An Introduction to the Administrative Hierarchy

Chair (sometimes also called Head) of Surgery at a College of Medicine is one of many leadership roles that a surgeon may aspire to. The Chair of Surgery is generally responsible for all academic, clinical, and research activities of the department. It is this commitment to the tripartite mission of the College of Medicine that distinguishes this position from the position of Chief of Surgery at a hospital. The Chair manages the faculty and support staff, and is responsible for departmental finances. In many institutions, the Chair of Surgery is also the Chief of Surgery at the major teaching hospital, but this is not always the case. The table below summarizes the traditional model. Few Colleges of Medicine adhere in all respects to all aspects of this model, but the basic concepts are transferable.

It's important to understand the differences and how your own interests and abilities might best fit. If your main interest is clinical care, Chief of Surgery might be the right job for you, rather than Chair. If you are intensely focused upon your own subspecialty, then Division Chief may be the perfect spot. If, on the other hand, you have broad interests that cross specialty and departmental boundaries and include all three aspects of the mission, couple with a desire to shape the future of surgery, you may be a potential Department Chair!

While the educational mission is central to all Colleges of Medicine, the relative emphasis on the clinical and research missions may vary. At most Colleges, all three are emphasized; in a few community-based Colleges, the major missions are clinical and educational. It's important to understand these differences and how you, as a potential surgical leader, might find the best fit with an institution. Thus, clinician-researcher who would be an excellent match for a research University position might be a poor match for a community-based College of Medicine.

If the Department is "Surgery", then potential Chairs may be drawn from all specialties encompassed within that Department. General (including Surgical Oncology, GI, and Trauma), Cardiothoracic, Vascular and Transplant surgeons tend to predominate. A minimum requirement is an impeccable reputation for clinical excellence. Board certification and Fellowship in the American College of Surgeons (or an equivalent for international medical graduates) are also considered basic requirements. Obviously, if the Department is "Neurosurgery" then only neurosurgeons need apply!

A surgeon becomes a desirable candidate for Chair at about the mid-career level. Typically promotion to Associate Professor will have occurred, and tenure will have been granted (assuming the individual is on the tenure track, as the vast majority are). Membership in key surgical organizations and invitation to participate in national committees serve as objective indicators of visibility as a rising star. Other desirable attributes include strong interpersonal skills and administrative experience and/or training (see below). 

Surgical Organizations

Participation in national organizations allows the aspiring Chair not only to attain visibility, but also tremendously widens opportunities to identify mentors. There are several categories of surgical organizations, and most academic surgeons belong to several in each category. The chart below lists some representative organizations as examples of each type.  

Your primary mentor (see below) should help you determine a realistic timeline to attain membership in various organizations, and assist in identifying people who can sponsor you. Successful election to membership in more selective societies requires not only a solid body of work in your field of expertise, but also people within the association who can sponsor you. It is particularly nice if these are people outside your institution who know you through your work (such people are also valuable when you are up for promotion and may help when the time comes to start looking at Chairs - more about this in the section on mentors).

Once you are a member, you need to continue to expand your visibility within the organization. There are several ways to do this. First of all, attend and participate in annual meetings. Stand up and ask questions or discuss papers - and, when you do this, state your name and institution clearly, to avoid the embarrassment of being asked who you are by the session moderator. Phrase your question succinctly. Prepare by looking at the abstract booklet or preliminary program before you go. Don't be obnoxious and prolong an already long session by asking deliberately abstruse questions, giving a mini-paper of your own, or reiterating points made by others. Rather, contribute in a brief and positive manner. Volunteer for committee assignments, or ask a friend to nominate you for committees.

If competition is keen, look for jobs no one else wants to take on. Give 150% to any assignment you are given. Tell people how much you enjoyed working with the committee, and very likely you will be asked again.

Attend and mingle at receptions and dinners. If your feet are up to it, stand in the back of the meeting room during some of the presentations - that way, you will see a large number of people as they go in and out. Speak to the ones you know, re-introducing yourself if you are unsure if they will remember you. Speak to anyone you recognize who has a reputation for being friendly. Surgeons who go to meetings are generally gregarious by nature - the misanthropes tend to stay home - so do not be afraid to approach people. 

