The papers in this issue of Academic Psychiatry (
1) describe the skills needed to be successful in administrative/executive leadership and increase our understanding of the multiple roles of and organizational issues faced by leaders in academic medical centers, in particular, by chairs of departments of psychiatry.
Historically, psychiatrists have been seen as leaders of a multidisciplinary clinical team, but residency programs have devoted minimal time to preparing psychiatrists for such positions or enhancing their effectiveness as leaders. The business literature has been a good source for understanding and knowledge development, although it has not been all that attentive to psychiatry. The Association of American Medical Colleges (AAMC) has addressed faculty development at all levels, produced handbooks for department chairs (
2), and initiated hands-on professional development opportunities for leaders—department chairs, deans and associate/assistant deans, directors of clinical services, and so forth. These materials and experiences have been highly useful to participants, but again, they are not specific to psychiatry. The recently published Handbook of Career Development in Academic Psychiatry and Behavioral Sciences (
3) is a wonderful compendium aimed more at the entry or junior level academician, but useful at all stages of development. Its identification of "smart strategies" and "questions to discuss with a mentor or colleague" adds to its practical usefulness and can enhance the pathway of the future academic leader. The Tool Kit (
4) developed by the American Association of Chairs of Departments of Psychiatry (AACDP) and authored by Dr. Munro can be a resource for many leadership positions, particularly for clinician executives (a term which well describes department chairs’ roles).
The articles in this volume of Academic Psychiatry provide a plethora of advice and suggestions for potential department chairs as well as other current or potential leaders in psychiatric organizations and institutions, and for that matter in a broad range of academic medical centers. The perspective is broad and varied—presenting the leadership "elephant" from the unique viewpoint and experience of each author. There is a saying among deans and site surveyors that "when you have seen one medical school, you have seen one medical school." This saying applies to psychiatry departments as well. There is no one "model" academic department of psychiatry in today’s environment; even dividing departments by the intensity of their research mission does not provide much similarity. Departmental and organizational structure, responsibility for undergraduate and graduate medical education, faculty (both paid and volunteer) composition, function and availability for clinical care and education, organization of clinical services and their relation to the educational institution, penetration of managed care, subspecialization, relationships with other departments, and funding and financial strength all provide a distinctive environment with challenges and opportunities for its leaders. Roger Meyer, in his insightful overview of missions and roles (
5), addresses multiple aspects of structure and function as well as leadership needs, but omits graduate education, which is a major responsibility in most academic medical centers. The quality of the residents, their skills, and the services they provide have an immense impact on how the department and the specialty are viewed. Further, funding of residency positions, as well as relations with other training sites, can present considerable challenges to the department and institution.
The theoretical and personal overviews of leadership, particularly of chairs—seem to provide a near religious exhortative approach—the "seven deadly sins" (
6) and "ten commandments" (
7). Each gives a sense of general principles, and each contains some wonderful pearls of wisdom. I prefer positive reinforcement (vide infra), and since Dr. Winstead’s commandments are more "thou shalts" than "thou shalt nots," I find them more comfortable in serving as a guide and encouraging leadership (
7). Dr. Wilson’s philosophical assessment of leadership tends to focus on the negative (
6). Though his examples of the nightmare boss will resonate with readers, many may respond with more discomfort to his pejorative tone in considering general human behavior and personal frailty. However, his precepts are important in preventing disasters, and his extensive annotated references are a must-read.
Psychiatrists tend to view the position of department chair, particularly in an academic department of psychiatry, as an ultimate leadership career goal; yet, psychiatrists are leaders in various clinical settings, in departmental subareas (both subspecialty and educational), and they take on leadership tasks external to the department, working with other physicians, and other health and mental health professionals. Each of these positions requires some particular knowledge and skill, just as there are certain abilities common to all. Broquet (
8), in considering institutional as well as departmental perspectives, stresses the importance of addressing the disconnect between authority and responsibility, of keeping a long-term as well as a short-term view, and the importance of balance and of team-building.
Though I have never been a chair, and my leadership in an academic department of psychiatry ended in the role of director of education, the lessons learned as a chief operating officer of a large organization (the American Psychiatric Association) and as a dean of a financially troubled school of medicine resonate with many of the experiences and suggestions of colleagues. In my comments, I plan to discuss some broad aspects of leadership—how it is defined and what attributes are needed to be a successful leader, the particular characteristics psychiatrists bring to these positions, some early issues for leaders, problems and pitfalls, and measures of success. I also will consider some special issues related to women leaders.
