Download Introductory Remarks Upon being invited, by my

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Introductory Remarks
Upon being invited, by my regional chapter president, to deliver a presentation on how the study of history could relate to medical staff services, I considered the movers and shakers of the last two millennia. Indisputably the man who has had the most impact upon western civilization is Jesus of Nazareth; but him I prefer not to discuss for reasons you can well surmise. Instead I chose a contemporary of Jesus, about whom I have done considerable research for many years: Caesar Augustus, the first Roman emperor, during whose lengthy reign Jesus was born.
Why Consider Augustus?
He took a republican constitution, carefully crafted and successfully employed for five centuries to obstruct development of a monarchy, and manipulated its elements to create a monarchy, which not only endured for fifteen centuries but became a model for many modern political systems, including our own. How often have you, as a Medical Staff Professional, felt
called upon to accomplish the impossible?
An unremarkable personal background
Augustus not his name but an honorary epithet meaning Consecrated
Born Gaius Octavius Thurinus on September 23, 63 BCE—
into an immensely wealthy but politically insignificant family
Prepared by his mother’s uncle Gaius Julius Caesar for a political career.
Entered the active political arena on learning Caesar had testamentarily adopted him.
How many of us have stumbled into medical staff services from other professions? 1
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The Historical Background,
as briefly and painlessly as possible
To secure physical security and economic supremacy, the Romans subjugated the rest of Italy and eventually all the principalities of the Mediterranean basin. The annual rotation of Roman magistrates proved an insufficiently stable mechanism for governing far‐flung possessions in an era of primitive communication.
Distant possessions required the presence of standing armies instead of the traditional citizen‐army mobilized only in times of war. By the beginning of the first century BCE, thinking Roman politicians had come to realize the concentration of executive and military authority, in the hands of a single individual or body of individuals over long periods of time, was the obvious solution.
The constitution of the Roman Republic, implemented in 509 BCE upon the overthrow of the Etruscan tyranny, was designed to forestall the redevelopment of monarchy.
So actually, Augustus was not terribly original
Efforts to establish monarchic rule within the context of the Republican constitution had been going on for at least half a century before his birth. Methods tried included
_Successive tenures of the executive office of consul without the mandatory 10 year lapse;
_Extraordinary peacetime military commands, conferred by executive order of the Roman Senate;
_Extended tenures of the emergency office of dictator. This office conferred supreme executive and military power on a single person; but the constitution limited its use to a tenure of six months in time of national emergency. 2
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_A secret coalition to manipulate the government covertly, much like our own Trilateral Commission of the 1970s – the so‐called First Triumvirate, 60 – 53 BCE. Julius Caesar was one of its members.
How often, as a Medical Services Professional, have you felt as though you are being asked to reinvent the wheel, to implement a process that has been attempted before – only to find this time the onus is on you to get it right once and for all?
Rising to the occasion Young Octavius encountered opposition after Caesar’s death
_from anti‐monarchist senators
_Mark Antony—who had apparently presumed he was going to be Caesar’s ideological successor. Using his own considerable financial assets, Octavius recruited an army from among Caesar’s loyalists, marched on Rome and imposed martial law. Acting under martial law, Octavius on August 19, 43 BCE had the Roman senate install himself and his cousin as consuls, both incumbents being deceased.
When you initiate a new policy or procedure—whether by your own choice or because your superiors entrust you with the task—be sure you have in place an effective means of challenging opposition. You cannot very well impose martial law: but you can secure the support of entities within and without your institution. These may include
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Your medical staff leadership
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Your administration
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Your bylaws committee
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Your legal department
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Your outcomes management division
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Your state medical board
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Your accreditation commission
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Your state or county health department
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CMS
Support can be passive, in the form of regulations and standards, as well as active in the form of advocacy.
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Sometimes force is the only viable approach
Imposing martial law forced Octavius’ enemies to accept him as a proponent with whom to be reckoned. Mark Antony immediately abandoned his opposition and agreed to alliance with Octavius. At times you simply have to dig in, aggressively and effectively to resist your opponent(s) in order to establish and/or defend your credibility.
High Hopes for another Constitutional Experiment
Being seriously underage for the consulship and having seized it
by force, Octavius hastily abandoned it.
Together with a third former functionary of Julius Caesar’s
dictatorship, in October of 43 BCE Octavian and Antony
secured passage in the Senate of what modern historians call
the Second Triumvirate—a grant of extraordinary executive
and military power, time limited to five years.
