Leadership in Academic Medicine: Capabilities and Conditions for Organizational Success

Abstract

During the past decade, the health care industry has experienced an upheaval that is expected to continue into the foreseeable future. Patients and physicians alike feel shortchanged by this rapid and perplexing transformation.1Fein R. The HMO revolutionDissent.Spring. 1998; : 29-36Google Scholar “This new order in health care, one governed by commercialism and free competition, presents academic medical centers and university physicians with unique challenges,” observed Wiley W. Souba, MD.2Souba W. Academic medicine and the search for meaning and purpose.Acad Med. 2002; 77: 2Crossref Scopus (49) Google Scholar All 3 missions of academic medicine—teaching the next generation of physicians, conducting groundbreaking research, and providing high-quality care to patients—are jeopardized by this future.2Souba W. Academic medicine and the search for meaning and purpose.Acad Med. 2002; 77: 2Crossref Scopus (49) Google ScholarTo survive in the 21st century, medical schools and teaching hospitals must develop their ability to innovate and change.3Commonwealth Fund Report AMCs need to develop capacity for innovation.Health Care Strateg Manage. 2001; 19: 10Google Scholar However, when compared to the governance, organization, and leadership structure of corporate entities, academic institutions lack the necessary infrastructure for such transformation.4Schwarz R. Pogge C. Physician leadership is essential to the survival of teaching hospitals.Am J Surg. 2000; 179: 462-468Abstract Full Text Full Text PDF PubMed Scopus (35) Google ScholarThe chairs of clinical departments represent the heart and soul of the leadership of medical schools and teaching hospitals. These leaders are well positioned to greatly affect departments and, ultimately, institutions. US medical schools have more than 3000 department chairs but only 125 deans.5Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 1). Association of American Medical Colleges Publications, Washington, DC2002Google Scholar Despite the fact that department chairs outnumber all other university administrators combined, policymakers have paid little attention to the roles, responsibilities, and needs of these leaders.5Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 1). Association of American Medical Colleges Publications, Washington, DC2002Google Scholar Compared to the considerable efforts made to groom university presidents and college deans, “relatively little has been done for department chairs … to help prepare them for their new responsibilities.”6Hecht I.W.D. The Department Chair as Academic Leader. Oryx Press, Phoenix, AZ1999Google ScholarA new department chair enters an unfamiliar world of administrative and managerial challenges. Most of these individuals are ill-prepared to succeed in this difficult leadership position.6Hecht I.W.D. The Department Chair as Academic Leader. Oryx Press, Phoenix, AZ1999Google Scholar One symptom of this challenge is an unacceptable turnover rate among department chairs. For example, the average tenure of a chair of a department of internal medicine is 3.7 years.7Pearson 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 ScholarUsing a case-based study methodology focused on chairs of departments of internal medicine at US medical schools, the author sought to identify the complex requirements necessary to ensure success as a department chair. This research sought an understanding of the experience of being the chair of a department, as well as the processes and conditions that influence the effectiveness of these leaders. Since departments of internal medicine are the largest and most complex units within medical schools, they are pivotal in the culture and success of academic institutions. The chairs of departments of internal medicine provide a critical view of leadership issues in academic medicine.After randomly selecting 10 chairs of departments of internal medicine, the author collected and analyzed their curriculum vitaes, administered 2 survey instruments that explored self-efficacy and job content, and conducted 3 structured (and open-ended) interviews with the chairs (Table). The first interview was conducted face-to-face; subsequent interviews were conducted by telephone. The interviews explored salient aspects of leadership based on the current literature regarding leadership in general and on previous research conducted specifically on department chairs at US medical schools.5Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 1). Association of American Medical Colleges Publications, Washington, DC2002Google Scholar These characteristics included training, challenges, skills, leadership style, organizational conditions, organizational structures, change management, performance measures, and evaluation. Perceptions and attitudes regarding stressors, burnout, emotional intelligence, perceived challenges, and potential reasons for failure were also explored.TableYears as ChairSpecialtyInstitutionFaculty SizeTime Spent on AdministrationResearch-IntensiveEducational and Clinical Emphasis16SubspecialistX101-20050%212SubspecialistX101-20075%33SubspecialistX>20035%48SubspecialistX>20060%55SubspecialistX<10035%69GeneralistX<10070%74SubspecialistX101-20060%85SubspecialistX101-20050%94SubspecialistX>20055%108GeneralistX<10057%Average6.45555% Open table in a new tab After the interviews were transcribed and independently coded, an emergent theme analysis of content was conducted. Through this in-depth analysis, a clear picture of the role and challenges of a chair of a complex department emerged.From a demographic perspective, the cohort of 10 chairs—whose ages ranged from 45- to 62-years-old—included 9 males and 1 female. The length of tenure in their present positions ranged from 3 to 12 