Mark Hertling, DBA

Last year, I wrote an article for the Journal of Hospital Medicine offering tips to healthcare providers in what was then an expanding COVID-19 environment.¹ These lessons were drawn from my experiences during the “tough fights” and crisis situations of my military career, situations similar to what healthcare providers experienced during the pandemic.

Now, as vaccination rates rise and hospitalization rates fall, the nation and healthcare profession begin the transition to “normalcy.” What should healthcare professionals expect as they transition from a year of operating in a crisis to resumption of the habitual? What memories and lessons will linger from a long, tough fight against COVID-19, and how might physicians best approach the many post-crisis challenges they will surely face?

My military experiences inform the tips I offer to those in the medical profession. Both professions depend on adeptly leading and building a functional and effective organizational culture under trying circumstances. It may seem strange, but the challenges healthcare workers (HCWs) faced in fighting COVID-19 are comparable to what soldiers experience on a battlefield. And now, as citizens return to “normal” (however normal is defined), only naïve HCWs will believe they can simply resume their previous habits and practices. This part of the journey will present new challenges and unique opportunities.

Healthcare has changed…and so have you! Just like soldiers coming home from the battlefield face a necessarily new and different world, HCWs will also face changing circumstances, environments, and organizational requirements. Given this new landscape, I offer some of my lessons learned coming out of combat to help you adapt.

Heading home from my last combat tour in Iraq, I found myself gazing out the aircraft window and pondering my personal experiences during a very long combat tour commanding a multinational task force. Pulling out my green soldier’s notebook, I rapidly scratched out some reflections on where I was, what I had learned, and what I needed to address personally and professionally. In talking with physicians in the healthcare organization where I now work, this emotional checklist seems to mirror some of the same thoughts they face coming out of the COVID-19 crisis.

Expect exhaustion. There’s a military axiom that “fatigue can make cowards of us all,” and while I don’t think I had succumbed to cowardice in battle, after 15 months in combat I was exhausted. Commanders in combat—or HCWs fighting a pandemic—face unrelenting demands from a variety of audiences. Leaders are asked to solve unsolvable problems, be at the right place at the right time with the right answers, have more energy than others, be upbeat, and exhibit behaviors that will motivate the “troops.” That’s true even if they’re exhausted and weary to the bone, serving on multiple teams, and attending endless meetings. There is also the common and unfortunate expectation that leaders should not take any time for themselves.

During the pandemic, most HCWs reported sleeping less, having little time to interact casually with others, and having less time for personal reflection, exercise, personal growth, or even prayer. My solution for addressing exhaustion was to develop a personal plan to address each one of these areas—mental, emotional, physical, spiritual—with a detailed rest and recovery strategy. I wrote my plan down, knowing that I would need to discuss this blueprint with both my employer and my spouse, who I suspected would have different ideas on what my schedule should look like after returning “home.” Healthcare providers have been through the same kinds of stresses and need to ask themselves: What recovery plan have I designed to help me overcome the fatigue I feel, and have I talked about this plan with the people who will be affected by it?

Take pride in what your teams accomplished. I was proud of how my teams had accomplished the impossible and how they had adapted to continually changing situations. Whenever military organizations know they’ll face the enemy in combat, they feel heightened anxiety, increased fear, and concern about the preparedness of their team. The Army, like any successful team, attempts to mitigate those emotions through training. During my reflections, I remembered the teams that came together to accomplish very tough missions. Some of those teams were those I had concerns about prior to deployment, but fortunately they often surprised me with their adaptability and successes in combat.

Leaders in healthcare can likely relate. Even in normal situations, organizational fault lines exist between physicians, nurses, and administrators. These fault lines may manifest as communication disconnects and distrust between different members who may not completely trust one another due to differences in training, culture, or role within the organization. But during a crisis, rifts dissipate and trust evolves as different cultures are forced to work together. Many healthcare organizations report that, during the COVID crisis, most personality conflicts, communication disconnects, and organizational dysfunctions receded, and organizations saw more and greater coordination and collaboration. Extensive research on leadership demonstrates that crises drive teams to communicate better and become more effective and efficient in accomplishing stated goals, resulting in team members who relish “being there” for one another like never before. These positive changes must be reinforced to ensure these newly formed high-performing teams do not revert back to work silos, which usually occurs due to distrust.

Just as important as pride in teams is the pride in the accomplishment of specific individuals during times of crisis. Diverse members of any organization deliver some of the best solutions to the toughest problems when they are included in the discussion, allowed to bring their ideas to the table, and rewarded for their actions (and their courage)! Just one example is given by Dr Sasha Shillcut as she describes the innovations and adaptations of the women physicians she observed in her organization during the COVID-19 crisis,² and there are many examples of other organizations citing similar transformation in areas like telemedicine, emergency department procedures, and equipment design and use.^3,4

Anticipate “survivor’s guilt.” During my three combat tours, 253 soldiers under my command or in my organization sacrificed their lives for the mission, and many more were wounded in action. There are times when bad dreams remind me of some of the circumstances surrounding the incidents that took the lives of those who died, and I often wake with a start and in a sweat. The first question I always ask myself in the middle of the night when this happens is, “Why did they die, and why did I survive?” That question is always followed by, “What might I have done differently to prevent those deaths?”

As we draw down from treating patients during the COVID-19 crisis, healthcare providers must also be wary of “survivor’s guilt.” Survivor’s guilt is a strong emotion for anyone who has survived a crisis, especially when their friends or loved ones have not. Healthcare providers have lost many patients, but they have also lost colleagues, friends, and family members. Because you are in the healing profession, many of you will question what more you could have done to prevent the loss of life. You likely won’t ever be completely satisfied with the answer, but I have a recommendation that may assuage your emotions.

In combat, we continually memorialized our fallen comrades in ceremonies that are attended by the entire unit. One of my commanders had an idea to keep pictures of those who had made the ultimate sacrifice, and on my desk is a box with the 253 pictures of those dedicated individuals who were killed in action under my command or in my unit. On the top of the box are the words “Make It Matter.” I look at those pictures often to remember them and their selfless service to the nation, and I often ask myself whether I am “making it matter” in my daily activities. Does your healthcare facility have plans for a memorial service for all those who died while in your care? Is there a special tribute in your hospital to those healthcare providers who paid the ultimate sacrifice in caring for patients? Most importantly, have you rededicated yourself to your profession, knowing that what you learned during the pandemic will help you be a better physician in the future, and do you have the knowledge that you are making a meaningful difference every day you serve in healthcare?

Relish being home. On that flight back to family, my excitement was palpable. But there were challenges too, as I knew I had to continue to focus on my team, my organization, and my profession. While images on the internet often show soldiers returning from war rushing into the arms of their loved ones, soldiers never leave the demands associated with wearing the cloth of the country. As a result, many marriages and families are damaged when one member who has been so singularly focused returns home and is still caught up in the demands of the job. They find it is difficult to pick up where they’ve left off, forgetting their family has also been under a different kind of intense stress.

These same challenges will face HCWs. Many of you voluntarily distanced yourself from family and friends due to a fear of transmitting the disease. Spouses and children underwent traumatic challenges in their jobs, holding together the household and piloting kids through schooling. My biggest recommendation is this: strive for a return to a healthy balance, be wary of any sharp edges that appear in your personality or in your relationships, and be open in communicating with those you love. Relying on friends, counselors, and mentors who can provide trusted advice—as well as therapy, if necessary—is not a sign of weakness, but a sign of strength and courage. The pandemic has affected our lives more than we can imagine, and “coming out” of the crisis will continue to test our humanity and civility like never before. Trust me on this one. I’ve been there.

