Page 106 - JSOM Fall 2022

Our Army requires its Soldiers to be current and competent in direct involvement in patient care, high­level interpersonal and
their specialty skills. Corollary examples include the need for motivational skills, commitment to high­quality practice, and
an airborne infantryman to conduct individual and collective empowerment of others. 9
training standards for airborne operations or for pilots to reg­
ularly fly in daytime and nighttime, operating in both instru­ Physicians should have the expertise and credibility with their
ment­flight and night vision–enhanced conditions to maintain subordinates that command – not demand – respect. Phrases
competency and currency of flight status. like “lead from the front,” “lead by example,” and “servant
leadership” are commonly used to describe military leadership,
Acceptance of specialty bonuses requires the MC officer to yet they have little applicability among their fellow physicians
be competent and current in their specialty, but there are no when MC officer­leaders do not engage, maintain credentials,
specified, required benchmarks beyond board certification. or practice their specialties.
Recently published by the Army Medical Command, the new
Individual Clinical Task List (ICTL) attempts to define specific During the Iraq Conflict, some general officers such as General
skills and procedures required for competence based on medi­ Stanley McChrystal and General James Mattis accompanied
cal specialty. While a work in progress, it is unclear if it will re­ troops in squad level units as observers. They were prepared
quire MC officers in administrative, operational, or leadership to function as infantrymen should the requirement arise. 10,11 It
positions to meet these standards. Often the sole requirement is unclear if senior military medical leaders could function as
for remaining a credentialed provider in Army medical treat­ practicing physicians at this basic level.
ment facilities is to practice a mere 40 hours per year.
While individuals may be concerned about leadership and the
There are issues with ownership of the readiness component responsibility which comes with it, commanders are rarely re­
and challenges to improving combat casualty survival. While lieved because of performance, barring ethical, legal, or publi­
5
readiness and ensuring operational billets are filled are the cized medical issues. MC leaders who do not practice medicine
core elements of military medicine, there is little emphasis and are not exposed to the same risks as the clinically active MC
no apparent requirement for these physicians to meet clinical officers they lead, such as the federal tort claims act, qual­
competency requirements. ity improvement, and patient surveys. Physicians are held ac­
countable for poor decisions made by officers/administrators
who are not affected by those decisions including logistics, au­
Leader
tomation, and contracting. Medical leaders are also burdened
With few exceptions, MC officers were the leaders in the by the unending phenomenon of building and increasing ad­
AMEDD until 1997 with the advent of branch immaterial ministrative staff. Often, this is at the expense of clinical posi­
command. This opened the competition for commands and tions, further decreasing the number of practicing physicians
flag rank to all of the AMEDD corps. Given that some corps and nurses in a system that the Government Accounting Office
do not practice clinical medicine or stop practicing it early in (GAO) deems very inefficient. 12
their career lifecycles, MC officers may have felt the need to
compete in a similar fashion. It is the rare senior military medical leader who maintains clin­
ical practice as they progress in rank. Working a shift in their
Many who aspire to be general officers place emphasis on respective clinics, operating room, or emergency department
being operationally, technically, and tactically proficient. In and utilizing the numerous electronic health care records, labs,
civilian medicine, clinical and academic excellence are sim­ radiology systems, and administrative and consulting systems
ilarly cited as the ultimate goals. However, competition for that are stand­alone and not interactive, would give them first­
commands and flag rank in the Army MC compromises the hand experience with issues that are not necessarily appreci­
importance of clinical and academic competence and currency. ated at the command­suite level. This is not to suggest that the
The reasons physicians avoid competing for these leadership leaders are not engaged, but there is a substantial difference
assignments are complex and varied, but the present promo­ between an email presence, night rounding, mass town hall
tion structure and professional military education require­ meetings, and a physical presence on the ground in which the
ments create substantial barriers for physicians to continue multiple inefficient administrative systems meet the patient in
the active clinical practice of medicine. MC officers who seek the clinical environment.
leadership assignments often do so out of a sense of duty and
obligation, not necessarily for individual ambition. This does
not however, justify the absence of a requirement for clinical The Way Forward
excellence. 1. Make clinical practice matter. Ensure that all medical pro­
viders including physicians, nurses, physician assistants,
There is a growing body of evidence that suggests health care medics, etc. continue to practice in their chosen fields.
works best when physicians are in leadership roles. In the civil­ Make it relevant and make it the standard.
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ian community, physician leaders were traditionally selected on 2. Emphasize the need for ICTL training for everyone. If un­
the basis of their national prominence and excellence as master available at the local military training facilities (MTFs),
clinicians, eminent clinical investigators, and revered educators. 7 seek out military relevant training in the civilian commu­
nity. Consider aligning these requirements with specialty
Many believe effective clinical leadership is essential for con­ bonuses.
sumers of health care to achieve optimal health outcomes and 3. Perform an evidence­based evaluation of nonmedical train­
experience optimal medical care. While currently no standard ing requirements and eliminate those that have little value.
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definition of clinical leadership exists, common themes men­ 4. Build clinical practice into staffing models for all leader­
tioned in the literature include clinical excellence and expertise, ship, administrative, and operational positions.

102 | JSOM Volume 22, Edition 3 / Fall 2022