Internal Medicine Department Chairs: Where They Come From, Why They Leave, Where They Go

Abstract

Internal medicine is traditionally the largest department in a medical school or teaching hospital. As a group, departments of internal medicine have the greatest responsibility for teaching medical students and postgraduate trainees, care for the greatest number of inpatients and outpatients, and are involved with the largest proportion of extramurally supported research compared with other clinical medical school departments.Turnover of leadership in internal medicine departments has serious implications for an institution. Although planned changes may facilitate much needed change in institutional direction, unplanned turnover can disrupt ongoing projects and recruitment, increase concerns among faculty, and destabilize departmental teamwork. In addition, recruitment of a new department chair is expensive and time-consuming.The annual turnover of leadership in departments of internal medicine varies widely but is approximately 18% per year, based on data from the last decade.1Clayton C.P. Grover A. O’Connell M. Association of Professors of MedicineBy the numbers: data on medical school-based departments of internal medicine.Am J Med. 2004; 116: 213-216Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 2Association of Professors of Medicine2006 APM Directory. Association of Professors of Medicine, Washington, DC2006Google Scholar, 3Pearson J. Ibrahim T. Turnover among APM members since 1971.Am J Med. 2002; 113: 706-710Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar This level of change is in line with turnover of other academic department chairs and is slightly less than the turnover of deans.4Stapleton F.B. Jones D. Fiser D.H. Leadership trends in academic pediatric departments.Pediatrics. 2005; 116: 342-344Crossref PubMed Scopus (30) Google Scholar Yet, little is known about the career pathways of the physicians who accept the position of internal medicine department chair.SurveyTo improve retention, it is important to identify the reasons why chairs leave their positions. A survey of current and former chairs of internal medicine departments at medical schools was conducted to determine what positions led to becoming a chair. Former chairs also were asked why they left their position, what position they held after serving as chair, and what advice they had for current and future chairs.Surveys were e-mailed to 164 former chairs of departments of internal medicine and 126 current chairs. Addresses were obtained from the Association of Professors of Medicine (APM) database and included all chairs of departments of internal medicine between 1995 and 2005. This time frame represents the most complete data available and allowed a collection of opinions from the most recent chairs. Responses were collected over a 2-week period. The survey was mailed to former chairs who did not respond to the email survey. Surveys of current and former chairs requested information about their position just before becoming chair of the department of internal medicine. The survey of former chairs also asked why the individual left the position, what position he or she took next, and what advice he or she had for current chairs. The surveys were brief to encourage response from busy professionals; names were not required. Questions about prior positions and reasons for leaving the chair position were multiple choice, with an “other, specify” option. Questions about subsequent positions and advice for current chairs were open-ended.Responses were received from 79 former chairs (48%) and 59 current chairs (47%). Of the 138 respondents, 133 provided information on the position they held just before becoming chair (Figure). Some respondents held more than one position simultaneously, resulting in 168 total positions (1.3 per respondent). The most frequent previously held positions were division chief (59%), vice chair (18%), and interim chair (9%). Unlike former chairs, current chairs not only held the more traditional roles of division chief, vice chair, or interim chair, but an increasing number held Veterans Affairs medical center (VAMC) chief of medicine and internal medicine residency program director positions.One hundred thirty-four respondents specified the location of their previous position. Of these responses, 62% of chairs (35 current and 48 former) previously held a position at the same institution as the chair position. The remainder moved to a new institution to serve as chair.Of the 79 former chairs who completed the survey, 78 responded (Table 1) with 129 reasons (1.7 reasons per chair) why they left the position of chair. Common reasons included existing barriers, desiring a new challenge, and disagreeing with the direction of the dean. Several respondents filled in additional reasons under “other”, including being chair “long enough” (ranging from 8 to 36 years), being in an interim position and leaving when the position was filled by a permanent chair, seeking a different career focus or a change in lifestyle, feeling effectiveness had been diluted or opportunities curtailed, unspecified dean-related issues, reaching a preset institutional term limit, being told that he or she would not be reappointed, entering semi-retirement, and feeling the department would benefit from new resources that would come with a new chair.Table 1Reason for Leaving the Chair PositionNumber of Former Chairs (n=78)Percent of Total ResponsesLooking for new challenges2026Did not agree with the direction my dean was taking1823There were too many barriers to allow me to be effective1621Was offered a more attractive job1317Retired1114Did not agree with the direction my university was taking810Dismissed79Was getting burned out68Other3038 Open table in a new tab Nine of the former chairs who responded had served only as interim chairs and had either not been offered or not accepted the position permanently. The respondents came to the interim chair position by way of division chief (n=3), vice chair (n=4), or by holding both the position of division chief and vice chair (n=1), with one person not responding to the question. After stepping down, interim chairs held the role of vice chair, program director, vice dean, clinical dean, associate dean, division