Chester “Trip” Buckenmaier III, MD,
COL (ret.), MC, USA

I recently took in the movie “Hacksaw Ridge” with my wife. Starring Andrew Garfield and directed by Mel Gibson, the movie dramatizes the heroics of Cpl. Desmond Thomas Doss (1919-2006), who served as a combat medic with the 77th Infantry Division in the Pacific theater of World War II, despite being a conscientious objector who refused to carry a weapon in combat. He is the first and only conscientious objector (he was a devout Seventh-day Adventist) to receive the Medal of Honor during that war. During a fierce battle on the island of Okinawa in 1945 against entrenched Japanese forces, Doss was credited with rescuing 75 casualties single-handedly from enemy-controlled ground, and doing so without a weapon in the face of intense enemy fire. 

He would go on in the ensuing days to be credited with many other acts of conspicuous gallantry as a combat medic before being wounded himself and evacuated. The movie version of events does an admirable job of conveying Doss’ dogged determination in an overwhelming situation. I certainly cannot know Doss’  mind as he performed these superhuman deeds, but common sense and prevailing wisdom would suggest he was playing an exceedingly dangerous game with his life. In a short interview with an elderly Doss at the end of the movie, he describes being focused at that time on “getting just one more casualty,” to the exclusion of all other concerns. Doss had a mission to save soldiers’ lives, and he was not going to allow the circumstances confronting him, to include withering enemy fire, to dissuade him from his vital work. He avoided ultimate failure by staying focused on a goal and refusing to quit. 

I was not aware of Doss’ story until this movie, and his story struck a chord deep within me. From his extreme story we can derive helpful lessons and patterns of behavior as we strive to be successful in the overwhelming and at times paralyzing bureaucracy called the federal health system. Personally I do battle with our system, trying to make improvements in the field of pain medicine while sustaining seemingly endless failures.

I am certainly not suggesting my situation is comparable to Doss’; any actual shots I have heard fired in anger were poorly aimed and never fired directly at me. I fight the battle of ideas in a bureaucratic system where the chief enemies are apathy and sloth. I do think a page from Doss’ playbook can be useful though, when tilting Don Quixote-style at federal medicine bureaucratic “windmills,” I know from personal experience that effecting change in our system can be agonizingly slow and frustrating. Even when an idea for change is generally agreed upon as good for our patients, implementing that change in the system at large within the time frame of one’s career can be a daunting and seemingly impossible task. Granted, changing the federal system is not as difficult as dragging 75 wounded soldiers from an enemy-infested battlefield where the cost of failure is death, but the metaphor plays well, and the feelings of helplessness in the face of overwhelming odds are recognizable. 

Winston Churchill (1874 -1965) reminds us that, “Success is stumbling from failure to failure with no loss of enthusiasm.” There is a part of me that finds it a bit creepy that he predicted so much about my typical federal medicine workday. I am not talking about my clinical workdays, where knowing the best course of action medically with a patient is usually not difficult and often intensely satisfying. I am speaking of affecting general change in the federal system through which that care is delivered. In that context, I think what Doss and Churchill were trying to help us understand is the beauty of persistence and devotion to a goal despite prevailing wisdom and pressure to admit failure and quit. Persistence is the single most effective weapon against the inertia within our system that bogs down constructive change. 

I imagine many within the federal medicine system are lamenting recent political upheavals and are unsure if the “juice” from their efforts is “worth the continued squeeze.” It may seem a more prudent course of action to keep one’s head down, avoid controversy and retreat to the anonymity of our large system. I sincerely hope that, for you, dear U.S. Medicine reader, this approach will not be the case in 2017. We cannot lament the issues challenging our patients and mediocrity within our systems if we are not willing ourselves to be agents of positive change. We all need to redouble our efforts at tilting at bureaucratic windmills and even dare to fail, so we can continue to achieve, in time, the excellence in medicine our servicemembers and families have come to expect and most certainly deserve.