COL David Bitterman Interview Transcript

The following is a transcript of my interview with Colonel David Bitterman, FACHE. To find links to the audio files and more information about the interview, please click here.

These transcripts are made possible by a gift from the NNEAHE.

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Bonica:	Welcome to the Forge Colonel Bitterman.
Bitterman:	Thanks.
Bonica:	You were an Air Force brat but you call California home, what made you decide to join the Army?
Bitterman:	My dad was as career Air Force non-commissioned officer and the last 2 years of his life was my last 2 years of high-school. I was a pretty good student in high-school but I knew I wanted to go to college and I knew I had to figure out a way to pay for it. My tryst in the Army was really as a vehicle to pay for my undergraduate education.
	I applied for and ROTC scholarship and won that scholarship. There were 5 of us children in our family. I was the 4th. I really didn't know much about the Army. I kind of knew a little bit about the Air Force because I grew up in the Air Force up to about my elementary school age. Again, it was just mostly a vehicle to get my college education paid for.
Bonica:	That's not uncommon. A lot of folks kind of start in that way.
Bitterman:	Right.
Bonica:	You got your scholarship and you went to University of California Davis. What did you major in?
Bitterman:	Majored in biology, biological sciences.
Bonica:	Were you thinking about ... A lot of guys they wind up doing that thinking medical school or something along those lines. Is that where you were going?
Bitterman:	That's exactly what I was thinking of doing. I had great plans of being a medical doctor. By that time, I have an older sister who is a nurse, loved the medical profession. It seemed like a great occupation. You're helping people, you're of service to people. Yeah. That was my plan. Went to UC Davis, had a great pre-med program. Really great reputation. I figured I'd be in the Army for 4, 5, years, take the MCAT, go right into med school and life would be perfect after that.
Bonica:	You did ultimately take an active duty commission.
Bitterman:	I did.
Bonica:	You became a medical service corps officer.
Bitterman:	Yes.
Bonica:	What is that?
Bitterman:	Medical Service Corps is one of the 6 commissioned cores in the Army medical department. There are 2 major sub-divisions of the medical service corp. There's the administrative series, which I'm one of those occupational specialties. Then there's a clinical sub-division. The clinical sub-division is much smaller and it includes things like audiologists, and clinical psychologists, and social workers, and podiatrists.
	Now all of the administrative areas are all of the non-clinical parts of the delivery of health care that exist either in the military or in the civilian sector. When I came in the military I was what they call a 70 Bravo which is a generic field medical assistant. As staff officer I was in charge of putting together, running all the logistics of personnel, the training, the operations for a combat medical unit, from the smallest most basic size of 20 men in a supporting and infantry battalion, up to a mobile army surgical hospital, MASH hospital.
Bonica:	This is in your early phase. You came in, you became a medical service and a 70 Bravo. General field medical assistant is what we call it.
Bitterman:	That's correct.
Bonica:	You started in infantry? Supporting the infantry.
Bitterman:	I was in a 660 man infantry battalion and I was in charge of 26 medics and we provided all the initial medical care, both in a deployed environment and in garrison while we were at home training for Army stuff.
Bonica:	How did you feel coming in straight out of being a biology major at US Davis, and the, if I remember correctly, the drum major of the UC Davis marching band? Is that right?
Bitterman:	Well almost. You almost go it right Mark. I was actually drum major my high-school ...
Bonica:	Oh! Of high-school. Okay.
Bitterman:	Marching band the last few years. I was in the Cal Aggie Marching Band first 2 years. Played the mellophone poorly but I did play.
Bonica:	Preparation to playing the mellophone and ROTC, how did that prepare you for this fist job as a medical platoon leader in the infantry?
Bitterman:	The ROTC programs, at most major universities across the nation, give commissioned officers a good grounding in the basics of military history and doctrine and what it's like to be a small unit leader. It really doesn't prepare you for the challenges of leading a team of, in my case, 26 men. You go through a short course. I went through a short course here called 'The Officer Basic Course' at Fort Sam Houston Texas in San Antonio, which was about 16 weeks long. Then I went to Fort Benning Georgia and learned how to jump out of perfectly good airplane, as they say, with a parachute on my back.
	Then I went to my unit and you are really a rookie when you arrive at your unit. If you're a smart second lieutenant, which is the grade you come in at, you'll listen to the more experienced officers who you outrank but who are far more experienced than you are at delivering health care in that setting.
Bonica:	Since you're still here and seem to be fairly successful I imagine you did actually listen to some of these gentlemen?
Bitterman:	I did.
Bonica:	Yeah, so tell me about that. Who did you find that kind of influenced you during that period?
Bitterman:	You know, we were an army that was changing at the time. I walked into my med platoon, what they call a battalion aid station. I was met by my platoon sergeant who had a cup of coffee in one hand and a lit cigarette in the other ...
Bonica:	This is the medical ...
Bitterman:	This is the battalion aid station where ... As I said we were an army in transition. Outward appearances aside, this was a very seasoned Vietnam vet who knew exactly how to doctorately support this large light infantry battalion. He influenced me a great deal. I actually had a good cadre of about 6 non-commissioned officers in that group that really taught me how to employ and use a medical platoon, in support of that battalion. It was really a phenomenal learning lab, really. Really kind of set the foundation for my future, I think.