These reflections open us to issues physicians must address in the months after your “redeployment” from dealing with the pandemic. When soldiers redeploy from combat, every unit develops a plan to address personal and professional growth for individual members of the team. Additionally, leaders develop a plan to sustain performance and improve teams and organizational approaches. The objective? Polish the diamond from what we learned during the crisis, while preparing for those things that might detract from effectiveness in future crises. It’s an SOP (standard operating procedure) for military units to do these things. Is this approach also advisable for healthcare professionals and teams in responding to crises?

Crises increase stress on individuals and disrupt the functioning of organizations, but crises also provide phenomenal opportunities for growth.⁵ Adaptive organizations, be they military or healthcare, must take time to understand how the crises affected people and the organizational framework, while also preparing for potential future disruptions. While HCWs and their respective organizations are usually adept at learning from short-term emergencies (eg, limited disease outbreaks, natural disasters, mass-casualty events), they are less practiced in addressing crises that affect the profession for months. It has been a century since the medical profession has been faced with a global pandemic, but experts suggest other pandemics may be on the short-term horizon.⁶ We ought to use this past year of experiences to prepare for them.

Pay attention to your personal needs and the conditions of others on your team. After returning from combat, I was exhausted and stressed intellectually, physically, emotionally, and spiritually. From what I’ve seen, healthcare providers fit that same description, and the fatigue is palpable. Many of you have experienced extreme stress. I have experienced extremepost-traumatic stress, and it is important to understand that this will affect some on your team.⁷ In addition to addressing stress—and this is advice I give to all the physicians I know—find the time to get a physical examination. While the Army requires yearly physicals for all soldiers (especially generals!), most healthcare providers I know are shockingly deficient in taking the time to get a checkup from one of their colleagues. Commit to fixing that.

Reflect on what you have learned during this period. Take an afternoon with an adult beverage (if that’s your style) and reflect on what you learned and what others might learn from your unique experiences. Then, take some notes and shape your ideas. What did you experience? What adaptations did you or your team make during the pandemic? What worked and what didn’t? What things do you want to sustain in your practice and what things do you want to eliminate? What did you learn about the medical arts…or even about your Hippocratic Oath? If you have a mentor, share these thoughts with them; if you don’t have a mentor, find one and then share your thoughts with them. Get some outside feedback.

Assess team strengths and weaknesses. If you’re a formal physician leader (someone with a title and a position on your team), it’s your responsibility to provide feedback on both people and processes. If you’re an informal leader (someone who is a member of the team but doesn’t have specific leadership responsibilities outside your clinical role) and you don’t see this happening, volunteer to run the session for your formal leader and your organization. This session should last several hours and be held in a comfortable setting. You should prepare your team so they aren’t defensive about the points that may arise. Determine strengths and opportunities by asking for feedback on communication, behaviors, medical knowledge, emotional intelligence, and execution of tasks. Determine which processes and systems either worked or didn’t work, and either polish the approaches or drive change to improve systems as you get back to normal. Crises provide an opportunity to fix what’s broken while also reinforcing the things that worked in the crisis that might not be normal procedure. Don’t go back to old ways if those weren’t the things or the approaches you were using under critical conditions.

Encourage completion of an organization-wide after-action review (AAR). As I started writing this article, I watched CNN’s Dr Sanjay Gupta conduct a review of actions with the key physicians who contributed to the last administration’s response to the pandemic. In watching that session—and having conducted hundreds of AARs in my military career—there was discussion of obvious good and bad leadership and management procedures, process issues that needed to be addressed, and decision-making that might be applauded or questioned. Every healthcare organization ought to conduct a similar AAR, with a review of the most important aspects of actions and teamwork, the hospital’s operations, logistical preparation, and leader and organization procedures that demand to be addressed.

The successful conduct of any AAR requires asking (and getting answers to) four questions: What happened?; Why did it happen the way it did?; What needs to be fixed or “polished” in the processes, systems, or leadership approach?; and Who is responsible for ensuring the fixes or adjustments occur? The facilitator (and the key leaders of the organization) must ask the right questions, must be deeply involved in getting the right people to comment on the issues, and must “pin the rose” on someone who will be responsible for carrying through on the fixes. At the end of the AAR, after the key topics are discussed, with a plan for addressing each, the person in charge of the organization must publish an action plan with details for ensuring the fixes.

Like all citizens across our nation, my family is grateful for the skill and professionalism exhibited by clinicians and healthcare providers during this devastating pandemic. While we are all breathing a sigh of relief as we see the end in sight, true professionals must take the opportunity to learn and grow from this crisis and adapt. Hopefully, the reflections and recommendations in this article—things I learned from a different profession—will provide ideas to my new colleagues in healthcare.

Last year, I wrote an article for the Journal of Hospital Medicine offering tips to healthcare providers in what was then an expanding COVID-19 environment.¹ These lessons were drawn from my experiences during the “tough fights” and crisis situations of my military career, situations similar to what healthcare providers experienced during the pandemic.

Now, as vaccination rates rise and hospitalization rates fall, the nation and healthcare profession begin the transition to “normalcy.” What should healthcare professionals expect as they transition from a year of operating in a crisis to resumption of the habitual? What memories and lessons will linger from a long, tough fight against COVID-19, and how might physicians best approach the many post-crisis challenges they will surely face?

My military experiences inform the tips I offer to those in the medical profession. Both professions depend on adeptly leading and building a functional and effective organizational culture under trying circumstances. It may seem strange, but the challenges healthcare workers (HCWs) faced in fighting COVID-19 are comparable to what soldiers experience on a battlefield. And now, as citizens return to “normal” (however normal is defined), only naïve HCWs will believe they can simply resume their previous habits and practices. This part of the journey will present new challenges and unique opportunities.

Healthcare has changed…and so have you! Just like soldiers coming home from the battlefield face a necessarily new and different world, HCWs will also face changing circumstances, environments, and organizational requirements. Given this new landscape, I offer some of my lessons learned coming out of combat to help you adapt.

Heading home from my last combat tour in Iraq, I found myself gazing out the aircraft window and pondering my personal experiences during a very long combat tour commanding a multinational task force. Pulling out my green soldier’s notebook, I rapidly scratched out some reflections on where I was, what I had learned, and what I needed to address personally and professionally. In talking with physicians in the healthcare organization where I now work, this emotional checklist seems to mirror some of the same thoughts they face coming out of the COVID-19 crisis.

Expect exhaustion. There’s a military axiom that “fatigue can make cowards of us all,” and while I don’t think I had succumbed to cowardice in battle, after 15 months in combat I was exhausted. Commanders in combat—or HCWs fighting a pandemic—face unrelenting demands from a variety of audiences. Leaders are asked to solve unsolvable problems, be at the right place at the right time with the right answers, have more energy than others, be upbeat, and exhibit behaviors that will motivate the “troops.” That’s true even if they’re exhausted and weary to the bone, serving on multiple teams, and attending endless meetings. There is also the common and unfortunate expectation that leaders should not take any time for themselves.

During the pandemic, most HCWs reported sleeping less, having little time to interact casually with others, and having less time for personal reflection, exercise, personal growth, or even prayer. My solution for addressing exhaustion was to develop a personal plan to address each one of these areas—mental, emotional, physical, spiritual—with a detailed rest and recovery strategy. I wrote my plan down, knowing that I would need to discuss this blueprint with both my employer and my spouse, who I suspected would have different ideas on what my schedule should look like after returning “home.” Healthcare providers have been through the same kinds of stresses and need to ask themselves: What recovery plan have I designed to help me overcome the fatigue I feel, and have I talked about this plan with the people who will be affected by it?

Take pride in what your teams accomplished. I was proud of how my teams had accomplished the impossible and how they had adapted to continually changing situations. Whenever military organizations know they’ll face the enemy in combat, they feel heightened anxiety, increased fear, and concern about the preparedness of their team. The Army, like any successful team, attempts to mitigate those emotions through training. During my reflections, I remembered the teams that came together to accomplish very tough missions. Some of those teams were those I had concerns about prior to deployment, but fortunately they often surprised me with their adaptability and successes in combat.

