The cost of the seat

The weight arrives after the decision is made. Somebody else pays for it.

I left the office at seven o’clock on a Tuesday evening in August. That was early for me in this role.

Earlier that day a decision had landed that I did not believe was justified and that was not mine to reverse. I was going to carry it out anyway.

I drove home. I told my wife that I was not okay with this. Five words. I did not elaborate and she did not ask me to, and then I sat down at the dinner table and was no use to anybody in my family for the rest of the night.

That is the entire scene. I want to be careful not to exaggerate it, because the size is not what I am writing about.

I have been in this position in more than one seat and more than one organization. The particulars change more than the shape does.

This newsletter has been about healthcare from inside the rooms where it gets decided — what the systems do, who carries the cost, which questions never get asked in time. Almost none of it has been about the person sitting in the chair. This one is.

Before I go any further, one obvious point. I hold the seat I am about to describe and I am paid to hold it, and the argument I am going to make — that this kind of weight is information rather than weakness — happens to be a convenient argument for the person making it. Read it knowing that.

The hour is the important detail in this scene, and anyone who has held a seat like this one already knows it. The nights you stay until nine or ten are ordinary nights. Those are the nights the work is winning, and there is a satisfaction in them that is easy to mistake for something healthier than it is. Leaving at seven is a different thing entirely. You leave at seven because you have stopped being able to do anything useful, and going home is the only honest option left in front of you.

I have watched other people do this for twenty years without once labeling it as a category. We have a full vocabulary for the clinician who is carrying too much, and we have built conferences and committees and wellness programs around it, most of which have not changed anybody’s Tuesday. We have almost nothing for the person who made the constraining decision, or for the one who was handed it and had to execute it. I had assumed that was because nobody had looked. That turns out to be wrong. I went looking and the work is there, almost all of it about nurses rather than about physicians or executives, which is a different problem and a smaller comfort.

The weight is not the decision itself. I believed it was for a long time, and I suspect most people who take these roles have it wrong in the same way. You imagine the hard part is the choosing. Sometimes it is. But the weight I am describing arrives after the choosing is over, when there is nothing left to decide and nothing left to argue, and you still have to carry the decision out in a body that disagrees with it. It has a name — moral distress — and finding that out was useful to me, because it meant I had been describing something ordinary rather than a private defect. That is all I need it for.

By Wednesday morning it had changed. What changed it was not comfort and it was not resolution. The situation did not improve. The decision stood. Nothing about Tuesday was any better on Wednesday than it had been the night before.

What moved was that I heard where my team actually was. They were the ones who would have to stand in front of their own teams and answer for something they were not permitted to explain, going into a weekend, with nothing anybody could act on. Measured against that, my Tuesday evening was not the hard part of the week. It was the part I had been treating as the subject.

Being petulant and self-centered in that moment was going to make the week worse for everyone.

Weight that has nowhere to go does not stay with the person carrying it. It comes back out as reactivity, and reactivity from an executive chair gets paid for by people who had no part in the decision.

I know what that looks like because I have been the one doing it, and it does not look like temper. It looks like a decision made faster than it deserved, because I wanted it off my desk. It looks like a meeting run short of what the agenda actually needed. It looks like a question I did not ask, because asking it would have opened something I did not have the capacity to manage that day. None of that reads as weight to anyone else in the room. It reads as decisiveness, or efficiency, or trust. And the cost of the question I did not ask lands on somebody else, weeks later, in a form they will never trace back to a Tuesday.

That is a mechanism and not a mood, which is why I distrust the advice to simply sit with it. Sitting with it is what I was doing at seven o’clock. What actually discharged it was being given something real to solve that belonged to somebody other than me.

I still work clinically a few shifts a month. That is not the same job as the one the people I stand next to on those days are doing, and I know it. Part of why I keep doing it is selfish in a way that took me years to understand. Clinical work is the only part of this job where the decision, the cost, and the person it lands on are in the same room within the same hour. Everywhere else in an executive seat there is a delay, and sometimes the delay runs to months. The delay is where the weight collects.

What the delay actually does took me a long time to see. In a room, the consequence arrives while you are still standing in it, and there is closure. You see who paid. You say something to them, or you do not and you at least know what there was to say. Either way it ends somewhere. Push that same sequence out by weeks or months and the closing never comes. You do not meet the person who paid. Most of the time you are never told. So there is nothing for the weight to close against, which is the whole reason it goes looking for somewhere else to land.

I do not think I can take anyone through something I have not been through myself, which means the part of this work that looks like weakness is the part that qualifies me to do it.

The objection to that is the one I take most seriously, and I would raise it myself if I were reading this from the other side. An executive describing what a decision cost him, while holding the authority that produced that cost for somebody else, is a difficult thing to read and it should be. I went looking at the severe end of this too, and there leadership shows up on one side only. Leaders are what harms people. They are not people who get harmed. I am not going to argue with any of it. I was the one in the room. Whatever the week cost me, it cost the person on the other side of it more, and the ordering there is not close.

What I would say is narrower. The distress is not a claim on anyone’s sympathy and it is not a defense of the decision. It is information. It tells me the decision had a real cost, and that I am still close enough to the work to feel it. The day I stop feeling it is the day I should not be trusted with the next one.

On Wednesday morning I made a call before seven, pushed for a different way to carry it out, and agreed on most of it. Later that day I sat down with the team, and instead of opening the way we normally open those, with what happened and what do we do now, I asked them how they were feeling about all that had happened. That is not a question I had ever led with in a debrief. It took about four minutes and it changed what the next hour was able to do.

Then we worked the rest of the day. The decision did not change. Everything downstream of it did.