Bonica:	Okay. Did you find a mentor at that time? Did somebody reach out to you at all? Above. You've been talking about you've learned a lot from the people who you were supervising. Did somebody reach out for you either parallel, at the peer level, or above?
Bitterman:	I don't think my experience was much different from most other second lieutenants. The battalion commander was a Vietnam veteran at the time. He was probably in his mid-40's. To me at the time he appeared older than dirt, you know, and incredibly wise and knew exactly what ... I got a lot of mentorship from him and from the battalion XO who was his second in command, who were just normal guys, who were just trying to achieve our Army's mission at the time.
	Then later on, as I progressed in my career, I ran into more and more mentors who really took great effort to kind of forming the way I thought and the way I acted, and really served as great examples for how I did the same thing later on in my career.
Bonica:	Okay. Can you give me an example of something you learned, early on, in this kind of initial phase, your first several years in the Army? Not that job necessarily but in terms of leadership, mentorship?
Bitterman:	You learn good things and bad things from watching people, I think. I learned early on in my career that maintaining an even temperament, it sounds very simple, but maintaining an even temperament and not flying off the handle was a pretty valuable life skill to have. I remember specifically, I was mid-grade officer, been in probably at this point about 10 years or so, and I thought it would be a great situational leadership, you adapt how you treat people based on your specific environment.
	At one point I thought, and I very specifically remember this, that it would be a good technique to be very directive and very assertive in one particular incident. This captain who was the recipient of my very directive and very assertive situational leadership style, at the time, came back to me about 4 hours later and with great personal courage sat down with me and told me how that was really not effective. Boy, talk about a important life lesson. You know?
	I took that and I did something with it and I've been very careful not to react emotionally. Reacting emotionally is the easy thing to do. Frankly you need, as a leader, you need to control your body language, you temperament, process what's going on around you and then react maturely and logically to your situation.
Bonica:	You spent, kind of, most of your early years in field units, is that right?
Bitterman:	Yes.
Bonica:	At what point did you kind of say, "You know, I like this Army thing. I kind of like being a medical service corp officer. I might let that whole medical school thing go." What drove that decision?
Bitterman:	I was in Korea. I was a company commander of a MASH hospital and I was busy studying for my MCAT, and this is at the time when we were at the cusp of, you were starting to see personal computers on desks and stuff, so I had stacks of 3 by 5 cards. We hadn't progressed to the point where we were doing online studying. I remember having these massive stacks of 3 by 5 cards and just going through the repetitive memory, and realizing that what I was learning, what I was trying to remember, what I was preparing myself for, was really something I didn't want to do for the rest of my life.
	I really believed that I was good at, and I really enjoyed, small unit leadership. I enjoyed influencing others. I enjoyed leading organizations. I looked at what some of our providers, physicians, were doing in this hospital and I realized that some of them had probably committed to their occupation for the wrong reasons. They were chasing the prestige, the paycheck, what comes with being a physician, a doctor, in our society. I realized that that wasn't, to me, as important as achieving my life goal. At the time I didn't know what my life goal was but I got there eventually.
Bonica:	Interesting. Okay. We can come back to that in a minute.
Bitterman:	Okay we will. Yeah we should.
Bonica:	Good. Okay. You're in Korea, at what point did you ... At some point you made a transition to working in "fixed facilities" as we call them. What was that? How did that come about?
Bitterman:	The very next assignment I was in Washington DC and I was assigned to I guess what you would call our corporate headquarters which is at the offices of the Surgeon General. It's where policy is made, it's where strategy is developed and I worked for a guy named Major David Rubinstein. I was a captain at the time, we shared a small office and he was probably my first really affective mentor.
	He had just recently gotten his masters in health administration through Baylor University and he talked to me about setting career goals and developing a plan to achieve those goals, what we now know in the Army as a career map. Helped me develop that career map. That really set the stage for me to, "Okay in 2 years from now," and this is back in 1991, "2 years from now I'm going to enter a masters in health administration program, matriculate through that program and start being a health care administrator in the Army, with the goal of down the road leading a hospital in the Army or in the civilian sector."
Bonica:	Okay. That's Major Rubinstein later ...
Bitterman:	Major General Rubinstein.
Bonica:	General Rubinstein okay. He had a pretty good plan going for himself as well.
Bitterman:	He did yeah.
Bonica:	Okay. You went to Army Baylor?
Bitterman:	I did. I entered Army Baylor program which is a collaboration ... It's a cooperative program between Baylor University and the Academy of Health Sciences down at Fort Sam Houston. Curriculum, all the professors are accredited by Baylor University. It's a great program, it's been in existence since I believe '52, '53. In fact we recently got word that US News and World Report is now the 7th ranked MHA program in the nation, which we're all pretty proud of. At the time, the first year, the didactic year, was a 60 semester hours crammed into 1 year.
Bonica:	Yeah. That's intense.
Bitterman:	It was pretty intense. There were 48 students in my course that started, 46 finished.
Bonica:	You did one year of didactic, meaning you were in a classroom for a year.
