150 Years On – What’s Left to Learn from the ‘Letterman Plan’?

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The story of MAJ Jonathan Letterman and the ‘Letterman Plan’ should exist forever in Combat Health lore as one of the professions most magnificent tales of innovation and success. Appointed as Medical director of the Army of the Potomac in 1862 and confronted with an Army of approximately 100,000, 30% of which were listed as sick or injured – likely a gross underestimation – Letterman set about revolutionising the structure and delivery of Combat Health services. Within less than two years his initiatives had halved the mortality rate of the Army, been adopted across the entire Union Army and been passed into Law by the politicians of the day. A number of European armies also quickly adopted Letterman’s battlefield clearance and care system after seeing its success at reducing mortality, and maintaining the physical capacity and moral will of soldiers to fight. Today, systems such as the Australian Army’s Land Based Trauma System continue to demonstrate incredible parallels to his system, leaving little doubt that he truly was the father of modern military health care.

Aside from the legacy of his overarching system of care, 150 years since its inception, what more can be drawn from this incredible tale to inform today’s Combat Health and more broadly military professionals? In particular what can we learn from this case study about military innovation?

Think Big, Start Small, Move Quickly

Letterman’s approach to gaining buy in for his broad reaching overhaul of the Combat Health system is perfectly aligned to the innovation model espoused by DEFAus and is a case study in support of the success of this approach. Letterman recognised early that he needed to drastically change the way health services operated within the Army if he was ever going to succeed in improving the health of those he was responsible for. Rather than blasting into his grand strategy straight away; his initial moves focussed on simple and easily implemented strategies. This had the effect of showing commanders that he really knew his stuff and could enhance their combat effectiveness through improvements in health policy and systems. From these early successes he then built and presented the detail for the broader reorganisation of forces and policy to achieve his end state. This end state was a completely integrated and consistent land based trauma system.

Relationships are key

As an enabler without any true command authority over the health assets across the Army – prior to his system, healthcare was siloed by regiment – in order to succeed Letterman needed a champion. He found his champion in Major General  George P. McClellan. It is likely that through six degrees of separation these men were known to each other prior to the commencement of the war and their appointments as Medical Director and Commander respectively. However the success of this Command–Specialist relationship can teach us much whichever side of the fence we sit. Letterman for his part was able to demonstrate how his plan was nested to McClellan’s mission success. McClellan for his part demonstrated a skill that Robert Sutton highlights as one of 12 key things that good bosses know. He ‘aimed to fight as if he was right, and listen as if he was wrong – teaching his people to do the same thing.’

An effective communication strategy is essential

Once Letterman had his champion the next hurdle was adoption across the force. This is where McClellan’s staff showed their brilliance by adhering to the rules of ABC – Accuracy, Brevity and Clarity. Despite the raising of the Ambulance Corps and the system that this brought with it, altering beyond recognition the way that health was delivered across the battlespace, General Order 147 articulated these changes and what was required across the command into a measly 16 succinct points!

Iterate or die

The final lesson to discuss is the idea that innovation is fluid. Letterman could have been well within his rights to say ‘BOOM look what I’ve done’ and rest on his early success, followed by tea and medals. But he didn’t, he continued to test and adjust, improve individual and collective training and the results spoke for themselves. On first hit out of the system at the Battle of Antietam in late 1862 the field was entirely cleared of its 12,410 casualties in a touch under 48 hours. Nine months later following the Battle of Gettysburg not a single wounded soldier from either side of the conflict – approximately 21,000 soldiers – remained on the battlefield the following morning. In today’s military environment modern health planners have continued the process of iterating upon Letterman’s brilliant idea. Innovation is about adaption – it never stands still.

Neither McClellan nor Letterman continued in their roles within the Army of the Potomac together for long. McClellan was dismissed from Command by President Lincoln due to his failure to aggressively pursue General Lee’s Confederate Army following the battle of Antietam – ironically the battle that demonstrated the effectiveness of the ‘Letterman Plan’ for the first time. Letterman himself turned in his commission and returned to civilian practice in January of 1864, approximately two months prior to his plan being passed into Law as the Ambulance Corps Act of 1864. With a strategic awareness that many of his successors could only dream of, Letterman fundamentally altered the delivery of Combat Health forever. Whilst hopefully few of us will ever be faced with a problem of the scale that confronted him, as the level of complexity of the battlespace grows so too does the delivery of health effect within it. As such, some of the simple lessons that can be drawn from a review of how the ‘Letterman Plan’ came to be can improve our ability to innovate, and protect and care for our most important asset – our people.

Thanks for reading. Paulatim.

About the author

Captain Nick Alexander is an Australian Combat Health Officer who is passionate about optimizing the physical and intellectual capacity of soldiers.