounded by hyperechoic border (classically described as a “honeycomb appearance”), c onsistent with previous reports,5 compared to distal peripheral nerves which were smaller hyper-echoic structures such as in the axillary region. Using the combined use of nerve stimulation, the needle was frequently repositioned after an initial injection of 5 ml of local anesthesia solution to optimize the spread of local anesthesia around neural targets. Incorporating ultrasound in advanced regional techniques resulted in a success rate of 95%, a 100% patient satisfaction rate, and no known complications. DISCUSSION The potential benefits of ultrasound-guided regional anesthesia are numerous. Nerve stimulation techniques for single injection blocks or placement of CPNB catheters can be extremely challenging in Soldiers with complex combat-related extremity injuries due to pain, amputation, or difficult patient communication due to other injuries. The use of ultrasound technology in regional anesthesia has unique application in these devastating extremity injuries.6 Higher success rates and decreased onset times have been previously demonstrated, as the anesthesiologist can optimize needle placement during injection to ensure appropriate spread.7-12 Because vascular, neural, as well as other structures such as pleura can be well-visualized, fewer complications from needle penetration or vascular injection should result. In the case of trauma, the sole use of ultrasound technique should also decrease pain compared to nerve stimulation technique causing extremity movement. The risks of the application of ultrasound are minimal; however, indirect challenges do exist such as maintaining a sterile field with extra equipment, increased cost, and the additional time for training required for ultrasound guided blocks. Finally, as the portable ultrasound’s distinct advantage of higher resolution compared to the smaller, hand-held ultrasound devices became apparent, other hospital specialists also began employing this highly capable ultrasound machine as a diagnostic tool in the emergency department, the intensive care unit, as well as in radiology, which expanded its utility within the 47th Combat Support Hospital. CONCLUSION Advanced regional anesthesia and aggressive acute pain management employing high-resolution ultrasound technology results in high success rates, low complication rates, high patient satisfaction, and great applicability in extremity trauma patients in a combat environment. As military anesthesiologists become more facile with ultrasound techniques, they will continue to be on the leading edge of acute pain management for the benefit of the wounded warrior. Medical logisticians should strongly consider the availability of at least one portable, high-resolution, ultrasound machine for each deployed combat support hospital, significantly advancing medical care across specialties. ACKNOWLEDGEMENT The GE Voluson i ultrasound system used in the procedures described in this article was provided by GE Healthcare Systems, Waukesha, Wisconsin. REFERENCES 1. Harcke HT, Statler JD, Montilla J. Radiology in a hostile environment: experience in Afghanistan. Mil Med 2006;171:194-199. 2. Rozanski TA, Edmondson JM, Jones SB. Ultrasound in a forward-deployed military hospital. Mil Med 2005;170:99-102. 3. La Grange P, Foster PA, Pretorius LK. Doppler ultrasound blood flow detector in supraclavicular brachial plexus block. Br J Anaesth 1978;50:965-967. 4. Buckenmaier CC, McKnight GM, Winkley JV, et al. Continuous peripheral nerve block for battlefield anesthesia and evacuation. Reg Anesth Pain Med 2005;30:202-205. 5. Marhofer P, Schrgendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N. Ultrasonographic guidance improves sensory block and onset time of 3-in-1 blocks. Anesth Analg 1997;85:854-857. 6. Plunkett AR, Brown DS, Rogers JM, Buckenmaier CC III. Supraclavicular continuous peripheral nerve block in a wounded soldier: when ultrasound is the only option. Br J Anaesth 2006;97:715-717. 7. Perlas A, Chan VW, Si mons M. Brachial plexus examination of localization using ultrasound and electrical nerve stimulation: a volunteer study. Anesthesiology 2003;99:429-435.

