Rich, Eugene C. MD; Magrane, Diane MD; Kirch, Darrell G. MD
The role of medical school deans has changed dramatically in the past 50 years.1–3 In the early 20th century, “the dean's official duties were relatively simple: correspondence; record-keeping; registering, seating, and cataloging students, issuing and distributing announcements and school bulletins.”4 In 1959, deans of the then 79 U.S. medical schools were responsible for the academic affairs of 10,350 full-time faculty and 29,000 medical students.5 In 2006, deans of 125 U.S. medical schools managed approximately 118,000 faculty and 68,000 medical students.6 Dramatic growth in all missions of the modern academic medical center (AMC) has greatly expanded the financial demands for maintaining success in these ventures1,2,7 and has greatly increased the complexity of the medical school deanship.1,3,8 Medical school deans now have a significant role in managing faculty practice plans, and in some cases they carry additional roles overseeing other health professions schools and/or as the chief executive officer of their teaching hospital. They are expected to be competent managers and visionary leaders within a complex environment of often-competing missions of education, research, and clinical care. They are accountable to a wide range of parties, from local and state governance, to university partners and oversight boards, to national accreditation agencies, as well as the students, faculty, and staff of the institutions they lead.
The Liaison Committee on Medical Education (LCME), in its guidance to the accreditation of U.S. Medical Schools, states that “the dean must be qualified by education and experience to provide leadership in medical education, scholarly activity, and care of patients.”9 The LCME does not, however, specify the essential qualities that ensure successful execution of this important leadership role. In view of the many challenges facing the modern medical school and the heavy consequences, both institutionally and personally, of failure for a new dean, much has been written in the past 10 years on the subject of leadership in academic medicine. In this article, we review the literature and resources for professional development of executives in order to identify the characteristics proposed as relevant to medical school deanship. From this, we propose a framework for the preparation and professional development of medical school deans to be effective in an environment of increasing organizational complexity.
In 2006, we collected descriptive and comparative references on the medical school deanship from a literature search, and then we supplemented them with materials from executive development programs and interviews with leaders involved in these programs. These interviews were conducted between July 2005 and June 2006. A PubMed search using the key words leadership, dean, medical school, and academic medical center to identify relevant publications since 1995 yielded 24 citations. From this list, we excluded four articles pertaining to medical education outside North America and 10 articles that that did not address the roles and responsibilities of medical school deans. As a result, 10 articles from this search were retained for this review. To this list the authors added references gleaned from review of citations within these articles as well as citations in course materials from Association of American Medical Colleges (AAMC) Executive Development programs. From this search for relevant literature, we identified 23 additional publications, resulting in a total of 33 resources for this review.
To provide context and face validity to the themes that evolved from the analysis of references, one of the authors (E.C.R.) conducted supplemental interviews with several long-serving deans (medical school deans in their position for at least 10 years) and with AAMC staff and associated consultants who conduct leadership development programs for the AAMC. In addition, we observed discussions on the demands and expectations of deans at AAMC Council of Deans Administrative Board meetings and at development programs for newly appointed deans. From the literature review and these supplemental sources, we identified an array of qualities relevant to service as a medical school dean. To summarize our findings, we applied the framework of knowledge, skills, and attitudes widely used by medical educators9–11 (List 1).
In view of the size and complexity of the modern AMC, it is not surprising that management skills and leadership skills are commonly cited as important for dean of contemporary medical schools. In two of the most comprehensive analyses, Yedidia8 and Clawson and Wilson12 list management experience and administrative skills as key qualifications. Yedidia8 cites management experience as a key qualification in his 1998 study of medical school deans. Clawson and Wilson,12 in the concluding chapter of their book The Medical School Dean, likewise list administrative skills among the most important characteristics of a medical school dean.