years, with an average of 6.4 years. The 10 departments varied in size, with the largest employing a total of 450 faculty.Before becoming department chairs, the 10 physicians were most often division chiefs, although some served as vice chairs of departments of internal medicine, internal medicine residency program directors, or center directors. The average length of administrative experience before becoming a chair was 9.1 years, with a range between 2 and 20 years. Of the 10 participants, 2 were general internists and 8 were subspecialists. The Figure summarizes information about the 10 chairs who were interviewed.The 10 chairs spent an average of 55 percent of their professional time in administrative duties for the department, the medical school, and the affiliated teaching hospital(s). None of the 10 chairs had advanced degrees in management, although one had a master’s degree in public health. Most of the participants reported that at an early stage in their careers, they had gravitated toward or had been presented with leadership experiences. Some were chief residents or were given significant management responsibility as junior faculty. All had significant experience in building programs, which they considered a satisfying experience.Although the participants were randomly selected, it is likely that only successful chairs agreed to participate in this study. Of note is that by length in their positions, performance of departments, results of change initiatives, and any number of additional measures, these 10 chairs were examples of successful leadership.Factors necessary for successThis study identified a number of critical factors essential for a chair to succeed as an effective leader of a department of internal medicine. In general, chairs viewed their success explicitly as departmental success at that institution. Such success, according to the chairs, was a function of the financial health and status of each of the missions of the department within the medical school.A critical factor for success is congruency in the expectations of the department chair, the medical school dean, and the chief executive officer (CEO) of the teaching hospital. Common expectations are considered a function of open and honest communication and dialogue. The chairs in this study personally experienced or observed recruitment processes during which information had been withheld from potential chairs. They knew of instances in which negotiations never identified or clarified existing institutional challenges. The result of such dysfunctional communication was the development of serious problems soon after arrival of the new chair. A separate study similarly found that failure of a chair could often be traced back to initial events involving the selection process.8Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 3). Association of American Medical Colleges Publications, Washington, DC2003Google ScholarSuccessful department chairs have mastered a basic set of leadership skills. The most important of these are communication skills, leadership skills (such as visioning, strategic planning, and change management), team building, personnel management, business skills, and systems thinking.Emotional intelligence and its concomitant skills are the most essential competencies for leaders to succeed in academic institutions. The 10 chairs emphatically stated that this ability was fundamental to their success and its absence the cause of their failures. They suggested that the absence of emotional intelligence often resulted in the demise of chairs and contributed to the high turnover among their colleagues.This finding is supported by research in fields outside medicine. Emotional intelligence is linked to bottom-line organizational performance in terms of productivity and profit.9Pfeffer J. Viega J. Putting people first for organizational success.Acad Manage Exec. 1999; 13: 37-48Google Scholar In leadership positions, 90 percent of the competencies necessary for success fall into the category related to competency in emotional intelligence.10Goleman D. Working with Emotional Intelligence. Bantam, New York, NY1999Google Scholar Productivity, profit, and performance are directly related to emotional intelligence.10Goleman D. Working with Emotional Intelligence. Bantam, New York, NY1999Google Scholar, 11Boyatzis R. Kolb D. Performance, learning, and development as modes of growth and adaptation throughout our lives and careers.in: Peoiperl M. Career Frontiers New Conceptions of Working Lives. Oxford University Press, London, England1999Google Scholar, 12Spencer L. The economic value of emotional intelligence competencies and EIC-based HR programs.in: Cherniss C. Goleman D. The Emotionally Intelligent Workplace How to select for, measure and improve emotional intelligence in individuals, groups and organizations. Jossey –Bass, San Francisco, CA2001Google Scholar, 13McClelland D. Identifying competencies with behavioral-event interviews.Psychol Sci. 1998; 9: 331-339Crossref Scopus (408) Google ScholarAlso related to emotional intelligence, communication is a vital skill for an academic leader. It is essential for chairs to have a clearly defined communication strategy with very specific targeted audiences, as well as disseminate a tailored message in multiple settings. To become effective communicators, leaders must understand several principles: simplicity of message, use of analogy and metaphors, the need for multiple forums, repetition, the use of examples, and the value of give and take with faculty and staff.14Kotter J. Leading Change. Harvard Business School Press, Boston, MA1996Google Scholar, 15Essex L. Kusy M. Fast Forward Leadership. Biddles Ltd, Kings Lynn, Great Britain1999Google ScholarAfter emotional intelligence, these chairs identified developing a vision as essential. One chair