chief, faculty member, or senior vice president for health sciences.Seventy-eight former chairs responded when asked about the primary position held immediately following chairship. The most common responses included returning to the faculty in a full-time or emeritus capacity (n=24); accepting a position as dean (n=7), associate dean (n=13), or vice dean (n=3); accepting a university leadership position (vice president or chancellor [n=4], associate vice president [n=1], center director [n=3]); or becoming a division chief or section head (n=9). Of those respondents who returned to the faculty, some did so as part of retirement or semi-retirement. The remainder of the respondents had accepted a broad variety of positions, including journal editor and medical director of a pharmaceutical company.Former chairs who had changed institutions to assume the role as chair moved to the position of dean more often than individuals who assumed the role of chair within their initial institution, according to 5 of the 7 deans responding. This observation was also true of 1 of 3 presidents, 2 of 3 vice presidents or vice chancellors, and 7 of 13 associate dean respondents.AdviceFormer chairs were asked what advice they would give to current chairs. Not surprisingly, former chairs strongly advised current chairs to maintain their skills in teaching, research, and clinical care. In particular, former chairs recommended that research continue while in the chair role or at least, not be completely abandoned. Teaching, a traditional role of the chair, also was considered critical.5Hemmer P.A. Alper E.J. Wong R.Y. Participation of internal medicine department chairs in the internal medicine clerkship—results of a national survey.Acad Med. 2005; 80: 479-483Crossref PubMed Scopus (6) Google Scholar In addition, current chairs were advised to stay active in patient care, maintain an outpatient or inpatient presence, maintain clinical skills, and be visible to faculty and students. Additionally, former chairs urged current chairs to participate in leadership development activities, build skills in organizational strategies and finance, and remain active in national societies.Formers chairs warned that “honesty, integrity, and values last—the recruitment package does not.” One former chair warned, “Do not to sell out your faculty because you are under pressure from above.” Interestingly, in a recent article exploring dean perceptions of the most important “leadership values in academic medicine,” integrity was rated as the most important.6Souba W.W. Day D.V. Leadership values in academic medicine.Acad Med. 2006; 81: 20-26Crossref PubMed Scopus (34) Google Scholar Given the consistency of response between deans and chairs of departments of internal medicine, one can only hypothesize that disagreements causing the schism between these 2 groups of leaders may be based on the perception that someone in the dyad failed to maintain one’s values. Current chairs were advised to maintain interests outside of medicine, take time for reflection, and not be consumed by their position.Even knowing that one should not “burn bridges” or “that nurturing the relationship with the dean should always be a top priority,” difficulty with the transition from the chair position is inevitable whether due to retirement or lack of contract renewal. Important advice from former chairs (Table 2) included seeking guidance from colleagues and understanding that the loss of the chair position is not necessarily a personal failure. Current chairs were urged to evaluate their effectiveness regularly, as well as to plan for their next position and for their exit. Prospectively, a current chair should consider the next career move with clear understanding of his or her personal strengths, weaknesses, and activities.Table 2Advice from Former Chairs to Current Chairs on Transitioning from the Chair Position•Don’t think of a chair as a permanent position. Evaluate your effectiveness regularly. Plan your exit.•Negotiate an exit package (“parachute”) at the time of appointment or re-appointment. The transition from chair will require financial support (3 years support was suggested). If retiring, consider transitional office space and administrative support.•Consider your next career move as soon as you become chair and re-evaluate your plan regularly.•Don’t threaten to resign. Try to address problems and if insurmountable, leave on your own terms.•Your next job should include things you enjoy now.•In addition to moving “up the ladder” to Dean, consider supporting a national cause or returning to research, practice, or teaching. Once you have a career goal, begin building the skills you need.•Don’t move on to a “higher” position just to prove yourself.•Don’t be afraid to take a step backwards to take one step forward.•The higher the office in academia, the less autonomy. Determine your level of authority in a new organization.•New opportunities are invigorating. Be willing to try something new. Look within and outside academic medicine.•Define the positives and negatives of a job change with regard to professional and personal issues.•Explore the financial status of your new institution in detail—both the medical school and the university.•Seek advice from friends before changing jobs.•Understand that life will change significantly.•Change direction. Consider what changes would be stimulating.•Consider the timing of a new opportunity.•Compare the ratio of soluble to insoluble problems in a potential new position.•Train and support your successor, if possible.•Loss of chairship is not necessarily your failure personally. Open table in a new tab DiscussionAdvice from former chairs was largely positive, which is encouraging for faculty who are considering an internal medicine department chair position. Unquestionably, the duties and challenges of an academic chair have expanded during the past decade and many leaders have advocated for change.7Cohen J.J. Siegel E.K. Academic medical centers and medical research: the challenges ahead.JAMA. 2005; 294: 1367-1372Crossref PubMed Scopus (29) Google Scholar, 8Marks A.R. Lost gold: the decline of the academic mission in US medical schools.J Clin Invest. 