Mentors

Mentors are absolutely crucial. You should have at least one primary mentor - an individual, preferably in your own institution (or perhaps the institution where you trained) who is knowledgeable in your subspecialty and who can guide your progression through the various associations. In time, this person may help you identify opportunities for leadership roles up to and including Chair.

For many surgeons, this will be their Department Chair or Division Director. If you are in a dysfunctional department, you will need to find a mentor at another institution. Start with the institution where you trained or where you went to medical school. Don't overlook potential mentors in closely related disciplines but be aware that the career path (and hence expectations) may differ between surgical and medical specialties.

The primary mentor isn't the only mentor you need. As you define your goals, articulate it to people who have been successful in the way in which you hope to succeed. Some will step forward and offer time, advice, or other insights. Be prepared to cross specialty, gender, race, ethnic, or other boundaries. Successful engineers, business people, scientists, and others outside of medicine also have a lot to offer.  

Interpersonal Skills

Be prepared to augment your interpersonal skills with either intensive effort or training in areas in which you find yourself deficient. You will need to be an excellent listener, a skilled negotiator, a moderator, and a role model. There will be times when you need to make rapid decisions based upon incomplete data, and others when you need to refrain from premature action. A Chair is expected to host departmental parties, receptions, and faculty recognition ceremonies. Your significant other will be expected to be a visible presence at your side.

Take advantage of any short courses or staff development opportunities that your own institution offers. Because these skills are needed in most leadership venues, abundant training opportunities in the form of short (one to two day) seminars exist. Although these may not be tailored specifically to the academic medicine arena, the basic principles apply.

From time to time national organizations offer courses in management and interpersonal skills, usually in conjunction with the annual meeting. The Association of Women Surgeons, the Association for Academic Surgery, and the Society of University of Surgeons have been all been active in this area. 

Administrative Training

Some find the formal structure of a degree-granting program such as an MBA or MHA to be useful. Completion of such a program provides additional evidence of your commitment to your career path. With the advent of distance learning and executive MBA programs, this route is open to virtually anyone. It takes considerable time (2-3 years) and is expensive ($30-50,000), however, and you need to decide if it is worth it. If you are a woman or a member of a minority group, you may face the implicit question, "can you lead a group of surgeons?" - training and experience help answer this question with a resounding yes.

Alternatives include short courses given by the American College of Physician Executives, Harvard, and some national specialty societies. These typically run one to two weeks and the tuition costs of $1-2,000 are significantly less than that of an MBA. While this seems like a bargain, remember that you generally must add significant travel, housing, and other costs. The more prestigious of these require institutional nomination and frequently you will obtain institutional support. 

Administrative Experience

There is absolutely no substitute for experience. Leadership roles abound in all institutions - there are committees and task forces to lead, sections and divisions to direct, and residency programs or medical student clerkships to direct. Any and all of these positions provide an opportunity to learn more about various aspects of the Academic Medical Center, and also to see if you like administrative responsibilities. Particularly valuable experiences for the aspiring chair include the following:

• Residency program director or codirector

• Clerkship director or codirector

• Surgical services committee membership, or membership on committees or task forces which involve the OR

• Faculty practice plan committee activities

• Executive committee or faculty senate membership

• Hospital Vice-Chief or Chief of Staff positions

• SICU directorship

• Director or leader of your section or division

• Chief of Surgery (if separate from Chair)

• Acting Chair, in the absence of your Chair from the institution

• Vice Chair of Department

How Do You Apply for the job?

The best way is to have your name submitted, in a letter of nomination, by someone highly placed in the field. Typically, this will be your primary mentor, to whom you will have confided your aspirations. At any given time there are around 30 chairs open, and (unfortunately) turnover has been brisk, so once you are ready to start looking it is fairly simple to "apply". Don't be shy about expressing your aspiration to friendly senior surgeons, and you will soon find yourself contacted by search committees. It is far better to have your name sent in by someone than to simply respond to an ad in a journal. Once the process starts, it seems to become self-perpetuating.