Foremost among the management skills described in the literature is the ability to assess the institutional environment and judge support for initiatives, both from institutional leaders and from faculty.1,3,8,12–16 Without support from university and AMC executives, the dean may not secure the necessary resources and/or authority to develop the medical school.8 Support from the faculty is equally important.10,17 As one experienced dean notes, “If your only support is from above, you are hanging!” (R. Krugman, MD, personal communication, 2005). Skills in negotiation, conflict management, and managing change are also seen as critical.11,12,18–21 Communication skills are, not surprisingly, also identified as a high priority for effective management in academic medicine.11,12,17,18 Those communication skills must address a wide audience of students, faculty, university and hospital administrators, and community members that include civic and state legislators as well as potential benefactors. Thus, both listening to and communicating with others are widely recognized as crucial managerial skills for deans.
The financial needs of medical schools have grown dramatically in recent decades.1–3,7,11,22,23 As a result, skills in financial stewardship and strategic planning are widely recognized as essential for deans.7,8,11,12,20–23 The dean must manage a complex organization with very narrow budgetary margins while advancing innovation and encouraging employee entrepreneurship. The changing environment for philanthropy and its growing role in AMC development has made skills in fundraising a more prominent feature of the dean's tool kit.12 Because financial management, strategic planning, and fundraising are not activities that the dean can accomplish alone, this is one of many areas in which the effectiveness of the dean hinges on building and managing expert teams.
Effective management of leadership teams increasingly is recognized as important for the success of complex organizations,24 and a dean must build teams that enhance organizational productivity.7,20,25 This requires the ability to recruit the right individuals into key positions.12,15,26,27 In recent years, leaders in academic medicine also have recognized the need to promote greater diversity in the physician workforce.28,29 Accordingly, skills in recruiting and promoting diversity among faculty and learners are important qualities for medical school leaders.11,30
Whereas numerous management skills are cited as relevant to successful deanship, it is not one's qualifications as an administrator, but as a leader, that the LCME highlights for the medical school dean.9 An adage widely attributed to Peter Drucker distinguishes manager and leader roles: “The manager does things right; the leader does the right thing.” Indeed, Clawson and Wilson12 emphasize this distinction between managers and leaders in medical schools specifically. A thorough review of the qualities of leadership is far beyond the purview of this article (the Library of Congress lists more than 4,000 books involving leadership published since 2001),31 but the various resources we used for this article provide multiple references to a relatively discrete group of qualities relevant to leadership of AMCs. Although many constructs exist for describing leadership qualities, the framework of the “seven demands of leadership” recently described by scholars of leadership at the Gallup Corporation32 was chosen as a means for grouping the identified leadership qualities, because it both highlighted issues raised by many experienced deans and encompassed the elements described in the literature. The leadership qualities described in this model are visioning, maximizing values, knowing self, mentoring, building constituency, making sense of experience, and challenging experience.
A critical characteristic that distinguishes management from leadership is the ability to develop and communicate an organizational vision, described by Gallup as “imagining and frequently articulating vivid pictures of the future.”32 This leadership trait is widely described as an essential quality for medical school leaders.12,16,18,33,34 An effective vision derives from and supports the values of the leader and the organization. Gallup names this leadership quality maximizing values. “Leaders bring direction and motivation by articulating through words and actions the values in which they believe. They provide opportunities for those they lead to discover their commonly held core values, thereby unifying and harnessing their beliefs.”32 Studies of medical school leadership frequently identify commitment to values as an essential leadership quality.12,16,33,35–37 The matching of vision and values has become particularly important with the growth in the size, complexity, and financial demands of the AMC.33
The definition of knowing self refers to the insight “that effective leaders have an acute sense of their own strengths and weaknesses … they know who they are—and who they are not.” By knowing oneself, the leader is consistent and genuine in his or her behaviors and dealings, and this lack of pretense enables the leader to be more effective in working with others. Various authorities on the medical school deanship reinforce this theme, emphasizing that leaders in academic medicine must understand themselves: “You cannot know your strengths if you do not also recognize your weaknesses.”12 Scholars of medical school leadership emphasize that leaders appreciate their own strengths and are able to identify and mobilize the complementary talents of others.11,16–18,20,21
In academic medicine, the skill of recognizing the unique talents of others may be particularly important in the time-honored role of mentor. Effective leaders should be expected “to accelerate highly talented individuals … to their optimal level of performance.”32 Mentoring has been widely recognized as a key factor in the success not only of deans, but also of medical school faculty.11,17,38–40 Assuming the position of dean only elevates and expands the importance and potential impact of this mentoring.12,16
In addition to mentoring, leaders also must be effective at building a constituency, or creating rapport at many levels. The effective dean must have the ability to build constituency for school initiatives, engaging faculty, staff, learners, and community leaders in organizational transformation.11,16,41 Without a broadly based constituency, the inherent inertia of an academic institution can thwart even the most well-intentioned initiative.
