Tenures for Department Chairs: How Short Is Too Short?

Abstract

The average tenure for chairs of departments of internal medicine at US medical schools has decreased from 5.272 years in the 1970s to 3.997 years in the 2000s (2000 to 2006). During the past 4 decades, the average length of an interim (or acting) chair’s tenure increased from 1.353 years to 2.355 years. These trends indicate that the leadership of departments of internal medicine is becoming increasingly destabilized. Becoming chair of a department of internal medicine at a US medical school has shifted from the capstone of a successful career to a stop on the way to other positions, such as dean of a medical school.1Nettleman M. Schuster B.L. Internal medicine department chairs: where they come from, why they leave, where they go.Am J Med. 2007; 120: 186-190Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The chairs of yesterday are now running centers and institutes, serving as vice deans for research, or leaving academic medicine to pursue other professional opportunities. Academic medicine has become more corporate: department chairs run “business units” rather than build academic programs in education, research, and patient care; mentor students, residents, fellows, and faculty; or teach, conduct research, or care for patients. This shift raises fundamental questions about the skills, knowledge, and attitudes necessary for chairing departments of internal medicine in the future as well as concerns about the amount of money medical schools spend to replace chairs. These costs include retaining search firms, involving faculty and staff in the search, and providing packages to entice the most appealing candidates. Since 1971, the Association of Professors of Medicine (APM) has tracked turnover for chairs of departments of internal medicine at US medical schools. Examining the turnover rates from 1971 to 2006 provides insights about the tenure of these important academic leaders. Unfortunately, APM and other organizations lack comparable data about the turnover rates among chairs or chiefs of departments of internal medicine at community hospitals. Founded in 1954, APM includes as institutional members departments of internal medicine at medical schools accredited by the Liaison Committee for Medical Education (LCME) and the Committee on Accreditation of Canadian Medical Schools (CACMS). LCME recognized 125 institutions in the United States and the Commonwealth of Puerto Rico in 2006. APM also includes as institutional members 3 separate departments at Harvard Medical School: Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, and Massachusetts General Hospital. In 2006, CACMS recognized 16 Canadian medical schools with departments of internal medicine. APM does not count the newest US medical school—Florida State University College of Medicine—as an institutional member, because that institution does not have a department of internal medicine. Since the accreditation of Florida State University College of Medicine in 2005, 17 new medical schools (or branch campuses) are now applying for LCME accreditation, hiring deans, seeking state approval and funding, maneuvering through the review process at universities, or being proposed by governors and state legislators.2Salsberg E, Grover A. Association of American Medical Colleges Center for Workforce Studies: Physician Workforce Updates. Washington, DC: AAMC Meeting on Physician Shortages and Medicare Resident Limit, January 2007.Google Scholar (In the future, the internal medicine community must consider the potential ramifications if new medical schools lack departments of internal medicine.) Therefore, APM had 142 institutional members in 2006 (124 departments at the schools accredited by LCME that have departments of internal medicine, 2 additional departments at Harvard Medical School, and 16 departments at schools accredited by CACMS). To examine consistent data from 1971 to 2006, this commentary focuses on the 126 APM institutional members in the United States in 2006. The number of departments of internal medicine has varied during the past 4 decades. In 1970, there were 96 departments of internal medicine at US medical schools. This number steadily increased until it reached 127 in 1990. The number of medical schools remained at 127 until 1994, when it decreased to 126. Because the first chair of a department of internal medicine at a new medical school is not considered turnover, APM uses the previous year’s total number of institutions to calculate the percent turnover of chairs. Table 1 shows how the number of medical schools fluctuated from 1970 to 2006.Table 1Turnover for APM Members (1971-2006)YearPermanent Chair TurnoverInterim Chair TurnoverTotal TurnoverMedical SchoolsCalculated Schools1970961971112131009619728412103100197311314109103197414317111109197515520114111197612315117114197711415120117197810313123120197996151241231980691512412419811521712412419829122112412419836410124124198475121241241985124161251241986628125125198716723125125198811102112612519891151612612619902092912712619911892712712719921292112712719934101412712719949413126127199514721126126199613720126126199720828126126199813922126126199917825126126200017112812612620011713301261262002168241261262003119201261262004711181261262005128201261262006191029126126 Open table in a new tab APM defines turnover as each time the chair of a department of internal medicine changes. These changes occur when a permanent chair steps down and an interim chair is appointed, when an interim chair steps down and a permanent chair is appointed, or when an interim chair is named as permanent chair. This third situation is classified as turnover because that individual’s role in the department has changed with the new title, which unsettles the faculty and staff, the department, and the institution. In addition, APM defines interim and acting chairs as the same. Since 1970, the turnover rate has varied