An excerpt from Self-Awareness and Trust: Leading Healthcare Teams from the Inside Out.
“Knowing yourself is the beginning of all wisdom.”
– Widely attributed to Aristotle
I had been away from the intensive care unit (ICU) for a couple of weeks. When I came back for a scheduled week of service, I put on my black fleece jacket (the same one I had worn hundreds of times before). As I slid my hand into the pocket, I felt something small and familiar. Three cough drops. Suddenly, I remembered. The last time I wore that jacket in the intensive care unit, I was sick. I had not been mildly congested, uncomfortable, or inconvenienced. I was genuinely ill.
I was sick enough that, had I been my own patient, I would have advised rest, fluids, and time away from work. I would have talked about using better judgment, concerns about infecting others, and the need for time for recovery. Instead, I showed up. I rounded. I staffed critically ill patients. I made high-stakes decisions. I wore a mask and carried cough drops like a quiet workaround for my own physiology. Standing there with my hand in that pocket, something unsettled me: not guilt, exactly, but recognition, and a question.
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Where did I learn this? Where did we learn that professionalism means pushing through illness and that patient care outweighs self-care? In medicine, we tell these stories constantly. We tell them with pride. Someone rounded with an IV in their arm. Someone stepped out of a procedure to vomit and stepped right back in. Someone collapsed only after the work was done.
We pass these stories down like folklore, cautionary tales stripped of their caution. Popular culture reinforces them, depicting physicians who operate through personal crises and collapse only after the final suture, inviting admiration rather than inquiry. We reinforce it with judgment of others and the whispered conversations about the resident “who called out.” There are complaints about covering for them, and they may even be labeled a bad colleague. Harsh words like “weak, soft, and lazy” get bounced around when others set and stand by their boundaries.
The message is absorbed quietly and early: Real professionals do not stop. These stories are not evidence of excellence, though. They are evidence of a culture that confuses constant readiness and excessive hours with competence. It rewards long hours in the hospital even after they have begun to erode judgment, empathy, and care.
The cost of constant readiness
In combat environments, hypervigilance is adaptive. It saves lives. Military training teaches constant scanning, anticipation of threat, and sustained alertness even in exhaustion. The sympathetic nervous system mobilizes instantly, attention narrows, reaction time shortens. In those moments, slowing down is dangerous.
I learned early in my military career that readiness was essential. Proving military readiness dictates everything down to the dollars that Congress allows the Department of Defense to spend. The problem is not that we learn the skill of readiness. The problem is that we carry it forward, unexamined, into environments where sustained hypervigilance quietly becomes harmful.
I carried this forward into my clinical work. Critical care medicine mirrors many features of combat: unpredictability, moral injury, responsibility for life-and-death decisions, and prolonged exposure to suffering. The ICU rewards vigilance, speed, and constant availability. Clinicians trained in crisis environments often excel there, but our physiology does not distinguish between the battlefield and the bedside. The human nervous system is designed for short bursts of threat response, not indefinite activation.
When survival physiology remains engaged over time, cognitive flexibility narrows, working memory degrades, and emotional connection with others suffers. Perspective shrinks. What once supported decisive action begins to undermine judgment, communication, and ethical reasoning. Readiness that is never down-regulated stops being an asset and becomes a liability, a pattern well-described in research on chronic stress and sustained sympathetic activation.
I saw this during a deployment, working as a psychiatrist caring for soldiers immediately after firefights. I remember one soldier in particular. He was walked into the tent by his battle buddy, his assigned combat partner. My first thought was that he looked fifteen or sixteen years old. Maybe I was just getting old. Maybe it was the shock making him appear younger than he was. He was nineteen.
He had damp curly black hair and bright blue eyes. The look on his face was one I had seen before, but never quite like this. Completely frozen. Completely inside himself. He was not physically wounded, but he could not walk in on his own. His battle buddy had one hand on his arm the whole way through the door, steady and quiet, the way you steady someone you are afraid might fall.
His buddy told me it had been his first firefight. He had frozen. Everyone around him had been worried, both about him and about what his freezing might mean for the others. I thanked the buddy and asked him to wait outside. Then it was just the two of us.
For an hour, he said nothing. I did not push. I waited and watched him closely, which in that tent, with that job, in that war, was its own kind of work. The noise of the unit moved around us outside the canvas walls. Inside, we were silent. When he finally spoke, he did not talk about what happened. He did not describe the firefight or the fear or the freezing. He looked at me and said, “I need to get back to my team.” That was it. That was everything.
He stayed in the psychiatric tent for a day or two. Then he went back. I do not know what happened to him after that. I never found out. That is one of the particular losses of that kind of work. People move through, and you hold what they gave you, but the story does not have an ending you ever get to hear.
What I do know is that I carried a deep sadness and concern out of that tent, and I could not let myself show it to anyone. I loved that work. Despite the weight of it, despite the relentlessness of it, I wanted to be there. It mattered to me. Every soldier mattered to me, but wanting to be there did not protect me from what the work was doing quietly, over time. I was the only psychiatrist. I was also a woman in a leadership role in a combat environment, which meant that the threshold for showing struggle felt impossibly high, not because anyone said so explicitly, but because I understood the calculus. I did not cry in that tent. Not once. I held it together with both hands, every day, for every soldier who came through.
The tears came later. They always did. And somewhere in the middle of all of it, I noticed something shifting. Soldiers would come in and describe things that should have moved me, and I would feel myself responding from a distance. I did not become indifferent. I continued to care for each soldier, but my experience and my responses were muted. The empathy was still there, but it was working harder to get through. I was afraid to tell anyone what was happening. I was the one who was supposed to hold the space for others to experience and express their emotions. Who checks on the psychiatrist in a combat zone? Nobody asked. I did not offer. I kept going.
That is what I mean when I say hypervigilance stopped being an asset. It did not announce itself. It did not come with an alarm. It just quietly narrowed everything until the feelings that were supposed to guide me were working at reduced capacity, and I had learned to call that functioning.
In war zones, the cost of constant readiness is understood, even if rarely addressed in real time. In medicine, we pretend it does not exist. We praise clinicians who never miss a shift and admire leaders who are always available. We quietly, even silently, penalize those who ask to step back, slow down, or recover. We confuse endurance with excellence and call it professionalism.
Years later, I was still practicing this level of readiness. I was standing in an ICU with cough drops in my pocket, sick and unwilling to stop. No one stopped me. The system did not identify my illness or exhaustion. The system failed to recognize that readiness without restoration degrades care over time.
Jess Bunin, MD, is a critical care physician and cofounder, All Levels Leadership.
All Levels Leadership is a physician-led health care leadership development firm dedicated to empowering professionals across the career spectrum. With a foundation in clinical care, academia, and governance, the organization delivers customized coaching, mentorship, and training programs that foster resilience, well-being, and leadership excellence. All Levels Leadership has presented nationally and internationally at events hosted by the American College of Physicians, the International Conference on Residency Education, and the Society of Critical Care Medicine. Committed to advancing inclusive and transparent cultures, the firm helps individuals and teams lead with clarity and purpose. Explore their programs and services at alllevelsleadership.com, and connect with them on LinkedIn. To read more about their work, including recent podcasts and publications, visit their podcasts and publications.
