Everyday, emergency physicians care for the patients of community-based physicians, physicians who started or joined a practice and remain in the same practice and community throughout their career—or plan to do so. Likewise, many emergency physicians envision the same trajectory for their career; although, concerns about restrictive covenants and contractual arrangements make this more of a wish than a possibility for some. Is career stability a realistic aspiration for the ED Director, the leader of your emergency department?
Historically, leaders in the not-for-profit world have enjoyed a level of career stability that their peers in the for-profit and governmental sectors have not. Perhaps this has been a reflection of different mechanisms for accountability or perhaps it is a manifestation of complacency, on the part of the managers and the boards of these not-for-profit organizations.
As we all recognize, hospitals are no longer part of that genteel not-for-profit tradition. Hospital CEO’s turnover is now at a nationwide average of 17% (2/3’s of it “voluntary”) according to the American Hospital Association. This is not much different from the 19% CEO turnover in major corporations reported by BusinessWeek Online. While it is likely that the proximate cause of any particular CEO’s departure is an error committed by the individual, to some extent they are setup for failure through expectations of CEO performance, which have been inflated, to the point where mere mortals no longer qualify. When the rare leader performs well for a sustained period, this raises the bar impossibly high for everyone else.
Over the past five years as the level of complexity of the hospital CEO’s job has grown, so too has the complexity and challenge of the ED Director’s job. While some directors’ positions may require little more than physician scheduling and quality assurance review with a modicum of “fire-fighting” the majority of ED Directors’ positions have evolved significantly as regulatory complexity, budget strictures, healthcare consumerism, technology and other factors have grown in importance. The job of ED Director is probably more difficult today than it once was: competition for patients and referring physicians has grown, new technology is pervasive, everything happens faster. There is much the ED leader must master and there is little agreement about the fundamental task the ED Director must accomplish. By comparison, defining the corporate CEO’s fundamental task is simplicity itself: Get the stock price up. Period. The hospital CEO’s fundamental task is no more obscure, though usually articulated as, “No margin, no mission.”
So, I’ve started wondering if longevity in the leadership role of a busy hospital ED is possible or is turnover inevitable. I’ve been contemplating my future as I’ve now completed six years as chairman at Maimonides Medical Center and I’m in the midst of finally settling myself and my family into a permanent living arrangement where my long-distance commuting is eliminated thereby attempting another 20 year or longer run in a single organization.
Some recent issues—including the speed of processing arriving ambulance patients through triage—have caused me to realize that the pareto optimum I described seeking in the October 2000 Emergency Medicine News isn’t a static point. (See the American College of Physician Executive’s series “Leading Beyond the Bottom Line.” target="_blank") Remembering that biological systems both decay at the level of the organism and evolve at the level of the species, so too, the ED as a unit must constantly evolve. If I as ED Director fail to support that constant evolution, inevitably my career stability will be compromised.
For the first 20 years of my career, my role models were all academic leaders, some among them the founders of our specialty. Some of them continue today in the leadership roles they held when I first met them 25-years ago. Others have changed positions but remained within the same institution or community. Their success and stability has come from doing a few things very well: running excellent training programs and delivering good patient care. I doubt if that formula is sufficient today.
I suggest that the ED Director’s fundamental task is or should be to recreate the ED as a learning organization. Peter Senge in 1990 wrote in The Fifth Discipline: The Art and Practice of the Learning Organization of the need for authoritarian organizations to transform into learning organizations if they are to overcome the risk of failure. While failure in the marketplace has not been the primary motivator for most ED Directors—that once unthinkable possibility challenges some of us today at the organizational level and consequent to our own human failings is always a possibility in our own career. Senge teaches that through the integration of the five component technologies of “systems thinking,” personal mastery (proficiency), mental models, building shared vision and team learning an organization could overcome the risk of failure but at the expense of the leader’s unquestioned authority.
How can such a model of management enhance career stability for the ED Director? Won’t transforming your ED into a learning organization enable the hospital to get along without you? Well, yes, it certainly could. But, then you would have built the reputation of accomplishing such a transformation and it’s likely that other opportunities—even in the same organization would develop for you, for remember that security truly comes from the inside and is not given to you by anyone else.
Those of us with children know that the joy of the daily work of child rearing leads to the important accomplishment of sending forth an independent person into the world. A strong, Emergency Department and learning organization would be a marvelous legacy for any director to leave behind.
When you get right down to it, for career security and countering complacency as in all of life, “Even if you’re on the right track, you get run over if you stand still.” (Will Rogers)
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