Leadership and Emergency Medicine

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207 Leadership and Emergency Medicine

J. Stephen Bohan

image      Key Points

• The value of leadership lies in its ability to form individuals into a group directed to a goal.

• Even small groups benefit from a leader.

• People seek leadership.

• The soul of leadership is integrity.

• The substrate of leadership is change.

• Leadership and management are different.

Perspective

The library of books on leadership is large and heterogeneous, although most of these books focus on large organizations, predominantly business. Most describe general principles, whereas some are specific to gender or career stage or are targeted to CEOs or school principals. None are specific to emergency medicine, and few are written for physicians. This chapter isolates the characteristics possessed by recognized leaders and then applies these characteristics to the context of emergency medicine.

Scope

The nature of the practice of emergency medicine means that leadership is a constant requirement. Few patients can be managed by one person, and many patients require the simultaneous attention of multiple people. A universal acknowledgment is that better care is delivered when such a group works under effective leadership. This same phenomenon is present at the department level. Thus, leadership is an everyday requirement that is vital to the agreed mission of the emergency medicine: respectful and good care for anyone, any time, irrespective of any restriction. The leader is an enabler of the goal of “always getting better” at this mission at every level: direct patient care, department operations and development, and national policy matters.

Leadership Qualities

Plato pointed out that it is difficult to say what quality is but that one recognizes it when one sees it. The same can be said, to a large extent, about leadership. Everyone recognizes an outstanding leader, but, despite listing various characteristics, it remains difficult to say what exactly makes that individual a leader worthy of note.

What is a leader? What do leaders do? Are leaders really managers, or is it the other way around? Can one learn leadership? Are leaders necessary? How big must a group be before it needs a leader?

Group Size and Leadership

Certainly, 2 people walking down a street do not need a leader, but observation tells us that 15 people walking down a street, as a group, do need leadership even for this simple task. The action as a group makes leadership necessary. Whenever one person acts in concert with another and is recognized to do so by others, then that group, as small as 2 individuals, needs a leader if for no other purpose than to communicate the needs and wants of the pair to the outside world. Obviously, leading a pair is easier than leading a group of 3, and so the complexity grows with each individual.

In large organizations (e.g., a university, a firm such as General Electric or Wal-Mart, the U.S. Navy), the leadership responsibility is divided at different levels. The chief executive officer (CEO) is expected to lead on matters of policy and general direction of the institution or corporation. As one travels down the chain of responsibility, the ratio of leadership to managerial skill changes.

Manager Versus Leader

Managers direct processes, whereas leaders create change. Managers are given goals and are responsible for the tasks required to achieve that goal. The responsibility of a leader is to make the organization better by creating goals. The leader generates or adopts and then adapts the “better idea” to the needs of the organization.

“The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.”

George Bernard Shaw

This process requires the leader to have a skill set for each of several roles:

Visionary: The ability to see that options exist.

Decision maker: The ability to choose among options. These options may be self-generated or given to the leader by others, but decisions need to be explicit and timely, neither too early (insufficient data, inadequately prepared staff) or late (problem requiring change is now too large, with a different set of options prevailing). Making decisions is hazardous, but leaders cannot be adverse to risk. Recognized leaders rarely revisit decisions and always look forward.

Informant: The ability to inform the members of the organization effectively of the nature of the change and the direction it will take them and also inform related individuals outside the organization of how they will be affected.

Tone setter: Setting the tone (creating the atmosphere) that will allow the change to develop is actually more important than any policy that directs the change.

All these roles (visionary, decision maker, informant, tone setter) require unfailing attention to interpersonal skills for the simple reason that someone else, and various others at various levels, will, of necessity, be executing the change.

Character

The primum non nocere of interpersonal skills is character. Recognition by others that the leader is a person of character is the bedrock of the respect needed to take people to a goal.

“He listens, he is honest and he always takes the high road.”

Cheryl Kane, street nurse, Boston Health Care for the Homeless, about her boss, Robert Taube

Character and selfishness are mutually exclusive. The leader must see and be seen to understand that the needs of the organization override individual interests and that “doing the right thing” is always in the interests of the organization. This includes recognizing that the needs of the organization are best served when the appropriate needs of the individual are properly served in the context of the community that is the organization. Character requires commitment, focus, and a willingness to undertake and exercise responsibility, including accepting responsibility for failures. Failures will always occur as change proceeds. The absence of failures means that change is not happening.

“Most things you try will fail.”

Richard Pearle, MD, CEO Kaiser Permanente Northern California

“If you are not succeeding, you need to double your failure rate.”

