Purpose: The challenges for senior academic leadership in medicine are significant and becoming increasingly complex. Adapting to the rapidly changing environment of health care and medical education requires strong leadership and management skills. This article provides empirical evidence about the intricate needs of department chairs to provide insight into the design of support and development opportunities.
Method: In an exploratory case study, 21 of 25 (84%) department chairs within a faculty of medicine at a large Canadian university participated in semistructured interviews from December 2009 to February 2010. The authors conducted an inductive thematic analysis and identified a coding structure through an iterative process of relating and grouping of emerging themes.
Results: These participants were initially often insufficiently prepared for the demands of their roles. They identified a specific set of needs. They required cultural and structural awareness to navigate their hospital and university landscapes. A comprehensive network of support was necessary for eliciting advice and exchanging information, strategy, and emotional support. They identified a critical need for infrastructure growth and development. Finally, they stressed that they needed improvement in both effective interpersonal and influence skills in order to meet their mandate.
Conclusions: Given the complexities and emotional burden of their role, it is necessary for chairs to have a range of supports and capabilities to succeed in their roles. Their leadership effectiveness can be enhanced by providing transitional processes and supports, development, and mentoring as well as facilitating the development of communities of peers.
Dr. Lieff is director of academic leadership development, Centre for Faculty Development, University of Toronto, Li Ka Shing International Healthcare Education Centre, St. Michael’s Hospital, and professor and vice chair of education, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Dr. Banack is an education researcher, Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada.
Ms. Baker is education research associate, Centre for Faculty Development, University of Toronto, Li Ka Shing International Healthcare Education Centre, St. Michael’s Hospital, Toronto, Ontario, Canada.
Dr. Martimianakis is director of scholarship, Department of Pediatrics, and scientist, Wilson Centre for Research Education, University of Toronto, Toronto, Ontario, Canada.
Dr. Verma is deputy dean, Faculty of Medicine, associate vice provost, Health Professions Education, and professor, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
Dr. Whiteside is dean, Faculty of Medicine, vice provost of relations with health care institutions, and professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Dr. Reeves is director, Center for Innovation in Interprofessional Education, and professor, Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, and affiliate scientist, Ki La Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada.
Correspondence should be addressed to Dr. Lieff, Centre for Faculty Development, University of Toronto, Li Ka Shing International Healthcare Education Centre at St. Michael’s Hospital, 209 Victoria St., Room 480, Toronto, Ontario, M5B 1T8; telephone: (416) 864-5929; e-mail: firstname.lastname@example.org.
The role of the department chair in academic medicine is multifaceted. They oversee a variety of missions, guide recruitment and retention, administer the academic infrastructure, raise funds, and maintain the school’s profile.1 They often find themselves “between a rock and a hard place,”2 eliciting support from leaders at the medical school and teaching hospitals while at the same time gaining and maintaining the confidence of faculty.3 Their role constantly evolves in response to the changing landscape of health care reform, care delivery models, economic constraints, health care and educational innovations, scientific understanding, technology, and recommendations for the future and advancement of medical education.4–10
Why then does the literature—which has looked at the needs and experiences of deans in academic health science centers11,12—pay so little attention to the role of department chairs? The literature that does exist is predominantlyanecdotal or opinion, with few empirical data. Commentaries have explored specific traits or resources that help chairs succeed, including strong communication skills, emotional competence, administrative support, and continuous self-assessment.13,14 Yet, although these personal reflections provide some insights, further exploration is needed to understand the “real” needs of department chairs.
Few empirical studies have explored the experiences of department chairs, in general, or of chairs in academic medicine, in particular. Studies in higher education and community colleges have begun to identify factors for success, emphasizing the importance of providing specific development and support.15,16 In academic medicine, suggested ways to enhance the success of chairs of internal medicine include changing the selection process to measure emotional intelligence, using organizational and leadership development, and instituting mentoring, coaching, and learning collaboratives.17 However, empirical research to support these recommendations is scarce. This article attempts to fill that gap by providing further empirical evidence to guide the design of support and development programs that can meet the complex needs of university department chairs in academic medicine.
To help us understand the needs of chairs, we adopted an exploratory qualitative case study approach.18 Case study methodology, used for in-depth investigation of individuals, groups, or events, allows researchers to continuously analyze data with the purpose of better understanding the phenomenon they are studying.18 We explored the experiences of department chairs in a faculty of medicine.19 Specifically, we wanted to describe the areas they felt were essential for success, were particularly challenging, or required more support or development.
