People who think that they have power, probably do. Those who don't think that they have it, don't. Real power, the only power that actually exists in the world, is getting people committed to your ideas. How is that done?
Rule number 1 is cautionary:
“Power corrupts. Absolute power corrupts absolutely.”
Lord Acton is right, but emergency caregivers need not worry about it because they don't have absolute power, despite the fact that they do have absolute liability.
Rule number 2 provides an important lesson that follows this rule: When you use power for yourself, you lose it.
When a person uses power for others or for the cause, that person gains power. The great Oxford dons have a power that can be both transferred and manipulated because of their understanding that they only have power if they give it away or share it. Only the person who has true power can actually share it. Thus, a person can gain power by taking whatever power he/she has gained and purling it back into the cause.
Power in Emergency Medicine
Real power in emergency medicine involves what can be done for others. Keeping the patient as central focus is everything. Emergency nurses and physicians are presented daily with the reality of customer service and the expectations it entails. Emergency medicine evokes so much emotion in other specialties, and at times generates anger, because it represents the conscience of medicine; it is the naked underbelly of American medicine and society. When physicians bemoan the call from the ED in the middle of the night, they are actually looking at a defect in themselves.
After all, the reason that emergency physicians are the focal point, why they sit at the bottom of the societal birdcage so to speak, is that emergency physicians have taken on the traditional role of “the doctor.” No group of physicians in this country deserves more to carry the staff of Aesculapius than the emergency physician.
- Who is there at 2 am to take care of the children on Christmas Eve?
- Who is there to comfort the homeless?
- Who is there to look after the alcoholics whom no one else will see?
- Who is there to deliver the news that they will never see their loved one alive again?
When emergency physicians interact with physicians in other specialties, they show them the ugly side of what American medicine has become. Sadly, for some physicians it has become more important to charge for a procedure than to take care of people. Power is shifting to those who care for patients on a regular basis because forces outside of medicine recognize that emergency physicians have done and will continue to do yeoman's service to our communities and to society by maintaining high standards of care to all patients for whom they care.
The popularity of emergency medicine residencies continues to rise. The number of outstanding people coming out of medical schools who want to practice emergency medicine is rapidly increasing. The specialty is growing stronger because it has looked after patients' interests. The proximity of the physician to patients and their problems—which, on the short term at least, can be solved—is immensely attractive to those who enjoy immediate gratification. This fact should be considered when the hospital complains about the emergency department (ED); it is critical for the hospital to understand the origins of such feelings.
Rule number 3: It is a strange rule of power to begin by seeking power and end by losing liberty. Power only goes to those who are committed.
If a doctor is a free, ethereal spirit, if he or she expects to just float in and float out, that doctor will never have power. Power goes to those who are committed to the cause. It never goes to those who want to pick and choose when they will be committed to an idea.
“Power without responsibility, the prerogative of the harlot throughout the ages.”
Who is this? This is the attending physician at the other end of the phone who wants to decide whether the patient should go home without having seen the patient. This is the doctor who wants to “Monday Morning Quarterback” to decide how medical care should have been given in the ED. Too often emergency medicine must deal with this type of physician.
The next lesson coming out of rule number 3 is the most important one of the discussion.
“Those who want real power must get it the old fashion way—earn it.”
Some EDs have tremendous influence in their hospitals and have few problems with attending physicians. In such departments, when the emergency physician says, “admit!” the attendings say, “Thank you!” In these situations, the emergency physicians have “saved” the attending physicians so many times that their credibility and integrity are well known. That credibility and integrity is only earned through constant, ongoing clinical contact that results from a well-managed ED in conjunction with articulate and well-trained emergency physicians. These EDs often play a substantial role in continuing medical education programs at the hospital, particularly in training physicians and nurses in resuscitation courses. These emergency physicians sit on every major committee of the hospital, investing time, energy, effort, and political capital in the future of their group. Respect and integrity earn power in any institution, regardless of its location. As Spinoza wisely noted
“Excellence is what we strive for, but consistency is what we demand.”
Effective contribution requires being there to do things. As Woody Allen said
“80% of success is showing up.”
Certainly 80% of power is showing up and doing the job consistently.
Loyalty and integrity are recognized and admired by friend and foe alike. Those who stand up for principles, even if not always liked, are respected. The medical staff does not have to love an emergency physician as an individual, but it is important for them to understand the physician's thought process and a goal and an aim toward which he or she is working. An emergency physician who views himself or herself as less qualified than the attending physicians will be treated that way. Earn, demand, and therefore attain respect.
The backpacker emergency physician is a thing of the past. Gone are the days when an emergency physician can wander in and say, “I'm skiing at Aspen for 6 weeks. I'm in for 2 months and I'm gone again.” This lack of commitment creates disrespect from physicians on the staff who are running practices and working hard. That same disrespect is shared by the nursing and administrative staffs. Any credibility as an active member of the medical staff is completely lost unless there is active, ongoing, deep commitment for the workings of the hospital and its medical staff, including committee work. Emergency physicians need an action plan and mission statement for their department. They should know and be represented on all strategically important committees of the hospital. Ensuring that discussions include the perspective of the ED is essential to ensuring that small problems do not get blown out of proportion.
In addition, the emergency physician has a unique perspective and can usually mention other cases that attending physicians on the medical staff have handled in a way that have created problems. An emergency physician may manage cases from other physicians' offices that were not optimally managed. Of course, it is never wise to talk indiscriminately about such cases, but it is important to recall, document, and remember them because they may “resurface” at politically important times.
Over time, this power becomes implicitly understood by the important political players in the hospital. “Great walls” crumble in the same way that they were built—1 block at a time. Whenever the ED leader thinks things are going well in the department and stops paying attention to detail, and starts missing a few committee meetings, that leader is slowly eroding the base of power 1 block at a time. It is critical to understand what is needed to maintain a power base so that the department is well represented and then it is necessary to stick to that plan. Finally, timing is everything. In any power relationship, the ED will come head-to-head with other departments or people at certain moments. Even at times of conflict there will be an issue on which the two departments can agree, and when the two of them agree on any issue, the possibility of further agreement becomes more likely.
Rule number 4 is a harsh reality.
“Political power grows out of the barrel of a gun—and The Joint Commission.”
Adapted from Mao Tse-tung
There is nothing as useful to success as being right. Leaders gain power when their goals and desires are aligned with those of the institution and regulatory agencies. The point is, a leader should always reference his/her desires and aims with a higher authority. The rules and regulations of what seems like an increasing number of regulatory bodies are discrete, if often opaque. If the hospital has a practice that contradicts the rules of the regulatory organizations, it needs to be pointed out. It is important to talk to the people who have the power to make decisions. There are often low-level administrators, who are often the victims of ongoing restructuring; these people may be involved in policy discussions but lack decision-making authority. For an ED director to carry out policy discussions with people who are not in the position to make policy is not only a waste of time, but also a dangerous practice.
Physicians must carry out policy discussions with people who can influence and change policy, which may vary according to the organizational structure of an institution. Emergency physicians are the masters in doing 2 things:
- Complaining to the wrong people (usually their partner or the nurses in the department)
- Taking the problems of the world on their shoulders.
- Why do emergency physicians assume the problems of the hospital and society?
- Why don't radiologists figure out who should be taking the patients who don't have doctors?
- Why don't anesthesiologists set up a follow-up clinic?
- Why don't pathologists run the in-house codes for free?
The political milieu, not common sense, dictates the current answer to these questions.