Sudip Bose, MD

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Serving as a combat physician in Iraq, where for 15 months I treated seriously injured soldiers while sometimes under enemy fire, proved an ideal laboratory to effectively demonstrate leadership under extreme stress.

Stress is a natural bodily reaction; it evolved to help us survive and thrive in trying—and even dangerous—circumstances. We can’t avoid stress, but we can decide how we handle it, which has everything to do with the mindset that creates the stress response.

When I was stateside working as an emergency physician, I was accustomed to hospitals having all the supplies I needed, including bags of blood for transfusions and an atmosphere where doctors could break the tension with cheesy jokes and light banter. But in combat, I was the 

I functioned like an ambulance on the scene, doing raids with the soldiers, where my practice theater included a military vehicle taking me into the action and my limited supplies stuffed into my backpack, not neatly stacked on shelves. Not just 

 the hospital. At other times, the action came to me—helicopters brought me bleeding patients who had undergone amputations and teetered between life and death.

To do my job well, I had to adopt an entirely different perspective than what I was used to back home. When you’re thrown into a difficult situation—one that’s foreign to your previous experience—you have to see things through a different lens.

That’s what’s necessary in civilian life too, when people have unexpected stress grenades explode in their own worlds. A critical leadership lesson I learned in Iraq, is that being on the frontline lets you stop the bleeding quickly. Since 80% of the preventable combat deaths are caused by bleeding out, tying tourniquets on these soldiers at the first opportunity made all the difference.

The same thing applies in healthcare, for those in the trenches treating people seriously ill with COVID-19 and for those in customer-facing positions processing COVID-related claims. Each is a frontline position requiring a different perspective, and it’s imperative that the C-level executives understand those separate perspectives.

The most critical error that leaders make is losing touch with their front line, those who deal directly with patients and their families. If your C-suite can understand the problems, challenges, and needs of the folks on both sides of the front line—the employees and the customers they serve—then your organization can deliver outstanding customer service. But many leaders can’t, or don’t want to adopt or understand those perspectives. The most common problem seen in this regard is the disconnect between the leadership perspective and the frontline realities—and that can make leaders lose their edge.

This lesson goes to the heart of your value proposition too. Everybody who can do a Google search, including every patient, becomes an expert and questions what you’re doing. They’re like the category of patients we call “verticals,” the ones who walk into the emergency room under their own power instead of being borne in on stretchers. They’re the ones who fill out the patient satisfaction surveys. In effect, everybody looking at your work and your industry with a critical eye is a vertical.

Talk about stress! The way to convince these people of your worth is to see and appreciate their perspective, as people whom you serve and as making decisions that impact their lives on what 

Leadership that passes the stress test successfully deals with what is commonly known as the pain-in-the-ass (PITA) factor. This has a combat corollary, too. We used to set up free clinics in Iraqi villages where people would come to us seeking treatment for chronic ailments; however, not everybody in those villages welcomed us.

Some of those patients came in on stretchers. One day, one of those patients started fighting with one of our medics. At first I was confused about what was happening, until another medic yelled “He’s got a grenade!” Five of us immediately tackled the guy—one taking the head, the others each arm and leg. But when we pinned him to the ground, we couldn’t find any grenade —because he had shoved it up his rectum.

All five of us cared enough to spring into action, despite the danger, and all of us assumed our separate roles. Because of this, the bomb didn’t go off and I’m alive today to tell you the tale. The moral of the story is: you must recognize the pain-in-the-ass factor—in our case, literally— and tackle it to the ground.

Whatever the challenge is, you’ve got to make everybody in your organization care about tackling it, whether or not it benefits them or their family or their finances directly.

Training to Do What You Don’t Want to Do

In our professions, we have to steel ourselves to do extremely difficult, stressful tasks that we may recoil against, because that’s what we’re trained to do. In basic training, I had to learn how to rappel down a long, steep tower holding a rope, and land safely so that I would know how to disembark from a helicopter in a war zone. I failed repeatedly before I succeeded and I hated it, but it was necessary. Under pressure, you don’t rise to the level of the occasion, you sink to the level of your training. You prepare this way in peacetime for wartime.