We studied the department chairs within a faculty of medicine at a large Canadian university in a multicultural urban center.20 The faculty of medicine has 2,667 full-time and 2,702 non-full-time faculty members within 25 departments. These basic science, clinical, rehabilitation science, and interdisciplinary departments range in size from 9 to 919 faculty members. Faculty are situated in a variety of settings, including the medical school, teaching hospitals, and research institutes. The medical school is embedded in the host university administratively, and the independently governed hospitals and research institutes are party to a university/hospital affiliation agreement. Typically, hospital and research institute faculty are more dependent on their base sites for resources or salary support than on the medical school or university.21 Department chairs, selected by a competitive peer-review process, serve five-year terms, which may be renewed once pending a successful review. Chairs are responsible for the academic missions of research, education, and service, but not for quality of clinical care, which rests with the hospitals’ clinical leadership.
We invited all 25 department chairs to participate in the study; 21 consented. Table 1 describes their demographic characteristics. Locally respected leaders in medical education or medical administration conducted the 75-minute-long, semistructured interviews from December 2009 to February 2010. Their deep knowledge of the field and context allowed them to probe and explore more richly than could a research assistant. During the interviews, which were digitally recorded, transcribed, and rendered anonymous, the participating chairs reflected on their perceptions and experiences in relation to their motivations for becoming chairs, their transitions into leadership, the nature of their work, their perceived learning needs, and their experiences as chairs.
We conducted an inductive thematic analysis of the data to explore emerging issues and themes. Two researchers independently read the transcripts and identified tentative issues and codes, organizing them into preliminary categories. The project team met frequently to discuss and refine these initial codes and categories. Eventually, through an iterative process of relating and grouping of codes, the team identified a coding structure divided into major themes and factors22 using NVivo qualitative data analysis software.
Ethical and quality issues
The local ethics review committee approved this study. Research rigor was established according to the dimensions of “trustworthiness” established for qualitative research findings: transferability, dependability, confirmability, and credibility.23 Transferability of the data was achieved primarily through rich description of the phenomenon under investigation. The team approach to data analysis enhanced the dependability of findings. Confirmability was improved through an audit trail which provided a transparent description of the research process from start to finish. Finally, investigator triangulation assisted in establishing credibility.
We have grouped the needs that emerged from the department chairs’ narratives into five main themes: cultural and structural awareness; network of support; infrastructure growth and development; interpersonal skills; and influence. Table 2 summarizes the coding structure and provides illustrative quotes.
Network of support
The participating chairs were acutely aware of the challenges of balancing multiple responsibilities within the role as well as responsibilities to their careers and themselves. Networks of support, they claimed, were essential to meeting these challenges. Although the makeup of each network was unique to the individual and his or her needs, we found commonalities in their critical elements.
Forming relationships with past chairs and other leaders within and outside the organization allowed the chairs to elicit advice, exchange information, and facilitate strategy. Forging connections with people in places of power was necessary for accomplishing their visions for their departments. The chairs also highlighted the importance of assembling effective administrative teams to help manage the volume of work. Surrounding themselves with people they could trust and to whom they could delegate was critical to managing their multiple responsibilities.
An emotive dimension also stood out in the construction of their networks. The chairs shared how networks helped combat feelings of isolation and loneliness. A small group of chairs spontaneously created an informal group that met regularly to discuss difficult issues regarding faculty, students, and systems. Although they recognized such sounding boards as an essential element in their ideal network, the majority of chairs had not established such a community of peers. Many chairs also turned to their families and friends; a supportive home environment seemed essential to their success.
Infrastructure growth and development
Infrastructure growth and development also appeared vital to the chairs’ success. They discussed the growth of their departments in terms of student enrollment, faculty recruitment, number of programs, space, and research capacity. Many measured their success by the number and quality of individuals in their department. They felt that having the “right” people on board would help move the department forward. They also viewed growth in terms of collaborations with other departments and organizations, which increased access to valuable resources. Related to this was the importance of promoting and managing the image of their department, through which they hoped to recruit more students and faculty members and stimulate opportunities for collaboration.
They also discussed the necessity of financial support. When they perceived a discrepancy between their funding and the cost of achieving their vision, they came up with creative ways to generate revenue. These included applying for external grants, persuading faculty to switch to merit-based salaries, providing educational materials for profit, relocating laboratory space, increasing enrollment, and forging ties to industry.
Finally, the cultivation of leaders emerged as a major theme. The chairs felt it important to encourage faculty within their departments to take on leadership roles. In particular, they were concerned with succession planning and having someone who could carry on their vision for the department.
The chairs discussed interpersonal skills as being essential to their success. In particular, they felt that talking to faculty members, residents, and students about their issues helped them sense the “pulse” of the department, enabling them to uncover and manage emerging needs and priorities. They found it particularly important to value people, identify their strengths, and recognize their accomplishments, as well as to identify potential weaknesses and provide appropriate supports. Although effectively working with others in various capacities was seen as critical, some chairs were surprised by how much time they spent on interpersonal work.