Leaders in healthcare can likely relate. Even in normal situations, organizational fault lines exist between physicians, nurses, and administrators. These fault lines may manifest as communication disconnects and distrust between different members who may not completely trust one another due to differences in training, culture, or role within the organization. But during a crisis, rifts dissipate and trust evolves as different cultures are forced to work together. Many healthcare organizations report that, during the COVID crisis, most personality conflicts, communication disconnects, and organizational dysfunctions receded, and organizations saw more and greater coordination and collaboration. Extensive research on leadership demonstrates that crises drive teams to communicate better and become more effective and efficient in accomplishing stated goals, resulting in team members who relish “being there” for one another like never before. These positive changes must be reinforced to ensure these newly formed high-performing teams do not revert back to work silos, which usually occurs due to distrust.

Just as important as pride in teams is the pride in the accomplishment of specific individuals during times of crisis. Diverse members of any organization deliver some of the best solutions to the toughest problems when they are included in the discussion, allowed to bring their ideas to the table, and rewarded for their actions (and their courage)! Just one example is given by Dr Sasha Shillcut as she describes the innovations and adaptations of the women physicians she observed in her organization during the COVID-19 crisis,² and there are many examples of other organizations citing similar transformation in areas like telemedicine, emergency department procedures, and equipment design and use.^3,4

Anticipate “survivor’s guilt.” During my three combat tours, 253 soldiers under my command or in my organization sacrificed their lives for the mission, and many more were wounded in action. There are times when bad dreams remind me of some of the circumstances surrounding the incidents that took the lives of those who died, and I often wake with a start and in a sweat. The first question I always ask myself in the middle of the night when this happens is, “Why did they die, and why did I survive?” That question is always followed by, “What might I have done differently to prevent those deaths?”

As we draw down from treating patients during the COVID-19 crisis, healthcare providers must also be wary of “survivor’s guilt.” Survivor’s guilt is a strong emotion for anyone who has survived a crisis, especially when their friends or loved ones have not. Healthcare providers have lost many patients, but they have also lost colleagues, friends, and family members. Because you are in the healing profession, many of you will question what more you could have done to prevent the loss of life. You likely won’t ever be completely satisfied with the answer, but I have a recommendation that may assuage your emotions.

In combat, we continually memorialized our fallen comrades in ceremonies that are attended by the entire unit. One of my commanders had an idea to keep pictures of those who had made the ultimate sacrifice, and on my desk is a box with the 253 pictures of those dedicated individuals who were killed in action under my command or in my unit. On the top of the box are the words “Make It Matter.” I look at those pictures often to remember them and their selfless service to the nation, and I often ask myself whether I am “making it matter” in my daily activities. Does your healthcare facility have plans for a memorial service for all those who died while in your care? Is there a special tribute in your hospital to those healthcare providers who paid the ultimate sacrifice in caring for patients? Most importantly, have you rededicated yourself to your profession, knowing that what you learned during the pandemic will help you be a better physician in the future, and do you have the knowledge that you are making a meaningful difference every day you serve in healthcare?

Relish being home. On that flight back to family, my excitement was palpable. But there were challenges too, as I knew I had to continue to focus on my team, my organization, and my profession. While images on the internet often show soldiers returning from war rushing into the arms of their loved ones, soldiers never leave the demands associated with wearing the cloth of the country. As a result, many marriages and families are damaged when one member who has been so singularly focused returns home and is still caught up in the demands of the job. They find it is difficult to pick up where they’ve left off, forgetting their family has also been under a different kind of intense stress.

These same challenges will face HCWs. Many of you voluntarily distanced yourself from family and friends due to a fear of transmitting the disease. Spouses and children underwent traumatic challenges in their jobs, holding together the household and piloting kids through schooling. My biggest recommendation is this: strive for a return to a healthy balance, be wary of any sharp edges that appear in your personality or in your relationships, and be open in communicating with those you love. Relying on friends, counselors, and mentors who can provide trusted advice—as well as therapy, if necessary—is not a sign of weakness, but a sign of strength and courage. The pandemic has affected our lives more than we can imagine, and “coming out” of the crisis will continue to test our humanity and civility like never before. Trust me on this one. I’ve been there.

These reflections open us to issues physicians must address in the months after your “redeployment” from dealing with the pandemic. When soldiers redeploy from combat, every unit develops a plan to address personal and professional growth for individual members of the team. Additionally, leaders develop a plan to sustain performance and improve teams and organizational approaches. The objective? Polish the diamond from what we learned during the crisis, while preparing for those things that might detract from effectiveness in future crises. It’s an SOP (standard operating procedure) for military units to do these things. Is this approach also advisable for healthcare professionals and teams in responding to crises?

Crises increase stress on individuals and disrupt the functioning of organizations, but crises also provide phenomenal opportunities for growth.⁵ Adaptive organizations, be they military or healthcare, must take time to understand how the crises affected people and the organizational framework, while also preparing for potential future disruptions. While HCWs and their respective organizations are usually adept at learning from short-term emergencies (eg, limited disease outbreaks, natural disasters, mass-casualty events), they are less practiced in addressing crises that affect the profession for months. It has been a century since the medical profession has been faced with a global pandemic, but experts suggest other pandemics may be on the short-term horizon.⁶ We ought to use this past year of experiences to prepare for them.

Pay attention to your personal needs and the conditions of others on your team. After returning from combat, I was exhausted and stressed intellectually, physically, emotionally, and spiritually. From what I’ve seen, healthcare providers fit that same description, and the fatigue is palpable. Many of you have experienced extreme stress. I have experienced extremepost-traumatic stress, and it is important to understand that this will affect some on your team.⁷ In addition to addressing stress—and this is advice I give to all the physicians I know—find the time to get a physical examination. While the Army requires yearly physicals for all soldiers (especially generals!), most healthcare providers I know are shockingly deficient in taking the time to get a checkup from one of their colleagues. Commit to fixing that.

Reflect on what you have learned during this period. Take an afternoon with an adult beverage (if that’s your style) and reflect on what you learned and what others might learn from your unique experiences. Then, take some notes and shape your ideas. What did you experience? What adaptations did you or your team make during the pandemic? What worked and what didn’t? What things do you want to sustain in your practice and what things do you want to eliminate? What did you learn about the medical arts…or even about your Hippocratic Oath? If you have a mentor, share these thoughts with them; if you don’t have a mentor, find one and then share your thoughts with them. Get some outside feedback.

Assess team strengths and weaknesses. If you’re a formal physician leader (someone with a title and a position on your team), it’s your responsibility to provide feedback on both people and processes. If you’re an informal leader (someone who is a member of the team but doesn’t have specific leadership responsibilities outside your clinical role) and you don’t see this happening, volunteer to run the session for your formal leader and your organization. This session should last several hours and be held in a comfortable setting. You should prepare your team so they aren’t defensive about the points that may arise. Determine strengths and opportunities by asking for feedback on communication, behaviors, medical knowledge, emotional intelligence, and execution of tasks. Determine which processes and systems either worked or didn’t work, and either polish the approaches or drive change to improve systems as you get back to normal. Crises provide an opportunity to fix what’s broken while also reinforcing the things that worked in the crisis that might not be normal procedure. Don’t go back to old ways if those weren’t the things or the approaches you were using under critical conditions.

