L. David Marquet, a decorated Navy Captain, transformed an underperforming submarine crew by empowering his subordinates to be leaders and reach their full potential. He called this intent-based leadership (IBL). What would happen if Marquet's model were implemented in Graduate Medical Education (GME)? In this letter to the editor, we summarize the potential of the IBL model in graduate medical education as opposed to the traditional leader-follower method. IBL harnesses human productivity toward the shared goals of GME, which are patient care and trainee learning. This shift in mindset could lead both teachers and trainees to focus more on the real reason that we undertake GME and change behaviors for the better. We suggest that IBL can and should be adopted in GME and propose that both patients and providers will benefit from this action.Keywords: David Marquet, Leadership, Graduate medical education, Intent-based leadership Dear editors:L. David Marquet was a man on the rise. He was a top graduate of the Naval Academy class of 1981 and was poised to assume command of the nuclear-powered attack submarine, the USS Olympia. He had been preparing diligently for this role for more than a year when plans changed at the last minute. Instead, Marquet would unexpectedly become Captain of the USS Santa Fe, a different type of submarine, which had the worst performance record in the fleet.A few weeks later, Captain Marquet would discover how rough the waters around him really were. He gave an order during a drill, "ahead two-thirds." This order was passed down the line, but when it reached the helmsman who was supposed to execute the order, nothing happened. Although this was a valid order on other ships, this was not one that could be executed on the USS Santa Fe. When questioned, the officer on deck said that he had repeated the order, knowing that it was wrong. Marquet knew something had to change.Marquet recognized the danger of the classic leaderfollower model that was commonly practiced in the military and elsewhere. His crew would blindly follow his commands even if they knew that these orders were unsound. He boldly turned his back on the conventional leader-follower paradigm and employed a novel model in which each crewmember engaged and contributed to his full intellectual capacity. He empowered his subordinates to be leaders, allowing each person to feel valued and to reach his full potential. He called this IBL [1].The results were astounding. "Santa Fe went from 'worst to first, ' achieving the highest retention and operational standings in the Navy." Even after Marquet left the Santa Fe, it continued to thrive, winning awards and promoting "more officers and enlisted men with increased responsibility than any other submarine".Can GME similarly benefit from IBL? We believe that the answer is yes. A search in the database, including PubMed and Google Scholar from February 1, 2015 through May 19, 2017 did not uncover values to measure the outcomes of IBL in GME. To our knowledge, this is the first let...
Objective: To review the literature on Hyrtl fissure (HF) and contribute our experience with a 2-year old who developed cerebrospinal fluid (CSF) otorrhea during routine tympanostomy tube placement. Methods: Data Sources: Pubmed and Google Scholar searches were conducted of articles in the English language literature from all time periods using the words Hyrtl, Hyrtl’s fissure, HF, and tympanomeningeal fissure. Study Selection: All relevant articles were reviewed to identify cases of HF. Results: Data Extraction: Nineteen cases, including ours, are described. Patient characteristics, method(s) of diagnosis and repair, and outcomes are reported. Computed tomography and intraoperative endoscopic images from our case are included. Presentation is more common in children (66.7% of cases where age was stated, n = 10) than in adults (33.3%, n = 5), and is most commonly unilateral (89.5%, n = 17). Cerebrospinal fluid otorrhea was the most common presentation. Six were discovered after tympanostomy tube placements while 3 were identified during cochlear implant work-up or after device failure. Surgical approaches described include endaural, transcanal, retrosigmoid, postauricular, and posterior fossa endoscopic. Multiple materials including bone wax, bone pate, fascia, muscle, and tissue sealant have been used. Our case describes an endoscopic repair in a child, which was successful at a 2-year follow-up. Data Synthesis: The small number of cases limits the utility of statistical analysis (n = 19). Conclusions: Hyrtl fissure is a rare but important entity that may be discovered when routine procedures have unexpected results. Hyrtl fissure should be included in the differential diagnosis when there is persistent clear otorrhea after a tympanostomy tube, cochlear implant misinsertion, meningitis, or unexplained middle ear effusion in an adult.
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