Here’s a perfect case in point. One of my buddies in Iraq was fatally shot by an insurgent just hours after we had had breakfast together. I was the one who arrived on the scene and had to pronounce him dead. Then a few minutes later, I had to treat my next patient who was screaming and kicking and spitting at me—the insurgent who had murdered my friend. He didn’t want my care, and I didn’t want to give it. However, I had to since he a was a detainee under the control of U.S. forces. I had to steel myself to do what I hated to do, which I did once my training kicked in.

No one bargained for dealing with a pandemic — with clients who may be hard-pressed to cover treatments for COVID-related as well as non-COVID illnesses, with their employees who may be fighting their own or contending with a family member’s life-or-death battles with the virus and wondering if their insurance will pay for care for themselves or their loved ones. Nevertheless, leadership under this kind of stress demands the resourcefulness and psychological resilience to confront what had been unforeseen crises, sometimes on the fly. Remembering and falling back on your professional training is crucial to making this happen.

When we’re faced with multiple competing tasks to perform, it’s human nature to prefer doing the easier ones and avoiding entirely the tasks that are much harder but more necessary. Again, an example from my time in Iraq is pertinent.

I was the only physician on the scene one day, when a dozen men exploded bombs strapped to their bodies amidst a throng of thousands of people on a religious pilgrimage. The injured and the dead lay everywhere, and quick decisions about whom to triage had to be made. Some victims in excruciating pain didn’t have life-threatening injuries, while others were so grievously wounded that there was nothing I could do to save them. As tempted as I might have been to attend to the less seriously injured or try to comfort the dying, I had to move on to treating those victims who had a chance to survive. Likewise, successful leaders must recognize when to let go and take up the tougher, higher-priority tasks.

What I had to do, and what you need to do in order to make those painful choices, is listen to what’s coming from the frontal lobe of the brain — the seat of logical, rational thinking — rather than to the interior, more primitive part of the brain, which releases the feel-good substance known as dopamine. Too often, many of the decisions we make under pressure are driven by which option delivers the most dopamine. Following those dopamine surges can lead to bad, even stupid decisions.

When we’re confronted with these pressure-packed decisions, our emotions come into play thanks to another part of the brain—the amygdala—which connects an event that’s happening to a reflexive emotion. Frequently, the dominant emotion is fear. Whatever that fear is—of imminent danger, of falling, of failing, of being judged harshly—we can’t control that emotion, but we can control our active response to it. Heeding that frontal lobe admonition lets us master that clear space between the emotion felt and the action taken.

That’s what kicked in for me when I saw my mortally wounded friend and right after that, had to treat his killer. The starkest example of what this felt like, was the day a chopper landed nearby and deposited six men who approached me with a newly captured, disheveled, blindfolded, wheelchair-bound Saddam Hussein—the deposed Iraqi dictator responsible for his country’s ruin. I was responsible for giving him immediate medical care, and regardless of what I felt about the guy, the only decision that logic and reason would permit was to treat him. What it came down to was this: he’s just a patient, so I need to treat him like a patient.

My training had steeled me to anticipate and prepare for worst-case scenarios such as this. In a way, this was like what I’d seen in emergency room practice in downtown Chicago, where you might be presented with a street gang member who’d been shot or the guy who had shot him. You embrace these moments of stress rather than shrink from them. Accepting that discomfort and stress disposes you to make those uncomfortable decisions that leaders in healthcare frequently must render. Harvard University did a study along these lines; it found that people who viewed stresses as challenging handled them much better than people who viewed them as adversity.

Doing the right thing under pressure, however much you want to do otherwise, is what a leader does. Over time, those decisions are habit-forming, and those habits develop character — your character, which is what you need to lead your people and your organizations wisely and responsibly in this time of pandemic-defined crisis.

Sudip Bose, MD, a combat veteran of the U.S. Army, is an attending emergency physician and medical director. He is the founder of The Battle Continues, a nonprofit focused on helping veterans fight their battles beyond combat.

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Leadership that passes the stress test successfully deals with what is commonly known as the pain-in-the-ass factor. 

Sudip Bose, MD

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