Encourage completion of an organization-wide after-action review (AAR). As I started writing this article, I watched CNN’s Dr Sanjay Gupta conduct a review of actions with the key physicians who contributed to the last administration’s response to the pandemic. In watching that session—and having conducted hundreds of AARs in my military career—there was discussion of obvious good and bad leadership and management procedures, process issues that needed to be addressed, and decision-making that might be applauded or questioned. Every healthcare organization ought to conduct a similar AAR, with a review of the most important aspects of actions and teamwork, the hospital’s operations, logistical preparation, and leader and organization procedures that demand to be addressed.

The successful conduct of any AAR requires asking (and getting answers to) four questions: What happened?; Why did it happen the way it did?; What needs to be fixed or “polished” in the processes, systems, or leadership approach?; and Who is responsible for ensuring the fixes or adjustments occur? The facilitator (and the key leaders of the organization) must ask the right questions, must be deeply involved in getting the right people to comment on the issues, and must “pin the rose” on someone who will be responsible for carrying through on the fixes. At the end of the AAR, after the key topics are discussed, with a plan for addressing each, the person in charge of the organization must publish an action plan with details for ensuring the fixes.

Like all citizens across our nation, my family is grateful for the skill and professionalism exhibited by clinicians and healthcare providers during this devastating pandemic. While we are all breathing a sigh of relief as we see the end in sight, true professionals must take the opportunity to learn and grow from this crisis and adapt. Hopefully, the reflections and recommendations in this article—things I learned from a different profession—will provide ideas to my new colleagues in healthcare.

Last year, I wrote an article for the Journal of Hospital Medicine offering tips to healthcare providers in what was then an expanding COVID-19 environment.¹ These lessons were drawn from my experiences during the “tough fights” and crisis situations of my military career, situations similar to what healthcare providers experienced during the pandemic.

Now, as vaccination rates rise and hospitalization rates fall, the nation and healthcare profession begin the transition to “normalcy.” What should healthcare professionals expect as they transition from a year of operating in a crisis to resumption of the habitual? What memories and lessons will linger from a long, tough fight against COVID-19, and how might physicians best approach the many post-crisis challenges they will surely face?

My military experiences inform the tips I offer to those in the medical profession. Both professions depend on adeptly leading and building a functional and effective organizational culture under trying circumstances. It may seem strange, but the challenges healthcare workers (HCWs) faced in fighting COVID-19 are comparable to what soldiers experience on a battlefield. And now, as citizens return to “normal” (however normal is defined), only naïve HCWs will believe they can simply resume their previous habits and practices. This part of the journey will present new challenges and unique opportunities.

Healthcare has changed…and so have you! Just like soldiers coming home from the battlefield face a necessarily new and different world, HCWs will also face changing circumstances, environments, and organizational requirements. Given this new landscape, I offer some of my lessons learned coming out of combat to help you adapt.

Heading home from my last combat tour in Iraq, I found myself gazing out the aircraft window and pondering my personal experiences during a very long combat tour commanding a multinational task force. Pulling out my green soldier’s notebook, I rapidly scratched out some reflections on where I was, what I had learned, and what I needed to address personally and professionally. In talking with physicians in the healthcare organization where I now work, this emotional checklist seems to mirror some of the same thoughts they face coming out of the COVID-19 crisis.

Expect exhaustion. There’s a military axiom that “fatigue can make cowards of us all,” and while I don’t think I had succumbed to cowardice in battle, after 15 months in combat I was exhausted. Commanders in combat—or HCWs fighting a pandemic—face unrelenting demands from a variety of audiences. Leaders are asked to solve unsolvable problems, be at the right place at the right time with the right answers, have more energy than others, be upbeat, and exhibit behaviors that will motivate the “troops.” That’s true even if they’re exhausted and weary to the bone, serving on multiple teams, and attending endless meetings. There is also the common and unfortunate expectation that leaders should not take any time for themselves.

During the pandemic, most HCWs reported sleeping less, having little time to interact casually with others, and having less time for personal reflection, exercise, personal growth, or even prayer. My solution for addressing exhaustion was to develop a personal plan to address each one of these areas—mental, emotional, physical, spiritual—with a detailed rest and recovery strategy. I wrote my plan down, knowing that I would need to discuss this blueprint with both my employer and my spouse, who I suspected would have different ideas on what my schedule should look like after returning “home.” Healthcare providers have been through the same kinds of stresses and need to ask themselves: What recovery plan have I designed to help me overcome the fatigue I feel, and have I talked about this plan with the people who will be affected by it?

Take pride in what your teams accomplished. I was proud of how my teams had accomplished the impossible and how they had adapted to continually changing situations. Whenever military organizations know they’ll face the enemy in combat, they feel heightened anxiety, increased fear, and concern about the preparedness of their team. The Army, like any successful team, attempts to mitigate those emotions through training. During my reflections, I remembered the teams that came together to accomplish very tough missions. Some of those teams were those I had concerns about prior to deployment, but fortunately they often surprised me with their adaptability and successes in combat.

Leaders in healthcare can likely relate. Even in normal situations, organizational fault lines exist between physicians, nurses, and administrators. These fault lines may manifest as communication disconnects and distrust between different members who may not completely trust one another due to differences in training, culture, or role within the organization. But during a crisis, rifts dissipate and trust evolves as different cultures are forced to work together. Many healthcare organizations report that, during the COVID crisis, most personality conflicts, communication disconnects, and organizational dysfunctions receded, and organizations saw more and greater coordination and collaboration. Extensive research on leadership demonstrates that crises drive teams to communicate better and become more effective and efficient in accomplishing stated goals, resulting in team members who relish “being there” for one another like never before. These positive changes must be reinforced to ensure these newly formed high-performing teams do not revert back to work silos, which usually occurs due to distrust.

Just as important as pride in teams is the pride in the accomplishment of specific individuals during times of crisis. Diverse members of any organization deliver some of the best solutions to the toughest problems when they are included in the discussion, allowed to bring their ideas to the table, and rewarded for their actions (and their courage)! Just one example is given by Dr Sasha Shillcut as she describes the innovations and adaptations of the women physicians she observed in her organization during the COVID-19 crisis,² and there are many examples of other organizations citing similar transformation in areas like telemedicine, emergency department procedures, and equipment design and use.^3,4

Anticipate “survivor’s guilt.” During my three combat tours, 253 soldiers under my command or in my organization sacrificed their lives for the mission, and many more were wounded in action. There are times when bad dreams remind me of some of the circumstances surrounding the incidents that took the lives of those who died, and I often wake with a start and in a sweat. The first question I always ask myself in the middle of the night when this happens is, “Why did they die, and why did I survive?” That question is always followed by, “What might I have done differently to prevent those deaths?”

As we draw down from treating patients during the COVID-19 crisis, healthcare providers must also be wary of “survivor’s guilt.” Survivor’s guilt is a strong emotion for anyone who has survived a crisis, especially when their friends or loved ones have not. Healthcare providers have lost many patients, but they have also lost colleagues, friends, and family members. Because you are in the healing profession, many of you will question what more you could have done to prevent the loss of life. You likely won’t ever be completely satisfied with the answer, but I have a recommendation that may assuage your emotions.

In combat, we continually memorialized our fallen comrades in ceremonies that are attended by the entire unit. One of my commanders had an idea to keep pictures of those who had made the ultimate sacrifice, and on my desk is a box with the 253 pictures of those dedicated individuals who were killed in action under my command or in my unit. On the top of the box are the words “Make It Matter.” I look at those pictures often to remember them and their selfless service to the nation, and I often ask myself whether I am “making it matter” in my daily activities. Does your healthcare facility have plans for a memorial service for all those who died while in your care? Is there a special tribute in your hospital to those healthcare providers who paid the ultimate sacrifice in caring for patients? Most importantly, have you rededicated yourself to your profession, knowing that what you learned during the pandemic will help you be a better physician in the future, and do you have the knowledge that you are making a meaningful difference every day you serve in healthcare?

