Institutional Readiness in Healthcare Is Infrastructure, Not Virtue
For thirty years, I worked inside the NIH Intramural Research Program. I served as a physician–scientist, led basic laboratory discovery, conducted human clinical investigation, and cared for patients whose lives were shaped by uncertainty at the edge of knowledge. I have deep respect for the rigor, dedication, and moral seriousness of the people who work there. I was one of them.
That long view has given me a particular vantage point: not just on science and protocols, but on what systems ask of people when responsibility is real.
Over time, I came to recognize something that initially felt difficult to name. The NIH-IRP carries one of the deepest responsibilities any institution can hold: stewardship of human beings through illness, uncertainty, and sometimes the final chapter of life itself. That responsibility does not end when a protocol concludes. It rightly extends to the person.
And yet, the system is primarily organized around protocols, investigations, and rigor rather than around the readiness for the people inside it.
Thinking about this recently reminded me of another federal institution: the FAA.
The FAA does not exist to optimize airplanes. It exists to protect people—pilots, controllers, and passengers—under conditions where failure is catastrophic. Its strength is not heroism or professionalism, but readiness infrastructure: explicit authority, non-negotiable pauses, human-factors design, and systems built on the assumption that people will sometimes be tired, afraid, distracted, or overwhelmed.
In aviation, no one is expected to compensate for missing infrastructure with virtue.
In health and research systems, we often tell a different story.
The NIH-IRP appears to rely—often implicitly—on professionalism, dedication, and resilience to carry people through moments of profound stress. These are real virtues. But they are not infrastructure. And when systems move quickly, or stakes are existential, the burden of adaptation quietly shifts onto patients, families, clinicians, trainees, and investigators themselves. In those moments, everyone becomes a passenger.
What I’ve come to understand is that responsibility changes what a system owes the people inside it.
When an institution’s responsibility extends to the end of a human life, readiness cannot be implicit — it must be built into the infrastructure.
This is not a criticism of NIH-IRP. It is an acknowledgment of its gravity. The institution already carries an enormous moral responsibility. What it lacks is a readiness spine proportionate to that responsibility—a way of holding people, not just processes, when stress is unavoidable.
I find myself wondering what it would mean for health and research institutions to take readiness as seriously as aviation does—not by importing procedures, but by embracing the same principle: systems should be designed so that safety and humanity are preserved even when people are not at their best.
Perhaps readiness is not a personal trait.
Perhaps it is something institutions must build.
Take care and be well,
Dr. Lawrence M. Nelson, MD, MBA
Director, My 28 Days® Initiative
President, Mary Elizabeth Conover Foundation, Inc.
