LESSONS ON LEADERSHIP AND RESILIENCY LEARNED IN THE HANOI HILTON POW CAMP FROM JIM BAILEY, POW SURVIVOR.

     I am indebted to Dean Taylor, MD for inviting me to the Feagin Leadership Program Annual meeting at Duke University. The topic on RESILENCY was one that I often pondered but was seldom able to locate material or experts to learn from. One panel discussion was on Resiliency Lessons Learned in the Military presented by: 

CDR (Ret) James Bailey

MAJ (Ret) Scotty Smiley & Mrs. Tiffany Smiley
MG (Ret) Paul Lefebvre
 

Commander James (Jim) Williams Bailey told us his story on resiliency in surviving 2063 days in captivity in Hanoi during the Vietnam war (June 28, 1967 thru February 18, 1973). Over the past several years I have read much about the Survivor’s Personality as written by many, but have not had the experience to listen to or speak to anyone forced to endure long periods of POW imprisonment and still coming out alive. No doubt there is a characteristic makeup in Survivors compared to those who are unable to endure (see table below).

      To summarize a six-year period of imprisonment and constant threat of torture would not do justice to the story but that background is needed for perspective.  LTJG James W. Bailey was the “backseater” of an F4B Phantom being flown by CDR William P. "Bill" Lawrence (commanding officer of Fighter Squadron 143 onboard the USS Constellation) as they were flying a mission over Nam Dinh, North Vietnam on 28 June 1967, when their aircraft was hit by enemy fire and the crew was forced to eject. Lawrence and Bailey were captured by the North Vietnamese. Bailey was held prisoner from June 1967 to February 1973. During that time, he and the other prisoners at the “Hanoi Hilton” were continually threatened with torture DAILY with no end in sight. While there were periods during this imprisonment he believed he would be release, each potential release was met with disappointment. Jim Bailey survived this ordeal by maintaining a set of personal rules as follows:

·         Deal with the isolation and hopelessness, because it will overtake you if you cannot manage it.  One day Jim assessed his situation and came to realize “You’re in a bad place” but “self-pity is the most destructive attitude a person can have.”
·         Maintain situational awareness. Be constantly aware of what you are doing and especially what you are saying.
·         Set goals and routines to keep on track. You dont want to sit idle and begin to overthink your situation
·         Keep a sense of humor as it will keep the hope and encourage others..
·         Accept circumstances beyond your control. There is nothing you could have done or can do so get over it and move on.
·         Learn to become stronger after each setback - each period of torture. Learn to Bounce back!
 

Others such as Leon Ellis (author of Leading with Honor: Leadership Lessons from the Hanoi Hilton– January 7, 2014) revealed similar survival traits and advice such as:

·         Know yourself
·         Guard your character
·         Clarify and build the culture- purpose, value acceptable behavior- courage
·         Confront your doubts and fears
 

I really appreciate Commander Bailey talking with us… this really hit home with me…. Not that I have had to endure anything even close to that, but have had a few harrowing experiences… These prompted me to look around to see about the survivor’s character.

Laurence Gonzalez and others have written much on the topic of the survivors’ trait and I found it interesting to see a real pattern in those who make it and those who just give in.

So I was hoping to chat with Commander Bailey at some point on:

1.    how have you used these lessons to teach young leaders to practice this?

2.    How do you teach the survivor’s personality – is it teachable? Can you train others to develop this character over time? or is it a situation where you are born with it or without it?

3.    How has this helped in furthering other leadership training you have done professionally or personally?

Hopefully he and I will connect and discuss this.

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

Survivability: The Survivor’s Personality
 Versatile/Tolerate change  Organized  Rational but hopeful  Empathetic:  Observant  Purposeful  Healthy	 Calm: Humble but self-confident  Help others  Self-Reliant  Resilient o Influence o Meaningful purpose o Open minded
Survivability: The Survivor’s Personality 71, 133, 136.

LESSONS ON LEADERSHIP AND RESILIENCY LEARNED IN THE HANOI HILTON POW CAMP FROM JIM BAILEY, POW SURVIVOR.