Relish being home. On that flight back to family, my excitement was palpable. But there were challenges too, as I knew I had to continue to focus on my team, my organization, and my profession. While images on the internet often show soldiers returning from war rushing into the arms of their loved ones, soldiers never leave the demands associated with wearing the cloth of the country. As a result, many marriages and families are damaged when one member who has been so singularly focused returns home and is still caught up in the demands of the job. They find it is difficult to pick up where they’ve left off, forgetting their family has also been under a different kind of intense stress.

These same challenges will face HCWs. Many of you voluntarily distanced yourself from family and friends due to a fear of transmitting the disease. Spouses and children underwent traumatic challenges in their jobs, holding together the household and piloting kids through schooling. My biggest recommendation is this: strive for a return to a healthy balance, be wary of any sharp edges that appear in your personality or in your relationships, and be open in communicating with those you love. Relying on friends, counselors, and mentors who can provide trusted advice—as well as therapy, if necessary—is not a sign of weakness, but a sign of strength and courage. The pandemic has affected our lives more than we can imagine, and “coming out” of the crisis will continue to test our humanity and civility like never before. Trust me on this one. I’ve been there.

These reflections open us to issues physicians must address in the months after your “redeployment” from dealing with the pandemic. When soldiers redeploy from combat, every unit develops a plan to address personal and professional growth for individual members of the team. Additionally, leaders develop a plan to sustain performance and improve teams and organizational approaches. The objective? Polish the diamond from what we learned during the crisis, while preparing for those things that might detract from effectiveness in future crises. It’s an SOP (standard operating procedure) for military units to do these things. Is this approach also advisable for healthcare professionals and teams in responding to crises?

Crises increase stress on individuals and disrupt the functioning of organizations, but crises also provide phenomenal opportunities for growth.⁵ Adaptive organizations, be they military or healthcare, must take time to understand how the crises affected people and the organizational framework, while also preparing for potential future disruptions. While HCWs and their respective organizations are usually adept at learning from short-term emergencies (eg, limited disease outbreaks, natural disasters, mass-casualty events), they are less practiced in addressing crises that affect the profession for months. It has been a century since the medical profession has been faced with a global pandemic, but experts suggest other pandemics may be on the short-term horizon.⁶ We ought to use this past year of experiences to prepare for them.

Pay attention to your personal needs and the conditions of others on your team. After returning from combat, I was exhausted and stressed intellectually, physically, emotionally, and spiritually. From what I’ve seen, healthcare providers fit that same description, and the fatigue is palpable. Many of you have experienced extreme stress. I have experienced extremepost-traumatic stress, and it is important to understand that this will affect some on your team.⁷ In addition to addressing stress—and this is advice I give to all the physicians I know—find the time to get a physical examination. While the Army requires yearly physicals for all soldiers (especially generals!), most healthcare providers I know are shockingly deficient in taking the time to get a checkup from one of their colleagues. Commit to fixing that.

Reflect on what you have learned during this period. Take an afternoon with an adult beverage (if that’s your style) and reflect on what you learned and what others might learn from your unique experiences. Then, take some notes and shape your ideas. What did you experience? What adaptations did you or your team make during the pandemic? What worked and what didn’t? What things do you want to sustain in your practice and what things do you want to eliminate? What did you learn about the medical arts…or even about your Hippocratic Oath? If you have a mentor, share these thoughts with them; if you don’t have a mentor, find one and then share your thoughts with them. Get some outside feedback.

Assess team strengths and weaknesses. If you’re a formal physician leader (someone with a title and a position on your team), it’s your responsibility to provide feedback on both people and processes. If you’re an informal leader (someone who is a member of the team but doesn’t have specific leadership responsibilities outside your clinical role) and you don’t see this happening, volunteer to run the session for your formal leader and your organization. This session should last several hours and be held in a comfortable setting. You should prepare your team so they aren’t defensive about the points that may arise. Determine strengths and opportunities by asking for feedback on communication, behaviors, medical knowledge, emotional intelligence, and execution of tasks. Determine which processes and systems either worked or didn’t work, and either polish the approaches or drive change to improve systems as you get back to normal. Crises provide an opportunity to fix what’s broken while also reinforcing the things that worked in the crisis that might not be normal procedure. Don’t go back to old ways if those weren’t the things or the approaches you were using under critical conditions.

Encourage completion of an organization-wide after-action review (AAR). As I started writing this article, I watched CNN’s Dr Sanjay Gupta conduct a review of actions with the key physicians who contributed to the last administration’s response to the pandemic. In watching that session—and having conducted hundreds of AARs in my military career—there was discussion of obvious good and bad leadership and management procedures, process issues that needed to be addressed, and decision-making that might be applauded or questioned. Every healthcare organization ought to conduct a similar AAR, with a review of the most important aspects of actions and teamwork, the hospital’s operations, logistical preparation, and leader and organization procedures that demand to be addressed.

The successful conduct of any AAR requires asking (and getting answers to) four questions: What happened?; Why did it happen the way it did?; What needs to be fixed or “polished” in the processes, systems, or leadership approach?; and Who is responsible for ensuring the fixes or adjustments occur? The facilitator (and the key leaders of the organization) must ask the right questions, must be deeply involved in getting the right people to comment on the issues, and must “pin the rose” on someone who will be responsible for carrying through on the fixes. At the end of the AAR, after the key topics are discussed, with a plan for addressing each, the person in charge of the organization must publish an action plan with details for ensuring the fixes.

Like all citizens across our nation, my family is grateful for the skill and professionalism exhibited by clinicians and healthcare providers during this devastating pandemic. While we are all breathing a sigh of relief as we see the end in sight, true professionals must take the opportunity to learn and grow from this crisis and adapt. Hopefully, the reflections and recommendations in this article—things I learned from a different profession—will provide ideas to my new colleagues in healthcare.

A few days ago, I had a heartfelt conversation with my good friend Dr Omayra Mansfield. Dr Mansfield has been an Emergency Department Physician for more than 12 years. She is also the wife of another physician and the mother of two young children, the recently appointed Chief Medical Officer at a hospital at AdventHealth, and one of the first graduates of the Physician Leader Development Course I teach.

“During the leadership course, you always provided examples of how physicians are like soldiers,” she began. She reminded me of my words describing how both doctors and soldiers are part of a professional body, how both have a cherished ethos and a set of directing values to guide both their path and their actions as a very special part of our society, and how of all the professions in our society, the military and medicine are the only two that deal in life and death, albeit in very different ways.

She had certainly paid attention in our seminars. Now, as she and her team faced the COVID-19 pandemic, she realized their daily challenges are expanding and they are now going to war. The leadership discussions that had sparked so much debate in our colloquia had now become real.

Dr Mansfield explained that beyond caring for patients, one of her key concerns was the physical and emotional well-­being of the clinical staff at her hospital: the physicians, nurses, technicians, and clinicians under her care. Getting to her point, she asked if I might have any suggestions based on my time and experiences in combat that might be helpful to her as she “cared for her troops” as they faced the battle ahead.

