“A leader is best when people barely know he exists. When his work is done, his aim fulfilled, they will say: ‘We did it ourselves.’ ”

—Lao Tzu, philosopher and writer

“Management is doing things right; leadership is doing the right things.”

—Peter F. Drucker, author and educator

In my previous blog on EM leadership I reviewed 4 major lessons I’ve learned from my experience as a health care leader.[1] In this post I’d like to build on those ideas to address other key aspects of leadership and to discuss ways I’ve used those principles to approach issues and challenges in Emergency Medicine and health care that we face today.

Leaders must be generous

Harry S. Truman, the 33rd president of the United States, famously said: “It is amazing what you can accomplish if you do not care who gets the credit.” He also kept a sign on his desk that said: “The buck stops here.” And, as depicted in the movie Oppenheimer, he told a morally distressed nuclear scientist not to worry, because the responsibility for dropping atomic bombs on 2 Japanese cities was his. Whatever you think of Truman’s policies and decisions, he understood that a leader should be generous. Give others credit, but take responsibility and blame on yourself. If you do that sincerely and consistently, your team will be grateful, loyal, and productive. And if you understand that as a leader, all accomplishments under your watch are reflective of your leadership, as are all failings; embracing the implications will be noticed and appreciated.

Generosity also means being generous at an interpersonal level. You don’t have to be, often can’t, and sometimes shouldn’t be friends with your staff, but you must acknowledge them as people. Kind words of support and acknowledgement of life events, good and bad, go a long way. Helpful personal advice and professional flexibility on obligations at times of stress will be long remembered and rewarded many times over.

Be a role model

I once gave a seminar on hospital leadership to a class of international graduate students. During the Q and A portion, a student from another country described a moral dilemma. They had moved to an unfamiliar region to take on a hospital leadership position and had found most of the professional staff were from one ethnic group while most of the lower-paid staff and most patients were from another, quite marginalized ethnic group. Racism was pervasive and it was expressed casually and openly. Legal remedies were not available, and so this student felt powerless to change things but also horrible to ignore them and to be seen as passively supporting the status quo. “What should I do?” they asked. Though they did not explicitly say so, I inferred that too aggressive a campaign for change might endanger their job and even their personal safety.

I asked if they would feel comfortable and safe making a point of treating the oppressed group with as much respect and courtesy as possible. Learn people’s names and say hello to them in the hallway. Thank them for their efforts. Where possible, identify people for promotion or recognition. And do so as casually and confidently as the opposite behaviour they’d been encountering, but without any fuss or explicit confrontation of the oppression they were witnessing. They seemed to be satisfied with this response.

Over my career spanning more than 4 decades, hospitals and large institutions have added many positions related to ensuring staff behaviour meets societal expectations. We now have ethicists, human rights officers, privacy officers, and officers for equity and diversity. Each has its place and role and can help protect vulnerable patients and staff as well as the institution itself. However, their presence does not negate the obligation to ensure, nor the value of leaders’ roles in modelling, correct behaviour. If a respected leader you report to leads by example on key issues in personal and professional ethics, I believe that is the most impactful way to create change and to ensure a healthy culture in our hospitals. As Peter F. Drucker said so well, “leadership is doing the right things.”

Find a mentor

Everyone needs a mentor. They might be someone who held your position elsewhere or previously or they may simply be a wise friend, colleague, former teacher, or acquaintance who is willing and able to serve as a mentor. I’ve been blessed to have a few influential mentors in my leadership journey from whom I’ve learned a great deal. The most important attribute of a mentor is the willingness to truly listen, as even the process of articulating a question or issue often brings clarity on its own to the mentee. Also, remember that the social contract for being a mentee requires you to be a mentor when asked.

Take care of yourself, too

Rabbi Hillel said: “If I am not for myself, who will be for me? If I am only for myself, what am I? And if not now, when?”[2] Leaders need to take care of themselves in multiple ways, but many find contract negotiations an extremely awkward task. While a seminar on negotiating strategies is beyond the scope of this blog entry, a few points are worth making here.

First, don’t focus solely on money. Consider the resources you require to be productive and successful in the role. This might include administrative support and office space, for instance. Second, discuss relevant strategic priorities of the institution. Will you and the people hiring you (e.g., the chief executive officer) be broadly aligned? Third, keep in mind that the negotiation process is part of establishing your ongoing relationship with the people you’ll be working for and with, almost like a first date! Ideally both sides are trying to make a good impression. As Maya Angelou said, “… people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

Leadership includes knowing when and whom to follow

We’ve all heard of the bandwagon effect, the phenomenon where people do something simply because others are doing it. Therefore, the first person or first few people to support a leader or a position publicly can have a powerful impact on their success. As a leader trying to influence others, find a few willing supporters who are ready to speak up. But all leaders also have bosses, so be a good follower and express your support publicly for leaders and issues you believe in.

Be committed

We can usually tell when a leader is not truly dedicated to their position or role. Maybe it’s a stepping stone to something else, or maybe it’s just not that important to them, and when that is clear even good initiatives will be difficult to advance because people will be unsure whether the leader is sincere and intends to see things through. On the other hand, if you are a leader who cares deeply for the work and for the people you work for and with, and if you are patient and willing to “play the long game,” it will show and it will earn you loyalty and trust.

Align with patient interests

In my last blog entry I talked about enlightened self-interest. The most common example in health care is understanding patient interests and then ensuring your position is aligned. Expressing yourself accordingly will increase your odds of success. For instance, arguing that EM physicians deserve a raise based on how hard we work is less likely to gain traction than is pointing out that adequate compensation is crucial to ensuring we have an adequate number of experienced, competent physicians to safeguard public access to high-quality and timely EM care.

A few of my quick takes on some controversial issues in EM

  • What’s an “appropriate” ED visit? To me, if a patient wants to see me or if they think they have an emergency, it’s appropriate! The only inappropriate cases are where patients really wanted to see their family doctors or specialists, could not get access, and came to the ED out of frustration.
  • What’s an “appropriate” virtual care assessment (including virtual urgent care)? If a patient prefers a virtual visit—to save time, trouble, or expense—then it’s appropriate for them to be seen virtually. If they had wanted to see their regular doctor in person and could not get access other than virtually, that’s inappropriate.
  • What’s the role of “diversion” in controlling ED input? In keeping with my first statement above on appropriate visits, I put little value in preventing ED visit number 1 by any means other than easing access to appropriate alternatives that the patient is seeking. Where I see value in diversion is if the system can help us prevent ED visits 2 through 5 (or 9 or 12) by giving good care and discharge instructions at visit number 1 and by the system ensuring access to timely follow-up care.

Finally, in July 2024 I will mark 42 years as a practising EM physician, and during most of them I have also been in a related leadership role. To survive in this wonderful but demanding setting, EM docs and nurses have to be smart and deliberate about taking care of themselves (and their colleagues) as well as patients. I am eternally grateful for the privilege of working with amazing people, getting to do an interesting job that matters, and receiving the trust of strangers in their most vulnerable moments.

References

  1. Ovens H. WTBS 29 Four key learnings from a career in emergency medicine leadership [blog]. Toronto, ON: Emergency Medicine Cases; 2024. Available from: https://emergencymedicinecases.com/emergency-medicine-leadership/. Accessed 2024 May 26.
  2. “If I am not for myself, who will be for me?” A discussion for developing a practice of self-care. Washington, DC: Hillel International; 2017. Available from: https://www.hillel.org/if-i-am-not-for-myself-who-will-be-for-me-a-discussion-for-developing-a-practice-of-self-care/

Dr. Ovens has no conflicts of interest to declare