2004; 114: 1180PubMed Google Scholar, 9Whitcomb M.E. The most serious challenge facing academic medicine’s institutions.Acad Med. 2003; 78: 1201-1202Crossref PubMed Scopus (6) Google Scholar Shrinking resources from state governments have increased the stress on undergraduate educational programs, particularly in public institutions. Changes in work hours and decreasing indirect medical education payments to teaching hospitals have placed chairs in conflict with hospital leadership. Despite the recent doubling of the National Institutes of Health (NIH) budget, the current inability of the NIH budget to reflect inflation increases the stress on research programs. In the face of these tensions, the chair is called upon to increase the productivity and stature of the department. Not surprisingly, one survey of obstetric-gynecology chairs revealed significant stress and symptoms of burnout.10Gabbe S.G. Melville J. Mandel L. Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention.Am J Obstet Gynecol. 2002; 186: 601-612Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Yet, many former chairs of internal medicine felt that being a chair was the highlight of their career.11Hazzard W.R. I love this job: notes of an internal medicine chairman.Acad Med. 1998; 73: 228-229Crossref PubMed Scopus (2) Google Scholar, 12Coller B.S. Reflections on being a chair of medicine, 1993 to 2001—part 1.Am J Med. 2004; 116: 68-72Abstract Full Text Full Text PDF PubMed Scopus (4) Google ScholarThe results of the survey showed that chairs of departments of internal medicine were drawn from a few key positions in academia, with division chief being the most frequent. Internal hires were common, even after recognizing that some interim chairs never became permanent chairs. A similar reliance on internal hires has been found in medical school deans.13Banaszak-Holl J. Greer D.S. Changing career patterns of deans of medicine, 1940-1992.Acad Med. 1995; 70: 7-13Crossref PubMed Scopus (9) Google Scholar The reasons for this trend are not clear. It is possible that internal candidates have advantages such as a detailed understanding of the institution, a demonstrated ability to work with institutional leadership, and a large base of support within the institution. Internal candidates may also be perceived as a more economical choice as they do not usually require extensive recruiting packages. However, it is also possible that qualified external candidates do not apply, are not identified, or decide not to move.The loss of a chair can destabilize a department, demoralize faculty, and require an expensive, time-consuming recruitment process to find a replacement.14Hash R.B. Weintraut R.J. Gabriel S.A. et al.Developing departmental consensus in the search for a new chair.Acad Med. 2001; 76: 759-760Crossref PubMed Scopus (1) Google Scholar This survey revealed that the reasons for leaving an internal medicine chair position centered on a desire to try something new or to escape frustration or dissatisfaction. The strategic vision of and relationship with the dean is one key factor in retaining the chair. Improved bilateral communication between the chair and the institutional leadership might help mitigate a developing schism. In “The Future-Oriented Department Chair,” Grigsby and colleagues suggest that retention may be improved by ongoing mentorship and development of existing chairs, and by creating a culture of peer support and recognition.15Grigsby R.K. Hefner D.S. Souba W.W. Kirch D.G. The future-oriented department chair.Acad Med. 2004; 79: 571-577Crossref PubMed Scopus (72) Google Scholar Other sources postulate that the departure of a chair is as much the responsibility of the institution as of the individual.16Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair: A Guide to Good Institutional Practice, Module 3. Association of American Medical Colleges, Washington, DC2003Google Scholar They also note that institutional support and mentorship for chairs is often lacking, especially with regard to internal appointments.The results of this study are subject to some limitations. For example, the reasons for leaving represented only the chair’s point of view. It is possible that deans and chancellors may have additional insight into the reasons why chairs depart. Another limitation is that one half of eligible chairs responded to the survey and respondents may not have been representative of chairs in general.Survey results show that chairs of departments of internal medicine bring significant administrative experience to the job and that they have diverse career opportunities after leaving the chair position. Advice from former chairs can be valuable to current chairs and to internal medicine departments wishing to recruit or retain talented chairs. Based on what is known about leadership positions in the department of internal medicine, the authors recommend that APM and the Alliance for Academic Internal Medicine (AAIM) consider:•Continuing to support courses, such as the AAIM Executive Leadership Program, that provides present and future leaders the knowledge and skills to be successful in administrative positions.•Developing a one-on-one mentoring/coaching program for academic internists who wish to consider serving in or who are appointed to administrative and leadership positions.•Working to identify individuals with a future in academic leadership early in their careers and offer them opportunities to expand the skills necessary to be successful.