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66 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 8. Silvestri E, Martinoli C, Derchi LE, Bertolotto M, Chiaramondia M, Rosenberg I. Echotexture of peripheral nerves: a correlation between ultrasound and histologic findings and criteria to differentiate tendons. Radiology 1995;197:291-296. 9. Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003;97:1514-1517. 10. Williams SR, Chouinard P, Arcand G, Harris P, Ruel M, Boudreault D, Girard F. Ultrasound guidance speeds execution and improves the quality of supraclavicular block. Anesth Analg 2003;97:15181523. 11. Soeding PE, Sha S, Royse CE, Marks P, Hoy G, Royse AG. A randomized trial of ultrasound-guided brachial plexus anaesthesia in upper limb surgery. Anaesth Intensive Care 2005;33:719–725. 12. Sites BD, Beach ML, Spence BC, Wiley CW, Shiffrin J, Hartman GS, Gallagher JD. Ultrasound guidance improves the success rate of a perivascular axillary plexus block. Acta Anaesthesiol Scand 2006;50:678-684. AUTHOR COL (Ret) Malchow is an Associate Professor of Clinical Anesthesiology at the Vanderbilt University Medical Center, Nashville, Tennessee. When this article was written, he was Staff Anesthesiologist at the 47th Combat Support Hospital, Mosul, Iraq. Subsequently, COL (Ret) Malchow was Chief, Regional Anesthesia and Acute Pain Management, Brooke Army Medical Center, Fort Sam Houston, Texas. Ultrasonography for Advanced Regional Anesthesia and Acute Pain Management in a Combat Environment The GE Volusion i ultrasound system in use at the 47th Combat Support Hospital in Mosul, Iraq. The GE Volusion i ultrasound system. Image courtesy of GE Healthcare Systems, Waukesha, Wisconsin.

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October – December 2009 67 INTRODUCTION According to CDR L. Pearse* (conversation, March 5, 2008), cardiovascular disease is the second leading cause of death, after neoplasm, in US Army service members aged 40 and older and accounts for 40-50 deaths per year among Active duty, Reserve, and National Guard Soldiers. The prevalence of heart disease among Army personnel of all ages is 3%, and increases to 9% in the population aged 40 to 65.1 Diagnosed hypertension is present in 2% of all service members and in 7% of those aged 40 to 65.1 Diagnosed hyperlipidemia is present in less than 1% of service members under aged 40 and in 3% of those aged 40 to 65.1 Obesity (BMI > 30) is present in 5% of all Army personnel, and increases to nearly 9% among personnel aged 40 to 65.1 Smoking prevalence decreases with age among Army personnel and is 27% overall, but 17% among personnel aged 40 to 65.1 In 2004, a worksite-based cardiovascular risk assessment was performed on a self-selected sample of 59 Soldiers aged 40 and olde r assigned to I Corps, Fort Lewis, Washington. In that voluntary program, 46% of participants had multiple cardiac risk factors and 18% showed a > 10% Framingham 10-year cardiac risk.2 METHODS In the current analysis, th e Fort Lewis worksite-based program was again offered to I Corps. In addition to identifying Soldiers with unm anaged cardiac risk, this analysis sought to determine whether or not Soldiers identified as having unmanaged cardiac risk factors would comply with instructions to follow-up with a primary care provider. Participation was voluntary, and was offered to all service members aged 40 and older. One week prior to the event a mobile phlebotomy team drew fasting lipids and glucose onsite at the unit headquarters. At that time, participants were asked to consent to be in the study. On the day of Cardiovascular Risk Factor Screening and Follow-up in a Military Population Aged 40 Years and Older COL Diane Flynn, MC USA MAJ Jeremy D. Johnson, MC USA Cathy J. Bailey, RN CPT Jason T. Perry, MC USA Charles A. Andersen, MD John G. Meyer, MD Nancy A. Cox, RN ABSTRACT Objective. This study analyzed a worksite-based cardiovascular risk assessment offered to Soldiers aged 40 and older to identify unrecognized cardiovascular risk and evaluate compliance with instructions to follow up for further evaluation. Methods. Participants had fasting blood tests, waist circumference and blood pressu re measurement and a carotid artery duplex scan performed at their worksite. A healthcare professi onal discussed the participants’ results with them and, if indicated, recommended follow up within the following one month. Results. Seventy-six (46%) of the 163 eligible Soldiers agreed to participate. Twenty-nine (38%) of the 76 participants were instructed to follow up for elevated blood pressure, glucose, or lipids. Only 7 of 29 (24%) complied with follow-up instructions. Conclusion. Voluntary worksite-based interventions can effectively identify Soldiers with unmanaged cardiovascular risk factors, but a more aggressive follow-up strategy should be used to ensu re these Soldiers receive indicated medical intervention. *CDR Pearse was Chief, Mortalit y Surveillance Division, Armed Forces Institute of Pathology, Washington, DC, in March 2008.

