The crisis you keep misdiagnosing

Room to Think, week one.

A senior colleague once told me she thought she was failing.

She was not. She ran a busy unit. She hit her numbers. Her patients did well and her juniors trusted her. From the outside, nothing was wrong. But every evening she sat in her car in the hospital car park for ten minutes before she could face the drive home. She had started snapping at people she loved. She read the same paragraph four times and took none of it in. She told me she had lost her edge, her patience, the version of herself she used to like.

She had not lost any of those things. She had run out of something. And because she could not name it, she blamed the only thing in the room she could see clearly. Herself.

We are good, in medicine, at naming what we can see. A rhythm on a monitor. A shadow on a film. A number that has drifted out of range. We are far less good at naming the thing that has no waveform, no image, no reference interval. So when a capable leader starts to struggle, we reach for the labels we already own.

We call it a leadership problem. We send them on a course about influence and difficult conversations.

We call it a communication breakdown. We commission a workshop, write a new policy, add a step to the handover.

We call it burnout, or a resilience gap, and we offer mindfulness at lunchtime and a wellbeing webinar nobody has time to watch.

None of it holds. The course is forgotten by the following Tuesday. The policy becomes another thing to comply with. The webinar is one more demand on a person who already has too many. We keep prescribing, and the patient keeps not getting better, and slowly we conclude that the patient is the problem.

Here is the reframe I want to leave you with this week.

Healthcare does not have a leadership crisis. It has an oxygen crisis.

I mean that almost literally. In medicine, oxygen is not one factor among many. It is the enabling condition. Get the oxygen wrong and it does not matter how strong the heart is or how clever the drug regime is. Everything downstream degrades. And the brain, the most oxygen-hungry organ we have, is the first to feel it. Starve it for seconds and higher function starts to fail before the person even knows anything is happening.

Leadership under modern pressure follows the same physiology. There is a kind of margin that good thinking runs on. Call it attention, emotional steadiness, the few seconds between a stimulus and your response, the bandwidth to hold more than one thing in mind without dropping the lot. When that margin is adequate, people are curious, steady, willing to be challenged, able to see the whole board. When it falls below what the role demands, the higher functions go first. Strategic thinking narrows to firefighting. Empathy shrinks. Curiosity collapses into certainty. The person becomes sharper, colder, quicker to close a conversation down.

This is the thing my colleague had run out of. I have come to call it Cognitive Oxygen® (COx), and I have spent years watching it deplete in people far too able to be failing.

The cruel part is how well the depletion hides. A starving heart does not stop. It compensates. It works harder, recruits reserve, holds the line, and from the outside it looks like it is coping right up until the moment it is not. Depleted leaders do the same. They go into a kind of permanent triage, and triage produces visible activity. Inboxes get cleared. Meetings get attended. The motion looks like competence. So the very thing that should alarm us reassures us instead. Everyone is busy, therefore everyone must be fine.

And there is the matter of shame, which keeps the whole thing in the dark. Naming your own depletion feels like confessing weakness, so people do not say it. They sit in the car park instead. They assume they are the only one. They are almost never the only one.

I want to be careful here, because this is where the usual story goes wrong. The usual story says: you are depleted, so you must look after yourself better. Sleep more. Be more resilient. The implication is that the problem lives inside you, and so does the fix.

That is the part I do not accept. The leaders I have watched struggle most were not the least intelligent, the least trained, or the least committed. They were the most stretched. Their environments had quietly removed the conditions that good thinking requires, and then asked them to think well anyway, and then, when the thinking suffered, offered them a webinar about themselves. The depletion was real. The diagnosis was aimed at the wrong target.

So the question is not “how do I cope better.” Coping better is what she had been doing for two years in that car park, and it was eating her alive. The question is the one we ask about any patient who is not improving on the treatment we chose. Did we get the diagnosis right?

Look again at the next capable person you see starting to fray. The one who has gone quiet, or short-tempered, or strangely certain about everything. Before you reach for the word leadership, or communication, or resilience, try a different question.

What in this system keeps taking the oxygen out of the room?

Ask that, and a great deal changes. The problem stops being a person and starts being a set of conditions. Conditions can be redesigned. And an oxygen crisis, once you actually name it as one, turns out to be the most treatable crisis there is.

That is where we are going, week by week. Not to make you cope. To help you see.

Next week: why a full night’s sleep stopped fixing it.