Do No Harm - Henry Marsh

Title: Do No Harm
Author: Henry Marsh
ISBN: 978-1-250-06581-0
Publisher: Raincoast
Softcover
Pages: 277

Henry Marsh is a renowned neurosurgeon out of the UK. He has drafted a book outlining some of his more memorable experiences over a forty year career in medicine with the intent of passing on to future generations of clinicians and surgeons some of his hard earned observations and lessons. What caught my eye, and why I have included it within my blog, was the similarity in terms of leadership lessons within his writings that may also be applied within both the military and medical contexts.

Marsh divides his book into a series of chapters that relate to a specific type of spinal or brain injury. Each serves as an introduction to a success or failure and an evaluation by Marsh on how he addressed the situation. This is not a medical text, it is a compilation of reminiscences using his medical field as a guide. He does not pull any punches and undertakes a critical analysis of himself and others as he relates the events for the reader.

Why is this relevant for a leader? A number of reasons:

1. Mentorship: Marsh instituted a process whereby junior doctors presented case files and recommended courses of action during a daily morning briefing attended by all regardless of experience. This promoted group learning and a forum within which diagnosis and treatments could be discussed. Marsh continuously challenged his doctors ensuring greater consideration and thought;
2. Empathy: He placed particular stress on the importance of not forgetting that patients and subordinates are universally human first and that this must not be forgotten when interacting with them; from both a treatment and an institutional perspective. Throughout his works he is extremely critical of the bureaucracy that treats patients as commodities as opposed to human beings;
3. Micromanagement: Marsh acknowledges that he had particular difficulty allowing junior doctors to learn by doing and being empowered to undertake procedures without his direct intervention. It is critical that subordinates be encouraged and trusted (within their capabilities) and overseen only as required;
4. Ethics: As part of his instruction regime, Marsh was a strong proponent of "because you can does not mean you should' in terms of treatment. That is to say, will the resulting quality of life merit the discomfort and risk of surgery? This oblique approach to medical intervention is very much in keeping with the mindset that leaders must maintain;
5. Error: Throughout his narrative, Marsh is quick to acknowledge his own fallibility. This is important for all as hubris is the precursor to catastrophic failure. To be an effective leader or professional, it is critical that we recognize our own shortcomings; and
6. Knowing When to Challenge: The author acknowledges that, with maturity, came a realization that he could not win every fight and that indeed, he was foolish to try. The recognition of what was truly important served to focus his attention and improved his time management;

The most important aspect of this book from a leadership perspective; however, was his ability to make decisions and function effectively as a doctor despite the fact that he had not been able to save all of his patients; indeed some that he had successfully operated upon were paralyzed, left with significant disabilities or were not cured but only provided a brief reprieve. Neurosurgery can easily lead to catastrophic failure and requires a deep conviction and mental strength to undertake for both surgeon and patient. Many in leadership positions become incapacitated by PTSD (Post Traumatic Stress Disorder) and are thus unable to continue with their responsibilities. Marsh writes very personally about his struggles to reconcile his role as a healer with the shortcomings that he has inevitably experienced. He assumes an empathetic 'real politique' perspective that maintains his touch with patients while concurrently strengthening his mental capacity to deal with those times when the cure 'was worse than the illness'. This is a critical lesson for leaders to learn and emulate.

A fascinating and engaging read for all regardless of ones experience level. Marsh has provided outstanding lessons and mentorship beyond the surgical ward.

The Sky Their Battlefield II - Trevor Henshaw

Original written by Chris Buckham. Published in the Journal of the RCAF.

Title: The Sky Their Battlefield II

Author: Trevor Henshaw

ISBN: 978-0-9929771-1-5

Publisher: Fetubi Books

Softcover

Pages: 406

Photos: 289

Historians undertake two main roles in the course of their studies, one is to gather first hand recollections, information and statistics and secondly, to take that information and interpret and recount it for future audiences. Henshaw has produced a reference work of enormous breadth and depth, cataloguing the losses, on all fronts, of the British Commonwealth airforces from 1912 until 1919, as well as United States casualties from 1916 onwards. 

The book is structured in a very logical way with an easy to follow layout, ensuring the reader can access whatever aspect of information that they are seeking quickly and efficiently. Commencing with a guide on how to follow the nomenclature of the book, he has incorporated in excess of 16,800 casualty (wounded, missing and killed) write-ups into the body of the book broken out by year, region and accident or combat. He has also referenced thousands of German records in order to confirm Allied losses.