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68 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 the outreach event, each participant was assessed for the following cardiac risk factors: elevated blood pressure, lipids, glucose, waist circumference, current smoking status and family history of premature cardiovascular disease. If systolic blood pressure was > 130 and/or diastolic was > 80, it was repeated in the opposite arm and the average of the two readings was recorded. In addition, each participant had an ECG rhythm strip and carotid artery duplex scan performed. After risk factor assessment was completed, a provider or nurse met with each participant individually and reviewed his or her risk of cardiac disease. If historical, physical, or lab findings revealed unmanaged cardiac risk, the individual was instructed to follow-up in his/her primary care clinic within the next 30 days. Each participant was provided with a written summary of his/her risk assessment and instructions for follow-up, if indicated. Smokers were also given information on resources for smoking cessation. Six months after the intervention, medical records of all participants were re viewed to determine if participants complied with follow-up instructions, as well as to compare any post-intervention blood pressure and laboratory values with baseline values. The studentÂ’s paired t test was used to compare baseline and follow-up Framingham cardiac risk among participants who complied with instructions to follow-up. RESULTS Of 163 members aged 40 and older assigned to I Corps, and therefore eligible for participation, 76 (47%) agreed to participate. The age range was 40 to 57 years with a mean age of 45 years. Men comprised 85% of the sample. Also, 53% of the sample were enlisted personnel. Twenty-eight (37%) participants had an average systolic blood pressure > 140 and/ or diastolic blood pressure > 90 on the day of the outreach program (Figure 1). Although a diagnosis of hypertension cannot be made based on the readings measured in a single day, this represents a substantial population at risk for uncontrolled hypertension. All but one participant had fasting lipids and glucose drawn within one month prior to the outreach program. Twelve participants (16%) had an low density lipoprotein (LDL) above their National Cholesterol Education Program goal.3 Five participants (7%) had a triglyceride > 200 mg/dL, and five (7%) had a fasting glucose > 110. Eight Cardiovascular Risk Factor Screening and Follow-up in a Military Population Age 40 years and Older Figure 1. Prevalence of cardiac risk factors among participants. Key to risk factors: 1. Elevated blood pressure 2. Elevated low density lipoproteins 3. Elevated triglycerides 4. Elevated fa sting blood sugar 5. Metabolic syndrome 6. Smokers 7. Carotid stenosis 0% 5% 10% 15% 20% 25% 30% 35% 40% 1234567Percentage of Participants Figure 2. Distribution of the Framingham Risk Categories among participants. 0% 10% 20% 30% 40% 50% 60% 70% 0%-5%6%-10%>10%Framingham 10 year coronary heart disease risk Percentage of Participants

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October – December 2009 69 THE ARMY MEDICAL DEPARTMENT JOURNAL participants (11%) were current smokers. Questions pertaining to past medical history revealed that eleven (14%) had a known history of hypertension, three (4%) had diabetes and one (1%) had a history of coronary artery disease. Eleven (14%) had a family history of premature heart disease. Seven participants (9%) met criteria for metabolic syndrome and one participant (1%) was found to have carotid stenosis of 30% to 50% on carotid doppler screen. Most participants were found to be at low risk of an adverse cardiac event with 68% having a Framingham 10-year risk of 0% to 5 %. However, 25% were found to have a Framingham 10-yr risk of 6% to 10%, and 7% had a Framingham 10-year risk greater than 10% (Figure 2). Of the 29 participants who were instructed to followup for elevated blood pressure, glucose and/or lipids, records review covering the 6 months following the worksite-based screening revealed that only seven (24%) had a documented follow-up visit for the specific reason of addressing cardiovascular risk. The seven who followed-up had a total of 10 cardiac risk factors. Among