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Leadership Education and Development at the Uniformed Services University COL Francis G. O ’Connor, MC USA*; Neil Grunberg, PhD*; Arthur L. Kellermann, MD, M P H f; LTG Eric Schoomaker, MC USA (Ret.)* INTRODUCTION The mission of the Uniformed Services University (USU) is to train, educate, and prepare uniformed services health profes sionals, officers, and leaders to directly support the Military Health System (MHS), the National Security, and National Defense Strategies of the United States and the readiness of our Armed Forces.1 USU’s commitment to this mission has not wavered since the school was founded in 1972. When the legislation that established USU was drafted, USU’s sup porters in Congress envisioned that its graduates would form the backbone of the MHS. In this way, it was anticipated that USU would serve for the MHS what the Service academies— the U. S. Military Academy, the Naval Academy, the Air Force Academy, and the Coast Guard Academy—played for the nonmedical line. Today, 42 years after USU opened its doors, its 5,000-plus alumni have validated this vision. Over this time span, USU has contributed greatly to the MHS, with growing numbers of physician, nurse, and allied health alumni rising to key roles.2’3 Recognizing the Department of Defense’s (DoD) growing interest in leadership training, USU’s faculty and administra tion recently examined the content, quality, and impact of the training we provide our students to prepare them for the challenges the MHS will face. As we undertook this critical work through a task force charged with adapting and refining the USU Strategic Framework, we asked ourselves how well USU fosters six core leadership attributes required of future military leaders: (1) understand the environment and the effect of all instruments of national power; (2) anticipate and adapt to surprise and uncertainty; (3) recognize change and lead tran sitions; (4) operate on intent through trust, empowerment, and understanding; (5) make ethical decisions based on the shared values of the medical, nursing, and dental professions bal anced with the Profession of Arms; and (6) think critically and strategically in applying health services support to joint warfighting principles and concepts in joint operations.2'3 In this manuscript, we describe USU’s approach to leadership development. Our program of instruction and experiential learning is designed to meet the Chairman of the Joint Chiefs of Staff, General Dempsey’s challenge of providing skilled leaders to the MHS to support the mission(s) of the DoD4,5 *Department of Military and Emergency Medicine. Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. tDean, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. doi: 10.7205/MILMED-D-14-00563
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THE LEADERSHIP CHALLENGE “USU must lead and excel in Leadership Training” Dr. Jonathan Woodson, March 4, 2014 Assistant Secretary of Defense for Health Affairs. At the inaugural meeting of USU’s 2014 Strategic Frame work Task Force, DoD Assistant Secretary Woodson chal lenged the faculty and staff of USU to embrace leadership training as a key element of its mission. Dr. Woodson made it clear that USU’s success would be judged by its ability to produce highly skilled uniformed health care providers and by its capacity to produce leaders who are capable of overcoming the managerial and leadership challenges that confront the MHS. He outlined three core requirements for this activity: (1) create officers who are the foundation for the future, (2) establish an unquestioned set of values, and (3) outpace any institution in the world in leadership training. Dr. Woodson’s vision of USU as the “leadership academy of the MHS” is completely consistent with USU President Dr. Charles Rice’s vision for the University: By the end of CY 2018, the USU of the Health Sciences will be widely recognized as the pre-eminent national educational institu tion for the creation of career uniformed services leaders in the health sciences who are prepared to serve the nation and support the readiness of the uniformed services. USU will be a central hub for uniformed services-related health education and training, research and scholarship, “leadership education and training,” and national security as it relates to global health. Each USU graduate will be a "health and health care professional and leader” prepared with an outstanding health education, inter-professional health training, “leader ship training,” and a deep and abiding commitment to self less service, the uniformed services ethos, and the security of the United States. USU’s emphasis on leadership is not limited to the School of Medicine. The University’s Daniel K Inouye Graduate School of Nursing (GSN) includes a rigorous leadership course in its Doctor of Nursing Practice (DNP) training pro gram. Both schools, along with USU’s Post-Graduate Dental College (PGDC) are striving to find means by which leader ship education and training between and among the schools can be jointly planned and conducted. The focus of this manu script is on current efforts to optimize leadership training within the School of Medicine (SOM). Because USU is dedi cated to inter-professional training, the SOM works closely with the GSN and PGDC to promote leadership development in every health care discipline.
