Isaacs’ Imperatives

I recently had the honor of delivering a grand rounds lecture to the Emergency Medicine Residency Program at Vanderbilt University in Nashville, Tenn. While there, I found myself reflecting upon what I had learned during my time working in emergency medical services. To my surprise, I realized that this summer I will celebrate 20 years as an EMS physician.

Vanderbilt’s emergency department chief and medical director of the Nashville Fire Department, (my good friend and mentor Dr. Corey Slovis), encouraged me to put these lessons learned and so-called “Isaacs’ Imperatives” to paper. I hope it will help you become the best provider you can be.

10. Demonstrate integrity in everything you do.
Although each one of us strives to be “the best” in our chosen field, becoming the best usually takes years of training and even more years of experience. However, every one of us can be the best at demonstrating integrity with absolutely no training or experience whatsoever. This means always telling the truth, meaning what you say, saying what you mean, doing what you say you’re going to do in a reliable and consistent manner, and writing only what you know or believe to be the truth. They are all choices. Any one of us can choose to demonstrate integrity in these matters. My mom and dad taught me to demonstrate integrity at a very young age. This may be the best gift they ever gave me.

For the past decade, I’ve begun every significant first conversation with the following:

“Here’s what you need to know about me: What you see is what you get . I have no hidden agenda. When you ask me a question, you can be absolutely certain that you will hear one of only three possible responses:

1. The truth as I know it;
2. I don’t know. Let’s find out together, or
3. I can’t discuss this with you right now. Here’s why. I hope to be able to contact you in a short amount of time to discuss that with you.

These statements, coupled with striving each day over a long period of time to prove these words true through actions, have allowed me to “survive” seven mayors, eight fire chiefs and countless administrators. I doubt every one of them would say I was the best medical director they ever met. But I’m certain none would question my integrity.

If you demonstrate integrity in everything you do, you will be successful and the world will become a better place.

9. Find your niche.
Some of us are born to do a certain job. I chased ambulances, fire engines and police cars on my bike after school when I was 10. Not everyone is fortunate enough to know exactly what they were meant to do from a young age. Some people have to stumble or even fall into their niches. But, I believe it’s your responsibility to find your role. You see, your niche is what you were meant to do. Your niche is what and who you were meant to be.

Whether you’re a physician, paramedic or student, finding your niche means figuring out what excites you the most about life. Then you must work very hard to learn as much as you can about it and become the best you can possibly be at it. Once you have done that, someone will (hopefully) want to pay you to do exactly what you love to do.

8. Know who you work for.
This isn’t as obvious as you think. Of course, we all have a boss. Some of us have two or three bosses. Pleasing your boss is not an easy task. Pleasing multiple bosses is an almost impossible task. Yet, it’s essential to know who your bosses are and, therefore, who you work for.

I was the new young medical director for the San Francisco Fire Department and (the separate and not-so-equal) San Francisco Department of Public Health’s Paramedic Division when I was faced with a number of complex and difficult decisions. These included whether to merge the paramedic division into the fire department and whether to maintain two paramedics on every ambulance or to change to one paramedic and one EMT.

While attempting to make these important decisions, I thought long and hard about whom I worked for. I believed that if I pleased my “boss”, then I was likely making a good policy decision.

When I looked at the San Francisco organizational chart, though, it was clear that I answered to the San Francisco fire chief, the San Francisco director of public health AND the chief of emergency services at San Francisco General Hospital. To confuse things further, my paycheck was signed by the University of California, San Francisco (UCSF). When the time came to make a decision, I naively and publicly stated that I worked for the people of San Francisco and that I would make decisions based upon what was in their best interests. Boy, was I confused.

I regret that I didn’t realize that the most important people I worked for were the paramedics, EMT’s and firefighters who were in the trenches. I had thought they worked for me. I didn’t realize then that I, in fact, worked for them. Those folks knew better than anyone what they needed to do a good job. If I didn’t do a good job for them, then they couldn’t possibly do a good job for our patients.

7. Pay it forward.
Many of you remember the 2000 movie with this name. The story lays out the concept of a third-party beneficiary in which a creditor offers the debtor the option of “paying” the debt forward by lending it to a third person instead of paying it back to the original creditor.

This can work in everyday life. I try each and every day to do one “extra” thing for one person I interact with during that day. It doesn’t matter who that person is — a patient, a paramedic, a colleague or a complete stranger. It doesn’t matter what the extra thing is as long as it’s not required of you.

Understand that the beneficiaries will not always recognize that what you have done is anything extra. That’s OK! Even if they do recognize it, they may not always acknowledge it.

But the “miracle” occurs when a person recognizes that you’ve done something extra, and they ask how they may repay you. You tell them that they can’t repay you directly. You teach them to “pay it forward,” and the world becomes a slightly better place.

6. Be part of the solution, not the problem.
No one likes a whiner. If your system has problems, you have a moral and ethical responsibility to point out areas for improvement. Doing so opens the door to better patient care, better patient outcomes, more efficient services and better working conditions. But simply pointing out problems without suggesting viable and cost-efficient solutions — or at least helping to implement system enhancements — is called “whining.”

Don’t do that. Any good executive manager knows that the best people working for him or her are those who, when they come to the manager with a problem, come also with a solution.

5. Find a great mentor and cherish him/her.
“Wise advisor,” 1750, from Gk.Mentor, character in the “Odyssey,” friend of Odysseus, adviser of Telemachus (often actually Athene in disguise).

