The Leadership Role of Emergency Directors

I remember day one of internship as if it was yesterday. There I was, proud but apprehensive. Only slightly more comfortable in my new clothes than my new role. There were more firsts to come. First day as a trainee, first night in-charge of ED, and eventually my first shift as a consultant. Each step-up involved a leap of faith. Increasing responsibility came with a subtle shift of identity.

I was appointed Director of Emergency Medicine at Hornsby Ku-ring-gai Hospital, on the northern perimeter of Sydney, in 2015. I had applied because I was curious. I have a longstanding, deep interest in people and systems – I’m the sort of person who reads health policy for fun. I also love writing and speaking. The job seemed like a good fit. An adventure and a challenge.

When I started as Director, I had a baby and a two year-old. I had been a FACEM for nearly four years.

‘Do you really think I’m grown up enough?’ I remember asking anyone who would listen. Bemused expressions revealed that becoming a Director didn’t appeal to everyone. ‘Are you really sure you want to do it?’ my colleagues asked back.

Nothing prepared me for the enormity of this first day. After a career of shared lockers, I suddenly had my own office. The sign on the door said ‘Director’. There was no shying away – I was Impostor-in-Chief. I spent the day rearranging the furniture, hoping no-one would notice how ill-equipped I was for the job.

I asked other Directors for advice. ‘Don’t go looking for work’, I was told. ‘It will come looking for you.’ That proved true very quickly. ‘Always know where your next holiday is coming from’ another Director suggested. I’m still working on that, five years later.

One of the best things about Emergency Medicine is visibility. Taxi drivers and dinner party guests know what we do. We’re television stars – romantic leads in hospital dramas and regular interviewees on the nightly news. We interact with everyone and anyone. Yet the ED Director role is cloaked in mystery.

A slice of the Director job translates directly from any modern managerial position description. There are obvious tasks, like writing rosters and coordinating recruitment. Working through incidents and complaints. Reviewing documents, signing forms and attending countless meetings. 

Despite a steep learning curve, I found these managerial responsibilities relatively easy to grasp. There were courses to do, modules to complete and helpful people willing to answer questions along the way.

But then there was leadership. 

What does leadership really mean? What training is required? There was far less to guide me with this crucial aspect of the Director role.

The internet overflows with leadership advice. Expensive courses with catchy-names and subscriber-only newsfeeds. As an emergency doctor, up to my ears in real-life, none of these really clicked. 

When I reflected on my own experiences of being led, I quickly discovered that it’s complicated.

A thank-you note after a busy shift. Feels great when you have a connection with the boss but comes across as a cynical exercise if the delivery is less than perfect. Honest feedback is cherished from someone you respect but can easily cross the line when a working relationship is uncomfortable. Personal questions are welcome from some people but intrusive or inappropriate from others. Favouritism never feels good, even when unfairness is more perception than reality.

What should happen when things go wrong? I remember times when I was grateful that the boss fixed it on my behalf, but on other occasions I wanted an opportunity to tell my side of the story. 

I had more questions than answers.

To what extent should I feel responsible for the actions of others? I have only limited influence over who is on the team, and emergency clinicians tend to have strong personalities and even stronger opinions. Is it possible to be both liked and respected? And still get the job done?

How much of myself should I give? Had I forsaken my right to complain about the everyday frustrations of life in ED? Should I own up to hiccups in my personal life or periods of low motivation? Would sharing my true feelings impact negatively on the team? How would I look after my own wellbeing?

There was a lot to learn.

The first step was a deep reckoning with myself. My biases, motivations and fears. My perceptions and projections. Personality traits likely to rub people the wrong way. My values and my needs. 

I’m physiologically incapable of pretence, so the only real option was to be myself. A human being – replete with flaws. 

I decided to always be honest. Open about things I could and could not achieve – personally and professionally. This requires humility. Willingness to listen to others and change my mind. Courage to own up to mistakes. Vulnerability to show how much I care. Integrity – always.

I fell into a strategy I describe as ‘emotionally engaged leadership’. 

Lots of effort goes into getting to know my colleagues personally, so I can be flexible in my interactions with them, based on their individual preferences and style. I aim to channel positive emotion, motivating the team through praise and encouragement. I try to validate the impacts of negative emotion, by allowing time and space for processing, recovery and re-connection.

I soon learned to trust my instincts. I’m guided by my values and feelings, testing each decision with the question ‘will I be able to sleep tonight?’ And I try to always treat others as I would like to be treated myself. 

So – as Director, what do I actually do?

I look after people. It’s my job to know the strengths of each clinician and help them perform at their best by assigning them tasks that match their aptitude and interests. To link them with opportunities for professional development. To make sure they stay home when they are sick, take meal breaks, go on holidays and get paid properly.

Psychological safety is enormously important. Creating conditions in which people can talk about problems without fear of reprisal. Managing change with consideration and care. Making sure procedural fairness is observed – especially when things don’t go to plan. Striving to make the ED culturally safe – a truly diverse and inclusive space, for clinicians and patients. Promoting emotional safety through civility, kindness and respect – and by understanding the negative effects of shame. 

As Director, it is important to take on difficult conversations and handle them with care. The team needs to know that wrongs will be put right.

I connect with people. Seeing, talking and above all, listening. Nuanced communication is paramount. Primarily, I act as interpreter between ED and hospital management. I have become fluent in ‘exec-speak’ and know how to translate a request for clinical resources into strategic priorities and KPIs. I’m also the main point of contact between ED and other clinical services – an advocate and defender of our work. I aim to build relationships and ensure that communication is constructive – because teamwork is fundamental to improving patient care. 

I make decisions. Understanding data is very important – patient flow statistics, quality measures, clinical outcomes, staffing and the budget. I read widely about ED practice and stay up-to-date with policy and guidelines. I go looking for ideas and innovations. Ideally, all big decisions are collaborative and multidisciplinary. Close partnership with nursing leadership is vital.

I’m liberal with credit and congratulations when things go well. I hold myself accountable when they don’t.

I inspire people. It’s my job to create shared purpose and meaning – to encourage people to engage, do their best and want to come to work, even on the bad days. Our department has a strong sense of family – a culture of love and belonging. Doctors, nurses and other staff members work together. We know each other well, look out for each other and celebrate our successes. I make sure everyone knows that what we do is special. A little bit of magic goes a long way.

The most rewarding part of my job is helping people grow – especially junior medical officers and trainees. I love being able to use the skills, experience and network I have built as Director to help people take on new challenges. In return, colleagues at all career stages support, encourage and look after me too. Everyone benefits from mentoring.

My heart bursts with pride as I watch doctors from our department graduate as fellows at the college ceremony each year – one of my favourite moments.

Five years on and I do feel more grown-up. But deep down I’m still me. I have been able to do things my own way. I can honestly say that I love my job.

I feel privileged to lead a team of dedicated clinicians providing excellent care to our community. I have agency to make meaningful change, which has been enhanced by my increasing engagement with ACEM over the last few years. And I’m a much better clinician because of insights gained as Director too. 

There have been highs and lows, achievements and set-backs, moments of exhilaration and extreme vulnerability. Being an ED Director is challenging and rewarding. 

Guess what? It’s also really fun.

Dr Clare Skinner

Article originally published in Your ED Summer 2020, an ACEM publication.