This week Sir Alex Ferguson retired as the manager of Manchester United Football Club, after 26 highly successful years in charge. Sir Alex has been an inspiration to me, in my life and my career. He has been one of the most successful football managers in history, winning a total of 49 major trophies. He has an insatiable appetite for success and was pretty good at achieving it. But what can we, as emergency physicians, learn from Sir Alex Ferguson?
In this post, I’ll explore the leadership lessons that we might learn from this giant in the world of football.
Perhaps the greatest secret of Sir Alex’s success is his passion, his desire for success. Throughout his career, he has been driven to never accept mediocrity, to be at the very top of the game. Emergency physicians can learn from this. We should never strive to be mediocre doctors. Our patients’ lives and well being depend on our drive for success. It could never be enough to accept mediocrity. We, too, should always strive to achieve the best outcomes for our patients.
Sir Alex was notorious for dishing out the so-called ‘hair-drier’ treatment. His red-faced, angry outbursts to under-performing players were routine in the early part of his career, and he used them to get the best out of his team. In Emergency Medicine, it is extremely rare (if ever) that we should need to raise our voices. However, it is right that we should demand the very highest standards from our team. When we lead a team, we should expect each team member to be focused on the task in hand and to perform to the best of their ability. Sometimes, it may be tempting to ignore the doctor who seems a little distracted or who starts to chat with the nurses about social things while awaiting the arrival of an anticipated ‘major trauma’ patient. If we are to get the best from our team, it is the team leader’s job to ensure that each member is appropriately focused on achieving the best outcome for the patient. This demands assertiveness and drive and an unwillingness to accept anything but the maximum effort and total concentration. Similarly, if a colleague doesn’t appreciate the urgency of a situation, it’s the team leader’s job to change that.
Sir Alex was the master of motivating his players. He always knew how to get the best out of them, and arguably won many of his trophies with teams that had less footballing ability than their rivals. One of the keys to this success was his ability to motivate players. First, he instilled in his players a belief that they were la creme de la creme. They didn’t doubt their ability and he let it be known that he had faith in them. Second, he was absolutely clear that winning was an expectation. He created a culture where winning became the norm. Losing a game was an absolute exception.
In Emergency Medicine, we need a culture where excellent performance is an expectation. We should expect that our patients go on to achieve an excellent outcome (whether that be defined in terms of mortality/morbidity or patient experience alone, depending on the context) and if they don’t they are an exception to the rule. Of course, we could never expect to win every game – some of our patients will die, some will have poor outcome and there will be times that we wish we could have given them a better experience – but doing all that we possibly can to achieve the best possible outcome should be our cultural norm. We should never accept anything below this standard.
Sir Alex used numerous techniques to motivate his players. One such technique was to remind them of the consequences of losing. Prior to the 1999 Champions League final, he said to his players:
“At the end of the game, the European Cup will be only six feet away from you and you’ll not even be able to touch it if we lose, and for many of you, that will be the closest you will ever get. Don’t dare come back in here without giving it your all”
If we appreciate the consequences of failing to perform to the best of our ability, we will be driven on to do better. In Emergency Medicine, perhaps there are times when the team leader could remind his/her team of the consequences of failure to perform (i.e. poor outcome for the patient) and how bad the team will feel if that happens. Like Fergie’s players, we shouldn’t dare to leave any shift without being able to say, hand on heart, that we have done our all for every single patient.
“Remember to praise – but don’t over-praise”
Success is something to be celebrated. Sir Alex Ferguson celebrated every success and he encouraged his players to do so too. This forms a positive feedback loop so that the players yearn for further success. In Emergency Medicine, this means recognising and rewarding our team when things go well.
Sir Alex, however, was cautious of over-praising his players. He said: “For a player – and for any human being – there is nothing better than hearing “well done”. You don’t need to use superlatives.” It’s important for us to remember to praise our team members, but it’s also important that it should be proportionate and genuine, and that we shouldn’t over-exaggerate the praise that’s due, or else it could come across as patronising and less motivational.
Sir Alex was certainly big on accountability. If a player under-performed on a football pitch or made a stupid mistake, he certainly let it be known that it wasn’t acceptable. He once said, “You can’t always come in shouting and screaming… But in the football dressing room, it’s necessary that you point out your players’ mistakes.”
Pointing out what people could do better is important. Be specific in feedback. Don’t hold back from letting people know when and how they could have done better – otherwise they may never know. But be proportionate and fair. Sir Alex certainly didn’t create a culture of fear, whereby his players were so afraid of making mistakes that their creativity was stifled. Instead, he let people know what he thought and then moved on. His discussions about such matters were always in private – he was careful to protect his players from the public eye when possible and appropriate.