A mentor is a trusted friend, counselor or teacher. This person is usually a more experienced person within a given field. A mentor can provide expertise to less-experienced individuals in order to help them advance their careers, enhance their education, and build professional relationships and networks.

I’ve been extremely fortunate to have many exceptional mentors, beginning with my mom and dad. I truly believe that nearly everything good that I am is a direct result of the mentoring provided to me by my parents.

I can’t be more grateful to my professional mentors, many of whom are world-renowned leaders in EMS. These individuals include Dr. Paul Pepe, chief of emergency medicine at UT Southwestern and Parkland Memorial Hospital; Dr. Ricardo Martinez, former NHTSA administrator during the Clinton administration; Dr. Corey Slovis, chief of emergency medicine at Vanderbilt University and medical director of the Nashville Fire Department; Dr. Ray Fowler, operational medical director of the Dallas-area BioTel EMS system; Dr. Ed Racht, medical director of Austin-Travis County EMS; Dr. Mike Callaham and Dr. Alan Gelb of the University of California, San Francisco; and fire chiefs Mario Trevino, Joanne Hayes-White and Eddie Burns, Sr. I wish I could name all of the great paramedic, firefighter and nursing mentors I’ve had over the years, but if I did I’m certain that the JEMS.com editors would kill me.

How do you find a mentor? First you have to identify someone who’s an expert in your niche area. (See No. 9) It’s best if this person isn’t the mortal enemy of your boss. (See No. 8). Contact your potential mentor by e-mail or introduce yourself at a professional conference. Briefly tell your potential mentor a little about yourself. Quickly segue into how much you admire them and their many amazing accomplishments. State how honored you would be if they would allow you to contact them in the future for advice on how you might, one day, become ALMOST as great as they are.

Smile, flatter profusely and repeat as appropriate.

If this fails to result in an offer to advise you in the future, fall to the ground crying, “I’m such a loser.” Grab the ankles of your potential mentor, rest your head on the top of their shoes, then sob and drool uncontrollably.

Some might say this is not the best tactic, but it has worked for me.

But seriously, finding a great mentor is one of the most important factors in ensuring your professional success. Great mentors don’t fall into your lap. You have to seek them out. Once you have a great mentor, cherish them. And then, re-read No. 7 and follow those instructions.

4. Frequently and enthusiastically recognize and reward hard work, exemplary performance and teamwork.
We’re relatively quick to identify deficiencies in patient care delivery, and we’ve developed complex and detailed systems for “ensuring” the quality of care we provide. Every emergency medicine attending, resident, medical student, paramedic and EMT dreads the phrase, “Do you remember patient X?” This question is usually followed by a gracious invitation (order) to attend morbidity & mortality (M&M) conference or visit with the chief and the medical director.

Does anyone like to do this? Not unless you’re a masochist!

I believe we need a new meeting to balance out M&M and chief/medical director conferences. We could call this the “Uniform Recognition of Outstanding Care Kommittee” (also known as the “UROCK” group.)

This group could meet monthly to thank everyone from the field providers to the administrators for maintaining the safety net for a system in crisis. Cash gifts could be given to the EMS personnel who provided the best service or who suffered either the most verbal abuse or the greatest exposure to spit, vomit, MRSA or creepy crawlies. In lieu of cash, we could provide tasty treats and coupons for heavily caffeinated beverages, tickets to sporting events or movies, written commendations, or simply a pat on the back and a hearty “well done”.

3. Apply the “mom test”.
Most everyone knows this test, and it goes by many names. I know it this way:

The Mom Test requires two things to work:

You have to have a mom (or have had a mom at one time).
You have to like your mom.

Whenever you’re not sure what to do for a patient, imagine the patient is your mom. Ask yourself, “What would I want the best physician, paramedic, nurse, EMT or firefighter to do for my mom if she were in a similar situation?” Your answer is almost certainly the best course of action and one you must take, unless extraordinary circumstances call for a different path.

2. Be the strongest patient advocate EVER.
Isn’t this simple? Not so much. Too often I hear someone say something like “this %$#%# doesn’t want our help. Let’s have security escort him out of the ER” or “this guy doesn’t want our help, so let’s go back to the station.”

While I do not believe in kidnapping out-of-hospital patients (the actual term is “assaulting”), or holding patients against their will, I do believe we must be the strongest possible advocates for our patients. Sometimes this means continuing to care even when patients no longer have the will or the ability/capacity to advocate for themselves.

When you aren’t sure what advocacy for a particular patient means, see No. 3.

If not us, then who?
If not now, then when?

1. Primum non nocere.
The Latin words for medical slogan, “First do no harm” — a fundamental medical precept of Hippocrates (ca. 460-ca.377 B.C.).

That’s it.

Period.

Nothing more to see here folks.

Move along.

End of discussion.

Conclusion
If you’re still reading at this point, it’s likely you’re committed to doing the best possible job. It’s my hope this paper will help you to achieve your goal. For always remember this essential principle spoken by Confucius, “He who wishes to secure the good of others, has already secured his own.”

S. Marshal Isaacs, MD, FACEP, is the medical director for the Dallas Fire-Rescue Department. He is also a professor of surgery (emergency medicine) at the University of Texas Southwestern Medical Center at Dallas, an attending physician in the emergency services department of Parkland Memorial Hospital and the deputy medical director of the Dallas Area BioTel EMS System.

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