Clinical Editor's Corner

Dynamic Leadership in the Cath Lab: Balancing Taking Charge and Being Part of the Team

Morton Kern, MD Clinical Editor Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California
Morton Kern, MD Clinical Editor Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California
The Cath Lab Basics 2009 course series ended in Tampa the first Saturday in December. Dr. Mike Lim and I enjoyed conducting a one-day ‘cath conference’ with the 180 cath techs and nurses from the region. Sitting at lunch, I asked my table of nurses from Venice, Florida, “What is the single biggest problem you have in your lab?” I was expecting comments like, “It’s the hemodynamics” or “I struggle with coronary anatomy” or “I don’t like covering the on-call nights.” But I was surprised to learn from them that their biggest problem was the personal dynamics with one of the techs in their lab. It had slipped my mind that the biggest struggle in any workplace is the human relationships, not the hemodynamic recording technique or heparin dosing. In these pages, I have previously addressed many topics that bear on interpersonal work relationship problems, talking about the scope of practice, communications in the lab, teamwork, and motivations to change behaviors in the lab. The leadership in the cath lab and hospital administration must contend with these issues on a daily basis. Ignoring such problems and not dealing with them promptly and properly will result in a lab that will degenerate into a tumultuous work environment that compromises patient care and makes personnel retention impossible. There is no one group or worker type who is consistently to blame for workplace disharmony (e.g. bullying, slacking off). Every group that works in a cath lab, including the physicians, takes turns at being criticized or doing the criticizing, blaming or taking the blame, failing to lead or failing to follow. This is the dynamic nature of personalities involved in the work of the cath lab. From firsthand experience working in many labs and visiting many more, I can safely say every lab in the country has its unique and at times quarrelsome interpersonal dynamics. In my lunch table example above — a situation probably more common in labs that are not fully cross-trained — the nurses reported difficulty working with one overbearing tech who liked to push his weight around in the lab. He felt he knew more, could do more and should be the lab leader but made no effort to be a leader (see Table 1) or become part of the team. He had behaved rudely to staff and patients alike despite being counseled against such behavior. I was told that written incident reports to his supervisor (the cath lab director was a tech and a friend) had no effect on changing his bad attitude. His actions before and during a case made communication between nurse and physicians difficult, and the confusion jeopardized patient care. What is a remedy for such a situation? Ideally, the lab manager or a supervising administrator or physician director who receives complaints conducts an investigation with all parties individually and addresses the offender in person and in writing. After the personal interviews and discussions, the lab leader must gather the entire team and discuss what behavior is expected and what is unacceptable. Further infractions result in demotion, transfer, or dismissal. A cath lab manager unwilling to assist in establishing good workplace rapport is not doing his duty and should seek help from his supervisor or find work elsewhere. Without such leadership, this workplace will ultimately lose their best staff and the quality of the cath experience for patients and staff will deteriorate. What personal characteristics are associated with successful leadership? These characteristics include motivation to learn, a high achievement drive and personality traits such as openness to experience, an internal focus of control, and self-monitoring. Leadership is also a process which includes managing interpersonal relationships, social influences, and team dynamics. Dynamic or collaborative leadership during a cath procedure often goes unnoticed and unmentioned, but can be observed in the smooth interaction and teamwork that makes a complex and potentially deadly procedure into a routine cath. The direction of the procedure is led at different times by different people. This silent transfer of leadership is what I call “dynamic” or “collaborative” leadership. For example, at the beginning of the case, the charge nurse directs the team to have the patient situated on the cath table, performs the time out, administers premedications, and initiates documentation. Leadership is silently transferred when the patient is being draped. The head tech then takes the lead, requesting specific equipment, setting out the catheters and sheaths, and preparing the sterile field. Leadership is again silently transferred during vascular access as the physician starts the procedure. The radiology tech may then become the leader, setting the fluoroscope and positioning the imaging systems. His requests are followed before angiograms can be adequately obtained. And so it will go throughout the case for hemodynamic data, percutaneous coronary intervention and post procedure care. The team dynamics dictate the success of the leadership roles. The best leaders are also the best followers when their teammates’ turn at leadership comes up. Everyone should be a leader and follower to be a good team member. What do you need to be a good leader in the cath lab? Whether you are a nurse, tech or physician, you need to have a good understanding of the procedures, your role in the lab and your scope of practice. You need a strong sense of duty to the patient and the team. You need to feel strongly about doing the right thing at all times and not accepting a poor work product (poor performance). You should assist everyone in the lab whenever possible when you are not attending to your specific task. You should provide an example of excellence and lead by excellent examples. You should not accept rude or unkind behavior, whether directed at you, at a patient or visitor, or co-worker, at any time. For managers, this advice goes double. For the team member suffering at the hands of a malignant co-worker, continue to document the offenses, request assistance from your manager and enlist the chain of command to see if a satisfactory resolution can be achieved. This process is your obligation and duty to the patients and the lab. A leader must delegate, direct, support and coach, ultimately realizing that there is no one best way to influence people. You have to be creative to be effective. Try it and see. _______________________________


Dear Dr. Kern, I have read, with interest, the conversation between you and Dr. Lewis (Cath Lab Digest November 2009, page 6) and ask that you allow me to make 2 comments: 1. As a past board member of the Association of Physician Assistants (PAs) in Cardiology, and the developer of the first U.S. PA Postgraduate Fellowship curriculum (to-be-accredited 2011), your readers should know that the concept of the MD-PA cardiology team has received widespread enthusiasm from both the American College of Cardiology, Heart Rhythm Society, and the American Heart Association leadership. In fact, we have a provision in the 12-month program for the PA fellow to participate in Heart House activities and cardiologists are preceptors for the PA fellows! So the idea proffered by Dr. Lewis, that PAs will exploit cardiology and thus the position of cardiologists, is quite weak. Team care supports better outcomes and affords expanded access to care - if utilized smartly. Just ask the 1,200+ PAs working alongside cardiologists. 2. PAs, as 75,000+ valued members of the patient care team, across all specialties recognized by the ABIM, have existed since 1967, when the first class graduated from Duke University. The 85% CMS reimbursement rate for cardiology consults is standard-of-care for Medicare patients. This may be troublesome for some physicians because of the new 2010 Physician Payment Rule passed in November, whereby there will be a deep cut in reimbursement across all cardiology codes, especially imaging, but those physicians already working with PAs in their practice actually grow the practice. This is because physicians with cardiology PAs in their practice utilize them for other duties outside of consults (they keep the $85 consult fee). I would argue we shouldn't complain or judge a professional group unless we have worked with them. We should all be working together, not bickering about turf. I know we can all do better... because it is all about the patient, not the clinician! Respectfully, Kenneth E. Korber, PA