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LEADERSHIP PARTNERS Military and Emergency Medicine The Department of Military and Emergency Medicine (MEM) has the academic responsibility in the University and the SOM to develop, implement, and oversee the curriculum in leader ship, officership, and military professionalism (Fig. 1). MEM has synthesized core values from the Services to develop operational definitions for leadership, officership, and profes sionalism. “Leadership” is influencing people by providing purpose, direction, and motivation. It is the sum of the quali ties of intellect, human understanding, and moral character to enhance the motivations, cognitions, and behaviors of individuals and groups to accomplish the assigned mission. “Officership” is a set of skills that allows one to function effectively as an officer in the uniformed services. Underlying officership are principles, practices, and values that guide an officer’s judg ment, decisions, behavior, philosophy, and vision. “Profession alism” includes critical attributes: personal courage, respect, openness, fairness, empathy, self-improvement, social respon sibility, integrity, honor, officership, nonjudgment, altruism, and leadership. The Chair of MEM is currently designated as the professor of military science, and is charged with overseeing the military medicine program of instruction for the SOM. The Chair and faculty of MEM report to the Dean, SOM. MEM’s intent is best expressed through the following mission and vision statements: Mission
"The mission of MEM is to train, educate, and prepare USU SOM students to support and ‘lead’ in operational and emer gency medicine environments in the U. S. Armed Forces, while
advancing the knowledge and practice of military medicine and supporting the overall mission of the SOM and University.” Vision
“To serve USU and the Nation as the pre-eminent academic department for the study, advancement, and application of operational arts and military health optimization, education in emergency medicine and ‘military medical leadership,’ while inspiring lifelong learning and a career of service.” Other Academic Departments in the SOM
Although MEM serves as the lead and the academic home for leadership, officership, and military professionalism in the SOM, all other academic departments play a critical role. The education and development of SOM students, as well GSN and PGDC, in leadership, officership, and professionalism is the responsibility of all University faculty and staff, particularly those in uniform. Faculty members from several SOM basic and clinical science departments (e.g., Medical and Clinical Psychology Department, Family Medicine, Preventive Medi cine, Medicine, Surgery), from the USU GSN, and from USUaffiliated Centers (e.g., Consortium for Health and Military Performance [CHAMP], Center for Disaster and Humanitarian Assistance [CDHAM]), also contribute to the MEM leadership curriculum and training experiences and coordinate with the USU Brigade (uniformed staff and faculty). Examples of related topics taught in the SOM that involve leadership, officership, and military professionalism are medical ethics and human con text in medicine. MEM functions as the lead to coordinate, synchronize, integrate, and reinforce this curriculum across all departments and across all 4 years of medical school. The Brigade
The Brigade, and particularly the Commandant of the SOM, plays a critical role in leadership, officership, and military professionalism in the SOM and other schools within the uni versity. This oversight role assures that students adhere to basic military requirements and standards of behavior expected of uniformed officers and is accomplished by fostering the appro priate military culture in the University. In addition, the Brigade staff participates in the implementation of the academic curricu lum as faculty members. The Brigade also has oversight of active duty faculty and staff and ensures that they are appropriate role models for students. MEM as the academic home, and the Brigade as the military command structure, are strategic partners and it is imperative that the academic curriculum is synchro nized with and, ideally, is integrated with the activities of the Brigade to achieve a common and coordinated approach. Office o f Student Affairs
FIGURE 1.
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USU MEM Leadership Model.
Office of Student Affairs (OSA) is responsible for coordinat ing and managing student experiences across all 4 years and works particularly closely with the faculty and Brigade when ever a student encounters life challenges, needs remediation, or merits academic deceleration. MEM, therefore, works closely and synergistically with OSA in the development and
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Leadership Education and Development at the Uniformed Services University
implementation of this curriculum, particularly when students need additional support or remediation. Leadership Curriculum This curriculum is based primarily on principles and approaches to officership, leadership, and military professionalism for all the military services but is tailored to the unique circumstances and educational program of USU, the SOM, and preparation to serve in the Military Health System (MHS). The academic basis of the curriculum draws upon many sources including service-specific policy and guidance for line officers; Joint doctrine, the academic literature on leadership and profes sionalism (particularly as it relates to health care); Liaison Committee on Medical Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), USU, and SOM policy and guidance; faculty expertise and experi ences; and current best practices in medical and military education and practice. The program of instruction is accom plished over 4 years of instruction. The curriculum is designed to prepare military medical stu dents for the initial operational assignments they are likely to have as general medical officers after internship or following residency, while also establishing the foundation for a career of leadership in military medicine. This curriculum is focused primarily on the medical officer in the operational setting. The curriculum provides critical knowledge, skills, and attitudes applicable to leadership in military treatment facilities and other nonoperational environments as well. The curriculum is built on core attributes of effective and ethical leadership and officership, including: — — — — — — — — — — — — — — — — —
Knowledge of self Adherence to core values Personal mission and vision Adherence to fundamental military standards and behaviors Physical, mental, and emotional fitness Effective followership Communication skills Conflict resolution Teamwork and teambuilding Problem solving and decision making Planning and organization Mission focus Technical competence Resource stewardship Risk analysis and focus on safety Development and welfare of subordinates Relationship with the line, the American public, and its elected representatives
Our curriculum is also based on the idea that for career military medical officers to progress as an officer and leader, they must first master the basic knowledge, skills, and attitudes required of a junior medical officer right out of medical school. Over time, a capable officer can build on these core attributes and develop the necessary skills to hold a senior staff position or even command a large military medical organization. To
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FIGURE 2.
U.S. Air Force Academy PITO Model.
accomplish these goals, students must develop and function on a continuum that starts with leading oneself at the indi vidual level and ends with leading others in large, complex organizations. This concept is based on the Air Force Academy’s Leadership Development "PITO” model (personal, interper sonal, team, and organization)6 (Fig. 2). In the PITO approach, the personal or individual traits at one end of the continuum refer to the core values, knowledge of self, accountability, professionalism, and other basic indi vidual attributes (Fig. 3). The next phase of the continuum centers on the interpersonal communication, conflict resolu tion. and basic followership skills that allow one to function effectively as a member of a group or small team. The next level in the continuum focuses on the additional skills, par ticularly leadership skills, necessary to be successful when leading or influencing a small team, such as a ward team or a battalion aid station. At this stage, additional abilities in organization and planning, building teams, and problem solving are important. At the top tier of the continuum are the more advanced abilities in all of these areas that are required to successfully lead and manage a larger team, such as a clinical service or even a large complex organization— whether a deployed military medical unit, a combat support hospital or a brick-and-mortar health care organization. Although this curriculum is oriented to the military medical officer in an operational setting, the knowledge, skills, and attitudes are highly applicable to the more conventional clini cal environment and will serve to reinforce the leadership, officership, and professionalism required in the practice of clinical medicine. The leadership curriculum is designed to be fully coordinated, synchronized and, ideally, integrated with
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FIGURE 3.