Interspaced within the text is an ongoing narrative of significant events that add dimension to his work. It is very easy to view these losses in a very two dimensional way, especially given the common structure of presentation; however, Hernshaw has provided hundreds of photographs that clearly present the grim results of many an airman's dream. His interjections highlight interesting events within the chronological layout of the text; thus he identifies, as examples, new aircraft introductions , air lessons learned during the Ypres battles, Hindenburg line preparations, and a myriad of other information relating to the development, execution and challenges of aircraft design and combat. The central theme however, of recognition and identification of the fate of aircrews, remains the central focus throughout.

Added to this publication is an Accident Addendum that outlines the fates of the 4,530 aircrew that were injured or killed in circumstances not directly related to enemy action. This is both very appropriate and informative as history tends to forget about those whose sacrifices resulted from old airframes, limited experience, poor air doctrine and a host of other 'behind the lines' reasons. Henshaw also incorporates those 'other rank' members who were lost but there is no known cause; their sacrifice is no less telling or significant. 

Another aspect of this work that lends weight and credence to it as an outstanding source for future historians is the analysis undertaken by the author of the information that he has gleaned from the official records. This represents the second phase of historical relevance: statistics are only as worthwhile as the interpretation of what they tell you. His evaluation and presentation in table form of the operational cause factors (ie bombing, strafing, reconnaissance etc) of loss is a goldmine of information in and of itself. His appendices include such components as: Western Front Losses 1914-1918 by Aircraft Type, Nature of Operations, Cost of Aircraft and Engines, AIR1 Casualties from Kew, RFC and RAF Roles of Honour and Analyses of Losses throughout the war from 1912-1919. Each of these is presented as useable raw data with emphasis placed upon key aspects and markers such as casualty rates by aircraft type. 

The amount of time and effort associated with researching and cataloguing the information within this book is staggering. The scope and depth of the analysis and the discussion of what the statistics amount to is second to none. Henshaw has provided for the reading public and the future historian, a treasure trove of information and a testament to the sacrifice of the personnel of the Royal Flying Corps, the Royal Air Force, Royal Naval Air Service, the Commonwealth air services and the nascent United States Airforce. One only begins to appreciate the vastness of the operations and the geographic scope of the undertaking when it is laid out for you in a format such as this. Henshaw is to be commended for producing a book of such richness and gravity.

Bomber Boys: Fighting Back 1940-1945 - Patrick Bishop

Title: Bomber Boys: Fighting Back 1940-1945
Author: Patrick Bishop
ISBN: 978-0-00-719215-1
Publisher: Harper Perennial
Softcover
Pages: 429
Photos/Maps: 61/6

Little in the study of the Second World War has elicited  more controversy than the bombing campaign wrought by the RAF (and Dominion nations) and the USAAF against mainland Europe. Questions abound regarding the morality and effectiveness of this campaign. Regardless however, of ones ethical position on the subject, the fact remains that the campaign did occur and was undertaken by young men, following orders, who suffered the highest casualty rate amongst the Allied war effort. A total of 125,000 aircrew served by the end of the war (this figure includes those still in training); of these, 55,573 were killed, 8,403 wounded and 9,838 made prisoner of war; a 44% casualty figure - and if one reduces the number of aircrew to those who flew operationally the casualty rate is closer to 65%.

Bishops book is not primarily a study of the success or failure of the bombing campaign, it is a look at the people who manned the bombers; how they trained, their recruitment, experiences, aircraft and recollections all set within the context of the war and the pressures therein. It provides a fascinating insight into their world and how different it was from that of the fighter or coastal patrol communities. Additionally, it encompasses a narrative on the ethical dilemma that crews dealt with relating to the doctrine of area bombing in a comparison of official policy, personal experience and national expectation.

In many respects, Bomber Command was a study in contrasts. On one hand, the casual way in which crews were formed (all new crew members regardless of rank or flying position were put into a room together and told to 'sort themselves out) into crews versus the controversy associated with the formality of rank amongst the crew members. The granting of commissions (officer status) was not consistent thus pilots could be sergeants or officers (as an example) and it differed on each crew. Yet, not only was the pilot viewed as the crew commander he was also expected to be the last to leave the aircraft in the event of a necessity to bale out. Additionally, this resulted in crews being broken up between Messes and receiving differing pay and benefits;a source of some irritation. Conversely, these crews were highly professional and amongst the most highly trained technicians in the war. All the more so due to the fact that this was the first true air campaign undertaken and many technical advances in such areas as navigation and bomb-aiming were needed to be learned and assimilated as the war progressed

It is perhaps fair to say that those associated with the bombing campaign became Kipling's  'Tommy Atkins'  of World War Two - needed by the population and the politicians during the war but quickly dismissed and ignored as an awkward and unseemly topic once their services were no longer required. Bishop has written an excellent study of those that undertook this thankless campaign and has shed light upon who they were and why they did what they did at a very personal level. An important read for leaders and politicians who call upon their military to undertake a distasteful task and their responsibility to acknowledge the sacrifices made, despite the potential cost.