Bitterman:	Yes. And then one year, the second year is called an "administrative residency" and so I went to Madigan Army Medical Center out at Fort Lewis Washington for my admin residency, along with a Navy lieutenant. We worked for ... The administrator of the hospital was a gentleman named Thad Krupka, a superb mentor who ... The whole purpose of this administrative residency was to teach the resident how health care is delivered at the user level.
	I rotated, throughout that year, throughout the hospital and through other civilian organizations too. I went into the operating rooms, I spent time with the anesthesia providers. I spent time in the emergency department with the senior surgical resident on a payday weekend, on a Friday night. I spent a week with the Group Health Cooperative of Puget Sound learning about managed care in one of our very first managed care organizations. I spent a week with the University of British Columbia, learning about Canadian health care and how it's delivered. Spent time at Harbor View Hospital, a level 1 trauma center up in Seattle, learning about trauma care.
	All of these experiences comprehensively came together and formed an experience base that I think a typical program you wouldn't have the opportunity to gain all these experiences and help you as you developed your own style of practice later on as a health care administrator. Really phenomenal program.
Bonica:	Okay. Yeah.
Bitterman:	Yeah.
Bonica:	I guess it's still relatively early in your career.
Bitterman:	Yes.
Bonica:	How did it change or establish what you wanted to do, that career plan you talked about?
Bitterman:	My career map terminated in my becoming the lead health care administrator in a medical center. Later on I changed that career map to be a commander of one of those, the CEO of one of those, organizations. You don't leave an NHA program and say, "Tomorrow I'm going to be a CEO, and I'm going to be a good CEO because I'm a good person." Right? You have to have life experiences, you have to have the skills, knowledge and attributes necessary to be successful as a CEO.
	My career map that I developed with my mentor, David Rubinstein, helped me chart a path to do that down the road, CEO. My first step was to be a good administrator, so right after I left the admin residency I became the administrator for department of surgery there at Madigan Army Medical Center. We had 12 surgical teaching programs, about 600 people in the department and I was responsible for all that administration, all the logistics, personnel actions, all the supplies, all the training, all the operations, of that very large teaching department.
	That was the first step. That later on, that and other assignments, qualified me to be considered for selection to be a deputy commander for administration, first in a small clinic and then progressively larger organizations after that.
Bonica:	When you were at Madigan, this was the first time you were now ... You had briefly at the Surgeon General's Office, doing policy kind of stuff.
Bitterman:	Yes.
Bonica:	Now you're at Madigan, as the administrator for the department. How is leadership there, that role, different than what you'd experienced before, particularly say in your experience with the line units, the infantry and the MASHes and so forth? How is that different?
Bitterman:	Much different. Leadership styles in a combat environment, in what we call a MTOE environment, it's an Army acronym, stands for modified table of organization and equipment. It's basically all the combat style units you see out in the Army. You know, MTOE units. Leadership styles there are very directive in nature, very mission oriented, you have a mission, you have your commanders in tent and there's not a lot of discussion about how to achieve something. You develop a plan, you train to that plan, then you execute that plan.
	Things are much more fluid and much different in a fixed facility health care environment. The decisions are made in a much greater proportion to a consensus driven effort. There are very many complex systems in health care and they're all inter-related. The government structure in many organizations is more matrix oriented and so you work across your organization rather than up and down silos. Chains of command are sometimes confusing. Sometimes you work for multiple people at the same time to obtain certain objectives and that managed chaos is actually very exciting.
	It's exciting to go to work in that kind of environment. You know what you're trying to do, you're trying to deliver world class health care to our deserving patients. You have great flexibility to achieve that objective through working in that kind of environment. The typical department chief in an academic teaching hospital like that is very seasoned, had they been there for a long time, and you have to convince yourself and convince them that what you're doing is to their advantage and to their patient's advantage. Sometimes their motivations aren't the same as yours. Sometimes they're not patient-centered. Sometimes they're self-centered. You've got to work through those issues with those very senior leaders.
Bonica:	Okay. You moved on, you did a number of things and I'm going to skip forward in your career just a bit to where you finally did have your first, what you refer to as a deputy commander for administration, or what's sometimes kind of translated by Army folk, like yourself, to be a chief operating officer. You had that and that was your first assignment in that position was at Radar Clinic ...
Bitterman:	That's correct.
Bonica:	In the DC area, followed by a second DCA slash chief operating officer role at Kimbrough Ambulatory Center which is up in Maryland right?
Bitterman:	That's correct.
Bonica:	Both of these were outpatient treatment centers, what's you learn ... Now you're in the role, the role that you've kind of been looking at and saying "I want to be there". What did you learn when you finally put on the hat and became the chief operating officer?
Bitterman:	I think the very first thing I learned was I still needed to learn. One practice I started when I took my first deputy commander for administration job was to sit down every week with my direct reports, and it was scheduled for an hour. I always approached with them, the first meeting I always told them, "Look this is our hour to debrief each other on what we are doing. For you to bring me up to speed on the issues that are happening in your area and for me to provide you the support I think you need to do you job."
	At that point I'd been in the Army for 14 years and I have pretty good experiential base, but I had all these other departments that were now reporting to me that I had no experience with, like social work, like pharmacy, like patient administration. I really had no background in those areas, so I really needed to learn from them and they needed to be able to trust me, trust their leader, that I would have their ... That I would support them as they needed resources to do their job.