     I am indebted to Dean Taylor, MD for inviting me to the Feagin Leadership Program Annual meeting at Duke University. The topic on RESILENCY was one that I often pondered but was seldom able to locate material or experts to learn from. One panel discussion was on Resiliency Lessons Learned in the Military presented by: 

CDR (Ret) James Bailey

MAJ (Ret) Scotty Smiley & Mrs. Tiffany Smiley
MG (Ret) Paul Lefebvre
 

Commander James (Jim) Williams Bailey told us his story on resiliency in surviving 2063 days in captivity in Hanoi during the Vietnam war (June 28, 1967 thru February 18, 1973). Over the past several years I have read much about the Survivor’s Personality as written by many, but have not had the experience to listen to or speak to anyone forced to endure long periods of POW imprisonment and still coming out alive. No doubt there is a characteristic makeup in Survivors compared to those who are unable to endure (see table below).

      To summarize a six-year period of imprisonment and constant threat of torture would not do justice to the story but that background is needed for perspective.  LTJG James W. Bailey was the “backseater” of an F4B Phantom being flown by CDR William P. "Bill" Lawrence (commanding officer of Fighter Squadron 143 onboard the USS Constellation) as they were flying a mission over Nam Dinh, North Vietnam on 28 June 1967, when their aircraft was hit by enemy fire and the crew was forced to eject. Lawrence and Bailey were captured by the North Vietnamese. Bailey was held prisoner from June 1967 to February 1973. During that time, he and the other prisoners at the “Hanoi Hilton” were continually threatened with torture DAILY with no end in sight. While there were periods during this imprisonment he believed he would be release, each potential release was met with disappointment. Jim Bailey survived this ordeal by maintaining a set of personal rules as follows:

·         Deal with the isolation and hopelessness, because it will overtake you if you cannot manage it.  One day Jim assessed his situation and came to realize “You’re in a bad place” but “self-pity is the most destructive attitude a person can have.”
·         Maintain situational awareness. Be constantly aware of what you are doing and especially what you are saying.
·         Set goals and routines to keep on track. You dont want to sit idle and begin to overthink your situation
·         Keep a sense of humor as it will keep the hope and encourage others..
·         Accept circumstances beyond your control. There is nothing you could have done or can do so get over it and move on.
·         Learn to become stronger after each setback - each period of torture. Learn to Bounce back!
 

Others such as Leon Ellis (author of Leading with Honor: Leadership Lessons from the Hanoi Hilton– January 7, 2014) revealed similar survival traits and advice such as:

·         Know yourself
·         Guard your character
·         Clarify and build the culture- purpose, value acceptable behavior- courage
·         Confront your doubts and fears
 

I really appreciate Commander Bailey talking with us… this really hit home with me…. Not that I have had to endure anything even close to that, but have had a few harrowing experiences… These prompted me to look around to see about the survivor’s character.

Laurence Gonzalez and others have written much on the topic of the survivors’ trait and I found it interesting to see a real pattern in those who make it and those who just give in.

So I was hoping to chat with Commander Bailey at some point on:

1.    how have you used these lessons to teach young leaders to practice this?

2.    How do you teach the survivor’s personality – is it teachable? Can you train others to develop this character over time? or is it a situation where you are born with it or without it?

3.    How has this helped in furthering other leadership training you have done professionally or personally?

Hopefully he and I will connect and discuss this.

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

Survivability: The Survivor’s Personality
 Versatile/Tolerate change  Organized  Rational but hopeful  Empathetic:  Observant  Purposeful  Healthy	 Calm: Humble but self-confident  Help others  Self-Reliant  Resilient o Influence o Meaningful purpose o Open minded
Survivability: The Survivor’s Personality 71, 133, 136.

COMMUNICATION AND TEAMWORK FAILURE AS A BARRIER TO ROBOTIC SURGICAL SAFETY- A call with MARCO A. ZENATI

COMMUNICATION AND TEAMWORK FAILURE AS A BARRIER TO ROBOTIC SURGICAL SAFETY MARCO A. ZENATI

In their recent communication ‘Communication and Teamwork Failure as a Barrier to Robotic Surgical Safety ‘ Marco Zenati makes some excellent observations in his summary of the issues surrounding communication and teamwork in the cardiac surgery suite:

1.      The difficulty level of team communication increases as the number of health care providers involved in patient care increases.

