In July 2022, I officially marked 5 years as Chair of the Department of Surgery at Boston University School of Medicine (BUSM), my tenure evenly divided between a time when we lived pandemic-free and another with COVID now a fact of life. In reflecting on the last 5 years, I developed a top-10 list, an homage to former late-night TV host David Letterman, which captures some of the most important lessons I have learned as Chair. As always in life, there have been a few surprises along the way.
IT IS NOT A POPULARITY CONTEST
We all want to be liked. It is human nature. However, it is important for those of us who get energy from feeling like “good people” doing the “right thing” to accept that not everyone is going to be a fan of ours. Any Chair who listens carefully will hear or overhear comments or criticism that may reflect unfavorably on their performance, or as a leader overall. My advice: after determining whether there is validity or potential value in the criticism, you have to move on. Not everyone is going to understand your decisions. People will interpret your actions through their own lens, and on some level, that has to be okay.
YOUR DEPARTMENT HAS NO IDEA WHAT YOU DO
Although there is no shortage of tasks that fall within the Chair’s scope of responsibilities, most members of your department do not know what you really do. They might not see you very frequently. They do not know about all the meetings you are in—the in-person meetings, the Zoom meetings, the captivating insurance meetings. Most people are just not aware of all the things you are required to do as a condition of the job on a normal day, never mind the crisis management that COVID, personnel issues, and other situations present. Perhaps they think you are in the closet counting the coins that you have taken from their compensation. Or maybe they think they do not see you because you spend too much time traveling to other institutions, giving exams, or giving talks at national meetings such as this one. The people in your department will not know what is entailed in being an advocate for the department and a force in the institution and community, which hopefully benefits all of them—your faculty, trainees, and staff.
IT IS NOT ABOUT YOU
If you take a leadership position, it cannot be about you anymore. Over the course of your career, you grow accustomed to being a high-achieving person. Personally, my happiest times are when I am operating—especially with the trainees—or doing science, writing grants, and running my own data. But, now it needs to be about raising the faculty up and raising the trainees up, not about my own career.1 As Chair, face it: you are highly unlikely to rise higher as a scientist or as a surgeon. I do not think you should. You have to accept that as an individual, you have now peaked. You ARE the scientist you are going to be. You ARE the surgeon you are going to be. And beyond that, it has to be about empowering others to rise in their careers and relishing the satisfaction that comes with watching them succeed.
IDENTIFY YOUR WEAKNESSES AND LEARN THOSE AREAS
It is always important but especially so in times of crisis, like COVID, to identify the areas in which you are the least confident. We all like to avoid our weaker areas, to throw our best pitches and play the games we know and love. It is important to fight that inclination. It is your areas of discomfort, the things that bore you, the things you are not good at; those are the areas where you need to spend the time required to achieve at least decent competence. Tap into the wisdom within your department or institution and learn from others. But resist the temptation to delegate to others without sufficient oversight, for example, to adopt a mindset of “I prefer big-vision stuff, so I’m going to let the surgeon who has an MBA and really likes the operations side of things take care of that. Meanwhile, I’ll focus on the things I really like—spending time with the residents or working on a research enterprise.” You have to learn all areas, regardless of natural affinity.
KEEP YOUR CORE ENGAGED
I got some advice early in my career, upon moving up to be Surgical Oncology Division Chief at Beth Israel Deaconess the University of Massachusetts Chan School of Medicine. UMass Chair Dr Demetrius Litwin, who remains a good friend, told me that it gets very exciting at this stage, “when you’re perceived as a rising star.” He said there is a lot of excitement, some shiny lights, and people suddenly start treating you like you are important. Mentors are proud of you; friends are happy for you; junior colleagues may admire you, while others may want something and sense a good opportunity in the form of your new status. Demetrius cautioned me not to lose my family or my real identity. It does not necessarily need to be nuclear family that is at risk; it could be your partner, or people in your life that you are close to, or a passion that you have. It is important to be centered on who or what is at your core, because at some point, all of this academic advancement or perks of the position will go away. I remember calling a famous previous Chair’s office once. When he answered his own phone, I stuttered, “Dr. Warshaw! I’m surprised. I was looking for your assistant.” His response was, “Well, I’ve gone from four secretaries to zero. So I’m answering my own phone.” Similarly, Dr John Cameron, who I was so intimidated by on my Johns Hopkins intern interview in 1995, has recently taken to Facebook with a vengeance and captioned one post of himself and 2 other towering figures this way: “Formerly important people.” At some point, your job goes away, but your family and whoever is important in your life will always be much more important than whatever temporary glamour or power that these positions may convey.