•Offering workshops at annual meetings to help academic leaders reflect on their present positions, their personal strengths and weaknesses, and potential next positions. Internal medicine is traditionally the largest department in a medical school or teaching hospital. As a group, departments of internal medicine have the greatest responsibility for teaching medical students and postgraduate trainees, care for the greatest number of inpatients and outpatients, and are involved with the largest proportion of extramurally supported research compared with other clinical medical school departments. Turnover of leadership in internal medicine departments has serious implications for an institution. Although planned changes may facilitate much needed change in institutional direction, unplanned turnover can disrupt ongoing projects and recruitment, increase concerns among faculty, and destabilize departmental teamwork. In addition, recruitment of a new department chair is expensive and time-consuming. The annual turnover of leadership in departments of internal medicine varies widely but is approximately 18% per year, based on data from the last decade.1Clayton C.P. Grover A. O’Connell M. Association of Professors of MedicineBy the numbers: data on medical school-based departments of internal medicine.Am J Med. 2004; 116: 213-216Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 2Association of Professors of Medicine2006 APM Directory. Association of Professors of Medicine, Washington, DC2006Google Scholar, 3Pearson J. Ibrahim T. Turnover among APM members since 1971.Am J Med. 2002; 113: 706-710Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar This level of change is in line with turnover of other academic department chairs and is slightly less than the turnover of deans.4Stapleton F.B. Jones D. Fiser D.H. Leadership trends in academic pediatric departments.Pediatrics. 2005; 116: 342-344Crossref PubMed Scopus (30) Google Scholar Yet, little is known about the career pathways of the physicians who accept the position of internal medicine department chair. SurveyTo improve retention, it is important to identify the reasons why chairs leave their positions. A survey of current and former chairs of internal medicine departments at medical schools was conducted to determine what positions led to becoming a chair. Former chairs also were asked why they left their position, what position they held after serving as chair, and what advice they had for current and future chairs.Surveys were e-mailed to 164 former chairs of departments of internal medicine and 126 current chairs. Addresses were obtained from the Association of Professors of Medicine (APM) database and included all chairs of departments of internal medicine between 1995 and 2005. This time frame represents the most complete data available and allowed a collection of opinions from the most recent chairs. Responses were collected over a 2-week period. The survey was mailed to former chairs who did not respond to the email survey. Surveys of current and former chairs requested information about their position just before becoming chair of the department of internal medicine. The survey of former chairs also asked why the individual left the position, what position he or she took next, and what advice he or she had for current chairs. The surveys were brief to encourage response from busy professionals; names were not required. Questions about prior positions and reasons for leaving the chair position were multiple choice, with an “other, specify” option. Questions about subsequent positions and advice for current chairs were open-ended.Responses were received from 79 former chairs (48%) and 59 current chairs (47%). Of the 138 respondents, 133 provided information on the position they held just before becoming chair (Figure). Some respondents held more than one position simultaneously, resulting in 168 total positions (1.3 per respondent). The most frequent previously held positions were division chief (59%), vice chair (18%), and interim chair (9%). Unlike former chairs, current chairs not only held the more traditional roles of division chief, vice chair, or interim chair, but an increasing number held Veterans Affairs medical center (VAMC) chief of medicine and internal medicine residency program director positions.One hundred thirty-four respondents specified the location of their previous position. Of these responses, 62% of chairs (35 current and 48 former) previously held a position at the same institution as the chair position. The remainder moved to a new institution to serve as chair.Of the 79 former chairs who completed the survey, 78 responded (Table 1) with 129 reasons (1.7 reasons per chair) why they left the position of chair. Common reasons included existing barriers, desiring a new challenge, and disagreeing with the direction of the dean. Several respondents filled in additional reasons under “other”, including being chair “long enough” (ranging from 8 to 36 years), being in an interim position and leaving when the position was filled by a permanent chair, seeking a different career focus or a change in lifestyle, feeling effectiveness had been diluted or opportunities curtailed, unspecified dean-related issues, reaching a preset institutional term limit, being told that he or she would not be reappointed, entering semi-retirement, and feeling the department would benefit from new resources that would come with a new chair.Table 1Reason for Leaving the Chair PositionNumber of Former Chairs (n=78)Percent of Total ResponsesLooking for new challenges2026Did not agree with the direction my dean was taking1823There were too many barriers to allow me to be effective1621Was offered a more attractive job1317Retired1114Did not agree with the direction my university was taking810Dismissed79Was getting burned out68Other3038 Open table in a new tab Nine of the former chairs who responded had served only as interim chairs and had either not been offered or not accepted the position permanently. The respondents came to the interim chair position by way of division chief (n=3), vice chair (n=4), or by holding both the position of division chief and vice chair (n=1), with one person not responding to the question. After stepping down, interim chairs held the role of vice chair, program director, vice dean, clinical dean, associate dean, division chief, faculty member, or senior vice president for health sciences.Seventy-eight former chairs responded when asked about the primary position held immediately following chairship. The most common responses included returning to the faculty in a full-time or emeritus capacity (n=24); accepting a position as dean (n=7), associate dean (n=13), or vice dean (n=3); accepting a university leadership position (vice president or chancellor [n=4], associate vice president [n=1], center director [n=3]); or becoming a division chief or section head (n=9). Of those respondents who returned to the faculty, some did so as part of retirement or semi-retirement. The remainder of the respondents had accepted a broad variety of positions, including journal editor and medical director of a pharmaceutical company.Former chairs who had changed