them, two with elevated blood pressure had normal blood pressure at follow-up and one with elevated glucose had normal glucose at follow-up. Of the remaining, two were started on medication for elevated lipids and two were started on medication for hypertension. No significant change in Framingham cardiac risk was observed among the seven who complied with follow-up instructions compared to their baseline ( P = 0.46). Eight of the 27 participants (30%) who did not comply with instructions for follow-up of elevated blood pressure were noted to have normal blood pressure at subsequent visits for unrelated reasons. Likewise, 2 of 12 participants who did not comply with instructions to follow-up for elevated LDL and 2 of 5 participants who did not comply with instructions to follow-up for elevated fasting glucose had normal laboratory studies at follow-up for unrelated reasons (Figure 3). DISCUSSION The value of screening for cardiovascular risk in Soldiers has been evaluated in several recent analyses. In a study of more than 15,000 US Army personnel undergoing routine annual h ealth risk assessment at Fort Lewis, WA, during 2004, the prevalence of blood pressure (BP) > 140/90 was 11.1% among Soldiers aged 17 to 39 and 27.2% among Soldiers aged 40 and older, suggesting that prevalence of hypertension in this group may be higher than previously known.4 The Longitudinal Health Risk Assessment Program (LHRAP) was a 3-year pilot program of 1,609 active duty Army Soldiers over the age of 35 years assigned to Fort Meade, Maryland, to identify Soldiers with chronic health risks, including hypertension, hyperlipidemia, obesity, and smoking at the time of periodic physical examination, and to encourage follow-up of these conditions.5 In this voluntary program, the prevalence of elevated blood pressure and smoking was similar to the overall Army population aged 40 and older, with BP > 140/90 found in 9% of male particip ants and 4% of female participants, and smoking found in 17% of all participants. However, the prevalence of elevated cholesterol and overweight or obesity was higher than the population of all Army personnel aged 40 and older, with total cholesterol > 200 observed in 50% of 0% 5% 10% 15% 20% 25% 30% 35% Elev BPElev LDLElev glucoseElev TGs Elevated BPa Elevated LDLb Elevated Glucose Elevated TGscPercentage of Participants Figure 3. Percentage of Participan ts with selected Risk Factors who complied with instructions to follow-up within six months or who had assessment of cardiac risk at visits for unrelated reasons. a. Blood pressure b. Low density lipoproteins c. Triglycerides No Follow up Normal Value at visit for unrelated reason Followed up as instructed

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70 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 male participants and 42% of female participants, and body mass index (BMI) > 30 found in 85% of male participants and 58% of fema le participants. Based on each participantÂ’s risk category, a case manager contacted participants and recommended appropriate follow-up consults and refe rrals. Approximately half of the participants with a >20% Framingham 10-year cardiac risk followed-up with the case manager. Approximately one-third of those with a 10% to 20% Framingham risk followed-up. Among those who followed-up, one-third had improvement in their cardiovascular risk category (M. Bell and M. Birk, unpublished report,* July 5, 2007). Worksite-based health promotion has been shown to enhance productivity of American workers by decreasing medical costs and absenteeism.6 Several critical reviews of the literature support the clinical effectiveness and cost-effectiveness of health promotion interventions at the worksite, with each dollar invested yielding between $3 and $6 of return on investment.7 Individual counseling and follow-up were among the most important components of successful programs.8 A follow-up physician visit, however, has not been shown to add substantially to the value of worksite cholesterol screening in changing diet, BMI, exercise levels, or smoking status.9 In this self-selected sample of active duty Soldiers aged 40 and older, about one-half of those who were offered cardiovascular risk assessment at the jobsite agreed to participate. About