used a metaphor to explain the value of developing, articulating, and implementing a vision: One phrase that stuck with me is that leadership is being a custodian of the shared vision … First, there has to be a vision, and someone has to have said where we are going to be. Then, it has to be shared. If the leader has the vision, but it is not shared, it may not work. And then there is being a custodian. That is, when everyone is off doing their part, someone has to remember where you were headed.A chair also needs to develop a strong, reliable leadership team within the department. This team usually included a group of highly skilled and motivated division chiefs; vice chairs representing each element of the tripartite mission; and a trusted, experienced departmental administrator. In addition to this structure, a successful chair delegates authority in an effective manner.Professional development in the managerial arena is critical. The 10 chairs developed their skills, knowledge, and attitudes in this area through mentoring. Formal training programs also provide an excellent means for attaining very specific competencies, particularly information about financial management and the theory of strategic planning. However, these courses do not provide an adequate forum to teach leadership. Two of the chairs reported that executive coaching is a very effective, beneficial method of developing leadership skills.These chairs also emphasized the importance of renewable resources for the success of both the chair and the department of internal medicine. In addition to negotiating a financial package for themselves, new chairs typically negotiate a financial and commitment package for the department. An initial financial package that is depleted in a few years without an alternative for renewal ultimately leads to failure. An ongoing relationship with the hospital and college of medicine that rewards success, as well as ensuring growth and financial stability is critical.Leading a modern-day department involves having the competence to manage a complex business. Generally, the 10 chairs believed that most faculty have had little management training. One chair described this challenge: “You are running a $50 to $100-million a year business, and you need a lot of business, organizational, management, financial, conflict avoidance, conflict resolution kind of skills like any executive of a large organization would.”A common challenge for these chairs was personnel management—particularly dealing with difficult people—which created tremendous stress for them. As one chair noted, “Dealing with a division chief who was frankly antagonistic, did not own his own behavior in terms of spending… It came as a surprise, and this is naïve of me, that there were people who could have reached that level who could act that way.” In general, the chairs felt ill-prepared to deal with these matters effectively.Clinical departments experience significant change on a daily basis. These 10 chairs were uniformly successful in managing change. Only one of the chairs recalled a failure in this regard; this success rate was in contrast to the other examples in the management literature, which indicate that 70 percent of change initiatives fail.16Senge P. Kleiner A. Roberts C. Ross R. Smith B.. The Dance of Change. Doubleday, New York, NY2000Google Scholar This finding corroborates that these 10 chairs represented an extreme example of successful leaders, who offer powerful examples for others. These chairs looked broadly for opportunities but chose carefully, which increased the likelihood of success.Finally, the 10 chairs underscored the significance of defining success for the department through clear goals. The chairs viewed this task as critical for guiding their departments. Most of the chairs developed a methodology for defining concise, specific goals for the department that related to the tripartite mission of academic medicine. At least eight of the chairs had specific goals with metrics that the department developed through a planning process. The departmental leadership used these metrics to assess progress towards accomplishing its mission.Barriers to successNot surprisingly, elements exist that proved to be barriers to success. These impediments created dysfunctional organizations, making it more difficult for a chair to lead a clinical department effectively. In particular, the 10 chairs of this study emphasized four barriers: the relationship between the chair and the CEO of the teaching hospital, the organizational structure of the institution, a lack of work-life balance, and the selection process for academic leaders. In The Successful Medical School Department Chair (Volume 3): Performance, Evaluation, Rewards, Renewal, Julien F. Biebuyck, MD, and William T. Mallon, EdD, also identified these barriers.8Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 3). Association of American Medical Colleges Publications, Washington, DC2003Google ScholarHospital CEOs were considered pivotal in either creating barriers or ensuring success for the chairs of clinical departments. Unfortunately, this relationship was more often a barrier. Unless the CEO shares a common vision for the future of the academic health center, as well as values medical education and research as much as patient care, an adversarial relationship develops. Too often, the financial bottom line became the only issue of concern for the CEO, which was at odds with the chairs who were trying to achieve the broader mission of the department.To make this situation worse, the 10 chairs indicated that some hospital CEOs were negative in their views about physician leaders. Some CEOs expressed a view that physicians were not valued partners in the enterprise but simply personnel that needed to be controlled. The chairs asserted that this