	That was the first thing I learned and then as I ... I went to Kimbrough, Kimbrough is a much bigger place, they also did ambulatory surgery and also served as a higher headquarters for 4 other clinics that were throughout Pennsylvania and Maryland. You learn to operate over time and distance in that kind of environment, too. You learn to trust subordinate leaders because, what's the alternative? You can't be everywhere all the time. You must develop relationships long-distance and trust that those subordinate leaders are going to do what you ask them to do.
Bonica:	That's a big transition from being able to walk in and look around at everything you're in charge of.
Bitterman:	That's correct.
Bonica:	I know, just from personal experience, I've worked with you, you're big on that. You do make a habit of walking around. Talk a little bit about that. Why is that important?
Bitterman:	I think it's vital important. I think that first off leaders need to know the environment that their subordinates are working in. They need to know the challenges, they need to know what constraints they're operating under. You don't get there by reading email, by sequestering yourself in you office.
Bonica:	Right.
Bitterman:	If your subordinates ... They really need to know that they can trust their leaders. There's dozens of management books out there about managing by walking around, and leadership rounds and whatever you call it, the reality is that the leaders need to get out so the subordinates can see and learn about their leader and learn that they can trust their leader to provide them the resources they need to get their job done.
	Health care delivery, in our country, is really, it's just a system of systems. There's a logistics system, there's a payment system, there's a hiring system in cases and how they interact with each other is really the science in health care administration. You don't learn those things unless you get out and experience them.
Bonica:	Okay. You kind of bring up a point that I wanted to ask you a little later but, I'll pose it now, and that is; your career spanned the adoption of electronic media, you were in probably before the existence of email as a management tool, before social media, you've seen that change the way we do business. Talk a little bit about the good and the bad. I mean you've made a point that you don't manage by answering email, but at the same time it is a useful tool right? Well it can be.
Bitterman:	It's very, very useful.
Bonica:	How have you seen the pluses and minuses of electronic media, of social media, how do you see that?
Bitterman:	It's about information sharing right? I believe that every person has a finite ability to deal with information effectively. You can process a lot of information ineffectively, but what do you do with the important bits of information that you really need to take action on. Throughout my career ... I came in the Army when it was all paper and it was all physical in-boxes and reading one thing at a time and doing things very sequentially and progressed to now, I very routinely, at my standing desk, because you gotta, at my standing desk I get 200 emails a day and very few documents in my inbox.
	Things are done very in a parallel manner and they're done in a distributed way to many multiple people. You sometimes wonder in that kind of environment whether you are as affective as you can be. I get very worried sometimes that our leaders today are treating thing very superficially because they're being overloaded with information. There's too much information. In fact I read a couple article about that recently, information deluge. What do you do with all of this? It's a dilemma. It's a paradox.
	Back, I think, 30 years ago we weren't nearly as effective, the healthcare system in our nation, because we didn't have the information. Now we have it and I think we're hampered by all of the information that keeps coming at us. You can't process it all. I'm not sure I answered you question but that's the challenge I'm dealing with on a daily basis. Parsing what's important from what's not important and spending the time with what's important.
Bonica:	Talking about what's important, from Kimbrough you were board selected to be the commander of the 2-12th Mobile Army Surgical Hospital, also known as a MASH, kind of like the TV show, right?
Bitterman:	Yes.
Bonica:	If I remember correctly this was the last MASH in the Army?
Bitterman:	That's correct.
Bonica:	You were the last commander of the last MASH, is that right?
Bitterman:	I was the last Lieutenant Colonial Commander, then it transitioned to be a combat support hospital after that, so a different type of organization. Yeah.
Bonica:	What is a MASH. Most of us know MASH from the TV show, what is a MASH actually? What's it's mission, what was it supposed to do doctorally? What did you do as the 2-12th Commander?
Bitterman:	Sure. A MASH hospital is a 100 percent deploy-able 36 bed surgical ICU. That's really it. It was designed doctrinally to follow very close behind expeditionary forces, that means a force that's moving into contact with the enemy, and then establish right up behind that force and provide very complex surgical care for the first month or so of combat, and that's exactly what the 2-12th did during the initial invasion into Iraq, during 2003. I joined the unit shortly after the unit had been in combat for about 2 months, I joined the unit down-range. Then we ...
Bonica:	They were in Iraq when you took command?
Bitterman:	They were in Iraq and they were the only hospital in Iraq for the first about 3 weeks of combat and so they say the preponderance of casualties that ... There were long lines of evacuation from where the invasion forces were farthest North into Iraq and so that group of men and women really did some heroic things before I joined them. Pretty incredible unit.
	The cool thing about the 2-12th MASH was it had such a great history. It was the most highly decorated combat hospital in the Army and you took a lot of pride in that history. You took a lot of pride in the reliance you had on the men and women you worked with and the team you worked with. It truly was a team of teams and it was probably one of the most enjoyable assignments I ever had. We weren't burdened with email. We weren't burdened with all the stuff we just talked about, you know, the electronic media. It was really very simple, you had a singular mission to deploy and support our combat forces.
