The level of risk in patient care today is higher than most physicians ever considered when choosing medicine. The references to war regarding the COVID-19 fight, including words like physician redeployment, bring into focus that what is asked of physicians today is parallel to going into battle. Appreciating that civilian health care providers never signed up for the current level of risk to themselves and their families, medical leaders must nonetheless prepare them for COVID-19 combat. This brings an urgent need for physician leaders to address both the psychological and logistical needs of humans going into battle.
I spoke with fellow psychiatrist and former Navy Captain Paul Hammer, MD, about the military mindset in preparing troops for battle. Dr. Hammer served two tours in Iraq and held the positions of Director of the Department of Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury as well as Director of the Naval Center for Combat and Operational Stress Control in San Diego.
The military mindset prepares troops to successfully go through their mission in a way that decreases immediate and residual emotional trauma. To do so, they instill in front line leaders their crucial role in building team members’ resilience through the following methods:
Mission: The leader establishes an identity for the teams’ mission by discussing why their undertaking is important and why each role is crucial.
Leadership Trust: The team needs to feel their leader is well-prepared, competent, and confident in helping them through their mission. The leader discusses how team members will protect themselves, what others are doing to support them, and expresses confidence in team members’ training and ability to successfully do their job. Also, the team knows their leader prioritizes bringing members safely through the mission. Ways this is shown include reminding staff of their strengths when they are feeling doubt and giving staff permission to take a break if they are showing signs of distress.
Specificity of Success: The leader provides clear communication about what constitutes success in the mission. This focuses on what they can control in carrying out their duties. When bullets are flying, success is recognized by their ability to follow through in this concrete way.
Recognition: The leader provides post-mission mental debriefing including recognition of all the team accomplished and how they followed through in spite of the challenges. This is especially important in health care settings when the level of trauma is high, and doctors are notoriously self-critical about problems they can’t overcome. For health care teams this includes appreciation of the loss and grief they faced, plus recognition of their ability to carry on through this.
Supportive Follow-Up: Team members know there is an on-call person they can connect with post-mission to debrief the resulting emotions and behaviors that may come up after they disband such as fear, family conflict,etc.
In medicine, providing follow-up support can be especially important as clinicians leave the hospital with fears of being infected, infecting their families, and reduced support if they choose to physically isolate themselves from loved ones.
One of today’s particular challenges is the anxiety and helplessness clinicians feel in adequately caring for their patients and themselves. As medical professionals our primary focus, unlike the military, is to save lives. To build psychological resilience during times of high patient death and limited resources, health care providers need to incorporate a mindset of success measured in maintaining their focus and continuing with what they can control in spite of all they cannot.
Crisis leadership involves communicating in ways you may have previously taken for granted. Verbalizing the why behind what you are doing can build confidence and commitment. Speak about why you choose to be at the hospital, in spite of the risk and anxiety it brings. Put into words what you value about being there, what your presence means to patients and others depending on your care. Share what each team member brings to the team, what would be missing if any one of them was not there. Aligning what they are doing with their goals can reinforce internal strengths to carry them through a difficult shift.
Project calm to bring everyone’s emotional activation down and let the team know you are a port in the storm. Show you are in this together. Be honest about the difficult situations you face; not being able to provide optimal care, being frustrated by policies or people, feeling the systems has let them or their patients down. Empathize they may face situations with no good answers. Model that this is a time to stop using shame and blame. Remind them that realistic expectations take into account they are working with people are tired, anxious, and adapting to ever-changing circumstances. Adopt a mindset that people are doing their best with what they have at the moment. This is a time to set aside the “should have done” and think of experiences in terms of lessons learned. Give them support to put aside negative thoughts to keep focused and moving ahead.
Team leaders should check the pulse of staffs' fatigue, tension, and fears through the shift and respond by empowering team members through pointing out their capabilities, brainstorming solutions together, or providing physical assistance. When you check in, expand your usual question from, “How are you doing, everything OK?” to “What is most stressful/challenging/difficult right now?” and “What could you use help with?” Opening up the opportunity to talk about their experience helps people take their emotional pulse and allows you to support them in applying their strengths to move forward.
Medical leaders hold an important role in countering the clinician's tendency to work past the point of exhaustion; when they notice this occurring, they can step in suggesting time out.
The stress caregivers are under today brings an urgency for leadership focused on resilience. Drawing from the well-studied lessons of crisis leadership, researched most in the military, seems particularly applicable for leaders wanting to provide the best outcome for their team and support for their members.
Cathy Lanteri, MD, FAPA; Lanteri Coaching, Lexington, Massachusetts. Dr. Lanteri is an executive coach whose work focuses on health care leadership development. She previously served on staff at the Brigham and Women’s Hospital, Boston, Massachusetts.
Paul S. Hammer, MD, FAPA; CAPT, MC, USN(RET). Dr. Hammer is a staff psychiatrist at Island Hospital, Anacortes, Washington. He has worked extensively with military organizations and is past president of the Academy of Organizational and Occupational Psychiatry.