one-quarter of participants were found to have unmanaged cardiac risk factors that were substantiated on subsequent measurement. The prevalence of cardiovascular risk factors was higher in participants than the overall population of Soldiers aged 40 and older. This increased prevalence may be due to adverse sel f-selection, which has been observed in other voluntary worksite health promotion programs, and suggests that relatively unhealthy individuals tend to be more likely to participate in voluntary wellness programs than healthier coworkers.10 Despite individual counseling of this at-risk group, only about one-quarter of participants with unmanaged cardiac risk complied with advice to follow-up. SUMMARY Voluntary worksite-based inte rventions appear to be an effective in identifying Soldiers with unmanaged cardiovascular risk. However, individual risk identification and counseling alone do not appear to be effective in motivating most Soldiers to seek follow-up care to modify their risk. The integration of Framingham risk calculation into the recently implemented annual Periodic Health Asse ssment of Soldiers aged 40 and older presents a valuable opportunity to identify unmanaged cardiac risk. This study suggests that once cardiovascular risk factors are identified, followup recommendations should be carefully monitored, perhaps involving telephone, mail, or email contact, to ensure that Soldiers found to have unmanaged cardiac risk factors receive indicated interventions. REFERENCES 1. McDonald M, Hertz RP. The Health Status of the United States Army: Findings from the Total Army Injury and Health Outcomes Database. Pfizer Facts. Pfizer, Inc; 2003. Available at: http:// www.usariem.army.mil/download/usarmystatus.pdf. 2. Bingham M. Presentation to the 18th Annual Pacific Nursing Research Confer ence. Honolulu, Hawaii; March 2005. 3. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143-3421. 4. Smoley B. Presentation to the Uniformed Services Academy of Family Physic ians Annual Meeting. Hilton Head, North Carolina; March 11-16, 2007. 5. Bell M, Birk M, Allen J, Jones C. Longitudinal Health Risk Assessment Program. Army Med Dept J January-March 2004:15-20. 6. Chapman LS. Meta-evaluation of worksite health promotion economic return studies: 2005 update. Am J Health Promot 2005;19(6):1-11. 7. Matson Koffman DM, Goetzel RZ, Anwuri VV, Shore KK, Orenstein D, LaPi er T. Heart healthy and stroke free: successful busi ness strategies to prevent cardiovascular disease. Am J Prev Med 2005;29(5 Suppl 1):113-121. 8. Pelletier KR. A review and analysis of the clinicaland cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: 1998-2000 update. Am J Health Promot 2001;16(2):107-116. Cardiovascular Risk Factor Screening and Follow-up in a Military Population Age 40 years and Older *Final written project report, US Army Center for Health Promotion and Preventive Medicine Health Promotion and Prevention Initiatives Program, July 5, 2007.

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October – December 2009 71 THE ARMY MEDICAL DEPARTMENT JOURNAL 9. Wang JS, Carson EC, Lapane KL, Eaton CB, Gans KM, Lasater TM. The effect of physician office visits on CHD risk factor modification as part of a worksite cholesterol screening program. Prev Med 1999;28 (3):221-228. 10. Haynes G, Dunnagan T, Smith V. Do employees participating in voluntary health promotion programs incur lower health care costs? Health Promot Int 1999;14(1):43-51. AUTHORS COL Flynn is Chief, Dept of Family Medicine, Madigan Army Medical Center, Tacoma, Washington. MAJ Johnson is the Associat e Program Director of the Family Medicine Residency, Tripler Army Medical Center, Honolulu, Hawaii. Ms Bailey, a Certified Chroni c Care Professional, is a Nurse Case Manager in the Health Outcomes Management Division, Madigan Army Medical Center, Tacoma, Washington. CPT Perry is a Resident in the Dept of Surgery, Madigan Army Medical Center, Tacoma, Washington. Dr Andersen is Chief of Vascular Surgery, Dept of Surgery, Madigan Army Medical Center, Tacoma, Washington. Dr Meyer is the Director, Health Outcomes Management Division, Madigan Army Medical Center, Tacoma, Washington. Ms Cox is the A Company Nurse Case Manager, Warrior Transition Battalion, Madigan Army Medical Center, Tacoma, Washington.