annually. Table 2 provides the turnover percentage for each year as well as averages over 3-, 5-, 7-, and 10-year periods. The turnover rate for permanent chairs in 1971 was 11%, compared with 15% in 2006. The turnover rate has gone as high as 16% twice, in 1990 and in 1997, and as low as 3%, in 1993. The 10-year averages clearly show a steady increase in the turnover rate for permanent chairs; this rate has been 10% or higher since 1990.Table 2Rolling Averages Since 1971Year% Full Chair3-Year Avgs5-Year Avgs7-Year Avgs10-Year Avgs% Interim Chair3-Year Avgs5-Year Avgs7-Year Avgs10-Year Avgs% Total3-Year Avgs5-Year Avgs7-Year Avgs10-Year Avgs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pen table in a new tab For interim chairs, the turnover rate was at 2% in 1971, compared with 8% in 2006. In 1982 and 2001, the turnover rate for interim chairs was 10%. The turnover rate has been as low as 2% four times, including the first year the data were recorded. During the last 12 years (1995-2006), turnover for interim chairs has been at 6% or higher. The turnover of interim chairs is rising because of the increased number of interim chairs appointed as permanent chairs. Only 3 of the 98 chairs of departments of internal medicine at US medical schools during 1970 were interim chairs. During 2006, there were 155 interim or permanent chairs; of that total, 29 served as interim chair, almost 19% of all chairs, although 10 of these 29 left the position before the end of the year, a turnover rate of 34%. Figure 1 provides information about interim chairs in the 1970s, 1980s, 1990s, and 2000s (2000 to 2006). The total number of interim chairs has increased in each decade, from 44 during the 1970s to 80 during the first 6 years of the 2000s. In addition, the number of interim chairs who become permanent chairs has grown from 2 in the 1970s (4.54%) to 21 in the first 6 years of the current decade (26.25%). When the turnover rate for permanent and interim chairs is combined, a wide fluctuation is evident. In 1986, the combined turnover rate was only 6%, as compared with 24% in 2001. The 10-year average takes into account irregularities during the 30-year span, illustrating a consistent increase in the percentage of total turnover. Between 1971 and 2006, the 10-year averages of chair turnover have increased from 13% to 19%. From 1970 to 1979, permanent chairs remained in the position an average of 5.669 years, while interim chairs served an average of 1.353 years. This gap increased during the 1980s, when the tenure for permanent chairs rose to 6.520 years and the tenure for interim chairs decreased to 1.224 years. During the 1990s, permanent chairs remained in the position 5.700 years as compared with interim chairs, who remained 1.324 years. From 2000 to 2006, permanent chairs served an average of 4.563 years, while interim chairs served in the position an average of 2.355 years. When averaged together, the combined tenure for permanent and interim chairs has decreased from a high in the 1980s of 5.846 years to a low of 3.997 years from 2000 to 2006. The tenures for chairs of departments of internal medicine at public medical schools were, on average, one half of a year longer than for their colleagues at private schools (0.49 years in the 1970s, 0.68 years in the 1980s, and 0.49 years in the 1990s). From 2000 to 2006, however, the tenures are nearly the same for chairs at public and private institutions. In fact, the chairs at private schools now have slightly longer tenures (0.07 years) than their colleagues at public schools. During the past 35 years, medical schools in the United States had an average of 6.5 internists chair the department of internal medicine (median=6). However, a few schools had a considerably higher or lower number of chairs. Since 1970, 15 internists have chaired (9 permanent and 6 interim) the Department of Internal Medicine at Meharry Medical College. In contrast, New York University School of Medicine has had only 2 department chairs during this time. Since 1970, 6 schools (George Washington University School of Medicine, Harvard Medical School Massachusetts General Hospital, University of Minnesota Medical School, University of Texas Southwestern Medical Center at Dallas, State University of New York Upstate Medical University, and University of Puerto Rico School of Medicine) have had 3 chairs. When these data were first recorded in 1970, men chaired all the departments of internal medicine at US medical schools. In 1973, the University of California, San Diego School of Medicine appointed Helen Ranney, MD, as the first female chair of a department of internal medicine. Dr. Ranney—who chaired the department for 13 years—is still the longest serving female chair. Of the 155 interim and permanent chairs of department of internal medicine during 2006, 15 (9.67%) were women. The tenure for female chairs in 2006 ranged from less than 1 year to 11 years. By the 2000s, the number of internists who chaired more than one department of internal medicine at a US medical school during their careers also increased. The number of internists who chair more than one department shifted, from 6 in the 1970s to 4 in the 1980s to 10 in the 1990s; from 2000 to 2006, 10 internists have already chaired more than one department. In fact, of the past 6 APM Presidents, 3 chaired more than one department during their careers. In comparison, the average tenure for deans of US medical schools is 3.854 years.3Data compiled from Member Medical Schools.http://services.aamc.org/memberlistings/index.cfm?fuseaction=home.search&search_type=MS&wildcard_criteria=&state_criteria=CNT%3AUSA&image=SearchGoogle Scholar As a result, deans and chairs of departments of internal medicine are in their positions for approximately 1 year less than the average chief executive officer of a Fortune 500 company.4SpencerStuart Life Sciences Practice Route to the top: snapshot of deans at US medical