Her request was a good one. Lessons from my military past immediately rushed to my mind. I started scribbling and came up with a Top Ten list of recommendations for anyone going into a tough fight. Here’s what I sent to her:

1. Find a battle-buddy. On the first day of Army basic training, drill sergeants pair new recruits with one another. That’s primarily for accountability purposes throughout the weeks of training—to ensure soldiers hold each other responsible for getting to the right place, at the right time, in the right uniform—but it’s also part of a larger psychological dynamic related to building teams and mutual support within organizations. Your battle-buddy is charged with keeping you out of trouble, having your back, and being there when you need it most. In combat, battle-buddies do all those things and then some; they protect you from harm in so many other ways. Healthcare providers during this crisis will sometimes feel all alone, and they need to rely on someone else to help them when times get really tough. Having a battle-buddy—for those at the healthcare team level, of course, but also among those at the level of clinical director, hospital administrator, CMO, or even CEO—will help get you through the tough times and provide sanity when you need it the most. So my first piece of advice: Find a battle-buddy.
2. Plan and prepare for things you don’t expect will happen. During a preparatory training exercise for our unit’s deployment to Iraq during the surge, when we thought the exercise was about to end, the trainers surprised us with a final crisis we had to solve. According to the scenario, Al Qaida had blown up a major bridge in our area, causing dire logistical problems for the security forces and challenges to the population as they brought their goods to market. I remember my initial reaction: “They don’t have the strength to do that. This’ll never happen,” I said to the Chief of Staff under my breath, as we started developing the required drill to counter the action and please the trainers. I quickly forgot about that lesson, until after we deployed. Two weeks into our 15-month tour in Iraq, the enemy blew the exact bridge that was part of the scenario, causing the exact problems that were predicted. Because we had prepared for the unexpected, we were able to quickly repair the bridge, reestablish the logistics flow, and satisfy the worried population. The lesson: Teams can hope for the best, but it’s always important to prepare for the worst—a lack of equipment, a key member of the team not being available to contribute, an overwhelming surge of patients—and then develop a plan to mitigate it. Take time to reflect, and ask yourself, What is the worst that can happen, what can the “enemy” do to disrupt our lives, and how do we prepare to counter it?
3. Get everyone into the fight. In every organizations, it’s often true that some people take on too much and try and do it all themselves, others do only what they’re told to do, there’s the unique few who want to contribute but don’t know how they can to help, and then there’s some who even attempt to avoid contributing at all. It’s important for leaders to know who on their team fits each of these categories. It’s even more critical for leaders to be able to find ways to relieve the overworked, assign tasks to those who might not know their role, bring those who want to contribute into the fold, and cross-train teams to help relieve those who are exhausted. Leaders must look across their “battlespace” and ensure everyone is contributing. Leaders assign everyone tasks and do their best to level—and lighten—the load of the overworked.
4. “Fatigue makes cowards of us all.” During any type of crisis, the body and mind will rapidly break down from lack of sleep, emotional strain, or overwhelming stress. While a 12-hour shift in a hospital is exceedingly tough even during normal operations, the COVID-19 crisis will demand dramatically more of all the members of any healthcare team. For that reason, leaders must incorporate rest cycles, team rotations, and half-days away from the hospitals even when all hands are on deck, as well as consider reducing shift times, if possible. Many who have experienced the disease in hot spots say this is really tough, but not attempting to plan for this will cause eventual breakdown and dysfunction. Take a break, do all you can to maintain a modicum of balance, and get away for a while.
5. Take time to huddle. Communication and information are always key, but especially critical during any crisis. One technique that has proven valuable, beyond meetings and shift changes, is a preshift and postshift huddle. Different from the formal passing of critical information, the huddle is a brief opportunity for teams to pass informal information, look each other in the eye, and perhaps even pray together. As a two-star general, I did that every morning in combat with my small team of sergeants, captains, and privates before we left the headquarters to visit units, and it gave us all the power of knowing we had shared information, and we had a common operating picture. It gave us strength. During a crisis, all kinds of communication, formal and informal, are key.
6. This ain’t peacetime. In a crisis, the enemy gets a vote. If leaders don’t find ways to counter the enemy’s action (and fast!), they’ll be behind the curve! It’s important to find the techniques and procedures that are bureaucratic (or even dumb) and overturn or eliminate them quickly. Decisions must be made with alacrity and with an understood flow, and people must be assigned responsibilities and held accountable to make things happen. In a crisis, speed in action will almost always trump perfection in understanding. Stay calm but ensure that those who might not understand this come around to the dynamics associated with the threat. A crisis isn’t the time for business as usual.
7. Force adaptation—don’t wait ’til things are over to adjust. In a crisis, faults and disconnects in techniques and procedures often bubble to the surface and cause consternation. Don’t wait for a break in the action to adjust and find new ways to do things because a break in the action will usually never happen. The military has an expression: “Those who adapt the fastest on the battlefield win.” Find ways to look for and then publicize your methods of adaptation to the team, pin the rose on someone to ensure the changes are made, and then have someone make a historical record so other teams might also learn from your scar tissue. Lessons from the fight must be incorporated by the organization, or they’re not “lessons learned.”
8. Talkin’ ain’t fightin’. During a crisis, it’s important to establish techniques of verbal shorthand between the members of a team, and everyone must know their responsibilities and required actions. In the military, this is called a battle drill; in medicine, you know it as a code. In these situations, leaders must find ways to pass information quickly, and the reaction should be immediate response. In a crisis, normal process must take on the dynamics of a “code.” All members of the team must understand that there are just times when things can’t be explained, but it’s also important that leaders know when to use this abbreviated format. Explain when you can, but act when you must.
9. Cherish your teams. Every single team will experience things that human beings aren’t designed or meant to handle—even those in the medical profession, who likely thought they had seen it all. There will be repeated and overwhelming trauma, with the expected emotional reactions. The approach during these situations requires empathy, humility, emotional understanding, and validation. Praise your team at every opportunity, find ways to turn mistakes into learning opportunities, but most importantly be human and find ways to provide memories that your team can cherish and look back upon. Give them memories.
10. Leaders don’t have the right to have a bad day. In 2004, after a 12-month deployment in Iraq, our unit was on our way home. We had been a long time away from our families, and we had experienced some tough fighting. A third of our unit had already returned to their families in Germany when we were told we would be extended because of a changing situation on the ground. A wave of frustration went through our 18,000 soldiers. Our commander then pulled us together, communicated our new mission, and told us he was also disappointed, but it was time we had to show our grit by getting those soldiers who had already returned to Europe back, unpack our equipment, and return to the fight. Then he said something I will always remember: “It’s tough, but understand your soldiers are looking at you to lead in this crisis … and leaders don’t have the right to have a bad day.” He didn’t mean we couldn’t be frustrated, or disappointed, or emotional, or even pissed off. He meant we just couldn’t show it when others were around. That’s one of the toughest things about leading during a crisis: The unimaginable is expected of leaders. And leaders have to be ready to lead.

All this advice may seem like philosophical musings rather than pragmatic thoughts for a crisis, but hopefully this advice will make a difference as healthcare providers tackle the issues ahead. Stay healthy, mitigate risks, but know that the calm provided by leaders will make a difference.

A few days ago, I had a heartfelt conversation with my good friend Dr Omayra Mansfield. Dr Mansfield has been an Emergency Department Physician for more than 12 years. She is also the wife of another physician and the mother of two young children, the recently appointed Chief Medical Officer at a hospital at AdventHealth, and one of the first graduates of the Physician Leader Development Course I teach.

“During the leadership course, you always provided examples of how physicians are like soldiers,” she began. She reminded me of my words describing how both doctors and soldiers are part of a professional body, how both have a cherished ethos and a set of directing values to guide both their path and their actions as a very special part of our society, and how of all the professions in our society, the military and medicine are the only two that deal in life and death, albeit in very different ways.

She had certainly paid attention in our seminars. Now, as she and her team faced the COVID-19 pandemic, she realized their daily challenges are expanding and they are now going to war. The leadership discussions that had sparked so much debate in our colloquia had now become real.

Dr Mansfield explained that beyond caring for patients, one of her key concerns was the physical and emotional well-­being of the clinical staff at her hospital: the physicians, nurses, technicians, and clinicians under her care. Getting to her point, she asked if I might have any suggestions based on my time and experiences in combat that might be helpful to her as she “cared for her troops” as they faced the battle ahead.