Antony dropped his challenge to Caesar’s adoption of Octavius
and recognized him as Gaius Julius Caesar Octavianus.
Since he now went by the name Caesar, modern historians
refer to him as Octavian in this period of his life to distinguish
him from his great uncle/adoptive father.
Innovation brings about revision or elimination of outdated policies and procedures and fresh approaches to implementation of existing ones. But when you innovate be prepared to justify your proposals, not only as beneficial to your institution but appropriate to and supportive of your bylaws and regulatory requirements. 4
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Back to the Constitutional Drawing Board
The Second Triumvirate seemed the perfect solution to the constitutional dilemma:
_conferred by the constitutionally authorized Senate; _ did not concentrate power in the hands of a single _time limited and revocable. It endured for a decade, but ultimately failed for lack of an effective mechanism for keeping its members from competing with one another for supremacy within their coalition. From this power struggle Octavian emerged the ultimate victor, in 30 BCE. The plan or policy which appears absolutely flawless on
paper may prove unworkable once put into practice.
Why did Octavian prevail over his Triumviral colleagues?
When Marcus Aemilius Lepidus tried to usurp more power as Triumvir than he had agreed to assume, Antony and Octavian stripped him of authority and sent him into retirement. The struggle between Octavian and Mark Antony was more complex. Rome’s dominions in the eastern Mediterranean were bordered by a crescent of petty kingdoms, extending from the Caspian Sea down to Egypt. Since the middle of the first century BCE the Romans had cultivated alliances with these principalities, because they formed a buffer against the hostile Parthian empire lying still farther east (in roughly what is now Iran, Iraq, Kuwait). When Antony eventually endeavored to dislodge Octavian from power, Octavian responded by inflaming the inherent xenophobia of his fellow Italians. He represented Cleopatra as a dissolute, sybaritic and corrupting siren, whose influence threatened to demoralize and emasculate the Italian people and dispossess them of their ethnic heritage. The result was a declaration of war on Cleopatra, and the resounding victory which impelled Antony’s suicide and left Octavian once again in a position to impose martial law.
The best defense of a controversial policy may lie in showing how it promotes and supports regulatory compliance or otherwise benefits your institution. 5
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The constitutional model once more
As commander of Rome’s entire military force Octavian could have himself up as an absolute monarch; but rather than risk violating the constitution he returned to it. His reform of 27 BCE, mandating he hold successive consulships and extraordinary commands, was still constitutionally unacceptable and may have been a stopgap while a better alternative was being developed.
For the final, workable settlement, Octavian—now Augustus—culled specific functions from the various Republican magistracies and had these conferred upon him—by decree of the Senate with the consent of the people and the army—for limited periods of time. Enacted in July of 23 BCE, this arrangement became the constitutional basis of the emperor’s authority for the duration of the Roman Empire.
Being required by your superiors to align an existing but outdated process or program to new requirements may prove more challenging—and more frustrating—than if you were allowed to develop an entirely new strategy. The weaknesses in a program or process you have created may not become apparent until it is up and running.
Augustus’ techniques for success: some examples for the Medical Services Professional
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Be patient and persistent, orderly and methodical
Appreciating military organization, Augustus developed the civilian administration directly answerable to him on a military model.
His favorite adage was Festina lente—Hasten slowly.
In writing and speaking he strove for chastity of speech, an aspiration with which he apparently struggled, for his correspondence with his family is very rambling.
He outlined topics in writing before discussing them verbally, even with his wife.
Be subtly persuasive
Cultivate support for a proposal with potential for opposition. Augustus’ standard procedures:
_Elicit—very ostensibly and courteously—the endorsement of the Senate _Make certain the legislation he proposed was sensible, comprehendible, demonstratively beneficial to the state, practical, and implementable
_Display humility, seeking identification as “first among equals
_ Mollify opponents
_Be overtly respectful toward those he could not win over while finding ways to circumvent their opposition His position as commander‐in‐chief of the military forces was a passive reminder he had the ability impose martial law; but he never flouted this authority. 7
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Demonstrate sensitivity and respect for propensities and inclinations of particular audiences
Augustus allowed provincials and allies to observe their own cultural and religious practices. A prime example: the synagogue his son‐in‐law erected in Rome.
He had his wife settle a territorial dispute between two queens of eastern buffer principalities, and induce the princess of another of these princedoms not to marry a covert insurrectionist the Romans had under surveillance.
