How to Avoid Being a “Horrible Boss”

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Being an ED chairman requires a skill set that you may never appreciate until you step into the role. Clinically, there are few surprises; it’s the little things that make being the boss a unique challenge, like dealing with a troubled provider, learning how leaders get treated differently, and feeling the responsible of running a 24/7 business. I’ve surveyed experienced colleagues – and done a little soul searching – to come up with these seven key challenges to being the boss of the ED.

Hiring Really Matters. A Lot.


As a resident undergoing my third phone interview for a local job, I was bewildered as to why the chairman wouldn’t invite me for a tour and formal interview. After my on-site interview, I finally asked him about his hiring process. He told me that the number one priority for him was hiring the right people and he was committed to an extensive (perhaps even exhaustive) interviewing process. He did this to avoid trouble down the line and told me I would understand when I was a chairman. I now completely understand his philosophy. Staffing makes all the difference for my job. While a bad staff creates problems for me, a good staff solves problems and keeps my cell phone silent. Even with a great staff – and I’ve been thrilled with mine over the years – be prepared to spend a surprising amount of time counseling, mentoring, evaluating/grading, interviewing, firing, hiring, and trouble shooting.

You’re No Longer One of the Guys (or Gals)

As a staff physician, you had the inside scoop on everything in the department, from funny email forwards to gossip about who wanted to quit. Let’s face it: as “The Boss,” that will necessarily change. Don’t be alarmed if a conversation dies when you walk in the room; it comes with the territory. While you can still be friends with your colleagues, you’ll just need to follow a few simple rules of fairness and sensitivity. You can socialize with staffers, but you’re never truly off the clock, and your behavior at a party will always reflect your leadership. One rule of thumb: drink less, leave earlier than the others.


On the upside, in my experience, your status will likely get you less push back from hospitalists and a more motivated nursing staff when you’re on duty.

We’re Guests of the Hospital

There’s a lot of politics in contract management and emergency physicians are not the docs bringing in the big bucks for the hospital. Therefore, screaming about issues or verbally assaulting the hospital president in the parking lot about bad bed flow doesn’t usually help our cause. We can accomplish a lot more by gentle and persistent influencing or lobbying. Remember that not all executives are created equal, and that it behooves emergency medicine leadership to develop a political approach that is appropriate for a guest who wants to be invited back to dinner. Additionally, remember that all politics are local; just because you got along great at one hospital with the cardiologists doesn’t mean that at your next hospital they’ll be your allies.

You Can’t Avoid the Paperwork


The chairman is responsible for the department’s paperwork. This may be the semi-annual OPPE forms or it may be your group of doc’s credentialing packets, HIPPA compliance training documentation, or even insurance forms. There’s a never ending stack of papers on my desk or in my email inbox that require something, and tracking a provider down a day before their re-credentialing packet is due (or they’ll be off the schedule and they’re your holiday night shift doc) sometimes gets frustrating. I’m told that the most effective medical directors get their docs to complete mandatory tasks before the deadlines and that this is probably a result of a combination of organization, efficiency, and respect of the group towards the medical director.

There actually is a Budget

Before I was the boss, it seemed so easy to just give a $5/hour raise or add a little coverage to help out the increasingly busy evening shift. But now I know that adding 3 hours of daily coverage at $150/hour equates to $164K annually, which may have just eliminated the profit. We need to work to understand the finances and to maximize productivity. Most medical directors spend a great deal of time planning budget requests built on sound business logic.

It’s a 24/7 Job

Part of the reason I went into emergency medicine was the shift work. Playing golf on a Tuesday morning was great, as was having beers with breakfast after a night shift, or Christmas shopping on a Thursday. Medical directors get caught between this world, the one where the next disaster could occur at 10 PM on a Friday night, and a typical corporate schedule, which has daytime meetings. When the hospital president wants to meet at 7:30 am to discuss an issue, they won’t care that you aren’t working clinically that day until 3 pm and had planned on having a personal life that morning. I knew I would have to give up much of my free time when I wasn’t working clinically but I didn’t anticipate the difficulty in balancing a part time administrative schedule that has a full time expectation.

Perception is Everything

Despite it being a 24/7 job, most ED directors spend a lot of time managing the hospital administration’s perception that we’re never working. They don’t see us on nights, weekends, and holidays. When we don’t answer our office phone at 8 AM, they don’t know that we worked until 2 AM the evening before. Administrators don’t live in a shift work world and other hospital department chairmen typically work when administrators
do. Therefore, success in their eyes is measured in more than just actual results and we
always need to fight to show that we’re active and engaged.

A Worthy Calling, In Spite of the Challenges

With all these inherent challenges, why bother going down the leadership road? The reason my colleagues and I continue in our paths is the opportunity to take on new challenges and  improve care on a broader level than one patient at a time. Between bundled payments, new core measures, and electronic documentation, there are some very exciting challenges coming our way that will require dedicated and energetic leadership.

Michael Silverman, MD, is a member of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.


EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Director of the Alteon-Mid Atlantic Leadership Academy. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

1 Comment

  1. How would you address issues to get the best result for your department? What advice do you have for navigating the politics of the hospital to get concerns addressed? Would you have particular insights for clearing up misunderstandings or addressing perceived injustice?

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