Operationalizing Operator Syndrome: What the New DoW Advisory Council Needs to Get Right

By: Mackenzie Witt, Pepper Phillips, MPH, Jennifer Byrne, OTD, Kelli Cabrera, OTD, and Kayleigh Bealer, MS

Beyond Recognition

The Department of War's (DoW) recent memorandum designating Human Performance Optimization as a Department-wide priority—and directing the creation of an advisory council to comprehensively address Operator Syndrome—marks a milestone in military health policy. Beyond establishing Human Performance Optimization as a Department-wide imperative, the memo formally recognizes Operator Syndrome as a priority warranting coordinated Department-level attention. While Human Performance Optimization is intended to improve health and readiness force-wide, Operator Syndrome is a clinical construct that describes the cumulative health effects experienced by special operations personnel. Therefore, comprehensively addressing Operator Syndrome will require DoW leadership and the advisory council to establish a standardized, evidence-informed framework to identify, assess, and monitor special operations and other combat-focused military occupations with suspected cumulative operational injuries within the Military Health System (MHS).

Establish a Clear, Scalable Implementation Framework

The advisory council’s success will depend on both the recommendations it produces and its ability to develop a coherent, scalable framework for operators with suspected Operator Syndrome across the MHS. This framework should aim to shift the MHS from a fragmented, symptom-based approach to one that recognizes and addresses the cumulative effects of operational service through holistic, multidisciplinary care. The value of multidisciplinary care models for addressing the complex health effects of sustained operational service — for both special operations personnel and the broader conventional military — has been demonstrated by existing human performance and operator health programs such as the U.S. Special Operations Command’s Preservation of the Force and Family (POTFF) and the Army’s Holistic Health and Fitness (H2F) program. [1,2] The advisory council has a unique opportunity to leverage the decades worth of lessons learned from these programs to establish standardized assessment methods, multidisciplinary clinical pathways, referral criteria, implementation guidance, and continuous monitoring for the special operations community. By developing, testing, and refining a framework within Special Operations Forces—where cumulative operational exposure is greatest and multidisciplinary human performance infrastructure already exists—the DoW can identify best practices, evaluate implementation and adopt evidence-informed clinical standards to inform broader implementation across the MHS.

Furthermore, the advisory council should establish a process for continuous evaluation and refinement. As the science of Operator Syndrome evolves, this framework should function as a learning health system, with new evidence informing ongoing updates to clinical guidance, assessment methods, and policy recommendations. Embedding rigorous evaluation at every stage of implementation will enable the DoW to identify best practices, monitor unintended consequences, and ensure that resources are directed toward interventions that demonstrably improve health, function, and operational readiness. Achieving this will require continued investment in measurement science to develop, validate, and refine standardized approaches to assessing Operator Syndrome.

Invest in the Science 

Dr. Chris Frueh’s foundational work, which first described Operator Syndrome in 2020 as a multisystem consequence of allostatic load and cumulative operational exposure, has catalyzed interdisciplinary research to develop evidence-informed approaches to assessment and care. [3] Building on Dr. Frueh’s conceptual framework, multidisciplinary research efforts are underway to develop standardized methods for characterizing and assessing Operator Syndrome. One example of this ongoing work is the collaborative development and preliminary validation of a standardized self-report instrument by researchers from 5by5 Performance Therapy and A-G Associates. Drawing on extensive clinical experience in the care of special operations personnel, this effort is intended to assess Operator Syndrome-related symptom patterns using a scientifically informed, standardized approach. Instrument development is guided by the existing scientific literature, clinical expertise, and established principles of patient-reported outcome measure development.

This collaboration demonstrates how innovative partnerships accelerate the development of clinical tools that strengthen policy, improve care, and optimize human performance and military readiness. As the advisory council establishes its agenda, it should actively encourage and leverage similar collaborations. The future of military medicine depends not only on government-led initiatives but also on strategic partnerships within and beyond the DoW that unite operational experience, clinical expertise, and scientific rigor.