I had a good friend in college who was brilliant and extraordinarily persuasive during arguments. One late night, a group of us were sitting around philosophizing in the pretentious way that college kids can do. My friend, who incidentally was a rabbi’s son, posited this thought: “Guilt is a useless emotion.” He later recanted, but even as a practicing Catholic, I will say that I do think it is important to let go of guilt. Otherwise, 1 could live in a state of feeling guilty all the time, especially those of us who have kids or trainees and myriad competing interests to worry about. I do not mean that you should not regret things. We all have decisions that we regret. We commit clinical errors. We may regret financial decisions we have made. We make mistakes at home. We make poor choices. So by all means, absolutely reflect on your mistakes, feel and express your regret, and learn from these experiences. Do better next time. But just the act of guilt—“I feel bad that I’m not home; I feel bad that I am at home”—helps no one. It is useless and at its most indulgent is wallowing in self-pity and helps nothing and no one. When you are running a department or participating in anything in your life, whether it is during COVID, pre-COVID, or post-COVID, anytime, guilt is largely a self-serving emotion. So yes, Adam, you were right: “guilt is a useless emotion” per se, unless you use it to improve subsequent choices.
YOU WILL BETRAY YOUR PEOPLE
This is hard. You will, at some point, be seen as a traitor to one or more of the groups to which you belong. There is a quote that has been attributed to Madeleine Albright, “There is a special place in hell for women who don’t help other women.” And everyone who is a member of a minoritized race has heard terms like “Oreo,” or “banana,” or “coconut,” even. With these in-group slurs, others are letting you know that you may represent a less privileged group on the outside, but you are actually a member of the majority, or one of the oppressors, on the inside. These are hurtful terms. I have observed myself that if a white male surgical Chair speaks up or is seen as a champion of women or the oppressed, he is viewed as being incredibly supportive. Research shows that women who speak up with ideas for change may not see the same benefits as men.2 If you are a female leader who speaks up against sexist terminology, you may be seen as thin-skinned, but if you support another woman, you may be seen as advantaging your own. Conversely, if you are a female leader who has to discipline another woman, it is seen as a betrayal. This scenario can apply for any minoritized individual. At some point, accept that you will be seen as a traitor. You may be called, as I was at 1 point behind my back by a (white) woman, “essentially a white male.” So, it is an interesting concept to grapple with. Outside your institution, people will say, it must be so great to have an X—fill in the blank—a member of your group as the leader. In honesty, the dynamic of being perceived as a role model and a person with power is much more complex than that.
YOU MUST LOVE ALL YOUR CHILDREN EQUALLY
You have to be fair. We need to be actively conscious of the fact that women, underrepresented in medicine individuals, and openly LGTBQ people, have not had the same privileges and have not been considered for the same opportunities as their majority-passing peers. I think about that a lot, but you also need to support members of your faculty who are promising but are not apparently minoritized. We have to strive for equity rather than blind equality. Also, you cannot favor your own subspecialty. I am an HPB surgeon and even beyond that, a pancreas surgeon mostly. But once you become the division chief of surgical oncology, you cannot arbitrarily take operating room time away from the breast surgeons in favor of the pancreas surgeons. And once you become Chair, you cannot just prioritize cancer surgery or surgical oncology or pancreas surgery. It is just as important—or maybe more important—to really care about what happens in cardiac surgery, and in the trauma and critical care division, etc. Whether it is clinical care, research, or compensation, you have to figure out what all of your teams need to succeed.
It is also essential to care about what happens beyond your own department to be effective not only in your institution but ultimately for your own department. In terms of COVID, we have wonderful advanced practice providers (APPs) in the Department of Surgery at Boston Medical Center (BMC). As the pandemic took hold, our surgeons were still busy because we were doing a large volume of trauma surgery. But internal medicine was completely swamped with all of the COVID patients and non-COVID patients and patients who were not in the hospital for COVID but who had COVID. So, we gave up 4 of our amazing APPs for a month, meaning that our residents had to combine services and do more work; they performed fewer operations but more floor and ICU work so these APPs could help on the hospitalist service. Our BMC surgery residents have traditionally had high-outlier case volumes and will be fine for American Board of Surgery requirements and ultimately becoming excellent surgeons, but nationally, there is concern that case numbers are down because of COVID.3 So was giving up 4 of our APPs temporarily good for the house of BMC surgery? Not particularly, although I like to think that it actually was good because we were perceived in the eyes of the hospital as being a good actor, and in it for the team. Down the road, when you are negotiating with other Chairs about various things, they will remember that you were a good soldier and your department helped them out in their time of need. What goes around comes around. Good karma is ultimately good for your department.
