Emergency Medicine Advocacy Handbook

Ch. 17. Leading Outside the Walls: Importance of Leadership Skills

Tuong Pham, MD; Thuy Nguyen, MD; Steven Nazario, MD

Chapter 17. Leading Outside the Walls: Importance of Leadership Skills

Recorded by Ryan Leone, MSc | Columbia University

From the earliest stages, our training in emergency medicine focuses on leadership in the emergency department. From making decisions alongside a multidisciplinary team regarding routine patient care to leading resuscitations at the head of the bed, these skills are developed and constantly fine-tuned throughout an EM residency. The same leadership abilities that help us navigate the intricacies of the ED can be transferred outside the walls of the department and allow EM physicians to participate and trailblaze in new arenas.

Health outcomes are the result of the complex interplay of socioeconomic status, health policy, and health care delivery systems – rather than solely the result of medical interventions.¹ To improve health outcomes on a broader scale, physicians should seek out and assume leadership roles within the health care system, academia, politics, and their community.

Learning to speak publicly and deliver information to a diverse crowd is a skillset most of us never received formal training on, but as the old adage goes, experience is the best teacher, and it is never too early to begin.

Why It Matters to EM and ME

There are numerous compelling reasons for EM physicians to lead outside of the ED. While the number of EDs in the US is dropping as hospitals close, the number of ED visits is rising even faster than the US population is growing.² Under Medicaid expansion and the Affordable Care Act (ACA), the number of ED visits continued to rise.^3,4 While COVID-19 may have temporarily decreased ED visits, it also degraded the ability of EDs to function smoothly, negatively impacting the well-being of emergency physicians and patients. Many of the advocacy issues highlighted throughout this book highlight the need for emergency physicians to choose leadership positions.

EM physicians are also uniquely qualified to lead in hospital and health system committees and administrations, as they interact extensively with each service in the hospital, providing a broad overview of the structure and function of the organization. Due to their position on the front lines of medical emergencies, EPs are sought after to provide expertise during bio-terrorism, natural disaster, trauma, and crisis events. These opportunities for leadership should be seized so that we can best advocate for our patients and profession beyond the bedside.

How We Got to This Point

In the current context, it is difficult to believe that most hospitals did not have anything akin to what we now recognize as an emergency department. The “emergency room” was often a place for patients to meet their primary care doctor when the patient needed urgent treatment necessitating admission to the hospital. EM has grown substantially over the past 60 years. Born out of the need for emergency care and emergency-specific training, we have established EM as a specialty with specialized residency training and established an official pathway to board certification through the American Board of Emergency Medicine (ABEM).

We’ve also established numerous organizations, including the American College of Emergency Physicians (ACEP) and other professional organizations such as the American College of Osteopathic Emergency Medicine (ACOEP), the Emergency Medicine Residents’ Association (EMRA), the Society for Academic Emergency Medicine (SAEM), the American Academy of Emergency Medicine (AAEM), and Council of Residency Directors in Emergency Medicine (CORD-EM) to represent and advance our specialty. The success of establishing EM as a specialty was achieved because of the initiative and leadership of like-minded individuals across the country who advocated for standardized care for patients with acute, unscheduled medical needs.

American Medical Association (AMA) guidelines call for physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human wellbeing.”⁵ It is essential that physicians engage in leadership at all levels to effect change in health care for a larger population than they can personally treat.

Current State of the Issue

Our emergency department patients frequently come to us with illnesses and injuries that demand a broader solution than just treating an individual patient at the bedside. Organized EM leads the way on issues affecting our patients like gun violence, opioid use disorder and motor vehicle safety, leading to improvements to protect society outside of the hospital walls.

Moving Forward

While these huge societal issues may feel daunting, there are many opportunities to be part of the solution to better support our specialty and improve health outcomes for the broader population.

Medical Education

Leadership can begin at any level, and there are many opportunities to get involved as early as medical school. In particular, Emergency Medicine Interest Groups provide programming that is designed to increase exposure to EM while in medical school, as well as address vital questions for those who are considering EM for their next step of training. Beyond leadership opportunities within these interest groups, they are also an excellent way to become involved with state chapters of ACEP and expand one’s network.

Peer-to-peer teaching from senior residents to junior residents is another way to be involved in education. Becoming a chief resident provides an excellent opportunity to teach and make changes to the curriculum. Many physicians eventually pursue a medical education fellowship to prepare for roles in directorship and professorship.

EM Professional Organizations and Hospital Leadership

To start, learn about the governance structure of the hospital or organization where you hope to pursue leadership opportunities. Familiarizing oneself with the process of leadership appointment or election and having meaningful conversations with current leaders can be informative.⁶ In emergency medicine, multiple organizations offer a plethora of leadership opportunities at state, regional, and national levels - including an initiative to ensure ACEP state chapters offer a resident position in their leadership structure. (Find that state leadership pipeline through www.emra.org.)

