Lessons Learned in a Term of Presidency of AAEM
Issue: March/April 2022
Author: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
Writing my last President’s Message is a bittersweet experience. As I approach the end of my term, I realize that being the President of AAEM was in many ways exactly what I expected and, in many ways, not at all what I expected. I expected to work long and hard. I did not expect to contend with the novel Coronavirus and the difficulties and contentions that it brought with it. I expected to learn and grow, but I did not expect to learn and grow to the extent that I did. As a high school senior, we were asked to write an essay on the five people we would want to invite to dinner if we could spend the evening with anyone, living or dead. I chose Mohandas Gandhi, Jesus Christ, Eva Peron, Mohammed Ali, and Albert Einstein. My style of leadership, inquiry, and decision making has at various times been reflective of all the five people I was fascinated with as a high school senior and remain fascinated by today. I have striven to meld the wisdom of Tim Grover’s “Relentless” (and yes, I am a cleaner) with that of Jim Collins’ “Good to Great,” and Fisher and Ury’s “Getting to Yes.” But like all people privileged with the task of leadership, I have learned my own lessons, discovered what works for me. When you become the president of an organization, you are suddenly besieged with requests to tell others “How did you get there?” and “what makes a good leader?” The truth is some of it is the same for every good leader, but some of it works for some and not others. I will share what I have learned.
The door can only be opened by someone who is already in the room. The goals and aspirations of both academic and community physicians focus on achieving roles and titles that are held almost exclusively by white males. Time and time again, networking and mentorship have been shown to be intrinsically valuable to both the achievement of these goals and the timing of their achievement. You can spend decades on the outside, pounding on and shouting through the door, or you can find (or be blessed with) an ally who understands his privilege, chooses to use it for the development of others, and simply turns the knob, opens the door, escorts you in, and gently guides you through the maze until you achieve your own leadership. In my career, that person has unequivocally been Dr. Peter DeBlieux. At AAEM, those people have been Drs. Mark Reiter, Kevin Rodgers, and David Farcy. In my JEDI work, that person has been Dr. Marcus Martin. If you are standing in the space of privilege, be that person. If you are standing outside the door, find that person. As people like Peter and Mark and Kevin and David and Marcus continue to do what they do, people who look like me are now in the room and at the table. Our job now is to be that person. None of our jobs are done until every person in the universe finds themselves in an environment that allows them to reach their full potential and give all they have to the world. And if you are on the outside of the door, never forget this: it is not a favor we give you by letting you in, it is an obligation we have to facilitate your gift and your obligation to the world, without which the world will be less.
The leadership should look like the membership. In 2003, with the publication of “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” the US Institute of Medicine officially acknowledged for the first time many of the facts that many of us have known all our lives, and one of these facts is that the composition of the physician team serving a community should look like that community. This makes for better outcomes for the community. Fortune 500 companies have quickly jumped on this train, recognizing the power of the BIPOC market as the population of Black and Brown people in the US steadily increases and as appreciation for the tremendous value of multi-culturalism becomes pretty much the norm. It is a source of great pride to me that my election to the Board seven years ago brought with it a trend of integration and multi-culturalism that has resulted in our current Board which is genuinely representative of the physicians practicing emergency medicine today, the trainees pursuing our specialty, and the patients who we serve. As part of my succession plan, I am working hard to ensure that the entire Board understands and appreciates the value that diversity brings to decision making and wise leadership. Studies show that the younger generation of physicians and residents consider diversity the acceptable norm. As government, public entities, private corporations, and educational institutions adopt policies that speak to their clear understanding of the value of diversity, and as governing bodies and judicial systems acknowledge that equity is the only way forward for a heterogeneous nation and a global society, organizations who maintain their status quo will quickly become irrelevant and be left behind.
