Relax into the tension: Paradoxes experienced by emerging leaders in emergency medicine (2023)

‘We need to intubate!’ Sarah, an ED registrar in charge, briefs her team. Under her leadership, the skilful team successfully manages the complicated patient. She calls multiple teams to expedite treatment, but they request more investigations. The patient spends hours in ED awaiting reviews. The next day, Sarah receives a complaint saying, ‘ED did not manage the patient adequately’. Clinical leaders in ED face increasingly complex value-related conflicts and organisational-imposed constraints in their work.1 As portrayed in the vignette above, Sarah followed protocol, provided excellent care, pushed for expedition, yet still received a complaint of inadequacy. Therein lies a common paradox of EM leadership. The organisational paradox literature presents four categories of paradoxes.2 These are learning, belonging, organising and performing, all of which reflect the core activities of organisations. Learning paradoxes arise when existing knowledge and practices are challenged by emerging knowledge and innovation. Belonging paradoxes are based on tensions of identity between various members of an organisation who are trying to establish homogeneity yet be distinct. Organising paradoxes arise as organisations become more complex and introduce competing processes needed to achieve a desired outcome. Paradoxes of performing result from different internal and external stakeholders trying to deliver their own conflicting strategies. The idea that ED is rife with paradoxes has been entertained previously, such as the notion that we are experts at waiting room medicine, or what Wears and Cook3 refer to as ‘getting better at being worse’. Even the concept of patient flow is a paradox, where differing perspectives and priorities breed perennial conflict.4 Little wonder that trainees, as leaders-in-training, are left puzzled, frustrated or worse, jaded, by the ideals of ‘leadership’ and how discrepant this is from their present reality of teeth-grinding, back-against-the-wall work.5 Furthermore, repeatedly encountering these professional challenges makes it nearly impossible to fulfil moral obligations to patients and colleagues.6 In other words, leaders who aspire to uphold their principles may be broken by daily experiences of injustice and suffering, as Sarah experienced in the vignette. The resulting moral distress may bring about cynicism and apathy; an uncomfortable cognitive dissonance7 is formed when, as a leader, you know the morally right thing to do but you are constrained from doing it. The dissonance resulting from acting against one's core values makes it hard for anyone, especially those with less experience, to remain resilient. How might Sarah feel, and how should she respond? The paradox perspective introduces the concept that organisational tensions do not necessarily require immediate resolution (let us fix it), or resignation (let us give up), but a middle-ground approach where competing demands can be managed simultaneously (let us live with it).2 Smith and Lewis2 assert that, ‘the role of leadership is to support opposing forces and harness the constant tension between them, enabling the system to not only survive but continuously improve’ (p. 386). Living with a paradox (or supporting others to) can come in the form of acceptance – viewing tensions as opportunities for creativity and learning. Acceptance facilitates what the authors call ‘paradoxical thinking’. Instead of seeing tensions as dilemmas, paradoxical thinking encourages leaders to consider ‘both/and’ possibilities that embrace existing paradoxes. We have thus far focused on the negative aspects of organisational paradoxes in ED. In the next section, we flip the framing to present paradoxes in the form of recommendations that trainees – as emerging leaders – can utilise as they work on accepting, living with and engaging in paradoxical thinking. Increasing system and patient complexity, coupled with technological advances and the introduction of automation and artificial intelligence into EM, will create a demand for higher expectations of knowledge. As a result, exponentially more data will be readily available. Having more data may not necessarily translate to better care, but it could make ED even more confusing, potentially driving over-testing to reduce risk (see Paradox 2), while challenging existing dogma in practice. In balancing tensions, trainees need to ensure their focus remains squarely on patient care instead of caring about data,8 while being cognisant of the challenges in quantifying quality and the pressure to equate quality with quantity. In ED, we not only lack a defined patient population (i.e. no ‘gates’) but also have little control or power over our workflow.4 Hence, ED leaders must accommodate risk constantly, yet find it demoralising when other teams do not share risk,1 downplaying (e.g. ‘just discharge the patient’) or diverting responsibility (e.g. ‘doesn't sound like my problem’). Let us stop expecting the rest of the healthcare system to embrace the same degree of risk that we face: this is ours to bear. Our identity lies in being confidently uncertain yet enigmatically pragmatic.5 In looking after our patients, we have been overlooked. The mass exodus of emergency nurses9 is evidence we have not looked after our clinical staff during the COVID-19 pandemic. Well-being is good for work, but it does not make people well while engaging in work. The latter requires organisations to be grounded in managing what is nourishing for its workers, such as psychological safety and workplace inclusion, instead of working them to the ground. As leaders, we must step up where systems fail – putting staff well-being ahead of service provision. ED doctors embrace ‘MacGyver’ solutions, and yet we have not managed to solve the leadership paradoxes we face. Unfortunately, solutions in the form of black-and-white, top-down approaches, such as time-based targets, often are not sustainable, and can be fortuitously gamed.10 Alternatively, normalising deviance, such as celebrating waiting room medicine,3 or accepting external solutions not tailored to the ED context, such as in ultrasound infection control, causes more problems than it aims to solve. This level of forced resolution is untenable and will eventually – if not already – result in patients bearing the consequences. Instead, strategies such as accepting complexity, being open to alternate perspectives, and juggling confidence and humility may provide opportunities for leadership development amidst tribulation and conflict. In this article, we highlight the myriad of tensions and paradoxes that emerging ED leaders are expected to confront. We suggest that living with paradox entails, among others, the judicious use of data, expert mitigation of risk, diligent prioritisation of ourselves and harnessing complexity. It is our hope that trainees and clinicians may learn to rise above these traditionally frustrating paradoxes and lead well in EM. LYW is the recipient of a Swinburne University Postgraduate Research Award (SUPRA) scholarship, jointly funded by Swinburne University of Technology and ACEM. Open access publishing facilitated by Swinburne University of Technology, as part of the Wiley - Swinburne University of Technology agreement via the Council of Australian University Librarians. None declared. Data sharing is not applicable to this article as no data sets were generated or analysed during the current study.