What happens next is that you receive a letter from the search committee telling you that your name has been suggested to the committee. They will want your CV, so have it up to date, and several people whom they can contact for letters of reference. Considerable time may then pass. Out of 20-30 viable applicants, the search committee will select the most promising to invite for an interview. If you continue to appear promising, you will be invited back for a second interview (a.k.a. the "short list"). The search committee will usually narrow the field to 4-6 finalists, and recommend these to the Dean, who makes the final selection. The entire process may take a year or more. Commercial search firms are rarely involved. 

The process is generally quite open; it is both futile and counterproductive to try to keep the fact that you are "looking" from your boss and coworkers. Most people look at several Chairs over a period of several years before finally settling in. Being asked to look at a Chair is generally considered a mark of distinction that reflects well on both you and your home base, and may even help you get additional resources in your own department. Be careful, however, not to abuse the process. Don't go interviewing just for leverage - the world of academic surgery is a small one, and you will rapidly acquire a negative label among people who matter a great deal.           

How to Evaluate Jobs

Rare and fortunate indeed is the surgical Chair who secures a great job in the location of her or his first choice. If you will have to relocate (as most will), then make sure that geography will not be a last-minute problem for either you or your partner. Be prepared to travel, and to let location take a distinct second to quality of institution and job. Most parts of this country are excellent places to live, but be aware of your own (and your partner's) particular preferences. If you are a true bicoastal, then the rural Midwest is probably not your best choice.

Look very closely at the quality of the institution and the reputation of the department. Consider recent leadership. Find out what the institution will expect you to do and make sure that resources are available to do it. Ask other successful Chairs at other institutions to help you figure this out. Prepare a proposal, much as you would for a grant, and then figure out the budget. Go over this with your mentors, and then go over it with the leadership of the institution that is recruiting you. Go into these negotiations with a positive attitude - you, as a middle manager, should have access to the resources needed to do the job.

Some jobs are simply not doable. These are jobs located in failing institutions, with problems in the top leadership, or in parts of the country where HMO's, regional economy, or other systemic problems will preclude success. Don't set yourself up for failure.

Finally, there has to be a good match at the comfort level. You must be able to respect and feel comfortable with the people to whom you will report. Similarly, it helps a great deal if you like and respect most of the people whom you will be leading. Think of it as a match. Be prepared to be brutally honest as you evaluate yourself and the job - this is not a time to try to be something that you are not capable of being, or to fool yourself into taking a bad job because the location is great.            

Special Issues and Last Words

A supportive partner and a happy and stable home environment are key assets. You, in turn, will need to be able to leave the stress of the job at the hospital and keep your time with your partner, friends and family, as time to recharge. I've used the term "match" in describing the fit of the individual to the job. The match is crucial for this kind of leadership role. If you have prepared yourself well, and the match is right, the joys and rewards of the job should outweigh the stresses. If they do not, and you find the job hurting your own life and that of your family, then the match is bad and you should seriously reassess your situation.

I believe that the job of Chair, although extremely stressful, is one of the most rewarding opportunities within the field of surgery. As Chair, you are uniquely positioned to shape the future of surgery. I look forward with keen anticipation to the next generation of surgical leaders.  

References and Resources

Associations:

• Association for Academic Surgery

• Society of University Surgeons

Training opportunities:

• American College of Physician Executives

• Harvard CCPE Programs

• SkillPath Seminars (these are non-medical, very inexpensive, and excellent. They also sell audiotapes, books, and other management aids)

• Association of American Medical Colleges

• AAMC Women in Medicine (see especially the ELAM program sponsored by MCP Hahnemann University)

Books:

• Creswell JW, Wheeler DW, et al. The Academic Chairperson's Handbook. University of Nebraska Press, 1990. Mostly non-medical disciplines, but lots of fascinating case studies.

• Greene R. The 48 Laws of Power. Viking, 1998. Like it or not, it's good to know the rules and some of the historical ways in which people have manipulated other people. A sometimes terrifying book that draws on a wide variety of sources.

• Ridky J, Sheldon G. Managing in Academics: A Health Center Model. Matthew Medical Books, 1993. An excellent paperback, coauthored by a surgical titan.

• Tucker A. Chairing the Academic Department: Leadership Among Peers. 3^rd ed, Oryx Press, 1993.