MEM Leadership Curriculum.
the new medical student curriculum at USU. Although leader ship, officership, and military professionalism is at times explicitly taught and discussed, it also is integrated into the rest of the curriculum and reinforced in the School’s curricu lum. For example, relying on the student chain of command to ensure all students are prepared to attend USU’s annual Antietam Road March and are present and accounted for puts small team followership and leadership into daily practice. There are a myriad of such opportunities over the 4 years of medical school; no opportunity to exercise leadership or responsible followership should be overlooked. In addition, as is true of USU's curriculum overall, our approach uses a wide variety of educational modalities, including small group discussions, individual and team-based problem solving, criti cal analysis, simulations, laboratory/tabletop exercises, field application, and other experiences. By the time of graduation, our students are expected to be fully proficient in the first two phases (as an individual and small-team member), and prepared to assume the role of small-team leader at the first opportunity. Our graduates are also provided with the foundation they need to ultimately prog ress to leading large teams and organizations. Military Medical Practice and Leadership The Leadership Core of the Military Medical Practice and Leadership (MMPL) course of instruction introduces and rein forces leadership principles essential for the development of officers to lead the MHS. MMPL focuses on increasing personal self-awareness and communication skills, personal
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and interpersonal leadership perspectives, interpersonal and team perspectives, and functioning in challenging environ ments. Objectives of the MMPL leadership curriculum include Introduction to Military Medical Leadership, Effec tive Communication, Conveying Difficult Information, Crisis Communication, and Effective Team Building. Education is provided by didactic presentations, small group exercises, student activities and presentations, and group and panel dis cussions. Students learn about the history, types, models, styles, and components of leadership. Information about lead ership is framed in ways to enhance understanding and appli cation, including the “Four C ’s of Leadership” described by Callahan and Grunberg7: Character, Competencies, Context, and Communication. The program is designed to provide foundational and relevant education, as well as to enhance the leadership skills of every USU graduate. Medical Field Practicum 101 “Medical Field Practicum 101,” or MFP 101, is a 5-day field experience that takes place approximately 2 months into the 4-year medical school curriculum. The exercise is done in conjunction with the field patient experience where first year students play the roles of patients for the fourth year Opera tion Bushmaster. Playing the roles of patients is important to drive home the perspective of patients and to encourage students to be aware of how they are perceived by patients. They are observing the upperclassmen exercise leadership roles to begin identifying effective as well as not so effective leadership skills and traits.
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Leadership Education and Development at the Uniformed Services University
This exercise is an opportunity early in medical school for prospective military medical officers to be introduced to the practice of medicine in the deployed environment. It also gives them a perspective on the culture of military medicine. In MFP 101, medical students are introduced to their major roles and responsibilities as military physicians in the opera tional setting and some of the unique challenges they will face. In addition, MFP 101 is an opportunity for the students to begin to form their identities as military doctors and to get to know their classmates, with whom they will work closely for the next 15 years and beyond. Specifically with regard to leadership development, the students focus on their under standing of “self”-focusing on the “P” in the PITO model. All students receive instruction and perform inventories in both emotional intelligence and Myers Briggs testing. The spe cific goals of MFP 101 are to — Introduce the culture and life of military physicians, particularly in the deployed environment. — Provide an environment in which students begin to gain basic proficiency (knowledge, skills, and attitudes) in fundamental aspects of military medicine in the deployed setting. — Reinforce and foster core values and principles particu larly relevant to military medicine such as teamwork, leadership, professionalism, service, ethics, and integrity. — Promote individual identity formation as military medi cal officers. — Foster class identity, cohesion, and bonding. — Engender excitement and interest in operational military medicine. Antietam
Conducted during the first year of medical school, the Antietam Battlefield medical staff walk provides an opportunity for USU medical students to study a military campaign rich with medical problems that—while technologically different—remain valid teaching points for our students if put in the modem context. Objectives of the medical staff walk are to — Establish a military and medical foundation for the campaign through a pre-walk briefing and suggested reading materials. — Conduct a chronologically phased medical staff walk that describes the military and medical operations at Antietam. —• Describe/discuss/contrast medical operational problems of 1,862 in the context of the twenty-first-century battle field medicine. Summer Operational Experience
The Summer Operational Experience is a 2-week course of instruction designed to offer students without prior active duty, medical experience in their specific service. The intent is to engage students in an experience that is re-energizing and which may motivate some to continue in operational military medicine. The individual services vary in how they
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provide this experience. However, in all cases, there are a broad range of options available, enabling students to per sonalize their involvement. Medical Field Practicum 102
Medical Field Practicum (MFP) 102 focuses on advanced military medical skills and is a continuation from the “Combat Medical Skills Course.” The course spans 2 intensive weeks and is divided into morning didactics and afternoons skill/ procedures based labs. Objectives are to — Accomplish national training requirements for patient contact in hospital environments (BLS, ACLS) — Expand knowledge of rapid combat trauma assess ment and implement with realistic casualties in field environment — Appreciate environmental elements affecting troop per formance — Enhance understanding of medical operational planning, and multimodal combat pain control options. Medical Field Practicum 201
