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If only he had heeded the warnings and conducted unexpected investigations from time to time, he would have learned the extent of the many reported complaints. If only he had personally sampled the letters of complaints sent to him, he would have been alerted to the potential scope of the problem. If only he had asked a handful of Congressmen what the veteran constituents were complaining about, he would have begun to grasp the true situation. The tragedy was that he persisted in his belief that his military service had prepared him for his job. He was too proud to recognize that a problem existed, and that he had a responsibility to address it. As a result, he failed to conduct reasonable investigations.

Finally, when the falsification of patient records in one hospital was exposed, he ordered the whole system investigated. But it was too late. He was shocked to learn that he had consistently been lied to, and that his leadership had been inept. His nemesis is that his career will be remembered for this disaster, rather than for his earned accomplishments. Finally, Greek tragedies were intended to be lessons; in witnessing the downfall of the tragic hero, spectators were to draw lessons and behave accordingly.

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The views expressed in this opinion article are solely those of their author and are not necessarily either shared or endorsed by


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