2.      Team communication failures are widespread in the CV OR suites inevitably being associated with poor operative performance and patient injury.

3.      The specialty field of cardiac surgery is a dangerous and complex area… in recent years cardiac surgery has experienced a growing complexity of its case mix due to increasing patients’ age, co-morbidities, and introduction of advanced robotic technology. The advent of robotics reduces Surgeon situational awareness due to the narrow visual field and preoccupation of the computer screen as well as distance and obstructions to verbal communication.

4.      Weigmann found that cardiac surgeons make an average of 3.5 errors per hour (2007)

5.      El-Bardissi observed a strong correlation between the occurrence of technical errors and teamwork failures (51% of teamwork failures affected surgeon-technical team interactions).

6.      Surgical Safety should not be assumed by good clinical outcomes- that is, a good outcome may result in spite of a safety issue. When the outcome is good we tend to be blind to the safety issues (Outcome bias). Dr. Zenati then recommends that a common terminology be used to assure that we are accounting for adverse events whether they result in a bad outcome or not:

a.      System Vulnerability: exposure to or opportunity for an adverse event

b.      Safety-compromising Event: Aka near miss, where there is a variation in the expected course of care that has a potential negative effect on patient safety and puts the patient at risk for a measurable adverse change

c.       Contributing factor: conditions or properties that increase the vulnerability of the system increasing the risk for an adverse event.

d.      Compensatory factor: the condition or property that decreases the vulnerability of the system or reduces the severity of an adverse event.

7.      While non-technical skills (like communication, teamwork, decision making, leadership and situational awareness) have been associated improved outcomes, until recently these skills were only trained and assessed informally in healthcare.  Development of behavior rating systems in healthcare (NOTSS, ANTS, SPLINTS) are on the rise but not in use universally.

8.      Team situational-related communication events are directly associated with team situational awareness: Closed Loop Communication is extremely effective if utilized correctly and uniformly.

         I was very interested in reading this paper as it hit home as I recalled a conversation with Dr. Eghtesady in 2015 regarding their black box paper Application of the Aviation Black Box Principle in Pediatric Cardiac Surgery: Tracking All Failures in the Pediatric Cardiac. In that paper and in our conversation he revealed that healthcare staff is frequently inattentive even in the midst of critical phases in events: “videotaping the OR environment revealed how often individuals were not paying attention, despite their impression otherwise.”  This attitude appeared to have occurred during critical event phases as well.  With our knowledge of the importance of communication and situational awareness, revelations such as that are frightening as hell.

       Recently Dr. Zenati’s group presented a paper on the use of the HUB system as a workflow management system to use speech recognition software to record communication between OR personnel in the midst of complex communication processes. Using this software, critical steps and sub-steps were tracked and episodes of communication breakdown noted and staff alerted.

      In my conversation with Dr. Zenati, I wondered how successful he has been at resolving these communication gaps and improving his personal and the team’s situational awareness.

What other techniques is he using to engage his team? What is working there that is failing most other places?

      Dr. Zenati: “it’s a challenge….” Patient safety is at the front of everyone’s mind, but everyone is busy to it is not easy to motivate people to participate in safety research projects. Having said that, as an academic institution they have protocols for projects they are interested in, which translates to motivation of surgery and anesthesia coworkers to become involved as co-authors or to produce other papers.

       Regarding the HUB – “with the advent of complex procedures there is the potential for increased communication and other error”.  The HUB is a programed system for various common procedures. The system is set to recognize the various steps in the procedure while it is tracking key conversational components. It will remind you of the various steps and alert you if there is any variance.  The program guides you through complex decision processes. The system knows the commands for the initiation of the portion of the procedure as stated by the team (such as “AP ultrasound of aorta completed”). The system is also equipped with a timer to assess that specific critical components are done at the appropriate time and provide feedback during and at the end of the procedure. The system can filter out ancillary conversation and you can customize it with your own vocabulary.  At the end of the procedure it will provide a synoptic report for feedback to determine where you are or are not in compliance. They have found it very useful in very complex procedures where multiple teams are involved and the risk for communication breakdown is very high. It also has proven useful to assist trainees in process improvement.

