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• W2325781897 abstract "Prince Andrei listened attentively to Bagratión's colloquies with the commanding officers and the orders he gave them, and to his surprise, found that no orders were really given, but that Prince Bagratión tried to make it appear that everything done by necessity, by accident, or by the will of subordinate commanders was done, if not by his direct command, at least in accord with his intentions. Prince Andrei noticed, however, that though what happened was due to chance and was independent of the commander's will, owing to the tact Bagratión showed, his presence was very valuable. Officers who approached him with disturbed countenances became calm; soldiers and officers greeted him gaily, grew more cheerful in his presence, and were evidently anxious to display their courage before him. Leo Tolstoy, War and Peace1FigureThe ED interacts with nearly every department of the hospital and most of its medical staff. It also interacts with the community in which it resides, and this is the third axis of its social world. The emergency care system of the community is a diverse collection of agencies, each with its own rules, priorities, and chain of command. Every community has its own structure, traditions, and methods for providing services.2 Being medical provider of last resort involves the department in all manner of local issues. The ED cares for low-income people and for difficult patients no one else wants. The city where our ED was located had few true street people, but there was a large community of individuals that could be considered disadvantaged and a significant incidence of HIV. In any community, the ED may be a dumping ground for people whose behavior causes insoluble problems for their families, their doctors, police, and social service agencies. ED personnel in our study evinced an ambivalent attitude toward these patients and the cloud of problems that invariably accompanied them. On one hand, staff were reluctant to deal with them because their appearance and behavior were frequently off-putting, sometimes downright scary, and because social issues usually outweighed medical ones and were difficult or impossible to resolve. Yet most of the ED staff, physicians included, took pride in their ability to treat patients with whom, in their opinion, no one else in the medical community had the courage or resourcefulness to deal. They all described experiences with difficult, disruptive, or dangerous patients, and many stories of shared hazard had grown to mythic proportions within the department. Because these patients frequently required help beyond the capacity of the ED, they also tended to be the subject of some of the most intense and complex negotiations with other departments, outside agencies, and consultants. In a hospital with teaching clinics, this may be less of a problem, but in a community hospital, it is typically a minor triumph whenever an EP succeeds in persuading an office-based specialist to accept a marginal person as a patient. Unfortunately, such events tend to diminish the status of EPs in the eyes of the specialists, who judge it of dubious value to cultivate good relations with colleagues who send them such undesirable referrals. Emergency Medical Services (EMS) and its medical direction are the subject of extensive literature, but this deals mainly with the clinical and operational aspects of the system.3–6 The social and political nature of EMS has received little attention. Most striking is the diversity of the system and the multiplicity of chains of command and authority. In the community we studied, the EMS system consists of a 9-1-1 dispatch center run by the county, municipal advanced life support ambulance service, a second response paramedic unit that rendezvoused with outlying basic life support services, rural BLS ambulance services, state, municipal, and local police, fire, and other services like hazardous materials response and civil defense. Each one of these is separately administered under state, county, or local governments. Paramedics are employees of the hospital, and emergency physicians provide medical command via radio for ALS services, but BLS services are run by local fire companies, and ultimately answer only to their state licensing authority. Most EMS responses involve more than one agency, and while state law specifies jurisdiction in some situations, in the vast majority of cases EMS workers function in gray areas where there is no clearly defined chain of command. Thus, an element of negotiation is part of the majority of EMS responses. Most of the time this occurs rapidly and smoothly, almost unnoticeably. When a conflict arises, however, the problem is immediately compounded by the fact that there is no overall authority, no generally agreed-upon method for resolving disputes, and no final arbiter to whom all can turn. A paramedic returned from a call pale and shaking. He had been dispatched to an auto accident on a rural highway. The local fire department had responded to assist with the rescue, and the fire chief wanted to call a helicopter from a tertiary care center 40 miles away. The paramedic wanted to transport the patient to his own ED. They had stood beside the wrecked car, arguing ever more intensely, and the paramedic said he was certain they would have come to blows had others not intervened. The deciding factor was a state patrolman with EMT training who gave his support to the paramedic. The patient was transported to the nearby ED, and turned out not to have serious injuries. Other paramedics said they knew this