Managing the function of the emergency department: Is it time to define what we do and how to teach it?

EDs have unique characteristics when compared with most clinical settings. They quickly change from a state of functional resonance, where each patient is being handled in an orderly and efficient fashion, to chaos, with lots of activity but little being accomplished. The emergency physician (EP) in charge manages its function and tries to keep the department in control, or at least mitigates the effects of chaos. This might be likened to the skipper of a large ocean-racing yacht entering a storm, or an executive chef preparing dinner service for the unexpected arrival of a head of state. However, although EDs do have the unexpected storm (multi-casualty disasters), they are usually teetering between order and chaos on an hourly basis. Leadership skills are an essential part of specialty training across many medical disciplines. Recently, there has been an increase in the literature describing leadership and teamwork training in simulated environments, formal courses or workshops in management, and formal bedside trainee supervision programmes for improving clinical skills. These often involve skills in a particular clinical scenario, or generic managerial theory. In EDs, leadership training is often restricted to trainees practising to lead resuscitation teams, either by clinical supervision or simulation courses. Although the emergency medicine curriculum advises that trainees should ‘assume progressive responsibility for . emergency department management’, there is little evidence on the specific content of this statement, or how this progression should occur. Running an ED involves far more than leadership training applied to a particular context, or expert clinical skills, or running a clinical team. It involves operational management, systems knowledge and manipulation, diverse communication and diplomacy skills, ability to source information quickly, multitasking, and being able to deal with interruptions, all within a dynamic and highstakes environment. The EP in charge is required to: address changes in prioritisation and allocation of resources with short notice and wild fluctuations; have situational awareness to ensure a safe environment and efficient flow for all the patients within; constantly monitor for and resolve conflicts and deal with stress among staff, patients and relatives; and supervise other staff while providing high-level clinical, professional, ethico-legal and decision-making advice. This is often while also taking direct responsibility for care of one’s own patients, performing procedural tasks, managing critical clinical cases, and communicating with external and internal personnel. The stakes are high, with a dysfunctional ED becoming potentially dangerous with increased patient mortality. Being able to perform in such a manner is traditionally learned by experience. In EDs, learning these skills is unplanned and initially by having the ‘doctor in charge’ role forced upon the trainee when there is no senior consultant available, usually on a night shift. Occasionally, assistance is provided by an experienced nurse manager rather than by EPs. Rarely, if ever, is there an explicit understanding of what capabilities are expected of the doctor in charge, formal training or assessment that ensures trainees (or consultants) can adequately perform this role. This results in a narrow perspective on leadership and how to manage the ED. In this issue, Craig and Dowling describe an innovative solution to improving the learning of ED management skills by having FACEM-supervised ‘Registrar in