institutions to assume the role as chair moved to the position of dean more often than individuals who assumed the role of chair within their initial institution, according to 5 of the 7 deans responding. This observation was also true of 1 of 3 presidents, 2 of 3 vice presidents or vice chancellors, and 7 of 13 associate dean respondents. To improve retention, it is important to identify the reasons why chairs leave their positions. A survey of current and former chairs of internal medicine departments at medical schools was conducted to determine what positions led to becoming a chair. Former chairs also were asked why they left their position, what position they held after serving as chair, and what advice they had for current and future chairs. Surveys were e-mailed to 164 former chairs of departments of internal medicine and 126 current chairs. Addresses were obtained from the Association of Professors of Medicine (APM) database and included all chairs of departments of internal medicine between 1995 and 2005. This time frame represents the most complete data available and allowed a collection of opinions from the most recent chairs. Responses were collected over a 2-week period. The survey was mailed to former chairs who did not respond to the email survey. Surveys of current and former chairs requested information about their position just before becoming chair of the department of internal medicine. The survey of former chairs also asked why the individual left the position, what position he or she took next, and what advice he or she had for current chairs. The surveys were brief to encourage response from busy professionals; names were not required. Questions about prior positions and reasons for leaving the chair position were multiple choice, with an “other, specify” option. Questions about subsequent positions and advice for current chairs were open-ended. Responses were received from 79 former chairs (48%) and 59 current chairs (47%). Of the 138 respondents, 133 provided information on the position they held just before becoming chair (Figure). Some respondents held more than one position simultaneously, resulting in 168 total positions (1.3 per respondent). The most frequent previously held positions were division chief (59%), vice chair (18%), and interim chair (9%). Unlike former chairs, current chairs not only held the more traditional roles of division chief, vice chair, or interim chair, but an increasing number held Veterans Affairs medical center (VAMC) chief of medicine and internal medicine residency program director positions. One hundred thirty-four respondents specified the location of their previous position. Of these responses, 62% of chairs (35 current and 48 former) previously held a position at the same institution as the chair position. The remainder moved to a new institution to serve as chair. Of the 79 former chairs who completed the survey, 78 responded (Table 1) with 129 reasons (1.7 reasons per chair) why they left the position of chair. Common reasons included existing barriers, desiring a new challenge, and disagreeing with the direction of the dean. Several respondents filled in additional reasons under “other”, including being chair “long enough” (ranging from 8 to 36 years), being in an interim position and leaving when the position was filled by a permanent chair, seeking a different career focus or a change in lifestyle, feeling effectiveness had been diluted or opportunities curtailed, unspecified dean-related issues, reaching a preset institutional term limit, being told that he or she would not be reappointed, entering semi-retirement, and feeling the department would benefit from new resources that would come with a new chair. Nine of the former chairs who responded had served only as interim chairs and had either not been offered or not accepted the position permanently. The respondents came to the interim chair position by way of division chief (n=3), vice chair (n=4), or by holding both the position of division chief and vice chair (n=1), with one person not responding to the question. After stepping down, interim chairs held the role of vice chair, program director, vice dean, clinical dean, associate dean, division chief, faculty member, or senior vice president for health sciences. Seventy-eight former chairs responded when asked about the primary position held immediately following chairship. The most common responses included returning to the faculty in a full-time or emeritus capacity (n=24); accepting a position as dean (n=7), associate dean (n=13), or vice dean (n=3); accepting a university leadership position (vice president or chancellor [n=4], associate vice president [n=1], center director [n=3]); or becoming a division chief or section head (n=9). Of those respondents who returned to the faculty, some did so as part of retirement or semi-retirement. The remainder of the respondents had accepted a broad variety of positions, including journal editor and medical director of a pharmaceutical company. Former chairs who had changed institutions to assume the role as chair moved to the position of dean more often than individuals who assumed the role of chair within their initial institution, according to 5 of the 7 deans responding. This observation was also true of 1 of 3 presidents, 2 of 3 vice presidents or vice chancellors, and 7 of 13 associate dean respondents. AdviceFormer chairs were asked what advice they would give to current chairs. Not surprisingly, former chairs strongly advised current chairs to maintain their skills in teaching, research, and clinical care. In particular, former chairs recommended that research continue while in the chair role or at least, not be completely abandoned. Teaching, a traditional role of the chair, also was considered critical.5Hemmer P.A. Alper E.J. Wong R.Y. Participation of internal medicine department chairs in the internal medicine clerkship—results of a national survey.Acad Med. 2005; 80: 479-483Crossref PubMed Scopus (6) Google Scholar In addition, current chairs were advised to stay active in patient care, maintain an outpatient or inpatient presence, maintain clinical skills, and be visible to faculty and students. Additionally, former chairs urged current chairs to participate in leadership development activities, build