The chairs discussed the ability to deal with difficult situations and manage conflicts as an essential, though difficult, part of their role. They shared stories of conflicts between faculty, failures of students or faculty to thrive, and instances where faculty engaged in coercive behaviors. Many discussed the emotional burden of dealing with such situations. Finally, the chairs named communication skills as essential to their success. These included such capabilities as active listening, asking the right questions, and clearly and concisely conveying information about departmental issues.
Cultural and structural awareness
A dominant theme for the chairs was the ability to navigate the cultural landscape of their department, as well as the hospitals, institutes, and university. They noted both an explicit and an implicit culture that was nuanced. This included such things as history, social norms, and values within the hospital, their department, and the university. Appreciating these aspects of the culture was critical to their work. This proved particularly challenging for chairs coming from outside organizations or departments. They highlighted the importance of “doing their homework” and uncovering the values of the department before making any attempt to mobilize the department for change.
In addition, they believed it essential to have an in-depth understanding and perspective of the overall system, including the structures and processes within the hospital, their department, and university. Having an awareness of the available resources, contacts, and existing infrastructure was essential to their ability to perform to their full potential. This included understanding processes of recruitment, review, tenure, finance, and accreditation; promotional and academic misconduct issues; and human resource systems. In particular, participants highlighted the importance of understanding the bigger picture outside their department. The multitude of joint partnerships, the relationship between the academic hospitals, the university, and government, and the roles of the various research institutes were described as a “matrix.” To be successful, participants highlighted the importance of appreciating how this matrix functioned and where they fit within it.
Ability to influence
Many of the participants became departmental chairs to make a difference; they wanted to make meaningful changes to their organization. Indeed, most shared clearly defined visions or ideas for change. For many, the motivation to become chair arose from the belief that they would be better able to accomplish their visions from that position rather than as faculty members. They recognized that achievement required risky, sometimes unpopular decisions, which in turn demand courage, a difficult aspect of the role. Some chairs discussed the shift from wanting to please everyone to making tough decisions in the best interests of the department as a whole. They had to balance the need to take such risks with the need to garner overall support and engage their departments. It appeared that the credibility of the chair within the department and organization often encouraged shared ownership, helping to encourage faculty and students to support the vision of change.
Many expressed a need for influence to accomplish their goals. Some chairs expressed surprise and frustration over their “lack of power,” a result, they felt, of the disaggregated governance model in which faculty members are accountable to more than one institution (hospital and university) and chairs often straddle competing, even incompatible, agendas. In response, they felt the need to identify the sources and types of power within the system and to know whom to talk to in order to get things done.
Although department chairs play a key role in universities,24 very little is known about what they need to perform their academic leadership responsibilities (in contrast to their clinical leadership responsibilities). Our study provides rare empirical insight into the complex experiences and needs of chairs.
From the participating chairs’ narratives about their roles and responsibilities, we highlighted complex, interrelated groups of needs that will require the development of leadership and management skills and the construction of networks of support. These networks will range from adequate administrative infrastructure (a given in the business world, but not always provided to incoming chairs)25 to emotional backup from trusted colleagues, family, and friends (of particular value to newcomers, who are often unprepared for the isolation and pressures they will encounter)26,27 to opportunities to solicit advice from respected and trusted academic leaders (essential when dealing with challenging situations and individuals).28
In addition, successful chairs must have effective interpersonal skills. Among other things, they need to uncover and manage the needs of faculty, residents, and students, value members of their department, communicate effectively, and successfully deal with conflict. Because they are often targets of others’ dissatisfactions, frustrations, or anger, they must build effective relationships while managing the projections on them of these emotions.26,29
Furthermore, to develop infrastructure and growth within their departments, chairs must secure resources and recruit and cultivate others. For this, they need to understand organizational structure and process, appreciate social norms and values, and have an overall system perspective. The disaggregated governance model, similar to the model used at Harvard University,21 has complexities that require appreciation of the unique landscapes of its member institutions.
Finally, the need for influence to facilitate their vision emerged from our data. Influence in this circumstance involves the ability to leverage various sources of power in service of a particular agenda. Our data suggest that influence requires courage, the engagement of others, and their access to power systems.
An understanding of these needs provides new chairs and their employers’ key areas to focus on to ensure smooth transition and successful leadership. The data suggest that if attention is paid to providing chairs in academic medicine with supports and processes for transition, mentorship and development, and communities of peers, it will begin to address their needs.