Making sense of experience is a more complex leadership quality. “Leaders are able to deal with the complexity of business life and help those around them make sense of it. They do this by keeping things simple and making information accessible. This way, these leaders help individuals understand what's going on so that they are better able to achieve success.”32 Medical school faculties are accustomed to using facts to guide their decisions. In making sense of experience, the dean must have skills in interpreting and sharing data relevant to the circumstances of the school and its environment, then communicating these findings to the faculty in an effective way to provide the needed rationale for institutional adaptations.12,19,26,35 The complexity of the AMC often renders key facts, such as budgetary funds flow and allocation decisions, obscure even to those in leadership roles. Thus, making sense of experience implies a willingness on the part of the dean to work toward transparency to counter this obscurity and the mistrust it often creates.7
The seventh dimension of leadership within the Gallup framework is challenging experience.32 Effective leaders are always raising the bar for themselves and for the organization, creating new expectations consistent with their vision and values, and they must “challenge their teams to achieve significant work goals.”32 To challenge experience, deans must hold others accountable, acting decisively when needed, taking risks themselves, and encouraging bold actions in others.8,12,33,35,42
The professional training of medical school deans confers a deep knowledge of the art and science of clinical medicine, typically accompanied by highly focused content expertise in research and/or education. This background, combined with the dean's role as leader of a teaching institution, makes knowledge a natural, essential attribute of the medical school dean. Given the stunning breadth of knowledge relevant to human disease and the rapidity in recent advances of that knowledge, the scope of scientific knowledge for deanship might be expected to be equally comprehensive. Most discussions of knowledge required of the dean, however, implicitly recognize the impossibility of clinical and scientific omnicompetence and, instead, focus on knowledge specific to the duties of dean. In view of the growing financial and organizational complexity of AMCs, knowledge of AMC finance and governance are frequently mentioned as essential components of a qualified dean's knowledge base.12,20 Likewise, knowledge of the legal and regulatory environment for medical schools has become more important as well.43 Not surprisingly, deans are expected to have much greater knowledge of the school's policy-making milieu than is required of most faculty.
Although most deans are clinicians, the practice of medicine has become so highly specialized that understanding the challenges of practice in one discipline may provide relatively little insight into the challenges faced by other specialties. Accordingly, the dean should have sufficient knowledge to appreciate the variety of practice realities experienced across diverse medical careers. Similarly, a dean will often have deep expertise in a specific area of research but limited experience with the methods applied in other areas of scholarship. As leader of an organization dedicated to medical education, the dean must also have an appreciation and involvement with the medical education process.44 Thus, a dean must hold an appreciation of the needs and expectations of a diverse faculty focusing on the diverse missions of the AMC.15,16,26
In addition to knowledge and skills, there are other qualities that are certainly relevant to the role of medical school deans. Several authorities allude to the importance of temperament or personal style.16,27 One quality is repeatedly highlighted by scholars of the medical school deanship, perhaps because it is not one typically associated with academic success—commitment to the success of others (over one's own recognition).8,12,16 More common among those who have made a successful career in academic medicine is appreciation of the institutional culture. For the dean, however, this understanding of the culture must be combined with patience for the frequently cumbersome and arcane deliberative processes of the academy.16 “Patience with process,”8 though required of deans, may be a special challenge for individuals who have succeeded in academic medicine by being highly focused on action and results.