        So what could be next on Dr. Zenati’s research plate? They have a grant to begin tracking surgical disruptions using vision tracking technology to assess the degree surgeons are distracted during these disruptions. In addition, Boston is hosting the first AATS (American Association of Thoracic Surgery) Surgical Patient Safety Course: led by  Thoralf M. Sundt, III, MD (Massachusetts General Hospital ) and Steven J. Yule, PhD (Brigham and Women’s Hospital) June 24-15 2016. (http://www.aats.org/patientsafety/). The agenda includes the following:

-Use a non-technical skills taxonomy to assess behavior in a simulated video scenario

-Recognize the challenges and limitations of Human Factors approaches to the assessment of SA

-Identify common causes of and factors associated with medical errors in cardiac surgery

-Develop mechanisms to collate and analyze error causation

-Implement effective communication tools between and within teams, e.g. preoperative briefings, postoperative debriefings, and hand-offs

Steve Yule and I conversed about leadership skills previously this year, so this would be an excellent course for those interested in leadership development in their institutions.

 

 

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

 

Zenati MA, Maron JK. Communication and Teamwork Failure as a Barrier to Robotic Surgical Safety Proceedings of the Third Computer and Robotic Assisted Surgery (CRAS) Workshop. 2013.

 

Bowermaster R, Miller M, Ashcraft T, Boyd M, Brar A, Manning P, Eghtesady P. Application of the Aviation Black Box Principle in Pediatric Cardiac Surgery: Tracking All Failures in the Pediatric Cardiac Operating Room. J Am Coll Surg 2015;220:149-155.

COMMUNICATION AND TEAMWORK FAILURE AS A BARRIER TO ROBOTIC SURGICAL SAFETY- A call with MARCO A. ZENATI

COMMUNICATION AND TEAMWORK FAILURE AS A BARRIER TO ROBOTIC SURGICAL SAFETY MARCO A. ZENATI

In their recent communication ‘Communication and Teamwork Failure as a Barrier to Robotic Surgical Safety ‘ Marco Zenati makes some excellent observations in his summary of the issues surrounding communication and teamwork in the cardiac surgery suite:

1.      The difficulty level of team communication increases as the number of health care providers involved in patient care increases.

2.      Team communication failures are widespread in the CV OR suites inevitably being associated with poor operative performance and patient injury.

3.      The specialty field of cardiac surgery is a dangerous and complex area… in recent years cardiac surgery has experienced a growing complexity of its case mix due to increasing patients’ age, co-morbidities, and introduction of advanced robotic technology. The advent of robotics reduces Surgeon situational awareness due to the narrow visual field and preoccupation of the computer screen as well as distance and obstructions to verbal communication.

4.      Weigmann found that cardiac surgeons make an average of 3.5 errors per hour (2007)

5.      El-Bardissi observed a strong correlation between the occurrence of technical errors and teamwork failures (51% of teamwork failures affected surgeon-technical team interactions).

6.      Surgical Safety should not be assumed by good clinical outcomes- that is, a good outcome may result in spite of a safety issue. When the outcome is good we tend to be blind to the safety issues (Outcome bias). Dr. Zenati then recommends that a common terminology be used to assure that we are accounting for adverse events whether they result in a bad outcome or not:

a.      System Vulnerability: exposure to or opportunity for an adverse event

b.      Safety-compromising Event: Aka near miss, where there is a variation in the expected course of care that has a potential negative effect on patient safety and puts the patient at risk for a measurable adverse change

c.       Contributing factor: conditions or properties that increase the vulnerability of the system increasing the risk for an adverse event.

d.      Compensatory factor: the condition or property that decreases the vulnerability of the system or reduces the severity of an adverse event.

7.      While non-technical skills (like communication, teamwork, decision making, leadership and situational awareness) have been associated improved outcomes, until recently these skills were only trained and assessed informally in healthcare.  Development of behavior rating systems in healthcare (NOTSS, ANTS, SPLINTS) are on the rise but not in use universally.

