Leadership Strategy During Challenging Circumstances: Lessons from a Roman Emperor

Amanda Brahim, PharmD BCOP BCACP BCPS
Clinical Pharmacy Manager
Memorial Cancer Institute
Pembroke Pines, FL

Jameshia Below, PharmD
PGY-2 Oncology Pharmacy Resident
Memorial Cancer Institute
Pembroke Pines, FL

Dorinda Segovia, PharmD
Vice President – Pharmacy Services
Memorial Healthcare System
Pembroke Pines, FL

Leading a healthcare team is inherently challenging because of the many complex, high-risk tasks and competing priorities involved and the rapidly evolving changes to our landscape. Now imagine the stakes being amplified during times of adversity, when situational outcomes are dependent on the key tactics we employ in response to challenging circumstances. Some of the most successful strategies are encompassed in what is known as Stoic leadership.

Stoicism is an ancient Greco-Roman philosophy founded in the fourth century BC, and its principles can be applied to our personal and professional lives. Stoicism teaches us how to keep a calm and rational mind no matter the circumstances and to focus on what we can control, rather than letting events outside our control dominate our actions.

The Roman emperor Marcus Aurelius, the last of the five great emperors, ruled from 161 to 180 AD. The most powerful man in the world at the time, he was a stout proponent of Stoic philosophy and was renowned for his humanistic, level-headed leadership. He recorded his thoughts and observations in a journal, now known as Meditations.¹ These journal writings have inspired some of the greatest leaders in history. Stoicism gave Aurelius a guidebook for living a virtuous life, focusing on what mattered, and persevering despite setbacks—and he had quite a few during his reign. It was a time of impending wars; famine; threats to the throne; and, most relevant to us in this day, the Antonine Plague. This pandemic spanned the Roman Empire, persisted for 15 years, and claimed approximately 5 million lives in Europe. Yet this period was also a time of an expansion of power for the Roman Empire largely because of Aurelius’s leadership during adversity. Marcus Aurelius faced unprecedented challenges head on, with total composure and endurance.

Recently, our healthcare community has experienced challenges strikingly similar to those faced by the Romans more than 2,000 years ago. The COVID-19 pandemic tests our resilience daily. With restricted resources, conflicted governmental leadership, and limited relevant experience, we have battled a virus with the potential to cause mass casualties. As leaders, we control our response and set the stage for how others respond to adversity. Similar to Aurelius, by using the tenets of Stoicism, such as setting priorities, taking decisive action, and adapting and planning for the future, we are able to persevere during challenging times.

Setting Priorities

“If you seek tranquility, do less. Or (more accurately) do what’s essential. Do less, better. Because most of what we do or say is not essential.”—Marcus Aurelius, Meditations¹

Leaders face various sources of pressure that threaten to pull their attention in different directions. It takes skill to separate the distractors from the priorities. It is crucial to focus your energy on tasks that move your team forward, on what Aurelius called “the essential.” When you begin doing that, you are much more likely to hit your goals.

In our health system, it was determined that these things would be our priorities during the COVID-19 pandemic:

• minimizing disease spread and transmission to patients, healthcare personnel, and the community
• maximizing efficient use of resources, including staff, personal protective equipment (PPE), and medications
• maintaining the highest level of care, quality, and service for our patients and families.

Our primary tactic to achieve these goals was to accelerate the transition of digitization and automation. Fortunately, we were able to leverage our previously implemented telehealth platform enabled by our electronic medical record (EMR) system in selected areas within our system. The rapid expansion of that platform to include all oncology providers required the building of new appointment types and clinic schedules in the EMR and a massive preparation of devices and the physical space where the visits would occur. Physicians and staff had to be trained, and new workflows were created and implemented in an extremely short timeframe.

Our hospital system implemented large-scale community drive-through testing in collaboration with the National Guard. Staff members were retrained to provide testing and support the community. As the need for flexible space escalated, we converted conference rooms and other spaces to allow for additional capacity.

With physical-distancing recommendations in full effect, we still needed to maintain accurate medication histories and reconciliation services. We implemented a medication reconciliation call center to limit face-to-face interactions. By using an open flow of communication and collaboration, this method allowed pharmacy technicians to assess patients in the emergency department and on COVID isolation units without additional exposure risk. The leadership, physicians, and information technology and care teams collaboratively tackled this challenge with expedience, knowing that they were helping us care for our patients while protecting our teams.

Taking Action

“You have power over your mind—not outside events. Realize this, and you will find strength.”—Marcus Aurelius, Meditations¹

This is the most prominent principle in Stoic leadership. There are things we control and things we don’t. We should focus on the things we control, devoting our energy and actions to them. Identifying areas that we can control allows us to begin making plans, taking into account the multitude of possibilities justified by current evidence. Action requires courage, not brashness—creative application, not brute force. We need to act with deliberation, boldness, and persistence.

We researched our decisions meticulously, taking note of experiences in other parts of the world. We examined best practices as well as cautionary tales to devise the best approach. With flexibility, we relied less on traditional organizational structures and started locking in practices that sped up decision making and execution during the crisis.

