A real leader faces the music, even when he doesn't like the tune. - Anonymous

It was 1997. I was on my way home from Case Management Society of America's annual conference in Boston, MA. On the plane, I remember thinking that we are not just case "managers" but case "leaders." For those of us who had pioneered medical case management in the 1980s, we had evolved. We had a fledgling structure, processes, successes, challenges, and lots of passion and HEART!

Here we are now, ending 2012 and celebrating National Case Management Week, and we have much to celebrate. Our core competencies and knowledge base are constantly being updated, our Standards of Practice have been expanded, our credentials have garnered ever-expanding respect, and our case management departments are now working alongside of revenue departments-as we are acknowledged as being an integral part of the fiscal health of agencies and hospitals.

However, today is not an easy time to be a case manager. It seems that every regulatory change that is initiated falls on the plates of case management. The quandaries about our technically evolved medical care leaves as many ethical questions as saved lives. Medically, we have come a long way. There is an urban legend (or maybe a historical fact) in which a 19th century surgeon was trying to amputate his patient's leg. He succeeded, but accidentally amputated his assistant's fingers as well. Both died of sepsis, and an onlooker died of shock. It is the only known medical procedure to have a 300% fatality rate. Maybe not "best practice," but there was no ethical dilemma involved in the case (assuming the leg needed to be amputated).

Today there is the growing number of uninsured persons, with less-and-less chance of being eligible for Medicaid. In an emergent situation, no hospital will turn these people away, but the toll it takes on the fiscal health of hospitals is worrying. And the toll it takes on the emotional health of case managers is also worrying. And now, I am saying you are "leaders?!"

What makes a leader? Google "leadership" and 501,000,000 results emerge guiding would-be leaders to find out if they are born or made; what are the traits of leaders; how to improve leadership skills; leadership quotes, seminars, traits, and so forth. A more specific question is, What makes the HEART of a leader? Can it be put into words and defined-or merely described?

Perhaps because I am writing this on Memorial day (yes, it takes that long to publication!), let's move out of the realm of health care and pull from the military to find an example of a true leader; within this story, one can see what authentic leadership is about and discern the heart of leader.

Eric Greitens, a U.S. Navy SEAL, spoke at a university commencement in May 2012 and issued a unique challenge to the graduating class: to sacrifice, to serve one's country and to live magnanimously (Bennett, 2012). He called on the graduates to think above and beyond their own dreams, their own desires, and to be strong. Aristotle called this megalopsychia, a greatness of soul, and considered it one of the greatest moral virtues. Greitens posed questions such as, "What kind of service can I provide? What kind of positive difference can I make in the lives of others?" After dodging bullets, withstanding improved explosive device explosions, and going days without sleep, Greitens realized the strength he needed to excel as a SEAL were found outside his own physical abilities. In his weakest moments, Greitens was able to find his greatest strength in service. He went on to say, "The more I thought about myself, the weaker I became. The more I recognized that I was serving a purpose larger than myself, the stronger I became." This leader then instructed the graduates that, if they work every day to live an answer to those questions (What kind of service can I provide? What kind of positive difference can I make in the lives of others?), they will be stronger (Bennett, 2012).

The same for case management. Case management is hard; we all know that. What Greitens endured was harder. We work long hours, but we don't go without sleep for days; we dodge verbal assaults, but we don't dodge improved explosive devices and bullets. Some days, it may feel like a fight-but really? There are many changes coming in the case management world, both regulatory and payment issues. Medicine has come so far, so fast, and with this speed also comes ethical and legal challenges.

If I am expected to read the crystal ball and tell you all everything will be fine, I apologize. I don't know where the future leads. What I do know for sure is that as long as case managers provide collaborative care in an honest way (both to our patients and our colleagues) and we stay true to our strong foundation, we will improve lives. We have an opportunity to be leaders. In the 1980s, I did not know exactly how case management would unfold, but I trusted myself that if I served the patients, it couldn't be wrong.

Can the "heart" of a leader be described? Yes. Greitens has done it. Can it be summarized? Perhaps, within the heart of leader is a generosity of spirit that moves beyond any "entitlement" mentality and focuses on the larger picture. To the incoming case managers, please trust yourself and your instincts; you know what you should do. You know the kind of life you should live. You don't need an ethics course to know right from wrong, although you may need legal and ethical guidance in your future. In doing so, you will continue to change the face of case management. It is our time to lead. Collectively and individually, our actions will have consequences and our efforts will continue to make a difference.

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