schools.http://content.spencerstuart.com/sswebsite/pdf/lib/RoutetoTop07.pdfGoogle Scholar In addition, 41% of all deans are internists, which means that increased turnover among deans is likely to fuel turnover among chairs. Will the expected proliferation of US medical schools and branch campuses during the next decade exacerbate this situation as department chairs are targeted to lead these institutions? By contrast, the chairs of departments of obstetrics and gynecology at US medical schools serve an average of 7.2 years.5Gabbe 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 (152) Google Scholar According to a 2002 study, 22% of obstetrics and gynecology chairs “were somewhat/very dissatisfied with their positions.” The study noted “emotional exhaustion” in chairs who were newer to the position, were younger, worked longer hours, and had less personal support. The percentage of female obstetrics and gynecology chairs was approximately the same as internal medicine chairs (7.56%, compared with 9.67%). However, the female obstetrics and gynecology chairs “worked significantly more hours per week than male chairs” (76.9 vs 66.7 hours), which raises an interesting research question for internal medicine: do female chairs of departments of internal medicine work more hours, on average, than their male counterparts? Finally, how does the turnover rate for academic medical leaders—such as deans, internal medicine chairs, and obstetrics and gynecology chairs—compare with positions in other challenging fields (Figure 2)? For example, at the beginning of the 2007 season, the average tenure with their current teams for the 32 National Football League head coaches was 3.18 years; nearly one-third served as head coach of another team before moving to their current positions.6National Football Leaguehttp://en.wikipedia.org/wiki/National_Football_League#Current_NFL_teamsGoogle Scholar Does a correlation exist between short leadership tenures and more instances of lateral moves? In 2006, the presidents of US universities and colleges averaged 8.5 years in office, which is the longest tenure since the American Council on Education started tracking this information in 1986.7The American College President: 2007 Edition. American Council on Education, Washington, DC2007Google Scholar Similar to a university president in length of tenure, the Pope of the Roman Catholic Church has averaged a 13.8-year tenure since 1800.8New Advent The list of Popes.http://www.newadvent.org/cathen/12272b.htmGoogle Scholar Former APM President Robert G. Petersdorf, MD—who chaired the Department of Medicine at the University of Washington School of Medicine from 1964 to 1978—once characterized a department chair’s career as “hoping, coping, and moping.”5Gabbe 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 (152) Google Scholar, 9Petersdorf R.G. If I had to do it again: suggestions for today’s department of medicine chairman.Pharos Alpha Omega Alpha Honor Med Soc. 1991; 54: 12-16PubMed Google Scholar He felt that each stage lasts 5 years. For today’s chairs, each phase lasts 1 year—giving them one last year for scoping out another position. “Turnover among APM members since 1971” was published in APM’s section of The American Journal of Medicine in 2002.10Pearson 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 That commentary charted the turnover of chairs of departments of internal medicine at US medical schools from 1971 to 2001. With 5 additional years of data, the trends evident then continue to accelerate. The tenure for permanent chairs of departments of internal medicine is decreasing, the tenure for interim chairs is increasing, the combined tenure for permanent and interim chairs is getting shorter, and the number of internists who chair more than one department during their careers is increasing. Because faculty and staff in departments of internal medicine teach the most physicians, conduct the most groundbreaking research, and care for the most patients, the increased turnover of department chairs is troubling. Given academic medicine’s role within health care, the increased instability of departmental leadership has potentially catastrophic ramifications now and in the future. If the current turnover trends continue, academic medicine, in general, and departments of internal medicine, in particular, will be poorly positioned to respond to the changes that are expected to occur in education, research, and patient care during the next decade. The days of internal medicine chairs having longer tenures than popes are over. If academic medical leaders want to move to a more corporate structure—in which department chairs oversee business units within a larger enterprise, have tenures closer in length to those of National Football League head coaches, and view leading the most dominant department in the medical school as a mid-career job—then the role of chairing a department of internal medicine will fundamentally change, as will the selection process. The expected challenges and opportunities of the next decade necessitate a frank discussion about future leadership structures in medical schools. As “the organization of departments of internal medicine represented by chairs and appointed leaders at medical schools and affiliated teaching hospitals in the United States and Canada,” APM must engage the Association of American Medical Colleges (AAMC)—particularly AAMC’s Councils of Deans and Teaching Hospitals—in this dialogue as soon as possible.11Association of Professors of Medicinehttp://www.im.org/APM/Google Scholar The authors thank Sheila T. Costa for her contribution to this commentary. The commentary reflects the authors’ opinions and not those of Alliance for Academic Internal Medicine. At the time of article submission, Ms. Ringenbach and Mr. Ibrahim were employed by Alliance for Academic Internal Medicine. They currently work for the US Department of State and the American Society of Nephrology, respectively.