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“Uneasy lies the head that wears the crown.”

Williams Shakespeare, Henry IV1

The position of emergency department (ED) medical director is among the most sought-after and least understood in all of medicine. It is often assumed to be stimulating, rewarding, and gratifying. However, many who have held the position have found it to be difficult, thankless, demanding, and even demeaning at times. Because of the nature and complexity of emergency medicine, the job of coordinating the multidisciplinary services of a diverse group of providers under very challenging conditions is extraordinarily complex and requires talent, energy, and enthusiasm. Successful directors are

  • Leaders, who collaborate, share compelling vision, provide guidance and mentoring, support organizational alignment, delegate authority, act as role models, and so on.
  • Managers, who accomplish critical tasks, develop and implement improvement strategies, provide clinical expertise, set standards, ensure compliance, obtain and provide feedback, conduct meetings, handle complaints, recruit-orient-hire-fire, and so on.

Though difficult, successfully guiding the development of an ED can result in gratifying improvements in patient care, effective development and growth of staff, and personal and professional development of the director.

Regardless of the size, sophistication, or level of service provided in the ED, effective physician and nursing leadership is the necessary condition for success. In the current healthcare environment, sound leadership and management skills are required to provide the appropriate training, resources, facilities, and staff to deliver quality patient care and caring. The ED medical director must work collaboratively with other leaders and managers to achieve 2 goals (see Chapter 16):

  1. The first goal is to develop systems and processes that consistently provide good outcomes for ED patients. Further, these systems and processes work in the absence of senior or middle management and function effectively 24 hours a day, 7 days a week. Medical and nursing leaders in the ED must understand the insight:

  • “I don't care how the ED operates when you are there. I know it will operate well then. What I want to know is: how does it operate when you are not there? That's the true test of your leadership.”2

  1. The second goal is to design systems and processes that consider and incorporate the interests of both clinical patient care and the needs of the providers responsible for that care. The phenomena of stress and burnout can in part be attributed to failure to address needs of the providers and staff.

A superficial view of the ED medical director is a position of power, control, and authority. Nothing could be farther from reality. In fact, the critical competencies necessary for success in this rapidly changing healthcare environment are collaboration, cooperation, empowerment, alignment of incentives, and as Peter Block emphasizes, “stewardship.”3

Robert Greenleaf, the originator of the concept of servant leadership, noted effective leaders of ...

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