attitude often resulted in significant organizational dysfunction. Similarly, a survey of 123 CEOs of teaching hospitals minimized the role of the chair as member of the leadership team.17Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 2). Association American Medical Colleges Publications, Washington, DC2002Google ScholarThe organizational structure, in which a clinical department operated, significantly affects the ability of the chair to function effectively. Institutions that are structured as unified health systems and have developed a close alliance between the hospital (especially the CEO) and the school of medicine seem to have a collegiality, ease of operating, and competitive advantage. In contrast, where the school of medicine, the hospital, and the other departments are completely separate both functionally and administratively, competition and conflict commonly creates barriers to functioning effectively.The third major barrier was the lack of work-life balance for chairs of departments of internal medicine. Two of the greatest causes of stress were the sheer number of hours worked and the emotional pressure related to the position. A barrier to effectiveness, this imbalance seemed to be a contributing factor in the high failure rate of department chairs and the extraordinary turnover rate among academic leaders, including department chairs.According to the 10 chairs, many physicians hired as chairs of clinical departments lacked the requisite skills, knowledge, attitudes, emotional intelligence, and experience necessary to succeed. They felt the current selection process for academic leaders emphasized a traditional attitude that places a much higher value on research and scholarly experience than leadership or administrative ability. This emphasis results in newly hired chairs who discover that the job is quite different than they expected and that they lack the required competency. As one chair explained, “The fact is that the majority of chairs are chosen for skill sets that have little to do with the skill sets they are going to need to use.”RecommendationsTo overcome these barriers and strengthen the factors necessary for successful chairs of clinical departments, the academic medical community should consider four recommendations:Change Dramatically the Selection Process for Chairs of Clinical DepartmentsA strategic and targeted process that includes structured and formalized interviews incorporating measurement of emotional intelligence is needed. After the introduction of this type of selection process, turnover of executives in one large company dropped from 25 percent to 6.3 percent.13McClelland D. Identifying competencies with behavioral-event interviews.Psychol Sci. 1998; 9: 331-339Crossref Scopus (408) Google Scholar This decrease in turnover resulted in a savings of $3.5 million in recruitment costs over 18 months.13McClelland D. Identifying competencies with behavioral-event interviews.Psychol Sci. 1998; 9: 331-339Crossref Scopus (408) Google ScholarUse Organization Development to Improve Systems and Processes Within Academic OrganizationsOrganization development—which includes leadership development, process improvement, management of human behavior in systems, and change management—has produced impressive outcomes in other industries.18Walters P. Characteristics of successful organization development A review of the literature.in: Pfeiffer J.W. Somerset N.J. The 1990 Annual Developing Human Resources. John Wiley & Sons, 1990Google Scholar, 19Golembiewski R. Proehl C. Sink D. Estimating the success of OD applications.Train Dev J. 1982; 36 (86-95): 72Google Scholar Traditionally, academic medicine does not seek help from organization development as a discipline, and significant resistance to such interventions exists.20Weisbord M. Why organization development hasn’t worked (so far) in medical centers.Health Care Manage R. 1976; 1: 17-28PubMed Google Scholar Because the challenges that medical schools and teaching hospitals currently face are immense, organization development may offer much-needed solutions.Implement Innovative Strategies to Improve Leadership in Academic MedicineThis effort should include formal mentoring, learning collaboratives, and executive coaching as mechanisms to support chairs in their positions. Targeted training in emotional intelligence has succeeded in other industries and could benefit leaders in academic medicine.21Poras J. Anderson B. Improving managerial effectiveness through modeling-based training.Organ Dyn. 1981; 9: 60-77Crossref Scopus (36) Google Scholar In one manufacturing firm, accidents and grievances dropped by 50 percent and productivity goals were exceeded by $250,000 after supervisors were trained in these skills.22Pesuric A. Byham W. The new look in behavior modeling.Train Dev J. 1996; 50: 25-33Google ScholarRecognize That Rigorous Research in Leadership and Systems Development Is NecessaryAcademic medicine should consider such discovery a priority that requires funding from multiple sources. The management literature has clearly shown a positive correlation between leadership development and productivity, profitability, decreased turnover, and customer satisfaction.21Poras J. Anderson B. Improving managerial effectiveness through modeling-based training.Organ Dyn. 1981; 9: 60-77Crossref Scopus (36) Google Scholar, 23Buckingham M. Coffman C. First, Break All the Rules. Simon & Schuster, New York, NY1999Google ScholarAt the beginning of the 21st century, the leaders of US medical schools and teaching hospitals are required to manage hundreds of employees, oversee millions of dollars across the tripartite mission, and ensure patients receive high-quality care in a fiercely competitive marketplace. Besides these responsibilities, academic leaders must maintain complex research portfolios and educate hundreds of medical students, residents, and fellows. Critics imply that the leadership of academic medicine is out of touch with the real world1Fein R. The HMO revolutionDissent.Spring. 