Her request was a good one. Lessons from my military past immediately rushed to my mind. I started scribbling and came up with a Top Ten list of recommendations for anyone going into a tough fight. Here’s what I sent to her:

1. Find a battle-buddy. On the first day of Army basic training, drill sergeants pair new recruits with one another. That’s primarily for accountability purposes throughout the weeks of training—to ensure soldiers hold each other responsible for getting to the right place, at the right time, in the right uniform—but it’s also part of a larger psychological dynamic related to building teams and mutual support within organizations. Your battle-buddy is charged with keeping you out of trouble, having your back, and being there when you need it most. In combat, battle-buddies do all those things and then some; they protect you from harm in so many other ways. Healthcare providers during this crisis will sometimes feel all alone, and they need to rely on someone else to help them when times get really tough. Having a battle-buddy—for those at the healthcare team level, of course, but also among those at the level of clinical director, hospital administrator, CMO, or even CEO—will help get you through the tough times and provide sanity when you need it the most. So my first piece of advice: Find a battle-buddy.
2. Plan and prepare for things you don’t expect will happen. During a preparatory training exercise for our unit’s deployment to Iraq during the surge, when we thought the exercise was about to end, the trainers surprised us with a final crisis we had to solve. According to the scenario, Al Qaida had blown up a major bridge in our area, causing dire logistical problems for the security forces and challenges to the population as they brought their goods to market. I remember my initial reaction: “They don’t have the strength to do that. This’ll never happen,” I said to the Chief of Staff under my breath, as we started developing the required drill to counter the action and please the trainers. I quickly forgot about that lesson, until after we deployed. Two weeks into our 15-month tour in Iraq, the enemy blew the exact bridge that was part of the scenario, causing the exact problems that were predicted. Because we had prepared for the unexpected, we were able to quickly repair the bridge, reestablish the logistics flow, and satisfy the worried population. The lesson: Teams can hope for the best, but it’s always important to prepare for the worst—a lack of equipment, a key member of the team not being available to contribute, an overwhelming surge of patients—and then develop a plan to mitigate it. Take time to reflect, and ask yourself, What is the worst that can happen, what can the “enemy” do to disrupt our lives, and how do we prepare to counter it?
3. Get everyone into the fight. In every organizations, it’s often true that some people take on too much and try and do it all themselves, others do only what they’re told to do, there’s the unique few who want to contribute but don’t know how they can to help, and then there’s some who even attempt to avoid contributing at all. It’s important for leaders to know who on their team fits each of these categories. It’s even more critical for leaders to be able to find ways to relieve the overworked, assign tasks to those who might not know their role, bring those who want to contribute into the fold, and cross-train teams to help relieve those who are exhausted. Leaders must look across their “battlespace” and ensure everyone is contributing. Leaders assign everyone tasks and do their best to level—and lighten—the load of the overworked.
4. “Fatigue makes cowards of us all.” During any type of crisis, the body and mind will rapidly break down from lack of sleep, emotional strain, or overwhelming stress. While a 12-hour shift in a hospital is exceedingly tough even during normal operations, the COVID-19 crisis will demand dramatically more of all the members of any healthcare team. For that reason, leaders must incorporate rest cycles, team rotations, and half-days away from the hospitals even when all hands are on deck, as well as consider reducing shift times, if possible. Many who have experienced the disease in hot spots say this is really tough, but not attempting to plan for this will cause eventual breakdown and dysfunction. Take a break, do all you can to maintain a modicum of balance, and get away for a while.
5. Take time to huddle. Communication and information are always key, but especially critical during any crisis. One technique that has proven valuable, beyond meetings and shift changes, is a preshift and postshift huddle. Different from the formal passing of critical information, the huddle is a brief opportunity for teams to pass informal information, look each other in the eye, and perhaps even pray together. As a two-star general, I did that every morning in combat with my small team of sergeants, captains, and privates before we left the headquarters to visit units, and it gave us all the power of knowing we had shared information, and we had a common operating picture. It gave us strength. During a crisis, all kinds of communication, formal and informal, are key.
6. This ain’t peacetime. In a crisis, the enemy gets a vote. If leaders don’t find ways to counter the enemy’s action (and fast!), they’ll be behind the curve! It’s important to find the techniques and procedures that are bureaucratic (or even dumb) and overturn or eliminate them quickly. Decisions must be made with alacrity and with an understood flow, and people must be assigned responsibilities and held accountable to make things happen. In a crisis, speed in action will almost always trump perfection in understanding. Stay calm but ensure that those who might not understand this come around to the dynamics associated with the threat. A crisis isn’t the time for business as usual.
7. Force adaptation—don’t wait ’til things are over to adjust. In a crisis, faults and disconnects in techniques and procedures often bubble to the surface and cause consternation. Don’t wait for a break in the action to adjust and find new ways to do things because a break in the action will usually never happen. The military has an expression: “Those who adapt the fastest on the battlefield win.” Find ways to look for and then publicize your methods of adaptation to the team, pin the rose on someone to ensure the changes are made, and then have someone make a historical record so other teams might also learn from your scar tissue. Lessons from the fight must be incorporated by the organization, or they’re not “lessons learned.”
8. Talkin’ ain’t fightin’. During a crisis, it’s important to establish techniques of verbal shorthand between the members of a team, and everyone must know their responsibilities and required actions. In the military, this is called a battle drill; in medicine, you know it as a code. In these situations, leaders must find ways to pass information quickly, and the reaction should be immediate response. In a crisis, normal process must take on the dynamics of a “code.” All members of the team must understand that there are just times when things can’t be explained, but it’s also important that leaders know when to use this abbreviated format. Explain when you can, but act when you must.
9. Cherish your teams. Every single team will experience things that human beings aren’t designed or meant to handle—even those in the medical profession, who likely thought they had seen it all. There will be repeated and overwhelming trauma, with the expected emotional reactions. The approach during these situations requires empathy, humility, emotional understanding, and validation. Praise your team at every opportunity, find ways to turn mistakes into learning opportunities, but most importantly be human and find ways to provide memories that your team can cherish and look back upon. Give them memories.
10. Leaders don’t have the right to have a bad day. In 2004, after a 12-month deployment in Iraq, our unit was on our way home. We had been a long time away from our families, and we had experienced some tough fighting. A third of our unit had already returned to their families in Germany when we were told we would be extended because of a changing situation on the ground. A wave of frustration went through our 18,000 soldiers. Our commander then pulled us together, communicated our new mission, and told us he was also disappointed, but it was time we had to show our grit by getting those soldiers who had already returned to Europe back, unpack our equipment, and return to the fight. Then he said something I will always remember: “It’s tough, but understand your soldiers are looking at you to lead in this crisis … and leaders don’t have the right to have a bad day.” He didn’t mean we couldn’t be frustrated, or disappointed, or emotional, or even pissed off. He meant we just couldn’t show it when others were around. That’s one of the toughest things about leading during a crisis: The unimaginable is expected of leaders. And leaders have to be ready to lead.

All this advice may seem like philosophical musings rather than pragmatic thoughts for a crisis, but hopefully this advice will make a difference as healthcare providers tackle the issues ahead. Stay healthy, mitigate risks, but know that the calm provided by leaders will make a difference.

A few days ago, I had a heartfelt conversation with my good friend Dr Omayra Mansfield. Dr Mansfield has been an Emergency Department Physician for more than 12 years. She is also the wife of another physician and the mother of two young children, the recently appointed Chief Medical Officer at a hospital at AdventHealth, and one of the first graduates of the Physician Leader Development Course I teach.

“During the leadership course, you always provided examples of how physicians are like soldiers,” she began. She reminded me of my words describing how both doctors and soldiers are part of a professional body, how both have a cherished ethos and a set of directing values to guide both their path and their actions as a very special part of our society, and how of all the professions in our society, the military and medicine are the only two that deal in life and death, albeit in very different ways.