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72 http://www.cs.amedd.army.mil /dasqaDocuments.aspx?type=1 THE US ARMY MEDICAL DEPARTMENT REGIMENT The US Army Medical Department was formed on July 27, 1775, when th e Continental Congress authorized a Medical Service for an army of 20,000 men. It created the Hospital Department and named Dr Benjamin Church of Boston as Director General and Chief Physician. On April 14, 1818, the Congress passed an Act which reorganized the staff departme nts of the Army. The Act provided for a Medical Department to be headed by a Surgeon General. Dr Joseph Lovell, appointed Surgeon General of the United States Army in April 1818, was the first to hold this position in the new organization. The passage of this law marks the beginning of the modern Medical Department of the United States Army. Throughout its early history, the size and mission of the US Army Medical Department would wax and wane in response to military events around the world. There was, however, no formal regimental organization until World War I. Then, in the late 1950s, the brigade replaced the regiment as a tactical unit. In the reorganization that followed, some Army units lost their identity, their lineage, their history. This loss did not go unnoticed. The US Army Regimental Sy stem was created in 1981 to provide soldiers with continuous identification with a single regiment. Department of the Army Regulation 600-82, The US Army Regimental System, states the mission of the regi ment is to enhance combat effectiveness through a framework that provides the opportunity for affiliation, develops loyalty and commitment, fosters a sense of belonging, improves unit esprit, and institutionalizes the war-fighting ethos. The US Army Medical Department Regiment was acti vated on July 28, 1986, du ring ceremonies at Fort Sam Houston in San Antonio, Texas, the “Home of Army Medicine.” Lieutenant General Quinn H. Becker, the US Army Surgeon General and AMEDD Regimental Commander, was the reviewing officer. He was joined by general officers of the US Army Reserves and the Army National Guard, representing the significant contributions and manpower of the reserve forces in the Total Army concept. The Regimental web site (http://ameddregiment.amedd. army.mil/default.asp) is designed to provide you with useful information about the US Army Medica l Department (AMEDD) Regiment. Through the web site, you can learn the history of the AMEDD Regiment, the symbolism behind our heraldic items, how to wear the Regimental Distinctive insignia, and various programs available to you and your unit. The Office of the AMEDD Regiment is located in Aabel Hall, Building 2840, on Fort Sam Houston, Texas. The Regimental staff can provide further inform ation pertaining to the history of the Army Medical Department and the AMEDD Regiment, and assist with any of the services described in the web page. For additional information please contact the Ar my Medical Department Regimental Office at the following address: Commander US Army Medical Department Regiment ATTN: MCCS-GAR 2250 Stanley Road Fort Sam Houston, Texas 78234-6100 The telephone number is (210) 2218455 or DSN 471-8455, fax 8697. Internet: http://ameddregiment.amedd.army.mil/ Email: amedd.regiment@amedd.army.mil

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SUBMISSIONOF M ANUSCRIPTSTOTHE A RMY M EDICAL DEPARTMENT J OURNAL The UnitedStatesArmyMedicalDepartmentJournal ispublishedquarterlytoexpandknowledgeofdomesticandinternational militarymedicalissuesandtechnologicaladvances;promotecollaborativepartnershipsamongtheServices,components,Corps, andspecialties;conveyclinicalandhealthservicesupportinformation;andprovideaprofessional,highquality,peerreviewed printmediumtoencouragedialogueconcerninghealthcareissuesandinitiatives. R EVIEW P OLICY Allmanuscriptswillbereviewedbythe AMEDDJournalsEditorialReviewBoardand,ifrequired,forwardedtotheappropriate subjectmatterexpertforfurtherreviewandassessment. I DENTIFICATIONOF P OTENTIAL C ONFLICTSOF I NTEREST 1. Relatedtoindividualauthorscommitments: Eachauthorisresponsibleforthefulldisclosureofallfinancialandpersonal relationshipsthatmightbiastheworkorinformationpresentedinthemanuscript.Topreventambiguity,authorsmuststate explicitlywhetherpotentialconflictsdoordonotexist.Authorsshoulddosointhemanuscriptonaconflict-of-interest notificationsectiononthetitlepage,providingadditionaldetail,ifnecessary,inacoverletterthataccompaniesthe manuscript. 