Much to my family’s chagrin, the influence of British humor on my personality and sense of humor began as a preteen. I would stay up late at night for episodes of “Benny Hill” and my favorite, “Monty Python’s Flying Circus.” As a much older Army officer, I had somewhat recovered from my dry British satire fetish until I deployed to the British combat support hospital at Camp Bastion, Afghanistan, in 2009 and was redosed with episodes of Blackadder (and Cricket matches that still baffle me). My wife is now resigned to the fact that our conversations since are never really free of British comedic slapstick and anecdotes (You should pity her.).
The Monty Python “Firing Squad” skit has always been one of my favorite comedic bits.1 I have provided a link so readers can revel in this piece of comedy genius, but I will provide a brief (humorless) description of the sketch for the “won’t plays” in the audience. Imagine a clueless European traveler (Michael Palin) wandering in the former Soviet Union being picked up and thrown in the gulag for execution. The traveler remains ridiculously naïve to his situation, continuing to write in his travel log as the officer in charge of the firing squad (John Cleese) is preparing for his execution. The traveler, ever clueless, notes the line of riflemen in front of him and wonders what the target is? The order to fire is given, the guns discharge, and the officer turns to his firing squad and demands, “How could you all miss!” The bit progresses with Palin repeatedly being thrown back in his cell as Cleese’s riflemen continue to miss. This farce continues until Palin points out the riflemen are looking down the “Wrong part of the rifle sight.”
Working on large projects within the Military Health System leaves me often feeling like Palin, the traveler. The seemingly endless do-loop of committee approval process begins to feel like the project is continuously put against the wall to be shot (ended) but the merits of the program cause the committee to miss killing the project, and the program is thrown back into a cell awaiting the next committee. This process can and often does take years, and, just when a program has negotiated all the committees available, the governance and committee structure changes and the process begins anew (insert infinite sigh of hopelessness and despair here).
In moments of weakness, even though I am convinced of a project’s value to the services and the American taxpayer, I secretly pray for accurate aim from a given committee to render a coup de grace to the project, if only for the blessing of a clear, unambiguous decision rather than the living hell of endless death by “governance.”
If anything positive can be said about war, other than the advances in medicine forged in this poorest state of the human condition, it is the bureaucratic inertia that can be overcome during a “hot” war. I ache for the loss of life and waste I have witnessed in Iraq and Afghanistan but, forgive me, I sorely miss the clarity of purpose for medical operations during that time. If only we could have the latter without suffering the trauma of the former.
Decisions were made thoughtfully and efficiently with the best information available at the time to do “what was good for soldiers.” This was accomplished in the face of and despite the known unknowns and unknown unknowns, to channel a bit of Donald Rumsfeld. Were these decisions perfect? Absolutely not, but they were the best decisions at the time, and they got the job done while providing excellent practical experience for making better and more refined decisions in the future.
War, perhaps unlike any other human activity, teaches the terror of indecision using the calculus of lives lost. Blessed are the senior leaders with the guts and confidence to cut through the bureaucracy and make a decision (even a bad decision), act on it and call it their own, regardless of the outcome. That is a leader I want to follow, and fortunately I have been blessed with a few who fit this bill.
As our nation enters its 18th year of conflict in Afghanistan, with many other simmering conflicts globally, clarity of purpose that is reflected in action remains sorely needed to respond to the many challenges impacting federal medicine. Life expectancy in the United States has decreased for the third year in a row, mainly due to the ongoing opioid crisis, and the nation will be looking to the federal health system for leadership. Our system cannot afford to remain mired in endless governance process that for some officers has become the seat of purpose of their careers. Success for some is now measured in committee memberships and meetings attended rather than actual products or systems built.
As Chris Fussell, author of “Team of Teams: New Rules of Engagement for a Complex World,” states, “In any bureaucracy, there’s a natural tendency to let the system become an excuse for inaction.” I certainly understand that some bureaucracy is the cost of any meaningful human endeavor, for the alternative is chaos. That said, my new year’s call to action for federal medicine leaders and readers of this column is to take a serious look at the decision processes of your organization and ask the question, “Do my organization’s processes only begat more processes or new committees with no tangible or actionable decisions or products?”
I am convinced that my personal purgatory when I die will be an endless committee meeting concerning a painfully obvious course of action that will never be reached in a misguided attempt to discover the perfect decision. Federal medicine leadership should always be on guard against this hell on Earth.