fire chief, and that it was not unusual to have difficulty dealing with him. The physician's command of the ED is not a fiction. He is continually giving orders everyone expects will be carried out, but authority structure in an ED is based on cooperation and shared goals and values rather than simple exercise of power and rank. The ED is a team operation requiring non-physician personnel to spend much of their time working independently in situations where their judgments are crucial to patient welfare. Furthermore, the department is continually dealing with events, external and internal, over which no one really has control. Physicians, trained to solve problems creatively and idiosyncratically, attach great importance to individual judgment. Some doctors consider that relinquishing any degree of control threatens the integrity of the way they care for patients. Appropriate as this may be in some settings, such individuals are likely to experience difficulty working in the ED where they will be perceived by others as having an irrational desire to dominate and impose status. Another reason emergency physicians' orders are followed by subordinates is because there is a universal presumption that these orders will be compatible with the department's shared values. Just as importantly, physicians trust subordinates to be bright and motivated enough to master the details of protocols, even in situations where no explicit orders have been given and to act in ways physicians would consider correct. A kind of egalitarianism develops in which each team member comes to understand that they have certain responsibilities and also that they own a piece of the turf. Physicians have the ultimate authority: they make the most important decisions, give the orders, and may review and direct subordinates' work at any time; but they are expected to act in a manner that shows respect for the intelligence and autonomy of others. Emergency medicine is an intensely social specialty, and it is possible to use the tools of sociology in an effort to understand how the ED functions. In addition to the biological aspect of medicine, the concept of ED practice being fundamentally social suggests that important things need to be added to the knowledge base of the specialty. Emergency physicians must exercise a highly sophisticated kind of leadership, and this in turn depends upon their being able to trust that subordinates will provide care that is competent and conforms to shared norms and standards of quality. EPs' success depends as much on their ability to keep the team functioning smoothly and cooperatively as it does on scientific knowledge and technical skill. Like Tolstoy's General Bagratión, the EP may find that leadership in a crisis and the ability to do good are not necessarily the same thing as being in control of everything that happens. In prehospital services, the politics and negotiations that are a part of day-to-day operations are inevitable due to the multiplicity of agencies involved. This is another area to which social and organizational theory can be applied with a view toward promoting quality. A collaborative approach between medicine and sociology can make possible the application of sociological insight in a way that enhances practice without detracting from the importance of clinical medicine. Likewise, investigation of medical practice can broaden the range of sociological knowledge and theory. Research for this paper was partially funded by the Changing Dimensions of Trusteeship Project, Program on Nonprofit Organizations, Yale University, New Haven, Connecticut, from a grant provided by the Lilly Endowment. The authors wish to thank C. James Holliman, MD, for his comments on the manuscript. Continuing Medical Education in EMN Emergency Medicine News has always been the place emergency physicians could find breaking news, comprehensive clinical information, and viewpoints not expressed anywhere else in the specialty's publications. Now EMN is the place EPs can fulfill their continuing medical education requirements. In this and every issue, EMN offers a CME quiz as part of InFocus, the clinical column written each month by James R. Roberts, MD. Lippincott Williams & Wilkins, EMN's publisher, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. LWW has designated InFocus for a maximum of 1 hour in category 1 credit toward the AMA Physician's Recognition Award. Target Audience Statement: The CME activity in Emergency Medicine News is intended for emergency physicians with an interest in the diagnosis and treatment of various disease processes commonly seen in emergency departments, with special emphasis on evidence-based medicine. Accreditation and Credit Designation Statement: Lippincott Williams & Wilkins is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. LWW designates this educational activity for a maximum of 1 hour in category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he actually spent in the educational activity. Subscriptions to EMN If you are an emergency physician, you should already be receiving a subscription to EMN. If not, qualify for a complimentary monthly subscription by contacting Deborah Holmes at [email protected] or (212)886-1209 (fax). If you are not an emergency physician and are interested in subscribing, contact Lippincott Williams & Wilkins, 16522 Hunters Green Parkway, Hagerstown, MD 21740; (800)638-3030; in Maryland, call collect, (301)824-7300." @default.
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• W2325781897 title "The Sociology of Emergency Medicine" @default.
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