skills in organizational strategies and finance, and remain active in national societies.Formers chairs warned that “honesty, integrity, and values last—the recruitment package does not.” One former chair warned, “Do not to sell out your faculty because you are under pressure from above.” Interestingly, in a recent article exploring dean perceptions of the most important “leadership values in academic medicine,” integrity was rated as the most important.6Souba W.W. Day D.V. Leadership values in academic medicine.Acad Med. 2006; 81: 20-26Crossref PubMed Scopus (34) Google Scholar Given the consistency of response between deans and chairs of departments of internal medicine, one can only hypothesize that disagreements causing the schism between these 2 groups of leaders may be based on the perception that someone in the dyad failed to maintain one’s values. Current chairs were advised to maintain interests outside of medicine, take time for reflection, and not be consumed by their position.Even knowing that one should not “burn bridges” or “that nurturing the relationship with the dean should always be a top priority,” difficulty with the transition from the chair position is inevitable whether due to retirement or lack of contract renewal. Important advice from former chairs (Table 2) included seeking guidance from colleagues and understanding that the loss of the chair position is not necessarily a personal failure. Current chairs were urged to evaluate their effectiveness regularly, as well as to plan for their next position and for their exit. Prospectively, a current chair should consider the next career move with clear understanding of his or her personal strengths, weaknesses, and activities.Table 2Advice from Former Chairs to Current Chairs on Transitioning from the Chair Position•Don’t think of a chair as a permanent position. Evaluate your effectiveness regularly. Plan your exit.•Negotiate an exit package (“parachute”) at the time of appointment or re-appointment. The transition from chair will require financial support (3 years support was suggested). If retiring, consider transitional office space and administrative support.•Consider your next career move as soon as you become chair and re-evaluate your plan regularly.•Don’t threaten to resign. Try to address problems and if insurmountable, leave on your own terms.•Your next job should include things you enjoy now.•In addition to moving “up the ladder” to Dean, consider supporting a national cause or returning to research, practice, or teaching. Once you have a career goal, begin building the skills you need.•Don’t move on to a “higher” position just to prove yourself.•Don’t be afraid to take a step backwards to take one step forward.•The higher the office in academia, the less autonomy. Determine your level of authority in a new organization.•New opportunities are invigorating. Be willing to try something new. Look within and outside academic medicine.•Define the positives and negatives of a job change with regard to professional and personal issues.•Explore the financial status of your new institution in detail—both the medical school and the university.•Seek advice from friends before changing jobs.•Understand that life will change significantly.•Change direction. Consider what changes would be stimulating.•Consider the timing of a new opportunity.•Compare the ratio of soluble to insoluble problems in a potential new position.•Train and support your successor, if possible.•Loss of chairship is not necessarily your failure personally. Open table in a new tab Former chairs were asked what advice they would give to current chairs. Not surprisingly, former chairs strongly advised current chairs to maintain their skills in teaching, research, and clinical care. In particular, former chairs recommended that research continue while in the chair role or at least, not be completely abandoned. Teaching, a traditional role of the chair, also was considered critical.5Hemmer P.A. Alper E.J. Wong R.Y. Participation of internal medicine department chairs in the internal medicine clerkship—results of a national survey.Acad Med. 2005; 80: 479-483Crossref PubMed Scopus (6) Google Scholar In addition, current chairs were advised to stay active in patient care, maintain an outpatient or inpatient presence, maintain clinical skills, and be visible to faculty and students. Additionally, former chairs urged current chairs to participate in leadership development activities, build skills in organizational strategies and finance, and remain active in national societies. Formers chairs warned that “honesty, integrity, and values last—the recruitment package does not.” One former chair warned, “Do not to sell out your faculty because you are under pressure from above.” Interestingly, in a recent article exploring dean perceptions of the most important “leadership values in academic medicine,” integrity was rated as the most important.6Souba W.W. Day D.V. Leadership values in academic medicine.Acad Med. 2006; 81: 20-26Crossref PubMed Scopus (34) Google Scholar Given the consistency of response between deans and chairs of departments of internal medicine, one can only hypothesize that disagreements causing the schism between these 2 groups of leaders may be based on the perception that someone in the dyad failed to maintain one’s values. Current chairs were advised to maintain interests outside of medicine, take time for reflection, and not be consumed by their position. Even knowing that one should not “burn bridges” or “that nurturing the relationship with the dean should always be a top priority,” difficulty with the transition from the chair position is inevitable whether due to retirement or lack of contract renewal. Important advice from former chairs (Table 2) included seeking guidance from colleagues and understanding that the loss of the chair position is not necessarily a personal failure. Current chairs were urged to evaluate their effectiveness regularly, as well as to plan for their next position and for their exit. Prospectively, a current chair should consider the next career move with clear understanding of his or her personal strengths, weaknesses, and activities. DiscussionAdvice from former chairs was largely positive, which is encouraging for faculty who are considering an internal medicine department chair position. Unquestionably, the duties and challenges of an academic chair have expanded during the past decade and many leaders have advocated for change.7Cohen J.J. Siegel E.K. Academic medical centers and medical research: the challenges ahead.JAMA. 2005; 294: 1367-1372Crossref PubMed Scopus (29) Google Scholar, 8Marks A.R. Lost gold: the decline of the academic mission in US medical schools.J Clin Invest. 