She had certainly paid attention in our seminars. Now, as she and her team faced the COVID-19 pandemic, she realized their daily challenges are expanding and they are now going to war. The leadership discussions that had sparked so much debate in our colloquia had now become real.

Dr Mansfield explained that beyond caring for patients, one of her key concerns was the physical and emotional well-­being of the clinical staff at her hospital: the physicians, nurses, technicians, and clinicians under her care. Getting to her point, she asked if I might have any suggestions based on my time and experiences in combat that might be helpful to her as she “cared for her troops” as they faced the battle ahead.

Her request was a good one. Lessons from my military past immediately rushed to my mind. I started scribbling and came up with a Top Ten list of recommendations for anyone going into a tough fight. Here’s what I sent to her:

1. Find a battle-buddy. On the first day of Army basic training, drill sergeants pair new recruits with one another. That’s primarily for accountability purposes throughout the weeks of training—to ensure soldiers hold each other responsible for getting to the right place, at the right time, in the right uniform—but it’s also part of a larger psychological dynamic related to building teams and mutual support within organizations. Your battle-buddy is charged with keeping you out of trouble, having your back, and being there when you need it most. In combat, battle-buddies do all those things and then some; they protect you from harm in so many other ways. Healthcare providers during this crisis will sometimes feel all alone, and they need to rely on someone else to help them when times get really tough. Having a battle-buddy—for those at the healthcare team level, of course, but also among those at the level of clinical director, hospital administrator, CMO, or even CEO—will help get you through the tough times and provide sanity when you need it the most. So my first piece of advice: Find a battle-buddy.
2. Plan and prepare for things you don’t expect will happen. During a preparatory training exercise for our unit’s deployment to Iraq during the surge, when we thought the exercise was about to end, the trainers surprised us with a final crisis we had to solve. According to the scenario, Al Qaida had blown up a major bridge in our area, causing dire logistical problems for the security forces and challenges to the population as they brought their goods to market. I remember my initial reaction: “They don’t have the strength to do that. This’ll never happen,” I said to the Chief of Staff under my breath, as we started developing the required drill to counter the action and please the trainers. I quickly forgot about that lesson, until after we deployed. Two weeks into our 15-month tour in Iraq, the enemy blew the exact bridge that was part of the scenario, causing the exact problems that were predicted. Because we had prepared for the unexpected, we were able to quickly repair the bridge, reestablish the logistics flow, and satisfy the worried population. The lesson: Teams can hope for the best, but it’s always important to prepare for the worst—a lack of equipment, a key member of the team not being available to contribute, an overwhelming surge of patients—and then develop a plan to mitigate it. Take time to reflect, and ask yourself, What is the worst that can happen, what can the “enemy” do to disrupt our lives, and how do we prepare to counter it?
3. Get everyone into the fight. In every organizations, it’s often true that some people take on too much and try and do it all themselves, others do only what they’re told to do, there’s the unique few who want to contribute but don’t know how they can to help, and then there’s some who even attempt to avoid contributing at all. It’s important for leaders to know who on their team fits each of these categories. It’s even more critical for leaders to be able to find ways to relieve the overworked, assign tasks to those who might not know their role, bring those who want to contribute into the fold, and cross-train teams to help relieve those who are exhausted. Leaders must look across their “battlespace” and ensure everyone is contributing. Leaders assign everyone tasks and do their best to level—and lighten—the load of the overworked.
4. “Fatigue makes cowards of us all.” During any type of crisis, the body and mind will rapidly break down from lack of sleep, emotional strain, or overwhelming stress. While a 12-hour shift in a hospital is exceedingly tough even during normal operations, the COVID-19 crisis will demand dramatically more of all the members of any healthcare team. For that reason, leaders must incorporate rest cycles, team rotations, and half-days away from the hospitals even when all hands are on deck, as well as consider reducing shift times, if possible. Many who have experienced the disease in hot spots say this is really tough, but not attempting to plan for this will cause eventual breakdown and dysfunction. Take a break, do all you can to maintain a modicum of balance, and get away for a while.
5. Take time to huddle. Communication and information are always key, but especially critical during any crisis. One technique that has proven valuable, beyond meetings and shift changes, is a preshift and postshift huddle. Different from the formal passing of critical information, the huddle is a brief opportunity for teams to pass informal information, look each other in the eye, and perhaps even pray together. As a two-star general, I did that every morning in combat with my small team of sergeants, captains, and privates before we left the headquarters to visit units, and it gave us all the power of knowing we had shared information, and we had a common operating picture. It gave us strength. During a crisis, all kinds of communication, formal and informal, are key.
6. This ain’t peacetime. In a crisis, the enemy gets a vote. If leaders don’t find ways to counter the enemy’s action (and fast!), they’ll be behind the curve! It’s important to find the techniques and procedures that are bureaucratic (or even dumb) and overturn or eliminate them quickly. Decisions must be made with alacrity and with an understood flow, and people must be assigned responsibilities and held accountable to make things happen. In a crisis, speed in action will almost always trump perfection in understanding. Stay calm but ensure that those who might not understand this come around to the dynamics associated with the threat. A crisis isn’t the time for business as usual.
7. Force adaptation—don’t wait ’til things are over to adjust. In a crisis, faults and disconnects in techniques and procedures often bubble to the surface and cause consternation. Don’t wait for a break in the action to adjust and find new ways to do things because a break in the action will usually never happen. The military has an expression: “Those who adapt the fastest on the battlefield win.” Find ways to look for and then publicize your methods of adaptation to the team, pin the rose on someone to ensure the changes are made, and then have someone make a historical record so other teams might also learn from your scar tissue. Lessons from the fight must be incorporated by the organization, or they’re not “lessons learned.”
8. Talkin’ ain’t fightin’. During a crisis, it’s important to establish techniques of verbal shorthand between the members of a team, and everyone must know their responsibilities and required actions. In the military, this is called a battle drill; in medicine, you know it as a code. In these situations, leaders must find ways to pass information quickly, and the reaction should be immediate response. In a crisis, normal process must take on the dynamics of a “code.” All members of the team must understand that there are just times when things can’t be explained, but it’s also important that leaders know when to use this abbreviated format. Explain when you can, but act when you must.
9. Cherish your teams. Every single team will experience things that human beings aren’t designed or meant to handle—even those in the medical profession, who likely thought they had seen it all. There will be repeated and overwhelming trauma, with the expected emotional reactions. The approach during these situations requires empathy, humility, emotional understanding, and validation. Praise your team at every opportunity, find ways to turn mistakes into learning opportunities, but most importantly be human and find ways to provide memories that your team can cherish and look back upon. Give them memories.
10. Leaders don’t have the right to have a bad day. In 2004, after a 12-month deployment in Iraq, our unit was on our way home. We had been a long time away from our families, and we had experienced some tough fighting. A third of our unit had already returned to their families in Germany when we were told we would be extended because of a changing situation on the ground. A wave of frustration went through our 18,000 soldiers. Our commander then pulled us together, communicated our new mission, and told us he was also disappointed, but it was time we had to show our grit by getting those soldiers who had already returned to Europe back, unpack our equipment, and return to the fight. Then he said something I will always remember: “It’s tough, but understand your soldiers are looking at you to lead in this crisis … and leaders don’t have the right to have a bad day.” He didn’t mean we couldn’t be frustrated, or disappointed, or emotional, or even pissed off. He meant we just couldn’t show it when others were around. That’s one of the toughest things about leading during a crisis: The unimaginable is expected of leaders. And leaders have to be ready to lead.

All this advice may seem like philosophical musings rather than pragmatic thoughts for a crisis, but hopefully this advice will make a difference as healthcare providers tackle the issues ahead. Stay healthy, mitigate risks, but know that the calm provided by leaders will make a difference.