	It was very physically demanding. We traveled with 35 big 5 ton Army trucks, towing all of our equipment behind us is big trailers and when you got to your location you had about 12 hours to set up this massive complex of tents and containers to be able to receive your first patients. It was truly a fantastic group of people to work with. I was humbled everyday going to work.
Bonica:	What was your role? You're administrator, so you're not a surgeon, you're not treating the patients, so what was you role as commander?
Bitterman:	As commander my role was to train the organization to their mission and to provide them the resources they needed to get their job done. That's it in a nut-shell. I felt ... Sometimes my role was to buffer them from our higher headquarters in a sense. I think in every organization a good leader does that. You, as a leader, you develop the priorities for your unit, priorities in training, in manning, in resources and there are distractors that get in the way. You've got to guard against that.
	I think my role is also to influence those junior leaders and the soldiers of the MASH who were tired, who had families at home and who were distracted sometimes, who needed to be encouraged, who needed to be reminded of their mission. That wasn't really that hard of a mission to do. Incredibly dedicated group of men and women. The leadership experience there at the MASH was truly a humbling one. Yeah.
Bonica:	Great. From there you came to ... You took another chief operating officer, or DCA job back in DC, and that was to be DCA at Dewitt Army Community Hospital and the Dewitt Health Care Network. What was kind of unique about Dewitt?
Bitterman:	When I arrived at Dewitt in 2005 we had just ... First off, the hospital is located in the National Capital area so the politics of operating in the Nation Capital area was very unique. Secondly, very large health care network, served about 70,000 or so patients in the Northern Virginia area of 5 distributing clinics and a community hospital with 43 beds. The leadership team there was very unique.
Bonica:	Yes.
Bitterman:	I worked for a Colonial Patricia Horoho, who is now Lieutenant General Patricia Horoho, or Surgeon General and she had a unique approach to leadership. She spent an awful lot of time the first part of the 2 year tour I was there developing the effectiveness of our team, and she did that through a structured series of organizational effectiveness training sessions and really developed the trust between the 3 deputy commanders and the commander and the command sergeant major, in a huge way. In a way that I've tried to replicate in every other organization that I've been to since then. Remarkable leader and I learned a great deal from her.
Bonica:	[inaudible 00:38:40]. What is particular have you tried to replicate or carry from that, from those lessons? What did you take away from it saying, "This is what I want to do in the future."?
Bitterman:	Most organizations you go to you arrive into a team, a team that's already established, and there's a certain amount of time that goes by where team members learn to trust each other and learn what motivates each other. One thing that she did that I've tried to do is, very early in that team forming whether you're joining a team, or the entire team is forming new is, you bring in outsiders, trained organizational effectiveness trainers, who talk about the mission, who help you learn about each other, help you learn what motivates you personally, and you share that with the group.
	They do some personality indicator things lie, I'm and extreme extrovert. I know what motivates me, but others may not know that and so there's a series of exercises that you go through where you disclose this information. It really leads to some very quick turns on team forming, storming, norming. You go through the normal team forming process in a very short period of time. One that would take, a normal, 6 months period, you do that in a couple weeks. You get to a level of effectiveness much quicker.
Bonica:	You think it is useful to take some time to do these kind of exercises where you really do get to know each other?
Bitterman:	Absolutely and you form, you form expectations of each other. Everyone knows up front what ... These are our boundaries, this is how we're going to operate, this is how we're going to communicate with each other. We are all motivated by the organization achieving success. If the organization is successful we personally will be successful.
Bonica:	Obviously some of that can be helped by outsiders, which is a useful thing, you think it is useful to bring someone in from the outside even if, with your experience having an MHA and having been a commander, still useful to bring somebody from the outside rather than saying, "I can do this myself"?
Bitterman:	That's correct. Because sometimes you're too close to the situation, you can't be objective about how the team is developing.
Bonica:	From there you went down to here. You came down to Fort Sam Houston, where we are today, to Brooke Army Medical Center. It was Brooke Army Medical Center at the time, I guess kind of still is.
Bitterman:	Yes it is.
Bonica:	Brooke at the time or BAMC as we refer to it in the Army, and you were the DCA or chief operating officer there. BAMC is the second largest Army hospital with over 5,000 employees, 35 teaching programs, it's got a burn center and a level one trauma center. If that wasn't enough you were also involved, at the time, when I say it kind of still is, at that time the federal government had decided to make an investment to build, basically, double the size of the facility, merge it with the Air Force in a way to create the San Antonio Military Medical Center, a 700 million dollar project. Talk about the hours that took from.
Bitterman:	A piece of cake right?
Bonica:	Yeah sounds like it.
Bitterman:	This happened about 4 months after the Washington Post Walter Reed scandal. There was a lot of attention being paid to how our military treated our combat veterans, so we were standing up special organizations to take care of our recovering veterans. That was a very, a very tough time for our military and a very rewarding time for me, personally, at Brooke Army Medical Center. Now, 5 years later ... It's longer than that, gosh, 7 years later. Now it's the largest hospital in the Department of Defense. It's a 2 and a half million square foot hospital, state-of-the-art world-class everything.
	At the time we were really doing things one day at a time. Things were changing so rapidly. Developing relationships with our sister service, the Air Force, down in San Antonio. That was a day-to-day process. The process of developing our requirements for our new facility that we're building here and putting them on paper and doing the project management to do this huge capital improvement project. At the same time we were standing up other organizations to take care of ... It was just a very chaotic time.