Too Good to Be True: The Rise and Fall of Bernie Madoff - Erin Arvedlund

Title: Too Good to Be True: The Rise and Fall of Bernie Madoff

Author: Erin Arvedlund

eISBN: 978-1-101-13778-9

Publisher: Portfolio

Ebook

 

It may seem odd to review this book when a vast majority within this blog are of a military nature; however, the fundamental reason why I started reviewing books was to provide opportunities to learn from the successes and failures of others and to promote discussion, reflection and learning. The international disaster that was Madoff’s Ponzi scheme provides ample fodder to meet that baseline criteria.

Madoff was convicted in 2009 and sentenced to 150 years in prison for running what was called a ‘Ponzi scheme’ with an estimated value of 60 billion dollars (although exact figures are elusive). A ponzi scheme is when an individual takes money for the purposes of investing and provides  returns on that alleged investment but, in actual fact, never invests the money at all but instead uses new investors to offset the returns for older investors. The scheme collapses when the inflow of capital is not enough to cover the required outflow (especially when investors request a return of their initial capital). It is estimated that Madoff was able to run his scheme for upwards of twenty years or more before it failed in 2008. 

What is of interest to me in this case, is not what Madoff did but how he managed to convince people to disregard all of the warning signs (for indeed there were many) and continue to not only invest but leave their money with him. It is a fascinating study in human psychology that he was able to do this, and from a leadership perspective, a lesson that needs to be reinforced. Madoff was able to get to a point where, regardless of the evidence, people refused to acknowledge that there was a possibility of him being anything but above board. 

How was he able to do this: 

1.      Consistency in moderation: he promised reasonable returns and delivered without fail month after month regardless of the volatility of the market;

2.      He kept a low profile and conducted himself in a conservative manner;

3.      Perceived exclusivity of his clientele;

4.      He developed a very close working relationship with the SEC (Securities Exchange Commission) and ensured his goals were in tandem with theirs as much as possible;

5.      He ensured investors access to their money quickly and without question (usually in 30 days or less);

6.      Made himself very accessible to (certain aspects of) the media;

7.      He maintained an tight air of secrecy around his actual investment processes;

8.      He took advantage of investment traditions within communities (such as the Jewish);

9.      He was very charming and personable (very high EQ – Emotional Quotient) and made people at ease;

10.  He was not pushy or demanding;

11.  He established a number of ‘feeder’ funds that transferred money to his fund exclusively and provided a line of separation between him and the client; and

12.  He maintained a legitimate fund business that acted to distract attention from the ‘personal’ investment fund that he maintained. 

All of these activities (and the list is not exhaustive) were carefully cultivated to guide his investing public and the SEC into a sense of complacency and ease where they would not question his methods, only accept his results. 

People cast aside due diligence and common sense and adopted a herd mentality through: 

1.      A sense of being in a special/exclusive group that people wanted to belong to;

2.      Creating such a track record that it became anathema to question him;

3.      Being lazy and assuming that others had done the due diligence;

4.      Greed;

5.      Intellectual intimidation – not understanding what he was doing and not questioning it; and

6.      His reassuring personality and close relationship with such organizations as the SEC.

 

It is easy to fall into line with what ‘everyone’ is doing and it takes a great deal of personal courage to go against that tide; however, it is critical to “trust but verify” and to follow the adage of Frederick II of Prussia when he stated to a Major who had shown poor judgement: “I made you an officer to know when not to obey orders”. The book itself is a decent rendition of the events surrounding the Madoff case. It is, after all, a fairly simple story despite the smoke and mirrors. The author tends to reiterate the same information throughout the narrative but it is a reasonable read and an excellent lesson to be learned for all.

Wars, Pestilence and the Surgeon's Blade - Thomas Scotland and Steven Heys

Title: Wars, Pestilence and the Surgeon's Blade

Authors: Thomas Scotland and Steven Heys

ISBN: 978-1-909384-09-5

Publisher: Helion and Company Ltd

Hardback

Pages: 407

Photos: 78 

There are two things guaranteed when it comes to warfare: death and injury. The authors, following on their extremely informative first book "War Surgery 1914-1918", have undertaken to shed light upon the development of surgical and medical practices throughout the 19th Century; focussing particularly upon three capstone events: the Peninsular war of 1808 -1814, the Crimean War 1853 -1856 and the Boer War of 1899 -1902. Each is studied in detail with a view towards determining where things had improved, stayed the same or regressed. Concurrent to this they highlight the activities of individuals who made significant contributions in a variety of areas that moved both knowledge and yardsticks relating to medicine and the administration thereof. 

