Relax into the tension: Paradoxes experienced by emerging leaders in emergency medicine

In this article, we set the scene for organisational tensions that emerging leaders in EDs face and the moral consequences they present. We discuss four paradoxes of emergency medicine (EM), highlighting the need for leaders to be wary of the pursuit of more, to be comfortable with discomfort, to look after themselves and to accept complexity. We use the paradox framework as a theoretical grounding to help trainees to navigate these challenges. Consider, for example, the following vignette.


Introduction
In this article, we set the scene for organisational tensions that emerging leaders in EDs face and the moral consequences they present. We discuss four paradoxes of emergency medicine (EM), highlighting the need for leaders to be wary of the pursuit of more, to be comfortable with discomfort, to look after themselves and to accept complexity. We use the paradox framework as a theoretical grounding to help trainees to navigate these challenges. Consider, for example, the following vignette.
'We need to intubate!' Sarah, an ED registrar in charge, briefs her team. Under her leadership, the skilful team successfully manages the complicated patient. She calls multiple teams to expedite treatment, but they request more investigations. The patient spends hours in ED awaiting reviews. The next day, Sarah receives a complaint saying, 'ED did not manage the patient adequately'.
Clinical leaders in ED face increasingly complex value-related conflicts and organisational-imposed constraints in their work. 1 As portrayed in the vignette above, Sarah followed protocol, provided excellent care, pushed for expedition, yet still received a complaint of inadequacy. Therein lies a common paradox of EM leadership.

Categories of paradox
The organisational paradox literature presents four categories of paradoxes. 2 These are learning, belonging, organising and performing, all of which reflect the core activities of organisations. Learning paradoxes arise when existing knowledge and practices are challenged by emerging knowledge and innovation. Belonging paradoxes are based on tensions of identity between various members of an organisation who are trying to establish homogeneity yet be distinct. Organising paradoxes arise as organisations become more complex and introduce competing processes needed to achieve a desired outcome. Paradoxes of performing result from different internal and external stakeholders trying to deliver their own conflicting strategies.
The idea that ED is rife with paradoxes has been entertained previously, such as the notion that we are experts at waiting room medicine, or what Wears and Cook 3 refer to as 'getting better at being worse'. Even the concept of patient flow is a paradox, where differing perspectives and priorities breed perennial conflict. 4 Little wonder that trainees, as leaders-in-training, are left puzzled, frustrated or worse, jaded, by the ideals of 'leadership' and how discrepant this is from their present reality of teeth-grinding, back-againstthe-wall work. 5 Furthermore, repeatedly encountering these professional challenges makes it nearly impossible to fulfil moral obligations to patients and colleagues. 6 In other words, leaders who aspire to uphold their principles may be broken by daily experiences of injustice and suffering, as Sarah experienced in the vignette.
The resulting moral distress may bring about cynicism and apathy; an uncomfortable cognitive dissonance 7 is formed when, as a leader, you know the morally right thing to do but you are constrained from doing it. The dissonance resulting from acting against one's core values makes it hard for anyone, especially those with less experience, to remain resilient.

Living with paradox
How might Sarah feel, and how should she respond? The paradox perspective introduces the concept that organisational tensions do not necessarily require immediate resolution (let us fix it), or resignation (let us give up), but a middle-ground approach where competing demands can be managed simultaneously (let us live with it). 2 Smith and Lewis 2 assert that, 'the role of leadership is to support opposing forces and harness the constant tension between them, enabling the system to not only survive but continuously improve' (p. 386). Living with a paradox (or supporting others to) can come in the form of acceptanceviewing tensions as opportunities for creativity and learning. Acceptance facilitates what the authors call 'paradoxical thinking'. Instead of seeing tensions as dilemmas, paradoxical thinking encourages leaders to consider 'both/ and' possibilities that embrace existing paradoxes.
We have thus far focused on the negative aspects of organisational paradoxes in ED. In the next section, we flip the framing to present paradoxes in the form of recommendations that traineesas emerging leaderscan utilise as they work on accepting, living with and engaging in paradoxical thinking.
Paradoxes we can embrace in EM Paradox 1. Learning: more is not always more Increasing system and patient complexity, coupled with technological advances and the introduction of automation and artificial intelligence into EM, will create a demand for higher expectations of knowledge. As a result, exponentially more data will be readily available. Having more data may not necessarily translate to better care, but it could make ED even more confusing, potentially driving over-testing to reduce risk (see Paradox 2), while challenging existing dogma in practice. In balancing tensions, trainees need to ensure their focus remains squarely on patient care instead of caring about data, 8 while being cognisant of the challenges in quantifying quality and the pressure to equate quality with quantity.

Paradox 2. Belonging: being comfortable with discomfort
In ED, we not only lack a defined patient population (i.e. no 'gates') but also have little control or power over our workflow. 4 Hence, ED leaders must accommodate risk constantly, yet find it demoralising when other teams do not share risk, 1 downplaying (e.g. 'just discharge the patient') or diverting responsibility (e.g. 'doesn't sound like my problem'). Let us stop expecting the rest of the healthcare system to embrace the same degree of risk that we face: this is ours to bear. Our identity lies in being confidently uncertain yet enigmatically pragmatic. 5 Paradox 3. Organising: better self-care betters healthcare In looking after our patients, we have been overlooked. The mass exodus of emergency nurses 9 is evidence we have not looked after our clinical staff during the COVID-19 pandemic. Well-being is good for work, but it does not make people well while engaging in work. The latter requires organisations to be grounded in managing what is nourishing for its workers, such as psychological safety and workplace inclusion, instead of working them to the ground. As leaders, we must step up where systems failputting staff well-being ahead of service provision.
Paradox 4. Performing: the solution is…there is no solution ED doctors embrace 'MacGyver' solutions, and yet we have not managed to solve the leadership paradoxes we face. Unfortunately, solutions in the form of black-andwhite, top-down approaches, such as time-based targets, often are not sustainable, and can be fortuitously gamed. 10 Alternatively, normalising deviance, such as celebrating waiting room medicine, 3 or accepting external solutions not tailored to the ED context, such as in ultrasound infection control, causes more problems than it aims to solve. This level of forced resolution is untenable and will eventuallyif not alreadyresult in patients bearing the consequences. Instead, strategies such as accepting complexity, being open to alternate perspectives, and juggling confidence and humility may provide opportunities for leadership development amidst tribulation and conflict.

Conclusion
In this article, we highlight the myriad of tensions and paradoxes that emerging ED leaders are expected to confront. We suggest that living with paradox entails, among others, the judicious use of data, expert mitigation of risk, diligent prioritisation of ourselves and harnessing complexity. It is our hope that trainees and clinicians may learn to rise above these traditionally frustrating paradoxes and lead well in EM.