2. Assistance: AuthorsshouldidentifyIndividualswhoprovidewritingorotherassistanceanddisclosethefundingsourceforthis assistance,ifany. 3. Investigators: Potentialconflictsmustbedisclosedtostudyparticipants.Authorsmustclearlystatewhethertheyhavedone sointhemanuscript. 4. Relatedtoprojectsupport: Authorsshoulddescribetheroleofthestudysponsor,ifany,instudydesign;collection,analysis, andinterpretationofdata;writingthereport;andthedecisiontosubmitthereportforpublication.Ifthesupportingsource hadnosuchinvolvement,theauthorsshouldsostate. P ROTECTIONOF H UMAN S UBJECTSAND A NIMALSIN R ESEARCH Whenreportingexperimentsonhumansubjects,authorsmustindicatewhethertheproceduresfollowedwereinaccordancewith theethicalstandardsoftheresponsiblecommitteeonhumanexperimentation(institutionalandnational)andwiththeHelsinki Declarationof1975,asrevisedin2000.IfdoubtexistswhethertheresearchwasconductedinaccordancewiththeHelsinki Declaration,theauthorsmustexplaintherationalefortheirapproachanddemonstratethattheinstitutionalreviewbody explicitlyapprovedthedoubtfulaspectsofthestudy.Whenreportingexperimentsonanimals,authorsshouldindicatewhetherthe institutionalandnationalguideforthecareanduseoflaboratoryanimalswasfollowed. G UIDELINESFOR M ANUSCRIPT S UBMISSIONS 1.Articlesshouldbesubmittedindigitalformat,preferablyanMSWorddocument,eitherasanemailattachment(with illustrations,etc),orbymailonCDorfloppydiskaccompaniedbyoneprintedcopyofthemanuscript.Ideally,amanuscript shouldbenolongerthan24double-spacedpages.However,exceptionswillalwaysbeconsideredonacase-by-casebasis.In general,4double-spacedMSWordpagesproduceasinglepageof2columntextinthe AMEDDJournal productionformat. 2.The AmericanMedicalAssociationManualofStyle governsformattinginthepreparationoftextandreferences.Allarticles shouldconformtothoseguidelinesascloselyaspossible.Abbreviations/acronymsshouldbelimitedasmuchaspossible. Inclusionofalistofarticleacronymsandabbreviationscanbeveryhelpfulinthereviewprocessandisstronglyencouraged. 3.Acompletelistofreferencescitedinthearticlemust beprovidedwiththemanuscript.Thefollowingisasynopsisofthe AmericanMedicalAssociationreferenceformat: Referencecitationsofpublishedarticlesmustincludetheauthorssurnamesandinitials,articletitle,publicationtitle, yearofpublication,volume,andpagenumbers. Referencecitationsofbooksmustincludetheauthorssurnamesandinitials,booktitle,volumeand/oreditionif appropriate,placeofpublication,publisher,yearofcopyright,andspecificpagenumbersifcited. Referencecitationsforpresentations,unpublishedpapers,conferences,symposia,etc,mustincludeasmuchidentifying informationaspossible(location,dates,presenters,sponsors,titles). 4.Eithercolororblackandwhitephotographsmaybesubmittedwiththemanuscript.Colorproducesthebestprintreproduction quality,butpleaseavoidexcessiveuseofmultiplecolorsandshading.Digitalgraphicformats(JPG,GIF,BMP)andMSWord photofilesarepreferred.Printsofphotographsareacceptable.PleasedonotsendphotosembeddedinPowerPoint.Images submittedonslides,negatives,orcopiesofX-rayfilmwillnotbepublished.Forclarity,pleasemarkthetopofeach photographicprintontheback.Tapecaptionstothebackofphotosorsubmitthemonaseparatesheet.Ensurecaptionsand photosareindexedtoeachother.Clearlyindicatethedesiredpositionofeachphotowithinthemanuscript. 5.Theauthorsnames,ranksoracademic/certificationcredentials,titlesorpositions,currentunitofassignment,andcontact informationmust beincludedonthetitlepageofthemanuscript. 6.Submitmanuscriptsto: EDITOR ,AMEDDJ OURNAL ATTN MCCSDT 2419HOODSTSTEC F ORT SAM H OUSTON,TX78234-7584 DSN471-6301 Comm210-221-6301 Email:amedd.journal@amedd.army.mil