Michael Abrashoff became the captain of one of the worst ships in the U.S. Navy in 1997. The ship, the USS Benfold, was dysfunctional and the crew was sullen. The ship’s retention rate was abysmal (less than 28%). Morale was so bad that the crew literally cheered when the previous captain left the ship.
But Capt. Abrashoff transformed it into one of the Navy’s highest performing ships, turning it into a well-oiled machine that reduced equipment failures by two-thirds. It also operated on only 75 percent of its budget, had a 100 percent retention rate, and spearheaded successful process improvements that were copied throughout the Navy. A year after Capt. Abrashoff took over, the USS Benfold won the Navy’s Spokane Trophy as the most combat-ready ship in the Pacific fleet.
I heard him speak last year, and it wasn’t Capt. Abrashoff’s successes as a new leader that stuck with me. When asked what his greatest failure was, he said he didn’t do enough to help other ship captains. In his single-minded pursuit to take ownership of the problems on “his ship,” he neglected to give support to or learn from the other captains around him.
The parallels to emergency medicine are striking.
We all can take ownership over the “ship” of our emergency department, but we really need to develop relationships outside of the ED. Those relationships often mean the difference between a great working environment where we can focus on caring for patients or a dysfunctional hospital where we are constantly frustrated by our efforts to improve.
Many residents and young attendings alike don’t take the time to understand their environment, focusing instead on more obvious factors such as location, salary, benefits, and shift map. But the relationship your ED shares with the other “ships” throughout the hospital is incredibly important to the smooth functioning of the ED and your happiness as a clinician. It can be difficult to discern during the interview whether the department maintains a good relationship with the other hospital departments or if, like is often the case in many residencies, there is a strained relationship that is impeding the ability to work.
The ED’s Relationship with Other Departments
When you interview for a job, it is crucially important to ask about the relationship between the ED and other departments. The most important department to have a good relationship with, by simple admission volume, is internal medicine. But, of course, no one is going to tell you that the relationship is terrible. Instead, they may say something like, “Well, I guess it’s better than you’re used to in residency.” But that is likely a low bar to clear.
Most of us understand it can be tough to get the rest of the hospital to pay attention to what’s going on in the ED. It is sometimes the out-of-sight, out-of-mind location that gets ignored. I remember it once took three days just to get an acutely psychotic patient admitted. It was strangely nice to have a little continuity of care for once, but let’s be honest, I wasn’t the best person to be providing that. He was there waiting through multiple shifts, and it was a massive victory when he finally got a bed upstairs.
A better answer to this question would be to hear about how the ED and internal medicine services have worked together to solve a problem, ideally a boarding problem. Look for evidence that the hospital values the admissions process and cares about whether there are reduced boarding times. We all know lower boarding times equal better patient satisfaction and better patient outcomes, but sometimes this fact doesn’t really sink in throughout the rest of the hospital.
Emergency Physicians as Leaders?
Another important question to ask during your interview is whether any emergency physicians are in hospital-wide leadership positions. I remember walking through one hospital hallway where the photos of all the previous chiefs of staff were hanging. They all came from surgery. That is a good sign for the department of surgery, but it’s certainly not a good one for emergency medicine. A much better sign to see is a healthy mixture of departments represented in the top hospital leadership positions. It’s a great sign if emergency physicians have risen to the medical executive committee, chief medical officer, or another comparable position.
Finally, be sure to ask whether hospital leadership ever visits the ED, and if so, how often. It would be impossible to conceive of a hospital C-suite that didn’t at least occasionally walk the floors of the hospital, but for all the attention paid to the upstairs floors, they rarely walk through the ED. It’s chaotic, it’s loud, and there are lots of people bustling around. It can be an uncomfortable environment for those who aren’t used to it, even hospital CEOs. But the best hospitals have leadership that physically comes down to the department. It’s a sign that the hospital leader understands that the ED is a huge component of the hospital’s bottom line and its relationship to the community as the hospital’s front door.
Editor’s note: this post first published on EM News.