Most hospital and medical school committees actively seek participation from students and residents. This is a great way to observe how meetings are conducted and how agendas developed and followed, in addition to being an opportunity to develop relationships with people who may then serve as mentors. Committee work often leads to getting asked to take on special projects or prop up lagging ones.

Public Health/Health Policy Advocacy

Advocacy starts at many levels. At the individual level, physicians should advocate for each patient when needed. This may include things like arranging appropriate outpatient follow up with specialists for patients without insurance or encouraging harm reduction education for patients and staff to better care for patients with substance use disorder or homelessness. At the institutional or corporate level, physicians can lead the effort to address boarding/overcrowding issues, or work to understand the causes of high utilization in certain populations. There are many organizations for medical trainees at different levels to engage in advocacy at the local and national scale, including ACEP, NEMPAC, AMA, state medical societies, AAEM, and more. Emergency medicine trainees can learn the basics of health policy and advocacy by joining EMRA Health Care Policy committees and attending the annual ACEP Leadership and Advocacy Conference in Washington, D.C.

Recently, EMRA adopted the Mental Health and Emergency Medicine Providers policy, which was proposed and written by both medical student and resident members of EMRA. The policy aims to set the standards and goals for mental health support for emergency medicine residency programs.⁷ At a federal level, Congress passed the Dr. Lorna Breen Health Care Provider Protection Act in 2021 in an effort to support physician mental health after years of collaborative efforts on the subject. A recent ACEP Now article chronicles the journey of the bill, involving that extensive work by a large number of physicians, and sheds light on the opportunities for physicians at different training levels to participate in future health care policy efforts.⁸ Getting involved in advocacy work can help physician trainees learn about critical legislative issues and prime them for future advocacy roles. Two current examples are Dr. Amish Shah, an EM physician and State Representative in Arizona, who recently detailed his journey and experience during a webinar hosted by the EMRA Health Policy Committee⁹ and Dr. Arvind Venkat, a recent member of the ACEP Board of Directors who is now serving as a State Representative in Pennsylvania.¹⁰

Community Leadership

In addition to the national organizations, there are state and regional versions with similar needs and agendas. These are fertile ground for younger professionals eager to get busy working on solutions for all manner of thorny societal concerns.

Apart from EM-specific organizations, local newspapers, media outlets, and social media often seek representatives to lend their voices and perspectives regarding current events – particularly those related to public health. When hurricanes or other natural disasters strike, news outlets come looking for EM clinicians who can provide advice and recommendations for the general public. As our recent pandemic experiences have taught us, much of the public is hungry for expert advice, and EPs are well-suited to providing just that. Learning to speak publicly and deliver information to a diverse crowd is a skillset most of us never received formal training on, but as the old adage goes, experience is the best teacher, and it is never too early to begin.

• Seek opportunities to volunteer in one of our many EM interest groups.
• Attend a regional or national meeting.
• Join a hospital committee and become an active participant.
• Listen to podcasts or read books on the topic of leadership.
• Take advantage of opportunities such as the EMRA/ACEP Leadership Academy and the EMRA Health Policy Academy to learn about leadership and the health care system.
• Consider asynchronous, online education for additional training, including degrees such as Master’s in Business Administration and Master’s in Public Health.
• All emergency physicians benefit when leaders throughout our health systems, in our legislatures and in the media are emergency physicians.
• Leadership doesn’t have to be “big L” leadership – you can start by taking part in a committee in your hospital, state/national medical organizations or local news appearances – seize opportunities that become available.

References

1. Luft LM. The essential role of physicians as advocates: how and why we pass it on. Can Med Educ J. 2017;8(3):e109-e116. 
2. Sun R, Karaca Z, Wong HS. Trends in Hospital Emergency Department Visits by Age and Payer, 2006-2015. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb. Statistical Brief #238. 2018.
3. Klein EY, Levin S, Toerper MF, Makowsky MD, Xu T, Cole G, Kelen GD. The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments. Ann Emerg Med. 2017;70(5): e607-e614. 
4. Nikpay S, Freedman S, Levy H, Buchmueller T. Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases. Ann Emerg Med. 2017;70(2):215-225.e6. 
5. American Medical Association. AMA Declaration of Professional Responsibility. 
6. Emergency Physicians in Hospital Leadership an Information Paper. 2002. Accessed May 01, 2022.
7. EMRA Policy Compendium. Section IV: XVI - Mental Health and Emergency Medicine. Updated April 2021. 
8. Grantham J, McBride R. After Two Years of Tireless Advocacy, The Dr. Lorna Breen Bill Is Signed Into Law. ACEP Now. 2022. Accessed May 20 ,2022.
9. Health Policy Leaders in Emergency Medicine Spotlight Series: Arizona State Representative Dr. Amish Shah. Dec. 20, 2022.
10. Pennsylvania House. Rep. Arvind Venkat’s Biography. Accessed April 7, 2023.