Walking the Deck

The military's top doctor demands accountability, in person and online.

Dr. S. Ward Casscells, assistant secretary of Defense for health affairs, says Defense Secretary Robert Gates provided him with a one-word job description when he took over as the military's top doctor in April 2007: accountability.

Gates couldn't wait for Casscells to begin addressing the situation at scandal-plagued Walter Reed Army Medical Center. In fact, he wanted Casscells to start work the day after his interview, which was Thursday, April 12. The Houston-based Casscells pleaded for the weekend to get ready and negotiated to start on Monday, April 16.

Gates' urgency stemmed from the dire conditions at Walter Reed, which surfaced four days after President Bush nominated Casscells to succeed Dr. William Winkenwerder Jr. as head of the Military Health System on Feb. 22, 2007. On Feb. 18, The Washington Post ran the first in a series of articles depicting veterans of combat in Iraq and Afghanistan living in quarters with holes in the floor and black mold on the walls, and suffering from neglect at the hands of "disengaged clerks, unqualified platoon sergeants and overworked case managers."

The neglect was compounded by the fact that the Army's then-surgeon general, Lt. Gen. Kevin Kiley, seemed unaware of the problems at Walter Reed, even though he lived on the grounds of the 113-acre hospital complex, about a five-minute walk from the "bleak quarters" of Building 18, highlighted in the Post articles.

Casscells, a cardiologist, says he visits Walter Reed almost on a daily basis when he is in Washington. On some of those occasions, he goes on rounds with cardiology residents. Other times, he simply wanders the post, just as he does during unannounced visits to the National Naval Medical Center in Bethesda, Md.

"I drop in at odd hours to 'walk the deck,' as they say in the Navy," Casscells says. The idea is to get firsthand knowledge of what's going on in the mammoth MHS bureaucracy, which includes more than 130,000 medical and civilian personnel who staff 63 hospitals and more than 800 clinics worldwide.

Casscells seeks out virtual communication as well. In October 2007, he kicked off a project to transform its informative but bland Web site (www.health.mil) into a dynamic, two-way medium that invites the kind of tough discourse found on personal and commercial blogs, but rarely on military Web sites. The interactive nature of the MHS site-including comments on Casscells' own blog-provides him with immediate understanding of problems he might not have known about if they had to work their way through the chain of command.

When he started his blog, Casscells said he wanted to "capture the insights and experiences that matter." In December 2007, he did that by highlighting one soldier's frustrating experience at Walter Reed. Casscells gave the soldier, 1st Lt. Ryan Miller, and his mother, Rita Dougherty, space in the blog to tell their story. Dougherty and Miller, a West Point graduate who suffered extensive nerve damage and broken bones as a result of an attack in Baghdad in October 2007, wrote that "the doctors at Walter Reed are the most experienced and talented at fixing debilitating wounds and saving limbs and lives," but they are "often ghosts when it comes to dealing with the day-to-day duties of patient care and questions."

Once surgery is completed, they said, care is turned over to teams of junior doctors and the structure of those teams is "confusing and inefficient." It is "daunting," they said, "for patients to keep track of three to four medical teams that consist of a minimum of three members."

Hundreds of comments from clinicians in the field during a Web-based town hall meeting in June 2008 on the Armed Forces Health Longitudinal Technology Application convinced Casscells that changes were needed in the electronic health record system. The clinicians found AHLTA "intolerable" to use, he says, and their "frankly shocking and galvanizing" comments spurred him to take a new look at the system.

Dr. Harold Timboe, Walter Reed's commander from 1999 to 2002, said Casscells' use of the Web to interact with military health personnel reflects a "consensus-building approach" to management. Timboe said online polls and blogs enable feedback not available through ordinary channels in an organization as large as MHS, where the boss is insulated by layers of bureaucracy and reports.

Casscells graduated from Harvard Medical School in 1979 and spent much of his career as a clinician and in the academic and medical research fields. He served as a distinguished professor of medicine at the University of Texas Health Science Center in Houston and director of clinical research at the Texas Heart Institute before taking the MHS post. He had little hands-on experience with military medicine before 2005, when he joined the Army Reserve at age 53. Casscells was mobilized that summer as part of the Army's response to Hurricane Katrina and spent the end of 2006 in uniform as a colonel in Iraq, working as the military medical liaison to U.S. Ambassador Zalmay Khalilzad. Now he says he has never "had such a fun job in his life" as the MHS position, which allows him to work directly with patients while running one of the largest health care systems in the country.

Casscells downplays his management skills, especially in the areas of finance and personnel, but he has focused his efforts on leadership in a wired world. Accountability, he says, means that a manager not only needs to lead by example, but also listen to people throughout the chain of command. Casscells would like to keep his job beyond the change of presidential administrations in January, but adds that if he is replaced, he hopes his successor "will keep the dialogue going."