Scholars reflecting on the challenges facing the modern medical school dean have identified a broad array of qualities that seem relevant to this role. Many of these are confirmed through our literature review and key conversations with students of the practice and art of successful medical school leadership. These qualities include a number of leadership and administrative skills, relevant areas of knowledge, and some key attitudes.
There are also issues critical to the success of the dean that are independent of any knowledge, skills, or attitudes of the candidate assuming the office. Each dean has a unique portfolio of personal expertise and experience that may be specifically attractive or applicable to the needs of a particular institution at a specific time. Sometimes, “insider status,” as Yedidia8 calls it, is important. At other times, a particular focus of scholarship or recognized clinical expertise may be attractive to the faculty or to institutional leaders. Nonetheless, even the perfectly prepared dean is at risk of failure if the recruitment process is flawed. Problems can arise if there is not clear delineation to the dean of the institutional leaders' objectives and metrics for success. Furthermore, if the dean lacks clear authority delegated from institutional leadership, or if access to program development resources is not assured, the dean's tenure may be seriously jeopardized.3,8
Clearly, a review of an admittedly limited literature has limitations, and much further work remains to be done to define the key personal qualities required for a successful deanship. The first and most obvious challenge is how to define success as a dean. Our literature review offered no consistent definition of the successful deanship, and longevity often seems to serve as a surrogate for success. Perhaps this is not surprising in view of the specific circumstances under which any new dean assumes the post. The unique qualities of the candidate, as well as of the institution, pose a challenge to those who hope to describe the general attributes of success for a medical school dean. The diverse constituencies to which the dean is accountable, each with its own metrics for success, complicate the objective definition of a successful deanship. The students, the faculty, the patients, the university leadership, the hospital leadership, and the community all have aspirations for their AMC. For each institution, there is a dynamic interplay between these perspectives that ultimately determines the dean's success. Variations in key institutional factors are likely also key determinants of a dean's accomplishments. These factors could include organizational and environmental characteristics (e.g., research infrastructure, size of endowment, state funding, local economy) as well as variations in the dean's authority and scope of responsibilities (e.g., authority over graduate and other schools, research institutes, practice plans, teaching hospitals).3,8 Of course, local circumstances can change dramatically, sometimes in ways neither foreseeable nor controllable by the new dean. Perhaps it is for this reason that the aphorism, “if you've seen one medical school, then you've seen one medical school,” has been adapted for deanships: “if you've seen one dean, then you've seen one dean.”12
Additional objective evidence on the characteristics of a successful medical school dean could be quite valuable. This information could provide more systematic guidance to the development and selection of deans, as well as in institutional and national efforts in faculty development to promote future successful medical school leaders. Several challenging measurement issues must be overcome to lay the groundwork for such research, however. These include not just the quantification of relevant knowledge, skills, and attitudes, but objective measures of successful deanship. In view of the considerable institutional variability that would have to be accounted for in such a study, only extensive longitudinal data collection would provide sufficient information to disentangle all the variables critical to success in the deanship. Thus, it may be some time before leadership development programs for future deans could be strongly evidence based.
Despite these limitations, our literature review identifies a number of areas of knowledge and skill consistently affirmed by scholars as important to success for medical school deans. These characteristics can provide a basic foundation for needs assessment and professional development activities of academic medical executives preparing for and entering medical school deanships, and they can also provide insight to those charged with selecting their next dean. Attention to these issues will require effort, but the result clearly would be a better-prepared and more successful next generation of medical school leaders.
The authors would like to acknowledge R. Kevin Grigsby, PhD, for his advice and insights throughout this project. They would also like to acknowledge the support of the Council of Deans Fellowship of the Association of American Medical Colleges in the conduct of this work.
The views expressed are solely those of the authors and do not necessarily represent the views of the Association of American Medical Colleges.
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