Bonica:	And you were still running a very large hospital at the same time.
Bitterman:	Exactly right. You know when you felt like you were getting burned out and you were kind of at your ropes end all you really had to do was go walk down to the burn unit or walk over to the center for the intrepid, which is a world-class rehabilitation facility for burn amputation, amputee care and limb salvage care, and talk to any of those soldiers who were incredibly grateful for the care that was being delivered. That really gave you a second wind, and a third wind, and a fourth wind, and really kept you grounded in what the organization and what the Army was all about.
	I came into that job thinking, this is at about I think the 22nd year of service, I came into that job thinking, "I am retiring after this" because at this point I was just very tired, because you're working very hard, and that was one of the most professionally rewarding 3 years I've spent in the military. Really gave you a sense ... We are incredibly patient focused, which is a theme we want to get to across all of Army medicine. We really felt close to our mission and how we were delivering care to our patients. Really a remarkable time.
Bonica:	Okay. You did eventually get an opportunity to slow down, for about 4 months you got to be the chief of staff, chief operating officer if you will, for the Amedd Center and School, kind of the home of Army medicine education.
Bitterman:	Yes.
Bonica:	Except, like I said, you only got to do that for 4 months because the chief operating officer position for the Army medical department, the whole Army medical department went vacant and you were tapped to step into that role, kind of unexpectedly.
Bitterman:	Very unexpectedly.
Bonica:	You were suddenly ... You went from overseeing education and so forth to actually monitoring the functions of the entire medical department, a 13 billion dollar budget, 3.9 million beneficiaries, 50 facilities around the world, including 8 academic hospitals, and oh by the way, still in charge of training all the medical assets for the Army. What was that like?
Bitterman:	That was overwhelming.
Bonica:	Was it?
Bitterman:	That was incredibly overwhelming. I took Mr. Herb Kohli's job. Mr. Kohli had been serving our nation for 42 years at that point, either as a commission officer or as a department of the Army civilian. Superb leader and I knew that I wouldn't be able to replace Herb Kohli.
Bonica:	Yeah.
Bitterman:	I knew that the job as I worked it would be different than what he did. I knew that because, at the time when I took it we were reading in the media about sequestration, and budget cuts and doing our mission with fewer resources. Then it became not just sequestration but it came furlough of our Department of the Army's employees and a 40 percent decrement in our budget during that first year and being able to continue to deliver high-quality health care without a loss of quality. In many instances that very long 7 months that I did that job were really about dealing with the crisis of the hour, or of the day. At that point I think I relied in a huge way on relationships that I'd built over the last 20 plus years.
Bonica:	You called on a network that you had been building.
Bitterman:	I did. I really made great efforts to actively communicate with our 10 major subordinate commands throughout Army medicine. You're a very, very large enterprise. If we didn't make the effort to actively communicate then there was going to be a lot of chaos throughout our ranks and so I made a great effort to do that, to actively communicate. Through email, through phone, through face-to-face conversations.
Bonica:	When you're working at this level there's no more of just walking down the hall and shaking people's hands right?
Bitterman:	That's correct, yeah. There was a fair amount of that too because even at the corporate headquarters when you have 500 employees here at the corporate headquarters that they're reading the same newspapers that American citizens are about our nation is reducing budgets and furloughs and so there's a fair amount of walking around the headquarters and maintaining morale and doing that thing too. No, it wasn't like my early days when I did a lot of management by walking around and pulsing the morale and training and resource needs of my unit. I couldn't really do that effectively.
Bonica:	A different kind of communicate. Your saying communication is still center here it's just a different kind of communication you had to ...
Bitterman:	That's correct.
Bonica:	Really learn and [crosstalk 00:50:28]
Bitterman:	You have to be very up front, transparent in times when ... When times aren't going well, when things aren't going well you really need to communicate often and be as transparent as you possibly can with those you work with. They have to be able to trust you. Trust is hugely important. If they don't you're going to have a tough time meeting your mission.
Bonica:	You did 11 months in that position. Is that right? 11 months?
Bitterman:	It was about 7 and a half months.
Bonica:	Oh 7 and a half months okay.
Bitterman:	Then I was replaced by Mr. Fiorri and then I stepped down being the deputy for a couple months before I got my current position.
Bonica:	Okay. Now your current position is chief of staff of the southern regional medical command, or chief operating officer for the southern region medical command. Tell me a little bit, what is the southern regional medical command? What does it do? How does it ... What's it's mission?
Bitterman:	The southern region medical command is one of those 10 major subordinate commands of Army medicine that I just spoke about. Of the 10 there are 5 regional medical commands that provide health care. Our region is the southeast quadrant of the United States, so west almost all the way to El Paso Texas, up to including Arkansas and Oklahoma, all the way out to the east coast to include Puerto Rico is our region. We have 11 major hospitals or health clinics at installations across the southeast United States and they have many subordinate clinics that are within their facility or distributed throughout their geographic area. We have about 28,000 people we're responsible for.
Bonica:	They're employed by the [crosstalk 00:52:28]...
Bitterman:	They're employed by [inaudible 00:52:30]...