8.      Team situational-related communication events are directly associated with team situational awareness: Closed Loop Communication is extremely effective if utilized correctly and uniformly.

         I was very interested in reading this paper as it hit home as I recalled a conversation with Dr. Eghtesady in 2015 regarding their black box paper Application of the Aviation Black Box Principle in Pediatric Cardiac Surgery: Tracking All Failures in the Pediatric Cardiac. In that paper and in our conversation he revealed that healthcare staff is frequently inattentive even in the midst of critical phases in events: “videotaping the OR environment revealed how often individuals were not paying attention, despite their impression otherwise.”  This attitude appeared to have occurred during critical event phases as well.  With our knowledge of the importance of communication and situational awareness, revelations such as that are frightening as hell.

       Recently Dr. Zenati’s group presented a paper on the use of the HUB system as a workflow management system to use speech recognition software to record communication between OR personnel in the midst of complex communication processes. Using this software, critical steps and sub-steps were tracked and episodes of communication breakdown noted and staff alerted.

      In my conversation with Dr. Zenati, I wondered how successful he has been at resolving these communication gaps and improving his personal and the team’s situational awareness.

What other techniques is he using to engage his team? What is working there that is failing most other places?

      Dr. Zenati: “it’s a challenge….” Patient safety is at the front of everyone’s mind, but everyone is busy to it is not easy to motivate people to participate in safety research projects. Having said that, as an academic institution they have protocols for projects they are interested in, which translates to motivation of surgery and anesthesia coworkers to become involved as co-authors or to produce other papers.

       Regarding the HUB – “with the advent of complex procedures there is the potential for increased communication and other error”.  The HUB is a programed system for various common procedures. The system is set to recognize the various steps in the procedure while it is tracking key conversational components. It will remind you of the various steps and alert you if there is any variance.  The program guides you through complex decision processes. The system knows the commands for the initiation of the portion of the procedure as stated by the team (such as “AP ultrasound of aorta completed”). The system is also equipped with a timer to assess that specific critical components are done at the appropriate time and provide feedback during and at the end of the procedure. The system can filter out ancillary conversation and you can customize it with your own vocabulary.  At the end of the procedure it will provide a synoptic report for feedback to determine where you are or are not in compliance. They have found it very useful in very complex procedures where multiple teams are involved and the risk for communication breakdown is very high. It also has proven useful to assist trainees in process improvement.

        So what could be next on Dr. Zenati’s research plate? They have a grant to begin tracking surgical disruptions using vision tracking technology to assess the degree surgeons are distracted during these disruptions. In addition, Boston is hosting the first AATS (American Association of Thoracic Surgery) Surgical Patient Safety Course: led by  Thoralf M. Sundt, III, MD (Massachusetts General Hospital ) and Steven J. Yule, PhD (Brigham and Women’s Hospital) June 24-15 2016. (http://www.aats.org/patientsafety/). The agenda includes the following:

-Use a non-technical skills taxonomy to assess behavior in a simulated video scenario

-Recognize the challenges and limitations of Human Factors approaches to the assessment of SA

-Identify common causes of and factors associated with medical errors in cardiac surgery

-Develop mechanisms to collate and analyze error causation

-Implement effective communication tools between and within teams, e.g. preoperative briefings, postoperative debriefings, and hand-offs

Steve Yule and I conversed about leadership skills previously this year, so this would be an excellent course for those interested in leadership development in their institutions.

 

 

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

 

Zenati MA, Maron JK. Communication and Teamwork Failure as a Barrier to Robotic Surgical Safety Proceedings of the Third Computer and Robotic Assisted Surgery (CRAS) Workshop. 2013.

 

Bowermaster R, Miller M, Ashcraft T, Boyd M, Brar A, Manning P, Eghtesady P. Application of the Aviation Black Box Principle in Pediatric Cardiac Surgery: Tracking All Failures in the Pediatric Cardiac Operating Room. J Am Coll Surg 2015;220:149-155.

RESILIENCE AND BURNOUT: LESSONS FROM DR. WAYNE SOTILE PHD AT THE ANNUAL FEAGIN LEADERSHIP CONFERENCE DUKE UNIVERSITY.