IN THE END, FOLLOW YOUR CONSCIENCE
I love my job. It is a great job. I have no complaints. I just want you to know that there are nuances, and there will be difficult decisions for which there is no “perfect” solution. In the end, you just have to try to follow your conscience. Even if people do not like you. Even if people may think you are a traitor to whatever their particular causes are. Some may think that you are chasing your own limelight, that it is all about you or even all about the next job they suspect you of seeking. You just have to follow your conscience and ask yourself, “Is this right?” Take your own temperature. Check your own assumptions. Question whether there is some truth to the criticisms that people have of you. If there is, acknowledge it. Figure it out. But in the end, you have to try to do the right thing, not according to popular opinion but in your personal judgment. At the end of the day, you are the one you have to live with.
THERE IS ALWAYS A CRISIS. THERE IS NO “NORMAL”
At the Academic Surgical Congress, we were specifically asked to discuss conditions that apply to the pandemic. In the 5 years now that I have been Chair at BUSM and Surgeon-in-Chief at BMC, I can say that there is always a crisis of some sort. Talking frequently to my fellow Chairs, I can definitively say this is universal. The crisis may differ from COVID, the mother of all pandemics, but there is always some tumult. My first crisis was related to an revenue value unit restatement that suddenly meant the Department of Surgery was going to be paid less. Then there was something else, followed by something else. Google “#medbikini”—or please do not.4 Your leadership style cannot consist of careening from crisis to crisis. You have to have some overarching vision, and then when a crisis arises, you can figure it out within the context of your overall philosophy. You have to keep steering the ship, no matter that there may be big waves coming this way and that. One wistful approach is to hope: I will just wait until COVID is over, and then we will be back to normal. That is just not the way it is. We have to deal with COVID, and we hope fervently that someday COVID will be completely manageable, but we only have now—whatever “now” may include. It is not sustainable to have a mindset of “It’s all going to be better when ….” It is all going to be better when this, when that, when my ship comes in, when the cows come home. It is important to plan for the future but live in the present. One of my favorite books is The Lord of the Rings. At one point, Frodo says to Gandalf, “I wish it need not have happened in my time.” And Gandalf says, “So do I, and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us.” So, that is how I deal with crises. That is how I deal with COVID. Our BUSM/BMC Department of Surgery has come through COVID (waves 1, 2, and 3) remarkably well, and long may our department continue to come through subsequent crises. It is an honor to try to help us survive and thrive, whatever the storms.
Sometime before assuming my role as Chair, I read Marshall Goldsmith’s book What Got You Here Won’t Get You There.5 It is a sentiment that resonates with me 5 years in. At every stage in your career, you need to develop new strategies and skills, and on most days, I would say that I have embraced—perhaps even enjoyed—the challenges that come with leading my department. True friends with whom you can commiserate or turn to for advice help a great deal. So does a keen sense of the ridiculous during the more outlandish scenarios, although a poker face is usually necessary, too. I feel honored to have this job and am constantly impressed with the commitment, talent, and resilience of the people in various positions across the department who keep us going and thriving—despite the COVID. Meeting more of them and memorizing their names and faces, as well as what is important to them are on my Chair’s bucket list. Names are a weakness of mine but I keep trying. I can always do better.
1. Britt LD Scoggins CR, Pollock RT, Pawlik TM. Mentorship/sponsorship and leadership in academic surgery: similarities and differences. Surgical Mentorship and Leadership: Building for Success in Academic Surgery. Springer, Cham; 2018:81–90.
2. McClean EJ, Martin SR, Emich KJ, et al. The social consequences of voice: an examination of voice type and gender on status and subsequent leader emergence. Acad Manage J. 2018;61:1869–1891.
3. Hope C, Reilly JJ, Griffiths G, et al. The impact of COVID-19 on surgical training: a systematic review. Tech Coloproctol. 2021;25:505–520.
4. Goldberg E “Women Doctors Ask: Who Gets to Decide What’s ‘Professional’?” The New York Times
. 2020. Available at: https://www.nytimes.com/2020/08/02/us/women-doctors-medbikini-professional-gender-bias.html
. Accessed May 25, 2022.
5. Goldsmith M, Reiter M. What Got You Here Won’t Get You There: How Successful People Become Even More Successful. Hachette Books; 2007.