Bonica:	Report to [inaudible 00:52:30].
Bitterman:	That's correct, that's correct. Depending on what monies you count we're about a 1.8 to 2.4 billion dollar a year organization.
Bonica:	Okay. Wow.
Bitterman:	Yeah.
Bonica:	That's a huge scope.
Bitterman:	It is.
Bonica:	What do you do? What do you do as a COO, or chief of staff.
Bitterman:	My title is chief of staff, so I coordinate all staff actions within the headquarters and I serve as my bosses eyes and ears and her right-hand man really. She leads the organization, I run the organization.
Bonica:	Okay. Okay.
Bitterman:	If that makes sense.
Bonica:	Okay. Well tell me a little bit, what does that mean, on a day-to-day basis who are you meeting with, who are you talking to to do the running of the organization.
Bitterman:	Out in the region there are 11 different medical treatment facilities, hospitals, major medical centers. Each of those medical treatment facilities has a CEO, subordinate CEO.
Bonica:	Okay.
Bitterman:	My role really is to provide those leaders with the resources they need to be successful to make sure that they're delivering the health care that they contracted to deliver. Holding them accountable. In some cases going to our higher headquarters asking for more resources and in many cases serving as a buffer of information between our higher headquarters and that organization.
Bonica:	Okay. Okay.
Bitterman:	I know that's overly simplistic but that's really what I do.
Bonica:	Who else is here in the C Suite if you will that you coordinate with?
Bitterman:	Our government structure ...
Bonica:	Yeah that's [crosstalk 00:54:27]
Bitterman:	We've got our commanding general, in our case is a 2 star billet. Then I'm the chief of staff and then subordinate to me are we have about 8 other assistant chiefs of staff, for logistics and personnel and clinical operations and quality. I also am in charge of a number of special staff officers. We have chaplain, we have a public affairs officer, we have an inspector general's office that does investigations and serves as our commanders eyes and ears out in the organization. I basically ...
Bonica:	Yeah ...
Bitterman:	Go ahead Mark.
Bonica:	Do the hospitals report ... Or the subordinate organizations report ... The commanders of those organizations report to you, report to the general, how does that work?
Bitterman:	Routinely I'm talking to those commanders on a daily basis.
Bonica:	That's where you're talking about you're running the organization, probably filtering the information.
Bitterman:	Right. That's correct.
Bonica:	Okay. What's the role of the commanding general then, as leader, as you said.
Bitterman:	Our leader, our general, she gives us strategic direction. She gives us our priorities. She represents us to our higher headquarters and to the community and to our Army stakeholders. She's involved in the up and out communication and coordination and I am much more focused on the down and in coordination.
Bonica:	What on any given day might draw your attention to a particular facility in the region?
Bitterman:	Any number of things. We're very focused on delivering high quality, patient centered care across our enterprise. We're doing it every year with fewer and fewer resources. Our higher headquarters expects us to be accountable for the delivery of health care. Every week we focus on a specific service line. For example this week we're focusing on the delivery of in-patient care and whether our staffing levels are ... Whether we're overstaffed in certain areas, understaffed. Whether we're providing the average daily patient load that we should be doing. Whether we're achieving the patient satisfaction scores we should be in each of those areas.
	That's the big picture. The small picture may be we receive a congressional inquiry from a member of congress who is very concerned, they've gotten a letter or a phone call from a constituent who is concerned about a treatment of a soldier or a patient in one of our facilities and we have to investigate and provide a response to that constituent. It's any number of things like that.
Bonica:	It's very much the macro to the micro.
Bitterman:	Absolutely.
Bonica:	You're covering the range of things.
Bitterman:	That's correct.
Bonica:	What keeps you up at night as the chief of staff of [inaudible 00:58:13]? What do you worry about these days in particular? Anything?
Bitterman:	I worry about our ability to provide, and people say world-class care right? I worry about our ability to deliver world-class care in an environment that is becoming increasingly critical of our effort. I see the great work Army medicine has done over the last 13 years. Incredible work that the public may or may not appreciate because the public's been largely isolated, insulated I guess is a better word, from the great care that's being delivered. I worry that our current structure will be degraded in some way because of that insulation because the public doesn't know what's going on. I really don't know how to ...
	You know, our value system, our ethic is not to be self promoting in the Army. I think that works against us in many ways in that the public doesn't understand what we've done. Congress is holding us accountable for the delivery of health care and the resources we spend and so it's ... That does keep me up at night. Worrying about what the future will bring.
Bonica:	All right. Let's close on some thought about leadership and mentorship.
Bitterman:	Okay.
Bonica:	What kind of mentoring relationships are you involved with today, or now? How many of them come from kind of your position as chief of staff, so formal relationships, for example I was waiting to meet with you, you we're having a counseling session with one of your current reports, that's kind of formal arrangements but do you have informal mentors, mentees I should say, that kind of come to you for advice?
Bitterman:	Over the past 3 years I've been the consultant to the Surgeon General for health care administration, so that's a formal role and in that role I've really led the career development, leader development of all health care administrator in the army. My location here in San Antonio is pretty important and pretty integral to that because I'm located, geographically I'm the same installation where all of our leadership training is done for our officers.