Medical Field Practicum (MFP) 201 is a one-and-half-day field course conducted on the University campus. The course focuses on Tactical Combat Casualty Care (TC3), small unit leadership, and medical platoon drills. The Tactical Combat Casualty Care (TC3) training module includes patient assess ment, patient decontamination, and a training lane that pro vides an opportunity for the student to apply the three phases of TC3. Troop Leading Procedures are reinforced in the small unit leadership module as students are organized as treatment team sized elements (9-11 personnel), and given the mission of negotiating leadership reaction course-type challenges under medical scenarios. Medical platoon drills focus on introducing the student to scenario-driven medical battle drills in preparation for the Military Contingency Medi cine (MCM) course. After action reports and discussions include team leadership and medical treatment effectiveness. Medical Field Practicum 202
Military Contingency Medicine MCM, including its field component. Operation Bushmaster, is the capstone course for the 4-year integrated military medicine curriculum. MCM is 4 weeks long and includes both class room didactic teaching and an intensive, 4-day field train ing. The Advanced Trauma Life Support (ATLS) course is a prerequisite for the course and is provided by the Depart ment of Surgery under the guidance of the American Col lege of Surgeons. MCM is structured around a simulated deployment to the notional developing country of “Pandakar.” The classroom portion of the course represents the predeployment work-up for the deployment and is designed to provide the opportu nity for students to acquire/hone the critical knowledge, skills, and attitudes required for successful assignment and deployment as a tactical-level military medical officer in their
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Leadership Education and Development at the Uniformed Services University parent service. The course employs a variety of teaching methodologies ranging from lecture to small group discus sions, and applied practical exercises in order to build upon topics introduced throughout the entire 4-year USU military medical curriculum. Topics include, but are not limited to, military environmental medicine, applied field medicine. Health Service Support planning, Military Decision Making, prob lem solving, leadership, personal and family readiness, mass casualty (MASCAL) incident preparation and response, stabil ity operations, TC3, and medical intelligence. All coursework is designed to emphasize learning objectives focused on the current operational environment. Operation Bushmaster “Operation Bushmaster” (MFP 202) is the capstone event of the USU of the Health Sciences’ military unique curriculum. Over the course of this intense, 4-day exercise, fourth year USU medical students (and international guest students) and GSN students are evaluated on their medical knowledge and leadership abilities in a simulated, resource constrained, far forward tactical field setting. Students assume leadership and medical positions within a non-Service-specific battalion-aid station where they are presented with operationally current, reality based missions and operational problems for which they must plan and/or execute while simultaneously managing the medical care of simulated Disease and Non-Battle Injury patients, combat stress casualties, and combat trauma casual ties. Faculty members evaluate leadership skills, medical skills, combat stress casualty care, and point of injury care. In addition, a team of faculty and graduate students work together as part of the Bushmaster Research Activities Group to evaluate the leadership data gathered during Bushmaster exercises and to compare leadership performance to demographic variables, preclinical academic performance, and clinical rotation per formance to identify key elements that may help to improve the USU leadership program.
Leadership Capstone The medical school leadership curriculum provides an oppor tunity for students in their final year to expand and exercise their interest in military medical leadership through a Leader ship Capstone elective. Working under the tutelage and guid ance of a MEM or other SOM faculty, students develop a scholarly project addressing their principle interest in advanc ing their own attitudes, skills, and motivations to lead and potentially contributing to the further refinement of the entire USU leadership curriculum. These projects may include subjects as diverse as educational research intended to assess the impact of the elements of the curriculum, methods for better integrating leadership lessons, leveraging the often formidable talents and
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extensive leadership skills of members of the medical school classes that were developed before entering the SOM and the like. Efforts are underway to couple the Leadership Capstone program with similar programs in other nonmilitary medical schools and health professional schools and to synchronize the USU efforts with parallel programs in health leadership at the Walter Reed National Medical Center and Fort Belvoir Com munity Hospital or other academic programs in the network of MHS medical treatment facilities.
CONCLUSION In light of the serious and growing constraints being placed on our MHS and the growing array of threats to the national security of the United States, the U. S. military needs a steady supply of health care providers who possess the 6 leadership attributes described by General Dempsey. Given our congressionally chartered mission, USU must do more than educate clinicians (as important as that task may be); we must also produce health care professionals who are ready and able to function as high-performing team members, leaders of small groups and ultimately, directors of large and complex health care organizations. At USU, we do not consider leadership development a privilege reserved for a chosen few; we pro vide it to all. At the leadership academy of the MHS, nothing less will do.
REFERENCES 1. DepartmentofDefen.se: Instruction Number 5105.45 December 26, 2013: Uniformed Services University of the Health Sciences. Available at http://www.usuhs.mil/; accessed October 1, 2014. 2. Durning SJ, Artino AR Jr, Dong T. et al: The Long-Term Career Out come Study (LTCOS): what have we learned from 40 years of military medical education and where should we go? Mil Med 2012; 177(9 Suppl): 81-6. 3. DeZee KJ, Durning SJ. Dong T. et al: Where are they now? USU School of Medicine graduates after their military obligation is complete. Mil Med 2012; 177(9 Suppl): 68-71. 4. Decade of War, Volume 1: Enduring Lessons from the Past Decade of Operations (Washington, DC: Joint Chiefs of Staff, J7, June 15, 2012). Available at http://blogs.defensenews.com/saxotech-access/pdfs/decadeof-war-lessons-leamed.pdf. http://www.usuhs.mil/; accessed October 1,2014. 5. Capstone Concept for Joint Operations: Joint Force 2020. Washington, DC, Department of Defense, September 10, 2012. Available at www.jcs.mil/ content/files/201209/092812122654_CCJO_JF2020_FINAL.pdf. http:// www.usuhs.mil/: accessed October 1, 2014. 6. The United States Air force Academy. Officer Development System. Available at http://www.usafa.af.mil/shared/media/document/AFD-140828070.pdf; accessed September 22, 2014. 7. Callahan CW, Grunberg NE: Military Medical Leadership. In: Funda mentals of Military Medical Practice. Edited by EB Schoomaker, DC Smith. Washington, DC. Borden Institute, Office of the Surgeon General of the Army.