It is essential to plan for succession and to prepare the next generation. AAEM has traditionally used the invitation-only Leadership Academy as a way of identifying and training the Academy’s future leaders. During my term, we have expanded Leadership Academy to include the AAEM/RSA Board as well as individuals identified by the Board and by Committee/Section/Chapter/IG Chairs. We have gone from an average of 25 members per Leadership Academy to 75. Akin to the concept of citizen soldiers, AAEM is fostering the concept of member leaders. If individuals seek to serve and are identified by their Chairs and Board as having leadership potential, we train you! Our training process has increased to a longitudinal program encompassing a year of touch back sessions addressing those issues identified by Academy trainees as essential for their growth and development as well as a paired mentorship for those desiring this. We have successfully developed a cohort of Board candidates and Committee/Section/Chapter/IG Co- and Vice Chairs from our Leadership Academy attendees. Dr. Farcy put a process into place limiting Chair terms and setting up a Vice Chair system whereby Vice Chairs are mentored towards Chairship. In doing so, he created more opportunities for leadership, especially for our early and mid-career members. Sections, such as Critical Care and Women, have developed formal mentorship programs, and others such as JEDI have deliberate and strategic informal mentorship programs. AAEM/RSA and YPS have always held Board seats, always for the purpose of apprenticing leaders, and these programs have resulted in the robust linear growth of members towards Chairships and service on the Board. I am delighted to see the increase in the number of individuals running for the Board, and they represent individuals who were part of Leadership Academy or a mentorship program of AAEM. Just as I believe the Universe suffers if every person does not develop their full potential, so I believe that the Academy suffers if every member does not develop their full potential within AAEM. One of the perks of professional success is being able to choose who to mentor. If you are a leader, seek out motivated, ambitious people who are willing to work hard and coach them for leadership. If you are early in your career and you are motivated, ambitious, and willing to work hard, identify yourself to us. As Congresswoman Shirley Chisholm used to say, “If no one gives you a seat at the table, bring a folding chair.” We need a succession plan to ensure that the Academy continues to thrive!
Put your money where your mouth is. Actions speak louder than words. AAEM has long been the proponent of workplace fairness, physician leadership of our practices and our health care teams, due process, the absence of restrictive covenants, and the right of every patient with an emergency condition to be treated by a board certified emergency physician. But the fact is that we have been both fiscally and practically conservative. We have tended to be parsimonious with our spending and overly concerned with not offending anyone. Taking risks can be scary, but if you don’t stand for something, you stand for nothing, and if you don’t ask, the answer will always be no. Over the past few years, we have taken increased well thought out risks. We have put out position statements that are real statements taking real positions. And we have caught flack. But as we grow, we are realizing that it is more important to be on the side of right than to be popular. Being the biggest does not make you the best. Accordingly, we have stood up for the rights of doctors to speak out against policies that endanger patients. We have stood up for science when others have tried to make vaccines and face masks a statement of political affiliation or an issue of personal rights. We have stood up for the rights of patients to know who is treating them and what that professional’s training, education, and licensure are. We have stood up for patients’ right to be cared for by a physician-led team. We have stood up for the human right to be free from the abuses of power and authority.
Most recently, and probably most impactfully, we have risked all to stand up for the right of physicians to be the sole practitioners of medicine and for the right of patients to be treated not according to the fiscally motivated protocols of corporate medical groups (CMGs), but according to evidence based protocols developed by residency trained, board certified physicians. AAEM is suing Envision for the illegal practice of medicine in the State of California. (For full details of our lawsuit see reference link.1 Note that the plaintiff of record in the case is AAEM-PG, but that AAEM is paying all of the costs related to the lawsuit.) On behalf of AAEM, I have approached ACEP, CORD, SAEM, and the California Medical Association (CMA) and have asked them to:
• File an amicus brief on our behalf
• Make a public statement that they are opposed to the corporate practice of medicine and believe that a lay corporation practicing medicine is illegal and unsafe for patients
• Give us money to support this lawsuit (the lawyers are charging us $2 million and they may charge more if the case goes to appeal)
• That they put a link on their website allowing their members to donate to the AAEM Foundation to support the lawsuit.
I am awaiting responses from ACEP, SAEM, and CORD. Our attorneys believe that ACEP may file an amicus brief on our behalf and this would be a wonderful accomplishment and an outstanding example of how it is possible to collaborate on areas of mutual interest with mutual respect, while still disagreeing on other issues. CMA has met with our attorneys and expressed the intent to file an amicus brief. By the time you read this, I will have set up meetings with other organizations impacted by the corporate practice of medicine, such as the AMA, anesthesia, critical care, trauma surgery, radiology, radiation oncology, and others. I am making them all aware that their responses to our asks will be made public. AAEM is putting our money where our mouth is and we are urging others to do so as well. President Abraham Lincoln said you can’t please all of the people all of the time. My dad used to say that if everyone likes you, you’ve never stood for anything worth standing for. So, AAEM is standing for integrity. We are doing not the popular thing, but the right thing. This is what integrity looks like. We cannot be bought. We cannot be silenced. We say we are the champion of the emergency physician. We must create the workplace environment where every emergency physician is empowered to give the best care to every patient every time. And we will.