RESILIENCE AND BURNOUT: LESSONS FROM DR. WAYNE SOTILE PHD AT THE ANNUAL FEAGIN LEADERSHIP CONFERENCE DUKE UNIVERSITY.

 

    I am indebted to Dean Taylor, MD for inviting me to the Feagin Leadership Program Annual meeting at Duke University. The topic on RESILENCY was one that I often pondered but was seldom able to locate real experts to learn from. After our surprise visit from Coach Mike Krzyzewski, Wayne Sotile, PhD, discussed the role of building resistance to BURNOUT as a key process when developing a resilient leader.

    The first shocker came when Dr. Sotile explained that the development of a ‘balanced’ life is a MYTH. All we ever hear is how we need to balance our lives. He stated that inevitably what occurs when one tries to balance out work, family, themselves and an intimate relationship, is that you and those around you end up feeling angry, guilty or anxious, which is certainly not the model of a “balanced” life. Unfortunately, surgical professionals are at the top of the “most likely to be burnt out” list, so it behooves us to understand and take charge of this process. So why are medical professionals and especially surgeons so prone to burnout? As expected we are all high producers used to high demands. When we have high control we do great, but when we begin to lose control, then the stress levels go up. What happens when we are stressed? We get temperamental, angry, distressed and develop reduced mental processing powers: we “get mean and stupid”. What happens when we become mean, stupid and narcissistic? Those around us hate us and then we fight each other.

        So who suffers when physicians hit the burnout threshold? Well asides from us and our families, it turns out that our patients and teammates suffer. There have been multiple studies that correlate signs and symptoms of burnout to reduced quality of care due to an increase in medical errors, increase in litigations, and decrease in patient compliance and satisfaction.

    How do we know if we are burnt out? Dr. Sotile said that is easy, just look into the eyes of the ones we love, our teammates and our patients. If you see a look of distrust, then rest assured you are burnt out. If you are feeling guilty over or stressed over or arguing over priorities in your daily life…. You are burnt out.

    Is there anything we can do about this? The obvious choice is to blame and correct the system: increase efficiency and support, reduce documentation burden, develop leaders who foster engagement, work on our community,…. And on and on…. Dr. Sotile said that ultimately, you need to look into yourself and find what you personally can do for any real change to occur. Sure, you cannot control 90% of the stuff going on around you but if you really want to make a stance, figure out what 10% you can change. To make any changes you need to: “use realistic roadmaps. Honestly assess yourself. Counter hassles with uplifts, and deepen your relationships.”

 

At the end of it all Dr. Sotile left us with these messages to take home:

“Face what is beneath your feet not what you are grasping for.”

“ You don't just decide to be resilient…You need health, You need collaboration, you need career satisfaction, you need family satisfaction and to have that you must be satisfied at work.”

“It's not the number of hours you work but your attitude when you come home that affects your family- in the end you will see that, how you treat someone at work affects how they react when they get home.” So be nice to one another.

“Little changes (in your thinking, behavior, self-care, and ways of dealing with others) go a long way.”

“Find meaning- see the familiar in unfamiliar way”

“Rethink balance- only inanimate objects have balance. Don't mix your obligations - switch rocks regularly.”

“Look for joy in others- don't ruin it.”

“Don't share irritability, anger...”

“Give gratitude.”

“Enjoy moments of serenity.”

“Believe, have hope and have Interest.”

“Find Amusement, wonderment, pride, awe, and love as often as you can”.

 

 

After discussing this summary with Dr. Sotile, I had a few questions

• In dealing w very busy, very focused, and very skeptical physicians- what's the one thing you do that captures their attention to instill the desire to make a change (assuming they were not deemed a disruptive physician and this was recommended to them)?
• As one takes on additional roles from being a clinician and family partner and parent to include major leadership roles (Department Chair or Chief Surgery) you essentially have gone from two to three "competing" interests all of which are equally important. What's your advice to the leaders about making sure everyone senses that you have not deprioritized them- that is you are not even more distant?
• It's easy to say "I don't sweat the small stuff" but in family, clinical care and organizational leadership, what you class as the "small" stuff likely is not small to your patients, family, or organization. So how does one prioritize three seemingly non-intertwined worlds?

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com