Thomas Watson, founder IBM

Individuals of character rarely if ever complain, never gossip, and always follow through on what they said they would do. They are, and are seen to be, committed to making the organization and the individuals in it better. They hold themselves and others accountable while being loyal. Loyalty is a two-way street. The leader must be loyal to relevant external agents (the larger organization, the community, and its needs) while simultaneously acknowledging subordinates though recognition and by supporting them in time of personal need. Leaders are readily distinguishable from sycophants.

“Never complain, never explain.”

Anonymous

Strategic Positioning: Out in Front

If the prime role of the leader is to take the organization to a different place, then he or she needs to be “out in front.” With a combination of knowledge of the organization as it currently exists and a clear vision of the goal of what it should look like in the future, both near and long term, the leader needs to pull the organization forward by using the respect that he or she enjoys as the rope.

The position out in front is not to place the leader on a pedestal, nor is it to isolate the leader in any way. In fact, the distance between the leader and the group is actually crucial. When it is too close, the leader is just another member of the group participating in the group think, whereas when it is too far, the leader is not seen to have any relationship with the group at all. Walking and talking too fast put more and more distance between the leader and the group and erode the necessary organic relationship between leader and followers.

For example, if the drum major is 10 yards ahead of the band, he is leading it; if he is 50 yards ahead, he has no useful relationship with it. His signals are difficult to see and difficult to interpret if they can be seen, and the musical cues are dropped, with results that one would expect. This principle is true irrespective of the nature of the organization.

“Take no credit; share no blame.”

Anonymous

Communication

The person of character readily gains respect. This respect makes people willing to listen to what the individual has to say but, more important, makes them willing to talk to the leader because when integrity is recognized, trust exists. The individual telling his or her story is seeking, even demanding, attention and should receive it. That attention should be undivided because listening is the overarching virtue of a leader. The decision that follows is often viewed by the narrator as less important than the fact that the story was heard.

“Many a man would rather you heard his story than granted his request.”

Lord Chesterfield

There is much to be learned in listening. Buried beneath the words are essential truths about the individual and the job that he or she does, as well as the barriers that faced while doing it.

Discerning the nature and number of barriers to success at each level is a hallmark of a leader. It also implies the intention and action to remove those barriers and to allow individuals to succeed in their tasks.

Over and over, when individuals in large organizations are asked what could be improved in both their workplace and the organization as a whole, they reply “better communication.” By this, they imply the need to be listened to but also to be told “what is going on.” People left on the outside of the information stream feel powerless and neglected. Because a major purpose of any communication is to inform, the leader must be a successful informant. The message must be clear, so it must be simple and declarative. Avoidance of the passive voice enhances clarity. Jargon of any sort, whether medical, administrative, or managerial, should be avoided. The message must have a human touch to communicate not only the information but also sympathy with the recipient. To do this successfully in both written and oral forms takes practice and perhaps some coaching.

In the end, the whole purpose is to communicate the goal of the group and how any change promotes that goal. The goal itself must be a “good” something that makes both the group and the community better, and it must be easily recognized as such. Effective communication aids in this recognition. The “good” is a reflection of the leader’s beliefs, the underpinning of the leader’s character. The beliefs are then known and are seen to be the moral context in which goals and directives are enunciated. This sense of morality implies a sense of fairness and justice.

Fairness and Justice

Fairness and justice imply the absence of a special relationship between a leader and other individuals. Experience tells us that these relationships prevent us from viewing the object of our friendship or affection objectively, thus suggesting unequal regard among all individuals of the organization. The wise and successful leader develops successful acquaintanceship with members of his group but rarely friendship and never affection. This dispassionate approach is absolutely necessary to treating members of the group fairly and justly. Should affection develop, one of the individuals should leave the organization forthwith.

“Get your luvin’ at home.”

Peter Rosen

Also necessary for developing a sense of equity and fairness is the willingness to abide by the rules, whatever those rules may be. If the conclusion is that the rules are silly, counterproductive, or antiquated, then the successful leader will revise or remove them, but never ignore them.

Managing Leadership

Were one to possess and be able to exercise all the foregoing necessary virtues, one would be “the” natural leader, but such is only occasionally the case. Thus, one must have the ability to recognize one’s own weaknesses and “staff them.” This can be done by delegation. One may be excellent at decisional activities but a less than magnetic communicator. In that case, communication can, for some large part, be delegated, all the while taking precautions to ensure that the message is recognized as coming from the leader. The same holds for most activities, including fiscal, personnel management, and community affairs.