Scotland and Heys's evaluation falls into five distinct categories: medical surgery, administration and bureaucracy, logistics, lessons learned and statistical analysis. Each played a significant part in the expansion of knowledge and competency. The approach taken by the authors is to integrate the five together within the narrative in order to facilitate a multi-dimensional picture for the reader of the advancement (and regression) of medical support to the military.

It is both fascinating and disturbing to read about the lack of appreciation by British military (and civilian) leaders of the importance that a sound medical support system had for the successful execution of campaigns. It was only with the Peninsular campaign and the appointment of Dr James McGrigor as Wellington's Chief Medical Officer that the first steps in the formalization of medical care were taken. It was McGrigor who introduced the maintenance of patient records, standardized hospital care and recovery of wounded from the battlefield. He also established basic standards of training and education for those wishing to become military medical officers. Through his efforts, the first steps in the universality of care and the professionalization of the medical branch were taken. 

McGrigor and his colleagues are also remembered as the individuals who initiated not only the maintenance of statistics relating to illness, injury and a myriad of other information tracking for the British army but also, and just as critical, the interpretation of those statistics as a means of recognizing efficiencies and deficiencies of care. It is estimated that his ability to track and advise Wellington on the health of his army provided him an additional divisions worth of soldiers at a critical time during the war.

Crimea, which occurred almost fifty years after the conclusion of the Napoleonic Wars, was, from a medical perspective, a story of forgotten lessons and needless suffering and loss. A failure of effective reconnaissance, not enough time and effort put into preparation, a continued lack of appreciation of the importance of medical administration and provision and a complex and inefficient command structure all contributed to terrible losses resulting from illness and treatment deficiencies. 

The Boer war continued to be characterized by the shortcomings of the previous conflicts, despite noteworthy advancements in medical intervention techniques, knowledge of hygiene, administrative practices and doctrinal maturity. Death and personnel shortfalls due to illness continued to outnumber those caused by combat by a significant margin; again much of it preventable. For example, despite the fact that a vaccine for typhoid existed and was known to the army, it was decided not to inoculate the soldiers before departure. The net result was that during the Second Boer war 7,782 died of wounds while 13,139 died of disease.  

The authors also look at smaller wars throughout the 1800's and the impact of operational geography upon death and illness rates (providing copious statistics for deaths per thousand in different regions as examples). They provide outstanding analysis of the complex intersection of scientific advances (such as the discovery of germs, anaesthetic and disinfectant), surgical, statistical and support techniques (of such pioneers as Keough, McGrigor, Ogston, NIghtingale and Guthrie) plus the military and political paradigm changes necessary to enact the changes required to see improvements in support to soldiers well being and health.  

The British Army of the 19th century was old and steeped in its own traditions and foibles that set it apart from the civilian community it served. These traditions serves as strengths building regimental loyalties and comradeship; however, the also acted as impediments to change and a bulwark against what many perceived as interference from their political (read civilian) masters. Those promoting change within the medical services had to overcome the bias afforded to 'outsiders' in addition to learning and applying the lessons of hygiene, surgery and long term care. Each of these trials would have been formidable in and of themselves; together, as Scotland and Heys point out, they were decades in overcoming. 

One of the real strengths of this book lies in the attention that it draws to the plight of the soldier in undertaking his trade. The average reader can pick up any one of thousands of books written that outline tactics, weapons capabilities, weapons production or any one of the many facets of warfare, but very few discuss the grim details of the human toll of fighting; and they are indeed grim. The present day soldier owes an immeasurable debt to those poor souls who served as the means for learning the art of healing and supporting the recovery of those wounded in combat or ill as a result of geographic location. We owe an equal debt to those doctors and practitioners who through their efforts and study advanced the medical trade in a military context. 

The production value of this book is superb. The authors have incorporated a commendable series of endnotes for each chapter for further study but no overall bibliography. They have also provided for each of the focus wars, a brief synopsis of the what transpired. It is not particularly detailed but enough that it provides context without detracting from the focus of the book. I believe that it would have been very beneficial had they provided an organization chart of the command structure of the British military medical services for the periods covered as it was, as previously noted, rather convoluted and difficult to follow. The book is noteworthy however, for how readable and accessible the authors have made this subject to the reading audience.  Scotland and Heys are outstanding medical historians and are to be commended for their work in this book.