Break down silos; provide resources. Every six months during my presidency, I have met with the leadership of every Committee, Section, Interest Group, and Chapter. I have challenged them each to have three projects that they work on for each six month period. I have learned that the talent within AAEM is astronomical—the willingness to work for the good of our specialty is unparalleled. The creativity is boundless. But I have also learned that often great minds do think alike, and more than one committee may work on the same thing. Through my meetings with all of them, I have been able to put them together to work on projects in which there are shared interests. Often, a committee wants to do something, but doesn’t know how. Another committee may have the expertise. Wellness wants to make a policy statement. CPC knows how, even though they lack expertise on wellness. Critical Care and Palliative Care have a shared interest in teaching community docs how to have end of life conversations with patients dying of COVID in the ED and their families. JEDI wanted to become a Section and Women in EM knew how to do this. A State Chapter wants to lobby regarding a particular issue and Government Affairs has experience with this. We are an organization of volunteers, and it is impossible for one member to know what each group is doing, but each group has a board liaison who knows what the group is doing, and the president has the responsibility to be aware of what all the groups are doing. I was empowered to put people together in a way that facilitates them doing the best work that they can do. I learned that while I don’t need to be an expert in every area of EM or about everything that AAEM is doing, a good leader knows what her people are doing and fosters the kind of collaboration that allows them to be the best that they can be and to accomplish all their goals. Getting to yes is where we need to be. I told many of the groups that for me “no” is never the answer. Rather, the answer is either “yes” or “how can we make this happen?” When you lead an organization like AAEM, you quickly realize that the Committees, Sections, Chapters, and IGs know what they need, understand what is going on in their locales and/or their content areas, and they know what they want to do. Collaboratively, we can find the resources that they need to make that happen.
Communication is key. This maxim holds true in every area of leadership. Good communication helps break down silos, create awareness of the work that groups are doing and the resources that the organization has, but it also creates an atmosphere of sharing of ideas that allows us to grow as individuals and as an organization. In our personal lives, we have friends who like the things we like, who share our opinions and our lifestyles. In an organization, it is important to hear all voices. We need to hear from those who disagree with us. Those who agree with us likely have reviewed the same literature as we have and have come to similar conclusions through a similar deductive process. Those who disagree with us have something to teach us. They have likely looked at other literature from other sources, listened to other speakers, had other lived experiences, and can broaden the way we evaluate an issue, often modifying the conclusions we come to and the actions we take. Being challenged can be threatening and stressful, but it allows us to grow, being better informed and stronger. Hearing all voices also supports our membership by creating an environment in which we all can feel validated and valued, allowing us to continue to give of our time and talents in a way that fosters the growth of the group and the growth of the individual. An important aspect of communication that I sometimes overlook is thanks and praise. I frequently reflect on how grateful I am for things that others have done for me, ideas they have shared with me, ways in which they have helped make AAEM successful. I think about it, and often even tell others how grateful I am for that person, but it is less often that I tell the person for whom I am grateful. My presidency has afforded me the opportunity to see firsthand the acts of quiet heroism and selflessness, the acts of generosity and compassion that our members give to one another, to the Academy and to the specialty. I have focused more on communicating my thanks and my praise to those who have been so good to me and to AAEM. I have reflected on how meaningful it is to me when my acts of courage or generosity or hard work are noticed, and I have learned to make it a point to thank and praise others. There is tremendous power in words. Many people have extolled the habit of ending the day by thinking of three things to be grateful for. I try to do this and to also think of three people for whom I was thankful that day—and to tell them so.
Surround yourself with experts, especially people who are experts in areas that you are not. Early in our careers, many of us make the mistake of assuming we are not ready to lead because we don’t know “everything.” History bears out that the best leaders are the ones who surround themselves with experts. Insecure leaders, believing that they should know it all, often develop a defensive posture that results in authoritarian leadership. Like the Red Queen in Wonderland, they decimate anyone who disagrees with them or demonstrates more knowledge than they have. One of the comforts and pleasures of my presidency has been the opportunity to have experts in ultrasound, EMS, pain management, and so many other fields there to guide me when I was required to make decisions in areas in which I am not an expert. Knowing where to find the answers often ensures success more firmly than attempting to know it all. Great leaders know who to trust. In our case, people who LOVE the Academy and want its best, people who are not out for themselves but are for the organization, and people who have established expertise in their fields. The Legal Committee was there for me when members were being unfairly treated by their employers. The Ultrasound Section was there for me when ABEM asked me to help develop guidelines for the Focused Practice Designation (FPD) in Advanced EM Ultrasonography. When the Arizona State House asked for support on the position of board-certified physician led pre-hospital care teams, EMSS came with me. As the All EM Committee on Recommendations for ACGME formats our recommendations, the Workforce and Academic Affairs Committees are reviewing documents with me. Those who are experts on locums work came to me to create the AAEM-LG. The Past Presidents Council provides wisdom when I need to know how things were done when similar situations arose in the past. The Pain and Addiction Committee came to me with the idea of collaboration between AAEM and the American Society of Regional Anesthesia and Pain Medicine. AAEM staff routinely gives me guidance on bylaws and procedures. Some of the greatest blessings of becoming a leader in emergency medicine have been the opportunity to learn about content areas in which I am not an expert and the opportunity to witness the willingness of others to advise, guide, and contribute to the overall success of the Academy. And it is liberating to realize that I will never be an expert in everything—and that I don’t need to be.