These ongoing research efforts also underscore an important implementation challenge. As the DoW considers implementing new screening initiatives, these efforts should be guided by a validated clinical framework. Implementing screening before establishing a validated clinical framework introduces avoidable policy and operational risks. Without standardized assessment methods and evidence-based referral criteria, identification of Operator Syndrome will likely vary across providers and military treatment facilities, leading to inconsistent clinical decision-making, unnecessary referrals, and missed opportunities to identify service members who would benefit from comprehensive multidisciplinary care. These challenges are not unique to Operator Syndrome. Similar concerns have been raised by organizations such as the Endocrine Society about broad population-based testosterone screening, for example. Rather than recommending against testosterone screening altogether, the Endocrine Society supports targeted testing for individuals with specific symptoms and risk factors, emphasizing that no single symptom or biomarker should serve as the basis for identifying cumulative operational injury, and that laboratory findings should be interpreted in an appropriate clinical context to avoid the risk of unnecessary intervention. This is particularly relevant following Secretary Hegseth's directive implementing force-wide testosterone screening for service members over age 30. While expanded screening may facilitate earlier identification of health concerns, testosterone testing should serve as the starting point — not the endpoint — of clinical evaluation. Combining testosterone results with a comprehensive medical history, a validated assessment tool such as the Operator Syndrome Symptom Scale (OSSS), and additional laboratory testing provides a more complete picture of physiological dysfunction and supports more targeted, multidisciplinary care.

Advancing the Measurement Science 

Recognizing Operator Syndrome as a military health priority is an important first step, but sustainability will depend on the DoW’s ability to build the scientific infrastructure that supports evidence-informed decision-making. The DoW should treat investment in measurement science as a foundational priority.

Currently advancing to its next phase of development, the standardized self-report instrument being developed by 5by5 Performance Therapy in collaboration with A-G Associates includes items for the empirical evaluation of multiple symptom domains across physical, mental, physiological, and other performance health systems. Developed using established instrument-development practices, including subject-matter expert (SME) review, iterative item refinement, and psychometric evaluation, this instrument is intended for clinical intake screening and for appropriate interdisciplinary referrals. This multisystem screening tool is designed to identify common symptom patterns affecting the mind and body and to support occupational performance and overall health among operators.

A holistic screening framework supports the identification, intervention, and planning for the many factors affecting occupational performance. This is essential for military readiness and retention and can improve screening and continuity of care during and after service. Addressing Operator Syndrome through a single symptom or isolated laboratory value—such as relying on testosterone testing alone—evaluating the broader physiological systems, increases the likelihood that the underlying condition will remain unrecognized or inadequately treated. Optimizing warfighters' capacity to respond to conflict on a moment’s notice requires a fully functioning mind-body collaboration.

5by5’s extensive work on Operator Syndrome and the development of a self-report instrument to support the assessment of Operator Syndrome among special operations personnel have underscored the need for multidisciplinary expertise across every aspect of a holistic evaluation. It is imperative that physical and psychological assessments and treatments be evidence-based and include continuous, cumulative diagnostics throughout a military member's entire career. 

The DoW must prioritize selecting a multidisciplinary group of health and policy specialists with diverse expertise when evaluating the proposed advisory council’s nominated members. Relying solely on a single expert’s viewpoint for an entire advisory panel is as ineffective as isolating a single symptom in a comprehensive diagnosis. Council members must understand military healthcare, its operational systems and clinical outcomes, and how to optimize health and wellness to enhance lethality.

References

1. Whitehurst, R., Romanello, A., Reilly, N., & Goss, D. (2026). U.S. Army Holistic Health and Fitness Programs Outperform Traditional Physical Therapy Models for Soldiers. Military medicine, 191(3-4), e648–e654. https://doi.org/10.1093/milmed/usaf419
2. McBratney, C. M., & de la Motte, S. J. (2018). Collaboration Needed on Human Performance Optimization for Combat Athletes. Military medicine, 183(7-8), 143–145. https://doi.org/10.1093/milmed/usy020 
3. Frueh, B. C., Madan, A., Fowler, J. C., Stomberg, S., Bradshaw, M., Kelly, K., Weinstein, B., Luttrell, M., Danner, S. G., & Beidel, D. C. (2020). “Operator Syndrome”: A unique constellation of medical and behavioral health-care needs of military special operation forces. The International Journal of Psychiatry in Medicine, 55(4), 281–295. https://doi.org/10.1177/0091217420906659