2004; 114: 1180PubMed Google Scholar, 9Whitcomb M.E. The most serious challenge facing academic medicine’s institutions.Acad Med. 2003; 78: 1201-1202Crossref PubMed Scopus (6) Google Scholar Shrinking resources from state governments have increased the stress on undergraduate educational programs, particularly in public institutions. Changes in work hours and decreasing indirect medical education payments to teaching hospitals have placed chairs in conflict with hospital leadership. Despite the recent doubling of the National Institutes of Health (NIH) budget, the current inability of the NIH budget to reflect inflation increases the stress on research programs. In the face of these tensions, the chair is called upon to increase the productivity and stature of the department. Not surprisingly, one survey of obstetric-gynecology chairs revealed significant stress and symptoms of burnout.10Gabbe S.G. Melville J. Mandel L. Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention.Am J Obstet Gynecol. 2002; 186: 601-612Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Yet, many former chairs of internal medicine felt that being a chair was the highlight of their career.11Hazzard W.R. I love this job: notes of an internal medicine chairman.Acad Med. 1998; 73: 228-229Crossref PubMed Scopus (2) Google Scholar, 12Coller B.S. Reflections on being a chair of medicine, 1993 to 2001—part 1.Am J Med. 2004; 116: 68-72Abstract Full Text Full Text PDF PubMed Scopus (4) Google ScholarThe results of the survey showed that chairs of departments of internal medicine were drawn from a few key positions in academia, with division chief being the most frequent. Internal hires were common, even after recognizing that some interim chairs never became permanent chairs. A similar reliance on internal hires has been found in medical school deans.13Banaszak-Holl J. Greer D.S. Changing career patterns of deans of medicine, 1940-1992.Acad Med. 1995; 70: 7-13Crossref PubMed Scopus (9) Google Scholar The reasons for this trend are not clear. It is possible that internal candidates have advantages such as a detailed understanding of the institution, a demonstrated ability to work with institutional leadership, and a large base of support within the institution. Internal candidates may also be perceived as a more economical choice as they do not usually require extensive recruiting packages. However, it is also possible that qualified external candidates do not apply, are not identified, or decide not to move.The loss of a chair can destabilize a department, demoralize faculty, and require an expensive, time-consuming recruitment process to find a replacement.14Hash R.B. Weintraut R.J. Gabriel S.A. et al.Developing departmental consensus in the search for a new chair.Acad Med. 2001; 76: 759-760Crossref PubMed Scopus (1) Google Scholar This survey revealed that the reasons for leaving an internal medicine chair position centered on a desire to try something new or to escape frustration or dissatisfaction. The strategic vision of and relationship with the dean is one key factor in retaining the chair. Improved bilateral communication between the chair and the institutional leadership might help mitigate a developing schism. In “The Future-Oriented Department Chair,” Grigsby and colleagues suggest that retention may be improved by ongoing mentorship and development of existing chairs, and by creating a culture of peer support and recognition.15Grigsby R.K. Hefner D.S. Souba W.W. Kirch D.G. The future-oriented department chair.Acad Med. 2004; 79: 571-577Crossref PubMed Scopus (72) Google Scholar Other sources postulate that the departure of a chair is as much the responsibility of the institution as of the individual.16Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair: A Guide to Good Institutional Practice, Module 3. Association of American Medical Colleges, Washington, DC2003Google Scholar They also note that institutional support and mentorship for chairs is often lacking, especially with regard to internal appointments.The results of this study are subject to some limitations. For example, the reasons for leaving represented only the chair’s point of view. It is possible that deans and chancellors may have additional insight into the reasons why chairs depart. Another limitation is that one half of eligible chairs responded to the survey and respondents may not have been representative of chairs in general.Survey results show that chairs of departments of internal medicine bring significant administrative experience to the job and that they have diverse career opportunities after leaving the chair position. Advice from former chairs can be valuable to current chairs and to internal medicine departments wishing to recruit or retain talented chairs. Based on what is known about leadership positions in the department of internal medicine, the authors recommend that APM and the Alliance for Academic Internal Medicine (AAIM) consider:•Continuing to support courses, such as the AAIM Executive Leadership Program, that provides present and future leaders the knowledge and skills to be successful in administrative positions.•Developing a one-on-one mentoring/coaching program for academic internists who wish to consider serving in or who are appointed to administrative and leadership positions.•Working to identify individuals with a future in academic leadership early in their careers and offer them opportunities to expand the skills necessary to be successful.•Offering workshops at annual meetings to help academic leaders reflect on their present positions, their personal strengths and weaknesses, and potential next positions. Advice from former chairs was largely positive, which is encouraging for faculty who are considering an internal medicine department chair position. Unquestionably, the duties and challenges of an academic chair have expanded during the past decade and many leaders have advocated for change.7Cohen J.J. Siegel E.K. Academic medical centers and medical research: the challenges ahead.JAMA. 2005; 294: 1367-1372Crossref PubMed Scopus (29) Google Scholar, 8Marks A.R. Lost gold: the decline of the academic mission in US medical schools.J Clin Invest. 