Defeat is an inevitability. Every football team loses games, and every doctor loses patients sometimes. Sir Alex knew this, but he knew that what matters is not that we are never defeated, but that we respond every time we are defeated. If United was ever beaten during Sir Alex’s reign, you can bet your life that the next game Sir Alex would have his team fighting extra hard the next game – and usually they would over-perform in response.
When our patients have a poor outcome, it’s important to reflect on the case and how we managed it. It’s important to remember that there are always learning points, however well we think we may have done. We can always do better next time – and if we think we can’t, we’re missing something. It can be devastating when our patients do badly. I regularly take it home with me and sometimes lose whole nights of sleep thinking about it – and I know my colleagues do the same. It’s important that we learn from every case, particularly when patient outcome is bad (even if it’s nothing to do with us). The next time we see a similar case, we will then come out fighting and do even better – and, even though we may have done nothing wrong in the previous case, perhaps the subtle improvments we make could avoid the same bad outcome in future.
“Establish who is boss”
It’s important for a team leader to have a presence, to make it known that they are the team leader, and to gain their team’s trust and respect. When Sir Alex took charge of Manchester United in 1986, one of the first things he did was to assert that he was the boss, that he made the decisions, and that his players would have to respect that.
This enabled him to take charge of what some say had become a fairly unruly group of players, to gain the respect of the group, to have the necessary presence to reassure the players that they have a strong leader, and to give the team a direction.
When we take charge of a team in the ED we too must have a presence. Emergency physicians aren’t known for their large egos. But a team leader must have enough of an ego to assert their leadership and gain the respect and trust of the team that are necessary to enable the team to function safely and efficiently, and to give the team leader enough control to steer the team in the appropriate direction.
Sir Alex was excellent at maintaining good working relationships, whether that be with his fiercest rivals (e.g. Jose Mourinho, who still to this day calls Sir Alex ‘The Boss’ of all managers) or his most disobedient players (e.g. the multiple players who have supposedly demanded outrageous wages, transfers, or who have been indisciplined – including kung fu kicking fans). Relationships are vital and you never know when you might rely on them. If you lose friends with a radiologist because they don’t agree with a request for a CT scan, it’s going to be even harder next time you want a CT scan. Work on relationships, and always try to get on with everyone you work with. This extends not just to colleagues but to difficult patients. Having a good relationship with challenging patients may one day mean that you get them the treatment they need to save their life, or that you successfully diffuse a situation that could otherwise have escalated to violence.
Fergie was the master of managing egos. He worked with some of the strongest and most potentially challenging sporting personalities – Eric Cantona and Roy Keane are good examples. Yet he managed to harness their great talents and minimise any problems. We often have to work with difficult colleagues in the Emergency Department. It’s tempting to give up on them. If we take a leaf out of Sir Alex’s book, we’ll harness the positive talents from such people and use them in a way that minimises the potential for their weaknesses to cause problems. This may, for example, involve getting the best out of a trainee with particular strengths and weaknesses. We might play to their strengths while going out of our way to either (a) avoid the potential for their weaknesses to cause problems (e.g. supervision in Resus); and (b) improving their training to work on their weaknesses.
“Leadership is not just on the pitch”
Sir Alex didn’t just manage his first team squad. He overhauled the youth, scouting and coaching systems at Manchester United too. Indeed this was a key to his success as ‘Fergie’s Fledglings’ (the class of ’92, the product of his rejuvenated youth system) won him his greatest honour – the Treble – in 1999.
In Emergency Medicine we need to remember that our responsibility is not just to see patients. To do so is just fighting fires. Consultants (or attendings) must also focus on the important but non-urgent tasks that improve service provision in the longer term. We should always remember that looking at the ways we deliver our services in Resus, Majors, Minors, Minor Injuries, etc, is key to our effectiveness when we are working clinically and actually seeing patients. Like Fergie, we need to take ownership of all of these matters and shape our departments to achieve success.
Last but not least, Sir Alex always knew that it’s never over until it’s over. He instilled a belief in his players that every second counts. How often did his team score in the closing seconds of a match to change the outcome. We can learn from this, too. We should never give up on our patients. Our care continues until they have actually left our doors and quite often thereafter too.
Of course this applies most when we’re battling to treat disease, when small things may make a different to patient outcome. It may be that we remember to review every patient’s chest x-ray and blood tests before they leave for an Acute Medical Unit, so that conditions like community acquired pneumonia are spotted early and treated. It may be that we remember to go back to our patient, to check that their needs have been attended to, and to ensure that our care is ongoing even if we’ve referred them on to another specialty. Or it may be applicable in cardiac arrest – pulling out all the stops to provide excellent resuscitation, giving our patients the best chance of recovery even in the ‘injury time’ of their lives.
Being a Manchester United fan, it’s easy for me to learn lessons from Sir Alex Ferguson. But I hope that we can all use his example to improve our practice, even if you support City.
Thanks for the lesson in leadership, Sir Alex!