Our findings highlight the essential need to provide chairs with orientation processes and supports to enable their transition into the role. An orientation could introduce them to the current resources available to their department and the current infrastructure within which they are situated. However, the structural orientation must go beyond their department alone to include the sometimes confusing array of hospitals, research institutes, department and university structures, and processes and provide a system overview including the local governance and power structures. Individuals need to understand the demands and expectations of the roles going in so that they can ensure they are either capable or commit to learning the tasks and capabilities essential to the role. From a cultural perspective, they could be connected with key individuals and groups within and beyond their departments. Effort must be made to assist chairs in appreciating the history of the department and its existing social norms and values.
This orientation, ideally, should take place before they assume the position as chair. In particular, enabling a transition whereby the incoming chair would overlap or have multiple visits whilst the outgoing chair is still in place would provide opportunity to get the pulse of the culture as well as develop relationships with key individuals. Once they have assumed the position, a more formal orientation and/or materials might address common processes and problems that they will encounter and strategies and resources available to deal with them.
In addition, administrative infrastructure must be seen as essential to enable chair transition and success. In contrast to the business sector, chairs are expected to negotiate for necessary supports in spite of the fact that many have minimal awareness of departmental details prior to their arrival. An adequate standard of administrative support must be a requirement for incoming chairs.
Mentorship and development
Chairs in academic medicine value and would benefit throughout their terms from ongoing support and advice, which could take the form of mentorship. Mentors may include past chairs or more senior chairs, other leaders within the faculty, leaders external to the organization, or executive coaches. Indeed, chairs may require more than one mentor or advisor to fulfill their various needs and may prefer a combination of long- and short-term relationships.30,31
A past chair, or more senior chair, would be able to help chairs navigate the social norms and values and expected behaviors that are unique to their role and specific to their department and organization. Chairs need to be educated about strategies to appreciate culture at the levels of observed behaviors, espoused values, and shared tacit assumptions in order to identify cultural issues and consider the implications for their intentions, vision, and change efforts.32 It may be useful to be connected with someone who is still immersed in the culture of the organization to act as a cultural interpreter, because even academic cultures have their own language, behaviors, rituals, and symbols. This is not to diminish the value of an outsider or “fresh eyes” perspective that a leader from outside the organization may provide but, rather, to enable them to perceive the local organizational assumptions. Whether a mentor should be formally assigned or whether individuals should informally seek them out on the basis of need is a debate within the literature.33
Although still relatively untapped within the academic medicine landscape, executive coaches are used extensively within the corporate world.34 They can facilitate the development of key leadership skills, including humility, awareness of strengths and weaknesses, work–life balance, and collaboration.35 A coach can provide immediate feedback and support with challenging ideas and situations and can complement other learning opportunities.
Many chairs articulated their desire for leadership development early in their position. These chairs recognized their “amateur administrator” role, and some pursued their own development by self-directed reading or attending leadership development.36 Most had not, however, and felt that they would benefit from such experiences. Given their perceived needs and the challenging interpersonal demands of the job, such a program would need to make interpersonal aspects of leadership a top priority. Additionally, discussions about self-awareness and resilience, succession planning, academic systems and governance, change, human resource, and political and cultural aspects of organizational work and influence would address their needs. Rather than wait until one becomes a chair, “high potential” faculty who aspire to these roles should be encouraged to seek out development opportunities that would position them for success. Departments and faculties should also screen candidates for these leadership capabilities.
Community of peers
A third area to consider in supporting the complex needs of chairs is the notion of communities of peers. The importance of a network of coaching and support was highlighted in the data. Indeed, some participants discussed creating their own informal community of peers. This illuminates the importance of providing informal spaces that create opportunities in which peer coaching can be stimulated and encouraged.37 Peer coaching has been described as a “developmental relationship with the clear purpose of supporting individuals within it to achieve their job objectives.”38 It requires (1) equal status of partners, (2) focus on personal and professional development of both peers, (3) integration of reflection on practice to identify critical incidents for focus, and (4) emphasis on process as well as content that facilitates leadership skill development and accelerated career learning. Regular informal gathering and meetings can provide social opportunities whereby such relationships can develop.
When they first begin, chairs are often insufficiently prepared for the demands of their roles. The trust placed in these senior leaders to manage high risk and significantly important portfolios places the responsibility on the organization to ensure their leaders are capable and supported to deliver their mandates. Given the complexities and emotional burden of the role, provision of adequate administrative support as well as opportunities for orientation, leadership development, mentorship, and communities of peers will enhance the likelihood of early success. Many of the participants in this research expressed their strong desire for such support to enable them to address, from the onset, the demands of their multiple responsibilities with a sense of confidence based on usable knowledge and the application of newly acquired leadership skills.
Other disclosures: None.
Ethical approval: Ethical approval was obtained from the University of Toronto ethics review committee.
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