	On a typical week I will get mentorship requests, either an office call request, an email, a phone call, anywhere from 3 to 10 officers every week and I always make an effort to set aside time ... You know when you get the email at 9 o'clock in the morning you may not have the time right then to talk with that officer, but you always, always, set up time later in the day or later in the week, to sit down with that officer and talk with them about their career and what the future holds for them.
	I've really taken great pride in doing that over the last 3 years or so. I've been doing it all of my military career but this formal role I've been in had really been very rewarding for me personally. I'm going to leave the Army. The Army will keep rolling along with or without Bitterman. Right?
Bonica:	Right. I've noticed it still functioning without Bonica.
Bitterman:	It's still functioning without Bonica, and it will still function without Bitterman, but you know what, the things that you do as a leader either in a way that everyone acknowledges or just the things you do that are observed by other leaders, they really, they form the leadership recipe that makes somebody else a good leader and so the more time you can devote to more junior leaders, and developing their skill set and the way they think and act, I think pays huge dividends for the enterprise, down the road.
Bonica:	You talked a little bit about how you drew on your network.
Bitterman:	Yes.
Bonica:	Especially when you went into the position at MEDCOM as the chief of staff for the entire medical department. Can you talk a little bit about the importance of cultivating a professional network and how have you done that in your career? How have you done that I guess I should say.
Bitterman:	Well you do it within your organization and within ... In this sense the organization that I'm talking about is the United States Army, not necessarily the geographic location you're in. You do that through reputation. You do that through word of mouth, by picking up the phone and calling people, talking to people. You also do it between ... I've done a lot of community outreach, right.
	The vehicle I've used is my professional [inaudible 01:04:28], I belong to the American College of Healthcare Executives. I'm a fellow in the college. I've been a fellow for a while. I've been in the organization for 20 years now and like any other profession health care administrators need constant leader development and progression to be effective. That's what I've used as my vehicle.
	Doesn't matter whether it's American College of Health Care executives or one of the other great professional organizations we have out there. You really need, as a leader, no matter how old you are, how long you've been doing this work, you need to continue to learn and get better and foster relationships with others and help when someone calls asking for assistance, either a technique or even actual physical resources or someone to talk to, or talk to a group. You do what you can at that time because it'll pay dividend down the road. Did I answer your question?
Bonica:	Yeah. Absolutely that's great. What advice would you give to someone who's thinking of making the decision to become a health care leader, to take on, either a person like yourself who, a young person deciding, you know I want to get into health care administration, perhaps a clinician who's looking to make a transition into a leadership role from a clinical role? What would you say to them about the field? What should they do to try to decide, is this their calling, and what should they do to try to figure that out?
Bitterman:	That's a great question. I would tell you that, first off, you need to do some self-assessment on why you want to do ... Why you want to enter this career field. Much like my decision earlier on in my career not to pursue medical school, you need to do it for the right reasons, you truly are ... I think the best health care are really those that are cut from the servant-leader model.
Bonica:	Okay.
Bitterman:	You are of service to your community, whatever community you belong to. If you can do a self-assessment of you motivation and your goals and you realize that clearly the reason you're doing this is to be of service, I think you're doing it for the right reason.
Bonica:	If it's the right reason then it should make you pretty happy.
Bitterman:	Right. I tell young leader this all the time. If you don't love your work you need to find a new occupation because those who work for you know you don't love your work.
Bonica:	Earlier, at the beginning of the podcast you mentioned your life goal. Maybe we'll close on that thought, so what is your life goal and how does that fit into what we've been talking about.
Bitterman:	Yeah, so back in '91, when I did my career map with David Rubinstein, my career map went out to year 30 in military service. That's where I'm at right now.
Bonica:	It is. Right.
Bitterman:	What have I done with my career map and what's my goal? I see myself ... My role, I'd love to find a role, after I leave the military, where I can continue to influence young developing leaders. I think that is hugely important for the Army, for Army medicine. I think that's my life goal, to continue to be of service. I really think that's important.
Bonica:	That's a very respectable life goal. You did say 30 years is coming up. Mandatory retirement.
Bitterman:	Mandatory retirement.
Bonica:	Any specific plans yet or is that still too soon to say?
Bitterman:	I have, you know we've talked about balance, too, right?
Bonica:	Yeah.
Bitterman:	I have one goal when I leave the Army. I am going to ride my bicycle down the west coast of our nation, start in Vancouver Canada and end in Mexico.
Bonica:	That's excellent.
Bitterman:	Take about a month to do that and do a lot of thinking and reconnecting with America during that time. Then I'll come back here to San Antonio and I'll figure it out. I'm not being coy. I really ... A lot of people have been talking to me about, "Hey I've got this position Dave, are you interested in doing this?" Everyone of them I've told "That sounds very exciting and I'll be available after the first of August and I'll worry about it then. I really need to ... I think everybody needs to take time out in their life to figure out what's next, and how can I make the greatest impact in the very limited time we have left here on Earth right?
Bonica:	Yeah.
The folliw Bitterman:	That's what I want to do, take some time and do that.
Bonica:	That sounds great. Thank you so much for talking with me today. It's been a pleasure to see you again.
Bitterman:	Always great to see you Mark.
Bonica:	Thank you.