2004; 114: 1180PubMed Google Scholar, 9Whitcomb M.E. The most serious challenge facing academic medicine’s institutions.Acad Med. 2003; 78: 1201-1202Crossref PubMed Scopus (6) Google Scholar Shrinking resources from state governments have increased the stress on undergraduate educational programs, particularly in public institutions. Changes in work hours and decreasing indirect medical education payments to teaching hospitals have placed chairs in conflict with hospital leadership. Despite the recent doubling of the National Institutes of Health (NIH) budget, the current inability of the NIH budget to reflect inflation increases the stress on research programs. In the face of these tensions, the chair is called upon to increase the productivity and stature of the department. Not surprisingly, one survey of obstetric-gynecology chairs revealed significant stress and symptoms of burnout.10Gabbe S.G. Melville J. Mandel L. Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention.Am J Obstet Gynecol. 2002; 186: 601-612Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Yet, many former chairs of internal medicine felt that being a chair was the highlight of their career.11Hazzard W.R. I love this job: notes of an internal medicine chairman.Acad Med. 1998; 73: 228-229Crossref PubMed Scopus (2) Google Scholar, 12Coller B.S. Reflections on being a chair of medicine, 1993 to 2001—part 1.Am J Med. 2004; 116: 68-72Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The results of the survey showed that chairs of departments of internal medicine were drawn from a few key positions in academia, with division chief being the most frequent. Internal hires were common, even after recognizing that some interim chairs never became permanent chairs. A similar reliance on internal hires has been found in medical school deans.13Banaszak-Holl J. Greer D.S. Changing career patterns of deans of medicine, 1940-1992.Acad Med. 1995; 70: 7-13Crossref PubMed Scopus (9) Google Scholar The reasons for this trend are not clear. It is possible that internal candidates have advantages such as a detailed understanding of the institution, a demonstrated ability to work with institutional leadership, and a large base of support within the institution. Internal candidates may also be perceived as a more economical choice as they do not usually require extensive recruiting packages. However, it is also possible that qualified external candidates do not apply, are not identified, or decide not to move. The loss of a chair can destabilize a department, demoralize faculty, and require an expensive, time-consuming recruitment process to find a replacement.14Hash R.B. Weintraut R.J. Gabriel S.A. et al.Developing departmental consensus in the search for a new chair.Acad Med. 2001; 76: 759-760Crossref PubMed Scopus (1) Google Scholar This survey revealed that the reasons for leaving an internal medicine chair position centered on a desire to try something new or to escape frustration or dissatisfaction. The strategic vision of and relationship with the dean is one key factor in retaining the chair. Improved bilateral communication between the chair and the institutional leadership might help mitigate a developing schism. In “The Future-Oriented Department Chair,” Grigsby and colleagues suggest that retention may be improved by ongoing mentorship and development of existing chairs, and by creating a culture of peer support and recognition.15Grigsby R.K. Hefner D.S. Souba W.W. Kirch D.G. The future-oriented department chair.Acad Med. 2004; 79: 571-577Crossref PubMed Scopus (72) Google Scholar Other sources postulate that the departure of a chair is as much the responsibility of the institution as of the individual.16Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair: A Guide to Good Institutional Practice, Module 3. Association of American Medical Colleges, Washington, DC2003Google Scholar They also note that institutional support and mentorship for chairs is often lacking, especially with regard to internal appointments. The results of this study are subject to some limitations. For example, the reasons for leaving represented only the chair’s point of view. It is possible that deans and chancellors may have additional insight into the reasons why chairs depart. Another limitation is that one half of eligible chairs responded to the survey and respondents may not have been representative of chairs in general. Survey results show that chairs of departments of internal medicine bring significant administrative experience to the job and that they have diverse career opportunities after leaving the chair position. Advice from former chairs can be valuable to current chairs and to internal medicine departments wishing to recruit or retain talented chairs. Based on what is known about leadership positions in the department of internal medicine, the authors recommend that APM and the Alliance for Academic Internal Medicine (AAIM) consider:•Continuing to support courses, such as the AAIM Executive Leadership Program, that provides present and future leaders the knowledge and skills to be successful in administrative positions.•Developing a one-on-one mentoring/coaching program for academic internists who wish to consider serving in or who are appointed to administrative and leadership positions.•Working to identify individuals with a future in academic leadership early in their careers and offer them opportunities to expand the skills necessary to be successful.•Offering workshops at annual meetings to help academic leaders reflect on their present positions, their personal strengths and weaknesses, and potential next positions. The authors gratefully acknowledge the outstanding work of APM Communications Associate Melody G. Felzien, who compiled mailing lists, posted the survey, and collated results; and APM Director of Member Services Janet Stiles who compiled data of chairs of departments of internal medicine between 1995 and 2005.