It is said that we live in difficult times, and that reality is unavoidable for anyone who does not live as a hermit in a cave somewhere. For patients and their doctors, the signs of impending failure are equally unavoidable.
Health care consumes 18 percent of U.S. gross domestic product and continues to rise faster than the rate of inflation. Consumer confidence in the goodwill and scientific integrity of U.S. health care agencies has been profoundly shaken by misinformation surrounding COVID-19 and the anti-vaccination movement.
However, the issue of scientific integrity is much larger than COVID-19. The entire fields of psychology and psychiatry are now in crisis because of the failure of hundreds of published studies to replicate. Likewise, thousands of scientific studies have been retracted due to discovery of fraud, errors, data tampering, and plagiarism.
Concerns for the scientific integrity of these agencies are highly appropriate, although not for the reasons invented out of thin air by the vaxxers. Arguably, leaders of the U.S. CDC, FDA, Veterans Administration, National Institute on Drug Abuse, and others may have engaged in the largest and most deadly health care fraud in U.S. history. Many authors argue that the peer review system for health care journals has already failed, with many peer reviewers rejecting all submissions that contradict their personal and institutional biases or their financial self-interest. This bias is confirmed in the author’s own experience.
A health care insurance company senior official is assassinated on a New York street. Forty-one percent of young voters say that this killing was “acceptable.” Whether this view will influence jury selection or scheduling of the trial is not yet apparent.
I propose that the distortions chronicled above can largely be traced to failures of leadership among doctors and other thought leaders in the American health care industry and in our political system. Such leaders have fundamentally mistaken the requirements for effective leadership, and the implications of leadership style.
Military leadership lessons
As a former Air Force officer who served from 1967 to 1988, I have had extensive training in leadership styles, and in the requirements for effective leadership and influence.
We can begin with something that I wrote on KevinMD a little over a year ago.
“Contrary to impressions that many Americans have these days of service life, military leadership has never been primarily about ordering people around or swarming across beaches under fire, John Wayne style. Through 21 years and multiple exposures in professional military education, it was drilled into me that the first duty of military leaders is to teach mental discipline and focus, to empower our people and help them develop life competencies. The military mission does matter and can sometimes involve very hazardous conditions. But ‘take care of your people and they will take care of the mission’ is a fundamental value.”
Scientific investigation offers us many insights into the implications of various leadership styles. Well-known leadership styles include autocratic, democratic, transformational, transactional, and laissez-faire. These frameworks help leaders adapt to different situations.
Kurt Lewin’s foundational 1939 research identified three primary styles. Autocratic leaders make unilateral decisions with little input, ideal for crises but risking low morale. This style is leader-centered, and it can be effective in getting organizations to “move in the same direction, on the same day.” However, what is yet to be shown, sometimes with lethal consequences, is whether this direction will be the most effective in reaching its objectives.
Democratic, or participatory, styles solicit team input for consensus, boosting engagement in collaborative settings. This style is “follower-centered.” It also requires significant time to create buy-in among those who are led. Many management or leadership decisions must be made under time pressure and without full knowledge of important situational intelligence. So use of this style must be carefully qualified. Laissez-faire, or delegation, grants high autonomy to experienced teams. But it can lead to disorganization if it devalues periodic oversight and leader involvement.
In all of these leadership styles, “leadership by example” and the unquestioned integrity of leaders and influencers are vitally important. “Do as I say and not as I do” simply does not work. In military combat operations, such hypocrisy can get people killed in large numbers.
Unfortunately, the same results are now evident in American health care.
The cost of leadership failure
For multiple reasons, millions of patients and hundreds of thousands of their doctors are every day suffering and dying in the American health care system because of distortions in that system. Much of this sorry record seems directly due to failures of leadership.
Among for-profit health care insurance companies, people with severe chronic pain are considered to be “loss leaders.” These patients are complex, they do not get better, and they consume large amounts of resources. It is not surprising that patient antipathy toward health insurance companies is widespread. In social media venues, it is common to encounter the term “genocide” among patients who have been denied care.
Almost unknown to patients, an estimated 250,000 to 300,000 deaths occur each year in the U.S. due to adverse drug events (ADEs). These deaths include medication errors, overdoses, drug interactions, and allergic reactions in hospitals and other health care settings. ADEs are now considered the third leading cause of death in the U.S., surpassing deaths from stroke and respiratory diseases. Medication errors alone are estimated to cause between 44,000 and 98,000 hospital deaths annually. This sorry record must be improved. Among other measures, almost the entirety of pharmaceutical trials literature must be burned to the ground and done over. Previous failures to address genetic factors in drug metabolism have seriously distorted findings in thousands of clinical trials outcomes.
Doctors and their patients must also come to terms with the reality that in many areas of life, patients are their own worst enemies. Bad lifestyle habits, such as obesity, high salt and sugar intake, smoking, excess alcohol, and street drugs, contribute significantly to U.S. mortality. Combined, these factors are linked to 40 to 50 percent of premature or preventable deaths. Medicare data shows that about 25 to 30 percent of its expenditures occur in the last year of life. Roughly half of that expense occurs in the final month, largely due to aggressive interventions that are known by doctors in advance to offer minimal benefit.
A path to systemic reform
Improvements of American health, and improvements in leadership of the health industry, must soon begin and be sustained for at least a generation. Otherwise, the system will truly and disastrously collapse.
Health care officials at all levels must create a better balance between people and profit. A single-payer or not-for-profit health care system is mandatory if this balance is to be sustained.
Health care expenditures and public expectations must move toward greater emphasis on prevention and lifestyle changes. Some are very personally difficult and include reduced dietary processed sugar and salt intake, particularly in school lunches. We must also see reduced social media involvement in favor of more exercise and better sleep, alongside major reductions in alcohol consumption. Smoking cessation programs are necessary for those who have not already kicked the habit. There must also be a serious investment in quality of life improvements for all Americans, to counter the influences of desperation and poverty in promoting drug addiction. We must also recognize that the U.S. patent system needs changes to discourage marginal tinkering by big pharma companies or repurposing of proven treatments. Such measures are now responsible for a significant portion of our highly unproductive health care cost.
In all of health care leadership, we may be forced to embrace mottos long understood by military officers. Leaders must be willing to “lead, follow, or get out of the way” and remember to “cooperate to graduate.” The principle that “people matter” is paramount; if you take care of your people, they will take care of the mission. Finally, “it is time to kick tail and take names,” provided you are sure you are kicking the right tails.
The most powerful leadership style for both military service and American health care is not authoritarian. It is a style that influences and empowers others to speak and act cooperatively, starting from central messages of scientific and moral truth.
Richard A. Lawhern is a nationally recognized health care educator and patient advocate who has spent nearly three decades researching pain management and addiction policy. His extensive body of work, including over 300 published papers and interviews, reflects a deep critique of U.S. health care agencies and their approaches to chronic pain treatment. Now retired from formal academic and hospital affiliations, Richard continues to engage with professional and public audiences through platforms such as LinkedIn, Facebook, and his contributions to KevinMD. His advocacy extends to online communities like Protect People in Pain, where he works to elevate the voices of patients navigating restrictive opioid policies. Among his many publications is a guideline on opioid use for chronic non-cancer pain, reflecting his commitment to evidence-based reform in pain medicine.