It is an unequivocal fact that some people possess leadership talent, whereas others do not. These other individuals may possess other talents that are useful for the organization, such as insight, salesmanship, or the ability to absorb and relate financial information. The successful organization places the individual with a particular talent needed in the position in which that talent is useful, and the individual, once placed, does the same all the way down through the organization. Having individuals in positions for which they have no talent is impairing both for the organization and for the individual, and if this position happens to be a leadership role, then the impairment reverberates widely. Having individuals succeed is a fundamental necessity to the success of the organization. Removing unsuccessful people from positions for which they have no talent is never a bad thing. Keeping them in the position in which they are not succeeding does a substantive disservice both to the organization and to themselves as it perpetuates dysfunction and delays their placement into positions in which they can succeed.

Learning and Knowledge

Leaders must be knowledgeable. This requires being informed and trusting the informant. Thus, hiring trustworthy people is a key to success. This team of reliable informants helps the leader to “prepare relentlessly, to get the facts straight, to never assume anything.” Each episode of “doing the right thing and doing it correctly” sets an example of the standard expected of others. Just as a single adverse headline in a newspaper, truthful or not, can undo decades of reputation building, being mistaken even once on factual matters can serve to diminish credibility, a virtue on which leadership rests. This fact supports the notion that, as in everything else, successful leadership comes from talent supplemented by hard work. One can learn important elements of leadership, or at least improve on them.

Preeminent musicians practice several hours per day, as do star athletes. The skills of leadership are as amenable to improvement as any other skill. Presentation skills can be improved through education and practice. Focusing on individuals, for example, by learning and remembering names and personal facts of members of the team or work force, can alter the regard in which the leader is held, as can attendance at team social events. All these behaviors take initiative, time, and effort to learn and perform. Leadership is never a leisurely stroll in the park; attention can never lapse.

Effective Leadership

Leadership is about promoting and managing change. Changing people is more challenging than changing material. The effective leader is one who regularly succeeds in driving change. The methods for this entail all the previously mentioned characteristics and character traits. Communication must be regular but not frequent, simple, consistent and persistent. It should antedate the effective date of the change by a period measured in months and should become more frequent as date nears. The communication should be seen to be personal, should explain the value of the change to the group, and should continue well into the implementation period, until the change is stabilized in the culture of the institution or group. The use of e-mail is not an effective means of staff behavior change.

Leadership in Emergency Medicine

The scale of leadership in emergency medicine is usually small: the physician group, the department, the organization. The principles remain identical, however, irrespective of the size of the requirement. Leaders must be respected because without respect no willingness exists on the part of the group to listen to and adopt the goals enunciated. The fundamental requisite for respect is character and then, not far behind, is being good at the job. Technical skill (and “interpersonal skills” are actually a technique of the job) is necessary but not sufficient because it does not replace or make up for character deficiencies. Thus, anyone interested in being a leader in emergency medicine must devote a substantive amount of attention to becoming a respected clinician. This includes being completely knowledgeable about the core scientific knowledge, as well as having sufficient interpersonal skills to be respected by both patients and other staff members. With character and clinical skill in place, a leader in emergency medicine usually requires a record of academic accomplishment in addition to the record of administrative accomplishment (e.g., quality programs, emergency medical service activities, community outreach, fiscal management) that is needed in all emergency departments irrespective of size or mission.

An alternative to this traditional view exists. This alternative view holds that leadership skill is the most important attribute, as opposed to being the best physician. In other words, the person who is the best leader, be it a nurse, a physician, or an administrator, should be the leader.

“Asking who the boss should be is like asking who should sing tenor in a quartet, it is the person who can sing tenor.”

Henry Ford

The record of accomplishment is the interface between the bedrock of character and clinical skill and the leadership position. Once a position is achieved, what successful leaders do in emergency medicine differs little from what successful leaders do in any other organization. The exception is that leaders in emergency medicine are more often expected to continue clinical activities, whereas in other organizations, especially large ones, no such expectation of “working on the shop floor” exists. On a local level, leaders seek to move the organization forward, including the physician group and hospital activities, both internal and external to the department, that affect the department. On a regional and national level, the principles remain the same; only the scale changes. Regional and national leaders in emergency medicine seek to initiate and manage change, be it through education, legislation, or offering new structures in national and state policy or new ways of thinking about processes. They set and move toward goals by seeking to align talent and job requirements, to make the workplace hospitable and just, thereby reducing costly employee turnover, and to inform peers, other members of the organization, the public, and politicians. They listen, act, take responsibility, and pause and reflect often.

Suggested Readings

Campbell MJ. Five gifts of insightful leaders. Newton, MA: Charlesbank Press; 2006.

Gikley RW. The 21st century health care leader. San Francisco: Jossey-Bass; 1999.

Harvard Business Review. Harvard Business Review on leadership. Boston: Harvard Business School Press; 1998.

Maxwell J. The 21 indispensable qualities of a leader. Nashville, TN: Nelson Business; 1999.

Morrell M, Capparell S. Shackletons’s way. New York: Penguin; 2001.

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