His responsiveness to human nature is particularly evident in his efforts to ameliorate, with explanations, incentives and immunities, his rigorous and unpopular legislation to regulate family life. Under the Lex Julia de adulteriis (18 BCE), the legal
process against an adulterous female Roman citizen
was ruthless:
_Divorce
_Indictment in a court of law by the woman’s ex‐husband or by her father
_Examination of evidence
_If convicted, the woman and her paramour subjected to the capital punishment of banishment from Rome.
HOWEVER: If a husband was aware his wife was cheating on him but chose not to divorce and prosecute, the law did not apply unless:
_it could be proven the husband had observed his wife with her lover, or
_the husband profited financially from her adventure, in which case he was prosecutable as a panderer.
So if turning a blind eye kept the marriage intact, this more than dissolution fulfilled the spirit of the law, which was to encourage the stability of marriage and the rearing of children.
Incentives included tax breaks and exemption from certain legal restrictions for couples with more than three children.
The criminalization of abortion was clearly explained, not as a measure to protect the unborn but to prevent attrition of the pure Italian race.
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Exhaust persuasion and diplomacy before resorting to force of any sort
Augustus ceded governance of prosperous and well organized provinces to the Senate, and placed disordered areas under an administration directly answerable to him. This arrangement enabled him to maintain he was subserving the Senate by taking the problems areas to himself. In actuality this division of authority placed those regions with the highest concentration of troops directly under his control, and allowed him to hand pick the functionaries answerable to him.
While ostensibly respecting foreign cultural practices, he very subtly and quite successfully worked to undermine and replace them with Roman equivalents. In his own household Augustus educated the children of the rulers of the buffer states, and even for a while a captured Parthian prince, in Roman learning and culture.
And you must apply force, do so craftily
Back in 53 BCE an abortive Roman military campaign against the Parthians resulted in the capture of three legionary standards. In 36 BCE Mark Antony tried to retake the standards by military force and failed. Augustus bode his time until Parthia became embroiled with internal dissension, and then sent his stepson to the border with an army. The Parthian king was only too glad to surrender the standards, and Augustus’ popularity among the Romans soared. (20 BCE).
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Identify and accept your professional weaknesses, and find ways to circumvent those you cannot rectify
Recognizing he was a poor military leader, Augustus surrounded himself with the best of that class and carefully heeded their counsels.
Like all Romans, Augustus honored and sought to emulate Greek culture; but he had a poor command of the language. Rather than risk appearing foolish or unlearned, he relied openly on interpreters and translators. Do not not waste time and effort agonizing over or defending mistakes
Augustus corrected his mistakes and apologized if and when he felt the necessity for doing so, but thereafter moved and let the improvements make amends as they overruled the prior errors.
Try to forestall problems before they can develop Augustus shielded his Julia from potential suitors so she would not rue having to marry whom he selected for her. 10
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After Julia was widowed a second time, Augustus decided she must marry her stepbrother Tiberius, and he should serve as regent for her sons.
Knowing the stepsiblings were incompatible, Augustus spent a year considering alternatives for a son‐in‐law. His quest unsuccessful, Augustus prevailed upon the couple to wed. The marriage failed; the couple separated; Tiberius abandoned his responsibilities as regent; Julia took a coterie of lovers in blatant defiance of her father’s legislation against adultery.
Augustus’ experience exemplifies a situation in which all options are unsatisfactory. His failure to pay better heed to his instincts shows even the most brilliant and accomplished of individuals are not immune to making serious mistakes.
When developing a policy or procedure, be it political or medical, one needs to consider its potential impact on human feelings and accommodate them, even if doing so compromises efficiency in implementation. When promoting the interests of your organization, be prepared to put personal feelings aside
Augustus loathed Herod, king of the eastern buffer principality of Judaea; but Augustus retained Herod in power for his unflagging loyalty to Rome and his effective control of the restive and potentially rebellious Judaean populace.
Augustus did not spare his daughter, and subsequently her daughter, full prosecution and sentencing for violating his own legislation—his law against adultery.
When his chosen successor—his grandson Gaius—
predeceased him, Augustus put aside his personal feud with his stepson Tiberius and indicated him for the succession in Gaius’ stead.
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Augustus’ techniques for coping with stress
Recognize and accept the perpetual presence of antipathy
Despite his immense popularity, and his unsurpassed skill at diffusing opposition, Augustus was not without implacable enemies:
_Displaced oligarchs
_Long standing family rivalries
_Conquered nationalists
_Opponents of policies, e.g. his legislation against adultery and monetary extravagance
_Aspirants after his political position
During his lifetime he and his agents thwarted some half dozen plots against his life.
