Warfighting

My medical career has focused on the niche business of technology assessment for health insurance companies. Specifically, I have analyzed the published medical literature on literally hundreds of medical technologies to determine whether or not they would be still considered investigational. Insurance companies generally will not pay for investigational technologies. This odd little profession has suited me, since I have had a front row seat on the continual parade of interesting, whiz-bang and bizarre medical technologies, the latter of which you would not even subject your dog to. About two years ago, I departed the world of insurance companies and started work as a consultant to medical device companies, where I was now tasked with reversing the very medical policies that I had previously created.

It was one such project that was now taking me to California. I had spent several months researching the treatment options for fecal incontinence, resulting in a 30 page treatise of tables, facts and complex figures illustrating the orchestration of a very complicated set of sphincters that keep us from social embarrassment. It turns out that when that when one of these sphincters is blown – sort of like when the elastic gives out in the waistband of your skivvies – there are not too many options besides the obvious techniques of diet adjustment and close proximity to a toilet. My client had come up with an implantable device that applied electrical stimulation that was designed to put the spunk back in the sphincter and make everything copacetic. By a weird coincidence, a previous project for a different client involved the subject of urinary incontinence. I felt pleased that I was now conversant with the ins and outs of our two most important sphincters. It reminded me of a professor who used to say, “I just hope that I die with all my sphincters intact.”

My report provided the background resource document for the upcoming strategy session, where members of the team were supposed to anticipate the insurance company’s reaction to this new product. Would insurance companies pay for it? Were the consequences of fecal incontinence fully appreciated? How do you define fecal incontinence? While that may seem simple, one person’s inadvertent skid mark could be considered a near fatal embarrassment by a more fastidious person. What kind of standards could be imposed for objectively evaluating the severity of incontinence? Just before I left, I received a slim book that we were asked to read in preparation for the meeting. I had slipped it into my bag without really looking at it, figuring I would read the book on the plane.

I was taken aback to find that the book was called “Warfighting: The US Marine Corps Book of Strategy,” which is required reading for all marines. The cover of the book featured a close up profile of a frenzied horse with a wild eye and widely flared nostril, straining mightily against the reins. There was a large vein popping out along the length of his nose. The horse looked like it was about to explode in fury. What could this 100 page book possibly have to do with fecal incontinence? The inside cover noted that Warfighting shows how to use the Marine Corp’s battle strategies to manage your way to victory in every confrontation, whether corporate or personal.

One of the endorsers on the back cover of the book was Ed McMahon, identified as a “television personality,” who blurbed, “Being a good marine transfers easily to being successful in your chosen field.” Now it seems to me that Ed McMahon, as a chuckle-headed second banana to Johnny Carson, does not represent the leadership skills of a Marine. I recently happened to stumble across McMahon on the show “The Dog Whisperer,” where a dog trainer comes to your house to whip your wayward dog into shape. Ed and his wife had some sort of yappy lap dog that had totally taken over the household – it may have been that the dog kept trying to bite Ed when he tried to bed his wife. And since I also try and keep up with my People magazine, I can tell you that overextended Ed was one of the most high profile victims of the mortgage meltdown; the bank has foreclosed on his house. It looks like Ed needs a crash refresher course on Warfighting to take control of this situation.

Although I was perturbed about reading a book about war strategies, I wanted to be a gamer, so I settled in. The jacket advised that as we read the book, we should substitute the word “combat” with “competition,” “soldier” with “frontline worker,” and “enemy” with “rival.” Now my interest in the project was really the science behind fecal incontinence and the challenges of investigating it. I really had no interest in treating insurance companies like the enemy, grabbing market share and hitting projected revenues. But I guess that is why my colleagues get stock options and bonuses and I do not.

The book starts out by defining war, which like the definition of fecal incontinence, should be self-evident, but in this book takes 19 pages. There are such obvious statements as, “violence is an essential element of war, and its immediate result is bloodshed, destruction and suffering,” and, “at least one part to a conflict must have an offensive intention, for without the desire to impose upon the other there would be no conflict.” I think that we can all agree that if nobody is willing to fight, there is no war, but maybe I am oversimplifying this in some way. Subsequent chapters extol the virtues of surprise and boldness, which most recently has been translated into the catchier phrase, “Shock and Awe.” It turns out that surprise and boldness is a relatively new tactic for the military, replacing the previous attrition strategy which was based on superior firepower. “The attritionist gauges progress in terms of … body counts and terrain captured.” While attrition rode the good guys to victory in WWI and II, the limitations of this strategy became glaringly apparent in the guerrilla war that was Vietnam.

As I finished the book, I realized that there were two gaping holes in this treatise that may leave the marines on the front lines scratching their heads. First, there was no guidance on identifying the enemy. While US soldiers helpfully garb themselves in distinctive uniforms, this seems to be a one way street, since our opponents do not extend us the same courtesy. Secondly, there is no definition of winning the war, i.e. how do you know when it’s over? Now here is where fecal incontinence shines. The enemy was me, since I originally wrote the negative coverage policies when I worked for the insurance industry – I was basically trying to undo my previous handiwork. Winning is easily defined – it would be when access to electrical stimulation becomes not a privilege, but a federally mandated right, such that anyone with even a smidge of fecal incontinence could raise an unfettered hand and say, “Implant me!”