The Fox and the Hedgehog
Issue: July/August 2019
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
How We Respond to Stressors
We all know that an emergency department is a stressful place to work. During any shift we can see, and personally experience, an array of responses to stress and challenges. Many emotional styles can be seen, and it is important to try and understand where these responses come from in order to accurately interpret what the individual is trying to accomplish. Responses to stress range from the valued team builder who creates a sense of accomplishment and value, to the angry provider who creates turmoil. We can become leaders and survivors, or the burned-out physicians who really need collegial help. All individuals come to the table with their own set of strengths and weaknesses. All of us must understand our individual abilities and challenges if we are to survive and prosper. Learning how others respond to the same stresses at the same time is just as critical for our success as mastering our own response. If we do not notice or appreciate the way others are dealing with the same challenges, we are setting ourselves and our department or group up for failure.
One way to categorize the way we think is to divide people into foxes and hedgehogs. Originating with the ancient Greek poet Archilochus, this idea has been discussed by many authors, including most famously by the philosopher Isiah Berlin in the 1950’s.
Hedgehogs know just one technique for survival: curling into a ball when threatened, with spines directed outwards. Foxes use many tricks to survive. The hedgehog way of thinking tries to make all problems conform to one overarching guiding principle. This thinking is usually much more direct and single minded and can appear to be dogmatic or uncompromising. The hedgehog, however, can be inspirational and lead a department to success by his overriding belief in one big thing, which at times is exactly what is needed to steady a sinking ship. Rallying around the flag may be just the thing a department needs in times of crisis. Do you recognize any hedgehogs in your life? In the emergency department, you can identify those people who seem to emphasize one formula or “best practice.” This is the consultant who is brought in to fix things by teaching you the importance of patient satisfaction scores, flow models, or whatever else their perceived magic bullet is. They are stubborn and seek conformity to their model of success, and to many seem overconfident in their idea. If you think like a fox then this approach can seem dogmatic, and many foxes will try and undermine the director, administrator, or consultant who is trying to convince you that this “one big thing” will right the listing ship.
The fox faces each day as a new challenge and tries to plug whichever hole is letting water in the ship that day. The fox may seem distracted, but is often trying to figure out a plan or tactic that will work today. They don’t have one formula but see the world as a complex mess that needs different responses on different days. That may mean anything from setting yourself up for a procedure because the tech called in sick, to seeing patients in the triage room to get things going, as there is no physical space to see a new patient anywhere else. The hedgehog sees only the forest while the fox sees only the trees. Do you have foxes in your emergency department? These individuals can appear to be scatter-brained and unfocused, because they are not concentrating on what you think is important. Maybe they are calling the lab to see if there is something going on with the chemistry machine that day, instead of monitoring the average turn-around time for chemistry over the last year. It is a different way of thinking. Obviously, both can be very useful on a particular day with a particular problem.
Which One Are You?
So which one are you, or do you think you are a hybrid? Which do you think would work better in your emergency department and what style does your director or administrator fit into? Some situations definitely call for a firm hand, directing people down a definite path.
Other situations call for a more adaptive and improvisational approach. What is important is that we recognize how we are thinking and how the people around us are thinking, and how those may be at odds. These different styles lead to conflicts, and not just in the emergency department. During a conflict we need to stop and think about why there is a problem. The key is to understand the other side’s method of dealing with problems.
Our answer to suggestions cannot be that our patients are “the worst,” so the consultant’s ideas will never work in our ED. Both being too rigid and too reliant on improvisation have pros and cons, but the interaction of people with different styles needs to be recognized and made productive.
Please think about these two worldviews, and consider how the other side is thinking before you act and respond.