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Leadership Education and Development at the Uniformed Services University COL Francis G. O ’Connor, MC USA*; Neil Grunberg, PhD*; Arthur L. Kellermann, MD, M P H f; LTG Eric Schoomaker, MC USA (Ret.)* INTRODUCTION The mission of the Uniformed Services University (USU) is to train, educate, and prepare uniformed services health profes sionals, officers, and leaders to directly support the Military Health System (MHS), the National Security, and National Defense Strategies of the United States and the readiness of our Armed Forces.1 USU’s commitment to this mission has not wavered since the school was founded in 1972. When the legislation that established USU was drafted, USU’s sup porters in Congress envisioned that its graduates would form the backbone of the MHS. In this way, it was anticipated that USU would serve for the MHS what the Service academies— the U. S. Military Academy, the Naval Academy, the Air Force Academy, and the Coast Guard Academy—played for the nonmedical line. Today, 42 years after USU opened its doors, its 5,000-plus alumni have validated this vision. Over this time span, USU has contributed greatly to the MHS, with growing numbers of physician, nurse, and allied health alumni rising to key roles.2’3 Recognizing the Department of Defense’s (DoD) growing interest in leadership training, USU’s faculty and administra tion recently examined the content, quality, and impact of the training we provide our students to prepare them for the challenges the MHS will face. As we undertook this critical work through a task force charged with adapting and refining the USU Strategic Framework, we asked ourselves how well USU fosters six core leadership attributes required of future military leaders: (1) understand the environment and the effect of all instruments of national power; (2) anticipate and adapt to surprise and uncertainty; (3) recognize change and lead tran sitions; (4) operate on intent through trust, empowerment, and understanding; (5) make ethical decisions based on the shared values of the medical, nursing, and dental professions bal anced with the Profession of Arms; and (6) think critically and strategically in applying health services support to joint warfighting principles and concepts in joint operations.2'3 In this manuscript, we describe USU’s approach to leadership development. Our program of instruction and experiential learning is designed to meet the Chairman of the Joint Chiefs of Staff, General Dempsey’s challenge of providing skilled leaders to the MHS to support the mission(s) of the DoD4,5 *Department of Military and Emergency Medicine. Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. tDean, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. doi: 10.7205/MILMED-D-14-00563
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THE LEADERSHIP CHALLENGE “USU must lead and excel in Leadership Training” Dr. Jonathan Woodson, March 4, 2014 Assistant Secretary of Defense for Health Affairs. At the inaugural meeting of USU’s 2014 Strategic Frame work Task Force, DoD Assistant Secretary Woodson chal lenged the faculty and staff of USU to embrace leadership training as a key element of its mission. Dr. Woodson made it clear that USU’s success would be judged by its ability to produce highly skilled uniformed health care providers and by its capacity to produce leaders who are capable of overcoming the managerial and leadership challenges that confront the MHS. He outlined three core requirements for this activity: (1) create officers who are the foundation for the future, (2) establish an unquestioned set of values, and (3) outpace any institution in the world in leadership training. Dr. Woodson’s vision of USU as the “leadership academy of the MHS” is completely consistent with USU President Dr. Charles Rice’s vision for the University: By the end of CY 2018, the USU of the Health Sciences will be widely recognized as the pre-eminent national educational institu tion for the creation of career uniformed services leaders in the health sciences who are prepared to serve the nation and support the readiness of the uniformed services. USU will be a central hub for uniformed services-related health education and training, research and scholarship, “leadership education and training,” and national security as it relates to global health. Each USU graduate will be a "health and health care professional and leader” prepared with an outstanding health education, inter-professional health training, “leader ship training,” and a deep and abiding commitment to self less service, the uniformed services ethos, and the security of the United States. USU’s emphasis on leadership is not limited to the School of Medicine. The University’s Daniel K Inouye Graduate School of Nursing (GSN) includes a rigorous leadership course in its Doctor of Nursing Practice (DNP) training pro gram. Both schools, along with USU’s Post-Graduate Dental College (PGDC) are striving to find means by which leader ship education and training between and among the schools can be jointly planned and conducted. The focus of this manu script is on current efforts to optimize leadership training within the School of Medicine (SOM). Because USU is dedi cated to inter-professional training, the SOM works closely with the GSN and PGDC to promote leadership development in every health care discipline.
