Further Thoughts on Power

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Having begun the discussion on power last month, we move now to the types of power that emergency physicians actually possess, and how they can be utilized. The first is the power to reward. I urge you to use it early, often and with reckless abandon.

We have in our grasp the power to reward and the power to punish. What kind of leader will you be?


Having begun the discussion on power last month, we move now to the types of power that emergency physicians actually possess, and how they can be utilized. The first is the power to reward. I urge you to use it early, often and with reckless abandon. Passing out compliments, sending people notes, talking with administration when they do something right, is the best way to go. Can emergency physicians do better at this? Every single one of us. My suggestion is this: ten times as many compliments as criticisms. All criticisms in private, all compliments in public. The power to reward not only makes the individual feel better, but it also makes the patients feel better about the care that they are receiving. They like to hear compliments given to their nurse or tech by the physician. It helps to reassure them that the care is going in the right direction. Whenever an administrator has spent time and effort in getting something to the department, make sure it’s recognized and celebrated. At this point, emergency medicine only needs friends, no enemies.

Secondly, we do own the power to punish. Can you make a coworker or subordinate feel badly? Of course. It takes no managerial skill to utilize the power to punish. But this command and control strategy really went out with red meat. There is no good basis to think that public flogging and humiliating of coworkers does anything to increase their sense of loyalty or their desire to take good care of patients. Is there a need to occasionally use the power to punish? Absolutely. But it is the sword which you can carry and only rarely pull out of the sheath. Every human being is a “one” and they always watch how you handle another “one.” What you could do to someone else, you can do to them. Think about it. Would you rather them watch you compliment people or cut off their heads. This is a power technique which the skillful emergency physician learns early on how to use.

Next we have the power of authority. Although the age of absolute hierarchy is over (“Me doctor, you banana boo”), there is no question that people still look up to doctors. In all of the national surveys, if at the lower end of the admiration scale are used car salesmen and members of the House of Representatives, the upper end of the scale still includes Supreme Court judges and physicians. Never, ever hesitate to utilize such power in a beneficent, clearly visible way. Being Doctor so-and-so counts with both the patients and administrative authorities. This lapses over into the power of expertise. You can, and they can’t; this is a medical strong point. There is a reason that they bring their children to you. They take their wills and estates to their lawyers, they take their cash to their bankers, but their children – the thing most valuable to them – they bring to you. No matter what type of payment system we have, those who have expertise will still be put in a position to make decisions about patients’ lives. This power is the strength of science and the profession and should always be wielded in an skillful, beneficent manner.


Lastly is the power of reference. All control is an illusion. The only control you possibly have is when you get people to control themselves. Reference to such institutions as major specialty organizations (like ACEP) or state organizations (such as the state medical society) or regulatory agencies like the Joint Commission, put you on the side of the angels. Communication is still the most important source of power, so take the time and effort to explain to people why the major agencies in charge of health care are in line with your thinking and treatment plan. It’s not just Doctor X who is requiring something to be done, it is the whole of medicine which is now shifting and moving. Use of this power of reference is essential in making those who are somewhat difficult to move along come in your direction.

Followers make leaders; leaders don’t make followers. What you do in a leadership role in exercising power is to take those basically good and willing impulses in people and focus them towards an actual outcome. I have never spoken with a person who wanted to do a bad job. Some say that 85% of all problems are due to the system, not the individual. So when you see the system interfering, free the individual to act. The last thing you want is a robot, someone who does exactly what you tell them to do. Those are the people who aren’t doing the things which the common person of good heart would see and do naturally. You need to have a reasonable expectation of acting in defense and in protection of the patient. Celebrate that independence. Do not put those you lead into such a lock step situation where they cannot make reasonable decisions driven by humanitarian interests and the best traditions of medicine.


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