1998; : 29-36Google Scholar, 24Alpert J.S. Flanagan D.M. Botsford N.A. The future of academic medical centers in the United States Passing through the valley of the shadow of death.Arch Intern Med. 2001; 161: 1047-1050Crossref PubMed Scopus (9) Google Scholar and not able to rise to this new challenge. Unfortunately, the 10 department chairs interviewed for this study agree with much of this assertion.Too often, academic medicine maintains a rigid, hierarchical organization that continues to choose leaders for skills more appropriate to a “cottage industry” than the business of health systems. Academic medicine must change its values, approaches, and processes if it is going help solve the health care crisis in this country. This shift will require incorporating new beliefs, values, and approaches to leadership and organizational issues, as well as innovative approaches by motivated leaders. During the past decade, the health care industry has experienced an upheaval that is expected to continue into the foreseeable future. Patients and physicians alike feel shortchanged by this rapid and perplexing transformation.1Fein R. The HMO revolutionDissent.Spring. 1998; : 29-36Google Scholar “This new order in health care, one governed by commercialism and free competition, presents academic medical centers and university physicians with unique challenges,” observed Wiley W. Souba, MD.2Souba W. Academic medicine and the search for meaning and purpose.Acad Med. 2002; 77: 2Crossref Scopus (49) Google Scholar All 3 missions of academic medicine—teaching the next generation of physicians, conducting groundbreaking research, and providing high-quality care to patients—are jeopardized by this future.2Souba W. Academic medicine and the search for meaning and purpose.Acad Med. 2002; 77: 2Crossref Scopus (49) Google Scholar To survive in the 21st century, medical schools and teaching hospitals must develop their ability to innovate and change.3Commonwealth Fund Report AMCs need to develop capacity for innovation.Health Care Strateg Manage. 2001; 19: 10Google Scholar However, when compared to the governance, organization, and leadership structure of corporate entities, academic institutions lack the necessary infrastructure for such transformation.4Schwarz R. Pogge C. Physician leadership is essential to the survival of teaching hospitals.Am J Surg. 2000; 179: 462-468Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar The chairs of clinical departments represent the heart and soul of the leadership of medical schools and teaching hospitals. These leaders are well positioned to greatly affect departments and, ultimately, institutions. US medical schools have more than 3000 department chairs but only 125 deans.5Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 1). Association of American Medical Colleges Publications, Washington, DC2002Google Scholar Despite the fact that department chairs outnumber all other university administrators combined, policymakers have paid little attention to the roles, responsibilities, and needs of these leaders.5Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 1). Association of American Medical Colleges Publications, Washington, DC2002Google Scholar Compared to the considerable efforts made to groom university presidents and college deans, “relatively little has been done for department chairs … to help prepare them for their new responsibilities.”6Hecht I.W.D. The Department Chair as Academic Leader. Oryx Press, Phoenix, AZ1999Google Scholar A new department chair enters an unfamiliar world of administrative and managerial challenges. Most of these individuals are ill-prepared to succeed in this difficult leadership position.6Hecht I.W.D. The Department Chair as Academic Leader. Oryx Press, Phoenix, AZ1999Google Scholar One symptom of this challenge is an unacceptable turnover rate among department chairs. For example, the average tenure of a chair of a department of internal medicine is 3.7 years.7Pearson 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 Using a case-based study methodology focused on chairs of departments of internal medicine at US medical schools, the author sought to identify the complex requirements necessary to ensure success as a department chair. This research sought an understanding of the experience of being the chair of a department, as well as the processes and conditions that influence the effectiveness of these leaders. Since departments of internal medicine are the largest and most complex units within medical schools, they are pivotal in the culture and success of academic institutions. The chairs of departments of internal medicine provide a critical view of leadership issues in academic medicine. After randomly selecting 10 chairs of departments of internal medicine, the author collected and analyzed their curriculum vitaes, administered 2 survey instruments that explored self-efficacy and job content, and conducted 3 structured (and open-ended) interviews with the chairs (Table). The first interview was conducted face-to-face; subsequent interviews were conducted by telephone. The interviews explored salient aspects of leadership based on the current literature regarding leadership in general and on previous research conducted specifically on department chairs at US medical schools.5Biebuyck J.F. Mallon W.T. The Successful Medical School Department Chair (Volume 1). Association of American Medical Colleges Publications, Washington, DC2002Google Scholar These characteristics included training, challenges, skills, leadership style, organizational conditions, organizational structures, change management, performance measures, and e