Saturday, December 14, 2002

Living in the Fishbowl When “Experts” Throw Stones.

I’ve just returned from the ACEP annual meeting, the largest ever with a turnout of nearly 4000 emergency physicians and others. I learned lots there and also had a bit of a pre-JCAHO mental break. I heard a lot of discussion about “fairness for emergency physicians” and even participated in a lunchtime panel that considered the topic. However, while pulling my thoughts together for this month’s column, my focus was overtaken by events both in my own ED and in an exchange on emed-l, the emergency physician mailing list (subscribe using the ED Subscriber at the National Center for Emergency Medicine Informatics). So my thoughts on “fairness” will wait for next month.

Without belaboring the subject, at our hospital the discussion revolved around the management of a difficult airway. On emed-l the discussion recounted the challenge confronted by an emergency physician in managing a patient in active DTs ultimately with the use of propofol, a therapeutic decision that was castigated by the intensivist who admitted the patient. In both instances the emergency physician—in the fishbowl—was criticized for decision-making on the spot, which was associated with if not directly correlated to the patient’s salutary outcome. The public discussion on emed-l was particularly revealing because the widespread participation of emergency physicians confirmed for me that the phenomenon we were experiencing locally—was in truth universal.

The long thread of the discussion included recounting of experience and interpretation of scientific literature. I was reminded of how far we’ve come from treating patients in delirium tremens with paraldehyde (ask a long-toothed, gray-beard in your own institution). The comment that most resonated for me as a leader whose task these days is increasingly focused on developing other leaders, came from James Li, an assistant professor in emergency medicine at Harvard. What follows are his words.

“To echo the support many others have already given you, choosing propofol was warranted, given the course you outlined. More than that, the choice to use it indicates a thoughtful process of adaptability to failing therapy, where others might remain sighted only to traditional ways. Understand that a sign of superb training is a program's ability to evolve with state-of-the-art techniques. We didn't have the benefit of propofol (or RSI [rapid sequence intubation]) when I trained, and I recall first learning of its use in withdrawal therapy for heroin through an article I read several years after residency the same week I saw it used on ‘e.r.’

Aside from the benefit that practice gives over simple book awareness of updated techniques, know that if you practice in any environment conducive to continued growth, you will never outrun expert critics. Many things you choose to do will be severely questioned, not the least the choices you make that are novel ones, whether based on good evidence or not. Thus the greater lesson here is not that the intensivist was wrong (or simply overly rigid in his views), but that you must deal with him on a level showing some kind of professional maturity. This takes guts (to remain calm while undergoing criticism from someone possessing expert credentials), great communication skills (to be able to succinctly summarize, often while on your feet and in the middle of active management issues, the reasons why you choose to do what you do), intelligence (so you are actually making the right choices and have thought through the criticisms beforehand), and a solid psyche (so you are able to see even the harshest criticism in a professional light, and don't get sucked into personal affronts).

As a resident, it is often difficult to communicate on a collegiate level with attending-level experts when questioned about one's actions. There is a power play innate in these interactions that is never easy to ignore. So I'll just say this. We look for a quality in the residents we train that combines humility, competence, and fearlessness. These are the residents we send into the surgical M&Ms to defend the thoracotomy or facial trauma airway scenarios they faced in the ER. Where emotions run high, they are able to calmly defend their actions on a professional level (and one open to constructive criticism) that tempers the power plays and educates us all. In the great programs, the emergency attendings do the same for their own cases, to show you how it's done.”

Doctor Li reminds those of us who would be leaders that whether it is our residents, our colleagues or ourselves, equanimity in the face of our critics and our patients’ neediest moments best serves all: patients, profession, specialty and our leadership.

Also mentioned in the course of the discussion on emed-l was Teddy Roosevelt’s famous quote, “It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

While stirring, the focus of this quote is on the accomplishments of the “doer.” As physicians, our focus must be upon our patients. Thus, while I strongly endorse Dr. Li’s statement, I also teach that our role as a leader is to serve our patients, hospital, communities and staff—striving for the Pareto optimum among these competing goods. Our normal role is that of servant leaders. On a daily basis and as professionals, we can be quietly confident in our competencies. However, when challenged for acting in a crisis, where others might not, we must also be able to rise to the occasion, combining our humility and competence with fearlessness, in our service to our patients.

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