Editor’s Note: This is a commentary on Kastor JA. Chair of a department of medicine: Now a different job. Acad Med. 2013;88:912–913.
In his commentary in this issue, Kastor1 describes the reaction of many academicians to the complex state of academic health center governance in which we currently find ourselves.2 His 13 years of experience as a chair of medicine in a respected institution and his interviews with 44 chairs of other departments are revealing. My comments are from a background of a different specialty, surgery, and a tenure of 17 years as chair of surgery at the University of North Carolina at Chapel Hill.
Know the Role
Some years ago, when interviewing to be a dean, I asked one of my mentors why deans typically had such short tenures and limited success.3 His wise response was that most people who apply do not understand what the job is. Moreover, although the job of dean has been historically respected, the role may have changed or ossified to the point where it is no longer attractive.
As I looked at positions, I found further wisdom from a longtime mentor, Franklin Murphy, MD, former chancellor of the University of Kansas and the University of California, Los Angeles (UCLA). President Eisenhower had asked Murphy to be secretary of the department then known as Health, Education, and Welfare. When asked why he turned down the appointment, Murphy responded, “I don’t think I would be very good at it.” As Murphy demonstrated, understanding the job, its environment, and your own assessment of what you would do well and would like to devote time to is essential in planning a successful and personally fulfilling career.
Understand the Context
Currently our health care environment is undergoing major transformations. This is the first time that the social, scientific, technological, financial, and organizational aspects of the U.S. health care system are all changing at the same time.4 In the face of these major changes, current chairs of clinical departments retain their base mission of educating students, residents, and junior faculty; performing research; and providing clinical service. In recent years, however, the expansion of systems has increased the corporate aspect of the mission, as Starr5 predicted in The Social Transformation of American Medicine. Many deans, selected for their outstanding research and other academic characteristics, have had difficulty dealing effectively with the enhanced corporate dimension, with which they may have had little to no previous experience. Chairs, similarly, have tried to balance the missions and retain the core characteristics of academia. Individuals pursuing leadership positions in academic health centers today must be prepared to work within the complex health care environment while meeting the needs of the institution, patients, students, trainees, and faculty.
An important characteristic of the University of North Carolina that enabled me to succeed as chair was the collegiality among leaders. Chairs lunched together without agenda each Wednesday, and we maintained good relationships with deans and hospital administrators. Mostly, we had collegial resolution of any disagreements. Personally, I have always regarded the fellowship of chairs of other disciplines as one of the joys of my time as chair of surgery. Respect and appreciation of the cultures of different specialties is important for cultivating such an environment. Understanding the culture of the institution and the department is an essential part of effective leadership.
Stay Attuned to the Department’s Needs
Surgical departments are generally very clinic-oriented and are therefore able to adapt to the increased emphasis on clinical activity in the current environment. Clinical departments are often challenged to ensure that the latest (useful) robot or laparoscopic variant is in place. Moreover, modern operating rooms such as those at University of Alabama and UCLA hospitals are digitally configured and function as highly complex organizations integrating the skills of a disparate team with necessary tasks ranging from equipment maintenance and preparation to sterilization procedures and beyond. Comparable to Kastor’s observation that chairs of medicine have additional patient care responsibilities as a result of resident duty hours restrictions, surgery attendings often conduct operations to accommodate a shortage of house staff and residents’ 80-hour workweek. Surgeons do like what they do, though, and take pleasure in having an intervention and a result.
Surgery departments have adapted reasonably well to the increasingly entrepreneurial environment of academic health centers. At the same time, however, surgery departments have Balkanized by specialty into separate smaller departments. One solution to this problem is the Johns Hopkins model, also in place at Vanderbilt and Wake Forest, which places the chair of surgery over the various specialties and gives department status to each specialty, allowing them to participate in the executive committee of the school. This is an example of effective leadership guided by the needs of the department.
Be Aware of Policy Changes
One problem facing all specialties is the shortage of providers, whose growth is restricted by challenges to the traditional federal funding structure under Medicare for U.S. graduate medical education. Iglehart6 noted that the Affordable Care Act (ACA) had little provision for funding of graduate medical education and expanding the workforce. Medicare can no longer reasonably be expected to be the only source of graduate medical education funding, which requires over nine billion dollars a year.7 Moreover, the Bowles-Simpson Commission targeted Medicare education costs as a target for reduction. So, we are in need of increased residency positions and an all-payer system. Expanding Medicaid in the implementation of state exchanges as the ACA is implemented may be one way to maintain funding for graduate medical education, but the solution remains to be seen. Those aspiring to the position of department chair must understand the implications of these policy issues and be able to remain agile in the face of systemic shifts.
Embrace the Challenge
Kastor notes that his interviews with chairs of medicine concluded that “becoming chair of a department of medicine is not a fun job.” This statement brought to mind a comment from one of the new chairs at my institution several years ago. He was a few weeks into the job and was obviously overwhelmed by the spectrum of challenges and issues confronting him. A more senior chair asked him, “Are you having fun?” He responded, “I am challenged, frustrated, stimulated, and excited, but I can’t say that fun is the dimension I operate in.”
In looking back at my time as chair, it is not the difficulties of the position that come to mind. Instead, I remember the opportunity to hire 107 faculty members (several of whom are now division chiefs or chairs), to help develop a residency program that receives applications from two-thirds of the nation’s graduating seniors going into surgery, and to participate in local and national organizations in ways such as chairing the Association of American Medical Colleges and serving as the president of the American College of Surgeons. I would have to say that I cannot imagine a better job than being a department chair.
Other disclosures: None.
Ethical approval: Not applicable.
1. Kastor JA. Chair of a department of medicine: Now a different job. Acad Med. 2013;88:912–913
2. Sommer JW The Academy in Crisis: The Political Economy of Higher Education. 1995 Piscataway, NJ Transaction Publishers
3. Banaszak-Holl J, Greer DS. Turnover of deans of medicine during the last five decades. Acad Med. 1994;69:1–7
4. Sheldon GF. Great expectations: The 21st century health workforce. Am J Surg. 2003;185:35–41
5. Starr P The Social Transformation of American Medicine. 1982 New York, NY Basic Books
6. Iglehart JK. The uncertain future of Medicare and graduate medical education. N Engl J Med. 2011;365:1340–1345