There is tremendous value in interorganizational collaboration. It helps that I have been friends with many of the leaders of our fellow EM organizations for many years, so there has been a natural tendency to collaborate and sense of ease when discussing areas where we disagree. Over the course of my years on the Board, I also have become friends with many of those leaders whom I did not know before and in many cases, they were not the people I imagined them to be, but much more open and interested in cooperative engagement. I have learned to find common ground, to proceed with mutual respect, and to agree to disagree in spaces where no common ground exists. But, as previously stated, I have also learned to look with a fresh perspective at the positions of others and to give them space to share the information and the deductive process that led them to the position that they take. EM organizations in more than one country have the tradition of rivalry that is often unpleasant. I have learned from the grace demonstrated by President Nelson Mandela. If anyone had a reason to feel resentful, President Mandela did. Twenty-seven years of his life were stolen from him, and yet when asked why he felt no animosity towards his persecutors, he replied, “Resentment is like drinking poison and then hoping it kills your enemy.” Collaboration is far better than resentment, and inclusion is always better than exclusion.
Remain humble and have an attitude of service. Women and those under-represented in medicine tend towards imposter syndrome, never really feeling deserving of our achievements, no matter how hard we have worked for them. We tend to be plagued by Michelle Obama’s perennial question “Am I good enough?” Yet, at times, success can be intoxicating. And at times, the gravity of the decisions we make when we are in positions of leadership is overlooked and decisions can be made without adequate consideration. It is important to remember in any position of leadership that we are chosen to serve. To be in a position of service is a position of blessing and power. We are blessed to be able to give when so many are in the position of need. I have learned to be mindful that this is a position of obligation, one which I have taken on willingly, one which I chose, and hence my acts of service should always be a pleasure and a privilege. Being elected to serve means two things: that I was chosen because of the principles for which I stand and the values I embrace, and I was also chosen to represent the people who have chosen me. When a judgement call must be made, the membership is counting on me to make that judgement with the integrity and values that I represented to them when they voted for me. And when a decision must be made, the membership is counting on me to make the decision that reflects their wishes and interests, which may not always be my own. This is often a delicate balance, and there is no playbook for these situations. I have learned the value of Marvin Williams’ maxim that “There is no better test of a man’s integrity than his behavior when he is wrong,” and of President Truman’s model that “The buck stops here.” Taking ownership of the errors that are made by me and by the organization have allowed me to grow as a leader and as a person. Doing our best does not always result in doing what is best, but there must be integrity and transparency in our behavior. Part of that humility is, as I said, knowing who to trust, surrounding ourselves with experts, and listening to them, then weighing their sometimes conflicting advice and deciding based on all considerations, and sometimes still being wrong. I have learned that most people know what is best for themselves, and that sometimes I must trust their judgement when they say they are not ready for a role I would like them to take on. I have also learned that self-doubt is a common denominator in the human experience, and sometimes I must trust my judgement and provide the reassurance and encouragement and mentorship that others need to achieve their greatness. But I have learned that all this must be done with a spirit of humility and an attitude of gratitude for the privilege to serve.
Becoming the President of AAEM has been a dream come true for me. This is something that I wanted very much and that I achieved because others invested in me and mentored me and because the membership believed in me and the values that I bring to the practice of medicine and the education and training of our students and residents. I will be eternally grateful and always indebted to those who have paved the way for me, mentored me and trusted me to lead the best organization in emergency medicine. As I move on to my new job as a tenured professor and Associate Dean for Diversity at Brody School of Medicine at East Carolina University, my opportunities to serve will grow to encompass many residency programs, an entire medical school, and various pipeline programs that exist and that I will develop. Now, my job is making the dreams of others come true: mentoring, encouraging, empowering people to achieve their greatness and to embrace it so that they can give to the Universe all that they have to give. As you have honored me with your trust, so I honor each of you in your unique greatness. Realize your greatness and grow into it. Serve and love. This is truly a life of privilege and blessings.