207 Leadership and Emergency Medicine
Key PointsPerspective
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.”
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
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