As a MSP, you must recognize “You cannot please all of the people all of the time.” With this comment by Abraham Lincoln, Augustus would undoubtedly have agreed. You are always going to have opponents of some sort for some reason.
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Separate professional from personal enmity Augustus commended one of his grandsons for studying the writings of the great Roman statesman Marcus Tullius Cicero, whose execution for opposing the Triumvirate Augustus had condoned. After Tiberius abandoned Julia and withdrew into private life, Augustus denounced him as a political enemy, but allowed him to live as a private citizen in what was perhaps the most sumptuous property Augustus owned in Rome.
Augustus accepted without cavil the Senate’s prosecution and conviction of his daughter and granddaughter and their sentencing to banishment from Rome; but he insured while in exile they lived in very comfortable circumstances. Resist the opposing viewpoint or behavior, not the individual who perpetrates it.
Attend your physical health
Augustus’ overall health was consistently poor, plagued with respiratory problems and rheumatism: but other physical symptoms are suggestive of chronic stress:
_insomnia
_rashes
_a phobia, associated with lightning
_a nervous stomach, which he favored with
plain brown bread small fish
cucumber slices soaked in cold water
extract of elecampane (from which absinthe is distilled)
goat’s milk
loose cheese made from cow’s milk—ricotta!
He tended carefully to his health and addressed its issues, but did not expend time or energy obsessing over them. 13
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Take time to pursue hobbies
Augustus engaged in
Angling
Sailing
Writing: he composed
_An autobiographical account of his early life (until about 25 BCE)
_A poetic paean of Sicily
_A biography of his younger stepson Nero Claudius Drusus, a phenomenally successful military commander who met an accidental death at the age of 29
_A tragedy, which he did not finish, about the Trojan hero Ajax
_Epigrams, which he dictated while sitting in his bath
_A succinct memoir, extant today and a major primary source for his life and reign.
Collectibles: at his villa on Capri Augustus kept _Antique arms and armaments
_Bones of bizarre creatures—fossils!
Gambling: a passion his daughter and younger stepson shared with him.
Find humor within your vocation
Augustus remarked he had two spoiled daughters: Julia and the Roman state.
To a nervous petitioner he said, “You look as though you are attempting to offer a denarius to an elephant.”
To Tiberius he wrote: “We must not let ourselves become too concerned over what people say about us. Keeping them from doing us actual harm is enough of a challenge.”
On being discharged for insubordinate behavior, a flippant military tribune (essentially a second lieutenant) confronted Augustus: how was he to explain the dismissal to his father? Augustus replied, “Say you didn’t like me.” 14
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If you seek relief only at Joe’s Comedy Club, you will walk back into your office to find the stresses and frictions unchanged. Finding humor and relaxation within your work enables you to remain calm during confrontations and promotes diffusion of hostility. Some recommendations:
_Share with your coworkers the hyperbole you get _Keep a list of bloopers and lame excuses and reread them from time to time
_Use humor or an expression of earnest concern to put the angry or distressed at ease: “What a pickle! Let us see how we can untangle this problem for you.”
Eschew Alienation
With the exception of his wife Livia, who loved him ardently through 52 years of marriage, Augustus alienated all those nearest and dearest to him.
_His daughter, granddaughter and elder stepson rebelled overtly against him
_His younger stepson openly criticized his regime as blatantly unconstitutional
_Even before his untimely death, Augustus’ eldest grandson and designated successor Gaius resigned his powers for a private life, asserting the demands of the position for which Augustus had indicated him were beyond his capability to perform.
_Augustus’ two closest friends since childhood, one of whom was his daughter’s second husband, grew ambivalent toward him in the end.
Why this alienation? Augustus was a driver: hardheaded, intense, relentless, demanding. These characteristics made him an eminently effective king, but took their toll on his personal relationships.
The MSP needs to be a driver as well,
_to accomplish agendas within required time frames,
_to insure the accuracy of information collected, recorded and disseminated,
_to insure compliance with standards and make timely and appropriate corrections to deviations.
HOWEVER: being too much of a driver can demoralize your colleagues and staff.
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Conclusion
Nothing profound: nothing earth‐shattering: but hopefully some pleasant erudition, and some food for thought on how a mastermind from 2000 years ago handled many of the very problems that confront the MSP today. The whole purpose for studying history is to promote critical thinking about contemporary issues. Some pictures, and time for questions, to follow.
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