History of Emergency Department Administration

In addition to developing clinical expertise in emergency medicine (EM), emergency department (ED) administrative leaders also need to have effective leadership skills, an understanding of increasingly complex business and healthcare finance principles, and a working knowledge of institutional, state, and national policies and advocacy. Awareness and development of these attributes and content knowledge varies greatly by past experience, residency program administrative content, lessons learned in practice, and additional training sought. It can be challenging to find dedicated educational experience in this arena during medical school and residency as the focus is primarily clinical acumen, and while many residencies have built in administrative education regarding documentation and operations, it is often difficult to understand what you don’t know and what is most important until you are downstream from your clinical training.

ED administration focuses on creating the future for your patients and teams, embracing the dynamic nature of medicine, and creating the culture of care that your teams deliver and your patients experience. ED administrative leaders are in the center of patient care connecting with the health system. If you find yourself wondering how to improve things at a departmental or system level, consider exploring opportunities to become involved in EM administrative efforts. This experience may identify an unknown passion allowing for ongoing skillset development in this area and in time, the ability to have a greater impact on your community and patients.

Residents and students who pursue this career path typically enjoy learning constantly, refining their leadership acumen, leading projects or teams, and are drawn to the business and operational aspects of EM and their impact on patient care. Those who are particularly interested in implementation science or scholarship in ED administration may find academics a great fit.

Academic vs. Non-Academic Careers in Administration

Organizational structures differ greatly between institutions and departments. Opportunities for ED administrative effort similarly vary greatly between sites. It may include aspects of medical directorship (i.e. quality metrics, operations, patient complaints, 72-hour returns), revenue cycle, team development, contract management, and system navigation. The mix and breadth of each will be the defining aspect of the respective site. One of the draws of ED administration is how much flexibility there is in creating and defining your role that fits your passions and skills. With that being said, the below descriptions are just some examples of possible career trajectories. ED administration is not about titles or advancement, but rather how to grow your team and refine your approach to maximize the impact on patient care delivery.

Academic Institution

At an academic institution, the entry point is usually at the departmental level. Seek opportunities to participate with and eventually lead important projects or committees. This may create opportunities to become an Assistant Medical Director or similar role in that department. Gain experience and expertise. Find what interests you most and seek opportunities to grow in those areas. This may include ED (or system) Operations, Quality Improvement, Patient Safety, Risk Management, ED Observation, Patient Experience, Digital/Virtual Healthcare or other focus areas within your organization. As you gain experience, you may shift from the execution of individual ideas or projects to the management of strategy and resources at a higher level. Over time and with significant effort, you may seek a more senior leadership position such as Vice Chair or Department Chair, or a senior hospital leadership position such as Chief Medical Officer, Vice President, or President. Increasingly, many of these more senior leadership roles require obtaining an MHA, MBA, MHL, or similar advanced degree.

If you work at an academic institution, you will likely have a blend of educational and academic expectations alongside your administrative duties. While the exact nature of these responsibilities are often contractual within your department, ensuring that you align with the core educational mission of an academic institution and meet the academic standards (often seen in the measure of scholarship disseminated) matters. This means that you will constantly face the unique challenge of balancing academic demands and administrative duties. For instance, an initiative that increases patient throughput may decrease opportunities for bedside teaching while improving patient care. You will need to think creatively to allocate resources in a complex environment that accounts for education and research while ensuring the clinical enterprise remains of high quality and profitable. How to take that project and create scholarship is a unique nuance in academics. In addition, as you develop your expertise, it is not uncommon to develop ongoing publications, speaking engagements, or some other pursuits that advance the academic mission. Some ED administrative leaders find this challenge highly rewarding, while others prefer a non-academic setting without this added layer of complexity. That being said, non-academic organizations certainly come with their own unique challenges as well. The best approach is to keep an open mind, and try to explore different environments during your training to discover which one suits you the best.

The ultimate benefit of pursuing an academic career in ED administration is that you will advance the field of EM by carving out a unique area of administrative expertise that you can prove, replicate, disseminate, and teach to others. It also helps to create not only the future of EM, but create a balanced career of clinical and non-clinical effort. The recognition, scholarship, and trainee education that comes with this brand of expertise is traditionally only possible in academia. On a more practical level, an academic appointment may have a decreased clinical load (compared to community practice) with the balance of time dedicated to academic and administrative expectations.

Community Medical Centers

Outside of academia, options include being a director of a physician group practice, urgent care center, freestanding ED, or community hospital medical director. Community ED administrative leaders must know how to lead people, advocate for their department, and how to represent emergency medicine to the rest of the hospital. The ED is the front door of the hospital, and similarly hospital improvements such as site accreditation and patient care process improvements must be coordinated with the ED. ED administration also prepares you to pursue other types of management opportunities, such as working as a healthcare consultant or creating health policy, to name just a few.

How to Become an Administrative Leader

It takes time. Your desired work environment often will determine the optimal path to develop credibility and experience in ED administration. There are numerous options that may include experience prior to residency, administrative academic projects during residency, mentorship as a new graduate, physician leadership educational conferences, administrative fellowships, and advanced administrative degrees. Sometimes, it can mean saying yes to opportunities for projects that don't necessarily align with your long term goals where you can develop your skill set and gain recognition for positive efforts and outcomes. There are an increasing number of SAEM-accredited Administrative/Leadership Fellowships available. Many offer a two-year opportunity to grow your administrative and leadership capacity by teaching leadership skills, change management, patient flow through the ED, ED design, and healthcare finance. Many offer a concurrent post-graduate degree such as an MBA or MHA.

Identify mentors in the role that you aspire to achieve and identify current pathways for success. Learn from their experience, and identify what experience and additional knowledge might be required for future success. This is a fluid area of rapid growth - what allowed for success ten years ago will certainly be different today. Also, seeking an advanced degree is often best utilized with some additional experience as this helps you understand the greater value proposition of your ongoing studies - well beyond the alphabet soup next to your name.

If your dream is to be the EM Department Chair at a large tertiary care center, pursuing a fellowship at an academic institution likely makes the most sense. Comparing different fellowships, the ones that offer a master’s degree might be more practical, since prominent Department Chair positions are competitive and training in business administration would give you an edge over other candidates. If your dream is to work at a particular institution, then you may benefit the most from taking a position there right out of residency, especially if an interesting administrative project or role is already waiting for you. Regardless of your path, forming relationships with mentors who can help you fine-tune your career development from a variety of perspectives is critical.

If you're not sure what your goal is, try to leave your options open. It can be difficult, although not impossible, to return to academics once you leave it for an extended period of time. Because of this, you may want to consider pursuing a fellowship at an academic institution that also allows you to moonlight at community hospitals or other non-academic settings so you can experience multiple settings while you choose a specific career pathway. Alternatively, consider getting a job in a hospital system that has both a large academic center and community affiliates.