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LEADERSHIP PARTNERS Military and Emergency Medicine The Department of Military and Emergency Medicine (MEM) has the academic responsibility in the University and the SOM to develop, implement, and oversee the curriculum in leader ship, officership, and military professionalism (Fig. 1). MEM has synthesized core values from the Services to develop operational definitions for leadership, officership, and profes sionalism. “Leadership” is influencing people by providing purpose, direction, and motivation. It is the sum of the quali ties of intellect, human understanding, and moral character to enhance the motivations, cognitions, and behaviors of individuals and groups to accomplish the assigned mission. “Officership” is a set of skills that allows one to function effectively as an officer in the uniformed services. Underlying officership are principles, practices, and values that guide an officer’s judg ment, decisions, behavior, philosophy, and vision. “Profession alism” includes critical attributes: personal courage, respect, openness, fairness, empathy, self-improvement, social respon sibility, integrity, honor, officership, nonjudgment, altruism, and leadership. The Chair of MEM is currently designated as the professor of military science, and is charged with overseeing the military medicine program of instruction for the SOM. The Chair and faculty of MEM report to the Dean, SOM. MEM’s intent is best expressed through the following mission and vision statements: Mission
"The mission of MEM is to train, educate, and prepare USU SOM students to support and ‘lead’ in operational and emer gency medicine environments in the U. S. Armed Forces, while
advancing the knowledge and practice of military medicine and supporting the overall mission of the SOM and University.” Vision
“To serve USU and the Nation as the pre-eminent academic department for the study, advancement, and application of operational arts and military health optimization, education in emergency medicine and ‘military medical leadership,’ while inspiring lifelong learning and a career of service.” Other Academic Departments in the SOM
Although MEM serves as the lead and the academic home for leadership, officership, and military professionalism in the SOM, all other academic departments play a critical role. The education and development of SOM students, as well GSN and PGDC, in leadership, officership, and professionalism is the responsibility of all University faculty and staff, particularly those in uniform. Faculty members from several SOM basic and clinical science departments (e.g., Medical and Clinical Psychology Department, Family Medicine, Preventive Medi cine, Medicine, Surgery), from the USU GSN, and from USUaffiliated Centers (e.g., Consortium for Health and Military Performance [CHAMP], Center for Disaster and Humanitarian Assistance [CDHAM]), also contribute to the MEM leadership curriculum and training experiences and coordinate with the USU Brigade (uniformed staff and faculty). Examples of related topics taught in the SOM that involve leadership, officership, and military professionalism are medical ethics and human con text in medicine. MEM functions as the lead to coordinate, synchronize, integrate, and reinforce this curriculum across all departments and across all 4 years of medical school. The Brigade
The Brigade, and particularly the Commandant of the SOM, plays a critical role in leadership, officership, and military professionalism in the SOM and other schools within the uni versity. This oversight role assures that students adhere to basic military requirements and standards of behavior expected of uniformed officers and is accomplished by fostering the appro priate military culture in the University. In addition, the Brigade staff participates in the implementation of the academic curricu lum as faculty members. The Brigade also has oversight of active duty faculty and staff and ensures that they are appropriate role models for students. MEM as the academic home, and the Brigade as the military command structure, are strategic partners and it is imperative that the academic curriculum is synchro nized with and, ideally, is integrated with the activities of the Brigade to achieve a common and coordinated approach. Office o f Student Affairs
FIGURE 1.
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USU MEM Leadership Model.
Office of Student Affairs (OSA) is responsible for coordinat ing and managing student experiences across all 4 years and works particularly closely with the faculty and Brigade when ever a student encounters life challenges, needs remediation, or merits academic deceleration. MEM, therefore, works closely and synergistically with OSA in the development and
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implementation of this curriculum, particularly when students need additional support or remediation. Leadership Curriculum This curriculum is based primarily on principles and approaches to officership, leadership, and military professionalism for all the military services but is tailored to the unique circumstances and educational program of USU, the SOM, and preparation to serve in the Military Health System (MHS). The academic basis of the curriculum draws upon many sources including service-specific policy and guidance for line officers; Joint doctrine, the academic literature on leadership and profes sionalism (particularly as it relates to health care); Liaison Committee on Medical Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), USU, and SOM policy and guidance; faculty expertise and experi ences; and current best practices in medical and military education and practice. The program of instruction is accom plished over 4 years of instruction. The curriculum is designed to prepare military medical stu dents for the initial operational assignments they are likely to have as general medical officers after internship or following residency, while also establishing the foundation for a career of leadership in military medicine. This curriculum is focused primarily on the medical officer in the operational setting. The curriculum provides critical knowledge, skills, and attitudes applicable to leadership in military treatment facilities and other nonoperational environments as well. The curriculum is built on core attributes of effective and ethical leadership and officership, including: — — — — — — — — — — — — — — — — —
Knowledge of self Adherence to core values Personal mission and vision Adherence to fundamental military standards and behaviors Physical, mental, and emotional fitness Effective followership Communication skills Conflict resolution Teamwork and teambuilding Problem solving and decision making Planning and organization Mission focus Technical competence Resource stewardship Risk analysis and focus on safety Development and welfare of subordinates Relationship with the line, the American public, and its elected representatives
Our curriculum is also based on the idea that for career military medical officers to progress as an officer and leader, they must first master the basic knowledge, skills, and attitudes required of a junior medical officer right out of medical school. Over time, a capable officer can build on these core attributes and develop the necessary skills to hold a senior staff position or even command a large military medical organization. To
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FIGURE 2.
U.S. Air Force Academy PITO Model.
accomplish these goals, students must develop and function on a continuum that starts with leading oneself at the indi vidual level and ends with leading others in large, complex organizations. This concept is based on the Air Force Academy’s Leadership Development "PITO” model (personal, interper sonal, team, and organization)6 (Fig. 2). In the PITO approach, the personal or individual traits at one end of the continuum refer to the core values, knowledge of self, accountability, professionalism, and other basic indi vidual attributes (Fig. 3). The next phase of the continuum centers on the interpersonal communication, conflict resolu tion. and basic followership skills that allow one to function effectively as a member of a group or small team. The next level in the continuum focuses on the additional skills, par ticularly leadership skills, necessary to be successful when leading or influencing a small team, such as a ward team or a battalion aid station. At this stage, additional abilities in organization and planning, building teams, and problem solving are important. At the top tier of the continuum are the more advanced abilities in all of these areas that are required to successfully lead and manage a larger team, such as a clinical service or even a large complex organization— whether a deployed military medical unit, a combat support hospital or a brick-and-mortar health care organization. Although this curriculum is oriented to the military medical officer in an operational setting, the knowledge, skills, and attitudes are highly applicable to the more conventional clini cal environment and will serve to reinforce the leadership, officership, and professionalism required in the practice of clinical medicine. The leadership curriculum is designed to be fully coordinated, synchronized and, ideally, integrated with
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FIGURE 3.