We took action by forming systemwide collaborative groups, each with a specific purpose. A multidisciplinary infectious disease work group composed of physicians and pharmacists designed and continuously updated treatment algorithms. Criteria for the use of interleukin-6 inhibitors were developed in collaboration with cellular therapy teams, who were familiar with cytokine release syndrome. Another systemwide task force was initiated to maintain adequate inventory of PPE and critical drugs and help coordinate care between campuses, including patients’ access to newly initiated clinical trials.

Oncology patients were stratified into three categories: those who had life-threatening conditions that required immediate treatment (e.g., newly diagnosed acute leukemia patients), patients with serious conditions for whom treatment was not urgent but could not be delayed until the end of the pandemic (e.g., breast cancer patients undergoing active treatment), and patients with a disease stage for which treatment could wait until the pandemic subsided without adversely affecting outcomes (e.g., those in long-term follow-up). Each group was assigned appropriate levels of care based on the risk category. Our stem cell transplant program conducted a similar assessment, deferring consolidative transplant for conditions such as multiple myeloma. By setting priorities in patient management and system strategies, we were able to limit interruptions in patient care while mitigating risks.

Communication

A low-key, practical, and democratic communication style is crucial in times of adversity. Throughout his Meditations, Aurelius promoted the belief that no matter what happens, individuals should maintain control of the mind at all times, giving thought to the consequences of their words instead of reacting to their impulsive natures.¹ Effective communication during times of crisis is powerful because it reduces emotional distress caused by the unknown, provides tactical guidance, and demonstrates to team members that their leaders are genuinely concerned and involved in the situation.

Our institution implemented team huddles regarding workflow changes, resources, inventory management, treatment guidelines, staffing, and daily assignments, using a variety of communication channels. The system’s chief nursing officer sent out a daily Coronavirus Watch Board e-mail that included the current numbers of active cases, persons under investigation, mortalities, and discharges. The Watch Board communication also reported on the status of PPE supply, current guidelines regarding patient flow, masking protocols, etc. Communicating in a consistent, transparent manner was instrumental in maintaining the proper flow of information and getting necessary initiatives implemented.

A systemwide focus on communicating how we were keeping our team members safe was maintained. In several areas of the country, large numbers of front-line healthcare employees were infected. Reassuring our team, especially our front-line staff, that their safety was a top priority created a culture of camaraderie. Having this trust between leaders and team members is crucial during difficult times. Team members who feel that they are valued and appreciated will seek to provide high-quality work and find solutions to obstacles that may arise.

Turning Obstacles into Advantage

“The impediment to action advances action; what stands in the way becomes the way.”—Marcus Aurelius, Meditations (Book 5.20)¹

Massive changes such as those associated with the novel coronavirus could and should foster the strengthening of key values like collaboration, flexibility, inclusion, and accountability. We needed to continue to deliver service as usual, but in the most unusual of circumstances. We needed to be open to frequent and constant change in order to operationalize services as new information became available—thus forcing us to evolve our means as a consequence of rapidly morphing events. The need to operate differently gave our organization the opportunity to grasp new opportunities, embrace never-before-thought-of abilities, and expand our horizons and operations beyond previous limitations.

Newfound ideas that previously may not have been considered became a way of the future. Innovative ideas implemented in our system included new services, telephonic medication histories, patient counseling, and telepharmacy appointments and consultations. We also adjusted the operating hours of our dispensing pharmacy to be more convenient for patients. Our community pharmacy service line implemented home and mail delivery and developed a way to offer curbside pickup. This not only kept our volumes steady (we expanded ways to deliver our offerings for the meds-to-beds program) but also minimized potential COVID-19 exposure to discharged patients.

Planning for the Future

“Let no one rob me of a single day who is not going to make me an adequate return for such a loss.”—Seneca (Roman Stoic philosopher), On the Tranquility of the Mind, 1.11b²

Health care may never be the same again. However, we cannot let our short-term focus distract us from our long-term vision and plans, and we can’t dismiss the opportunity to capitalize on lessons learned.

One must plan and prepare for unexpected events. As we build new facilities, the experience of needing social distancing will enable us to think beyond what we know today and work on improving our emergency-preparedness through design, construction, and strategy development. Risk stratification, the development of new services, the removal of barriers, and shifts to telehealth will remain permanent tactics for facilitating access to care. The learnings regarding the importance of open communication and teamwork must pave the way for a higher-functioning system, making a better return on the time spent managing recent events.

Conclusion

Leadership during times of adversity can teach us about the types of leaders we want to be, no matter the circumstances. Leaders—with their own unwavering focus—must motivate others to see the tough times through, not just navigate through calm waters. As any crisis transitions from its urgent phase, the time pressure will ease, as will the need for split-second decisions. At that point, the plan must evolve into a more complex system that looks at recovery and getting things back to normal—whatever the new normal looks like.

An important tenet of Stoicism is that time must not be wasted and every day must be lived as though it is one’s last. Each day is a new opportunity to make a lasting impact. Maintaining this mindset helps us guide others to accomplish a shared vision. By paying attention to our own emotions, needs, and behaviors, we will be better prepared to handle times of crisis. Consequently, we will be more capable of containing the impact of a crisis, regaining control, and effectively preventing, or reducing the duration of, an extremely difficult leadership situation.

References

1. Marcus Aurelius. Meditations (trans. G. Hays). New York, NY: Modern Library; 2002.
2. Seneca. On the Tranquility of the Mind (trans. A. Stewart). 1900; independently published in 2017.