MEM Leadership Curriculum.
the new medical student curriculum at USU. Although leader ship, officership, and military professionalism is at times explicitly taught and discussed, it also is integrated into the rest of the curriculum and reinforced in the School’s curricu lum. For example, relying on the student chain of command to ensure all students are prepared to attend USU’s annual Antietam Road March and are present and accounted for puts small team followership and leadership into daily practice. There are a myriad of such opportunities over the 4 years of medical school; no opportunity to exercise leadership or responsible followership should be overlooked. In addition, as is true of USU's curriculum overall, our approach uses a wide variety of educational modalities, including small group discussions, individual and team-based problem solving, criti cal analysis, simulations, laboratory/tabletop exercises, field application, and other experiences. By the time of graduation, our students are expected to be fully proficient in the first two phases (as an individual and small-team member), and prepared to assume the role of small-team leader at the first opportunity. Our graduates are also provided with the foundation they need to ultimately prog ress to leading large teams and organizations. Military Medical Practice and Leadership The Leadership Core of the Military Medical Practice and Leadership (MMPL) course of instruction introduces and rein forces leadership principles essential for the development of officers to lead the MHS. MMPL focuses on increasing personal self-awareness and communication skills, personal
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and interpersonal leadership perspectives, interpersonal and team perspectives, and functioning in challenging environ ments. Objectives of the MMPL leadership curriculum include Introduction to Military Medical Leadership, Effec tive Communication, Conveying Difficult Information, Crisis Communication, and Effective Team Building. Education is provided by didactic presentations, small group exercises, student activities and presentations, and group and panel dis cussions. Students learn about the history, types, models, styles, and components of leadership. Information about lead ership is framed in ways to enhance understanding and appli cation, including the “Four C ’s of Leadership” described by Callahan and Grunberg7: Character, Competencies, Context, and Communication. The program is designed to provide foundational and relevant education, as well as to enhance the leadership skills of every USU graduate. Medical Field Practicum 101 “Medical Field Practicum 101,” or MFP 101, is a 5-day field experience that takes place approximately 2 months into the 4-year medical school curriculum. The exercise is done in conjunction with the field patient experience where first year students play the roles of patients for the fourth year Opera tion Bushmaster. Playing the roles of patients is important to drive home the perspective of patients and to encourage students to be aware of how they are perceived by patients. They are observing the upperclassmen exercise leadership roles to begin identifying effective as well as not so effective leadership skills and traits.
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This exercise is an opportunity early in medical school for prospective military medical officers to be introduced to the practice of medicine in the deployed environment. It also gives them a perspective on the culture of military medicine. In MFP 101, medical students are introduced to their major roles and responsibilities as military physicians in the opera tional setting and some of the unique challenges they will face. In addition, MFP 101 is an opportunity for the students to begin to form their identities as military doctors and to get to know their classmates, with whom they will work closely for the next 15 years and beyond. Specifically with regard to leadership development, the students focus on their under standing of “self”-focusing on the “P” in the PITO model. All students receive instruction and perform inventories in both emotional intelligence and Myers Briggs testing. The spe cific goals of MFP 101 are to — Introduce the culture and life of military physicians, particularly in the deployed environment. — Provide an environment in which students begin to gain basic proficiency (knowledge, skills, and attitudes) in fundamental aspects of military medicine in the deployed setting. — Reinforce and foster core values and principles particu larly relevant to military medicine such as teamwork, leadership, professionalism, service, ethics, and integrity. — Promote individual identity formation as military medi cal officers. — Foster class identity, cohesion, and bonding. — Engender excitement and interest in operational military medicine. Antietam
Conducted during the first year of medical school, the Antietam Battlefield medical staff walk provides an opportunity for USU medical students to study a military campaign rich with medical problems that—while technologically different—remain valid teaching points for our students if put in the modem context. Objectives of the medical staff walk are to — Establish a military and medical foundation for the campaign through a pre-walk briefing and suggested reading materials. — Conduct a chronologically phased medical staff walk that describes the military and medical operations at Antietam. —• Describe/discuss/contrast medical operational problems of 1,862 in the context of the twenty-first-century battle field medicine. Summer Operational Experience
The Summer Operational Experience is a 2-week course of instruction designed to offer students without prior active duty, medical experience in their specific service. The intent is to engage students in an experience that is re-energizing and which may motivate some to continue in operational military medicine. The individual services vary in how they
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provide this experience. However, in all cases, there are a broad range of options available, enabling students to per sonalize their involvement. Medical Field Practicum 102
Medical Field Practicum (MFP) 102 focuses on advanced military medical skills and is a continuation from the “Combat Medical Skills Course.” The course spans 2 intensive weeks and is divided into morning didactics and afternoons skill/ procedures based labs. Objectives are to — Accomplish national training requirements for patient contact in hospital environments (BLS, ACLS) — Expand knowledge of rapid combat trauma assess ment and implement with realistic casualties in field environment — Appreciate environmental elements affecting troop per formance — Enhance understanding of medical operational planning, and multimodal combat pain control options. Medical Field Practicum 201
Medical Field Practicum (MFP) 201 is a one-and-half-day field course conducted on the University campus. The course focuses on Tactical Combat Casualty Care (TC3), small unit leadership, and medical platoon drills. The Tactical Combat Casualty Care (TC3) training module includes patient assess ment, patient decontamination, and a training lane that pro vides an opportunity for the student to apply the three phases of TC3. Troop Leading Procedures are reinforced in the small unit leadership module as students are organized as treatment team sized elements (9-11 personnel), and given the mission of negotiating leadership reaction course-type challenges under medical scenarios. Medical platoon drills focus on introducing the student to scenario-driven medical battle drills in preparation for the Military Contingency Medi cine (MCM) course. After action reports and discussions include team leadership and medical treatment effectiveness. Medical Field Practicum 202
Military Contingency Medicine MCM, including its field component. Operation Bushmaster, is the capstone course for the 4-year integrated military medicine curriculum. MCM is 4 weeks long and includes both class room didactic teaching and an intensive, 4-day field train ing. The Advanced Trauma Life Support (ATLS) course is a prerequisite for the course and is provided by the Depart ment of Surgery under the guidance of the American Col lege of Surgeons. MCM is structured around a simulated deployment to the notional developing country of “Pandakar.” The classroom portion of the course represents the predeployment work-up for the deployment and is designed to provide the opportu nity for students to acquire/hone the critical knowledge, skills, and attitudes required for successful assignment and deployment as a tactical-level military medical officer in their
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Leadership Education and Development at the Uniformed Services University parent service. The course employs a variety of teaching methodologies ranging from lecture to small group discus sions, and applied practical exercises in order to build upon topics introduced throughout the entire 4-year USU military medical curriculum. Topics include, but are not limited to, military environmental medicine, applied field medicine. Health Service Support planning, Military Decision Making, prob lem solving, leadership, personal and family readiness, mass casualty (MASCAL) incident preparation and response, stabil ity operations, TC3, and medical intelligence. All coursework is designed to emphasize learning objectives focused on the current operational environment. Operation Bushmaster “Operation Bushmaster” (MFP 202) is the capstone event of the USU of the Health Sciences’ military unique curriculum. Over the course of this intense, 4-day exercise, fourth year USU medical students (and international guest students) and GSN students are evaluated on their medical knowledge and leadership abilities in a simulated, resource constrained, far forward tactical field setting. Students assume leadership and medical positions within a non-Service-specific battalion-aid station where they are presented with operationally current, reality based missions and operational problems for which they must plan and/or execute while simultaneously managing the medical care of simulated Disease and Non-Battle Injury patients, combat stress casualties, and combat trauma casual ties. Faculty members evaluate leadership skills, medical skills, combat stress casualty care, and point of injury care. In addition, a team of faculty and graduate students work together as part of the Bushmaster Research Activities Group to evaluate the leadership data gathered during Bushmaster exercises and to compare leadership performance to demographic variables, preclinical academic performance, and clinical rotation per formance to identify key elements that may help to improve the USU leadership program.
Leadership Capstone The medical school leadership curriculum provides an oppor tunity for students in their final year to expand and exercise their interest in military medical leadership through a Leader ship Capstone elective. Working under the tutelage and guid ance of a MEM or other SOM faculty, students develop a scholarly project addressing their principle interest in advanc ing their own attitudes, skills, and motivations to lead and potentially contributing to the further refinement of the entire USU leadership curriculum. These projects may include subjects as diverse as educational research intended to assess the impact of the elements of the curriculum, methods for better integrating leadership lessons, leveraging the often formidable talents and
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extensive leadership skills of members of the medical school classes that were developed before entering the SOM and the like. Efforts are underway to couple the Leadership Capstone program with similar programs in other nonmilitary medical schools and health professional schools and to synchronize the USU efforts with parallel programs in health leadership at the Walter Reed National Medical Center and Fort Belvoir Com munity Hospital or other academic programs in the network of MHS medical treatment facilities.
CONCLUSION In light of the serious and growing constraints being placed on our MHS and the growing array of threats to the national security of the United States, the U. S. military needs a steady supply of health care providers who possess the 6 leadership attributes described by General Dempsey. Given our congressionally chartered mission, USU must do more than educate clinicians (as important as that task may be); we must also produce health care professionals who are ready and able to function as high-performing team members, leaders of small groups and ultimately, directors of large and complex health care organizations. At USU, we do not consider leadership development a privilege reserved for a chosen few; we pro vide it to all. At the leadership academy of the MHS, nothing less will do.
REFERENCES 1. DepartmentofDefen.se: Instruction Number 5105.45 December 26, 2013: Uniformed Services University of the Health Sciences. Available at http://www.usuhs.mil/; accessed October 1, 2014. 2. Durning SJ, Artino AR Jr, Dong T. et al: The Long-Term Career Out come Study (LTCOS): what have we learned from 40 years of military medical education and where should we go? Mil Med 2012; 177(9 Suppl): 81-6. 3. DeZee KJ, Durning SJ. Dong T. et al: Where are they now? USU School of Medicine graduates after their military obligation is complete. Mil Med 2012; 177(9 Suppl): 68-71. 4. Decade of War, Volume 1: Enduring Lessons from the Past Decade of Operations (Washington, DC: Joint Chiefs of Staff, J7, June 15, 2012). Available at http://blogs.defensenews.com/saxotech-access/pdfs/decadeof-war-lessons-leamed.pdf. http://www.usuhs.mil/; accessed October 1,2014. 5. Capstone Concept for Joint Operations: Joint Force 2020. Washington, DC, Department of Defense, September 10, 2012. Available at www.jcs.mil/ content/files/201209/092812122654_CCJO_JF2020_FINAL.pdf. http:// www.usuhs.mil/: accessed October 1, 2014. 6. The United States Air force Academy. Officer Development System. Available at http://www.usafa.af.mil/shared/media/document/AFD-140828070.pdf; accessed September 22, 2014. 7. Callahan CW, Grunberg NE: Military Medical Leadership. In: Funda mentals of Military Medical Practice. Edited by EB Schoomaker, DC Smith. Washington, DC. Borden Institute, Office of the Surgeon General of the Army.
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