Leadership is best characterized by vision and mission, and the courage, character, and ability to put the precepts of this vision and mission into sustainable action. Leaders combine their ideas and values with the necessary energy and effectiveness to implement them. As noted by Drs. Meyer (
5) and Greiner (
9), most leaders at any level also function as middle managers. Being able to maintain quality and effect growth is a challenge. Good leadership allows institutions and organizations to grow, plan for, and keep pace with environmental changes. No growth means stagnation. The best leadership proactively addresses and implements change, and sustains success for the future. Such success also involves developing (producing and nurturing) the next generation of leaders. As Greiner states, "leadership is a moral enterprise" (
9). Though the effectiveness of good leadership is not always immediately apparent, its absence is felt at many levels and has long-lasting effects. In his reflections on leadership and in the vignettes describing his chairmanship, Dr. Buckley (
10) discovers underlying principles in a personal voyage but also documents the importance of recognizing and utilizing (as well as seeking) the resources necessary to effect the vision, noting how success becomes self-perpetuating.
Why are leaders chosen? Search committees vary, but they tend to be specialty (substantive) content-focused, beginning with a review of scientific accomplishments as listed in the candidate’s bibliography. Of course, demographics, focus, and institutional reputation play a part, as does charisma. Ready availability, minimal demands with acceptance of inadequate resources, and willingness not to rock the boat can make a candidate very appealing to a search committee and dean in an institution with financial difficulties or problems with stability. What tend to be missing are such factors as practical management experience, interpersonal skills, vision, and creativity.
In my experience, psychiatrists have developed knowledge and skills as a part of professional competence, which, although not specific to psychiatry, enable us to deal more effectively with some of the stresses and demands of leadership. In particular, psychiatrists have an understanding of individual and group dynamics, of the role and impact of power and authority, and of systems and their management. As Dr. Wilson notes, "Management is just psychiatry by other means" (
6). When he became dean at Case Western Reserve, the late Douglas Bond was noted to have said that the only difference in his position was that his "patients had tenure."
As clinicians, we understand the immense role that defenses and transference play in shaping behavior and have learned not to take some aspects of behavior, particularly negative judgments and accusations, personally. We understand the function of groups and know that group emotions and responses are often stronger than the sum of their parts. Though such power can be destructive, it can also be very positive if harnessed appropriately. We know the importance of cultural contexts. Culture sets the standards for "the way we do things here." As such, organizational culture includes published and espoused values, beliefs, and norms, but also unpublished and covert attitudes and standards that determine what kind of behavior is allowed, tolerated, approved, and endorsed. Is the culture traditional, hierarchical, authoritarian, democratic, change-averse, change-seeking, or supportive? How are newcomers or old-timers, different specialists, and diverse populations viewed?
Awareness of the institutional system and the place and function of the department within that system also utilizes clinical skills. How does the institution address discord and uncertainty? Are there differing views of the overall mission and priorities, conflicts between basic and clinical scientists, researchers and educators, goals for academic success and community service? How are these addressed and resolved?
Psychiatrists also have an understanding of the power that a title bestows. There is a relational aspect between actual power and perceived power, in which dominance derives from the endorsement of others and is conferred by that endorsement. Power and status include such factors as visibility, expertise, relevance, and job prestige. Other features, such as celebrity status and outside recognition, wealth, charisma, and personal attractiveness can have a major impact on influence and effectiveness. Psychiatrists are aware of the potential corruption of power, particularly in more authoritarian environments.
In understanding behavior and how to motivate and encourage change, psychiatrists recognize the importance of rewards and reinforcements. It is all too easy to forget that even the most accomplished and successful people have narcissistic needs. Money, while a significant and necessary reinforcer, is not the only measure of satisfaction; praise, recognition, promotion, and other perks are important. No matter what their role, most workers find pleasure in being part of a mission and being seen as a valuable and valued contributor to a successful operation. Behavioral approaches emphasize the importance of giving praise and credit generously, as well as limiting negative feedback, or providing it in a way that will teach and encourage. At the same time, leaders know that not every problem can be remediated and not every employee will work out no matter how hard they try to be of assistance.
Of course, there are pitfalls to being a psychiatrist. Just because the leaders are psychiatrists does not mean they understand what is going on. If the leader does understand what’s going on, it does not mean she or he can solve the problem, nor does it mean that the faculty or staff members become the psychiatrist-leader’s patients. Leading is not treating. Accepting bad behavior as illness needing treatment only prolongs difficulties. Psychiatrists generally understand that not everyone behaves according to rational and logical standards (other than to some degree of self-interest), and psychiatrists can identify psychological factors, especially transference, displacement, and projection. Nonetheless, this understanding can get lost on the administrative firing line.
There are two critical times for newly identified leaders. The first is when negotiating with the institution or organization (i.e., for the chair, negotiating with the dean). Once the terms of the employment agreement are set, it is difficult to modify them. Consequently, identifying what is needed and skill in negotiation are key. Assessing and evaluating the setting, infrastructure and resources, and demystifying the budget are early tasks. There are a number of printed materials (e.g., Getting to Yes, various "dummies" books) (
11—
14) which can be helpful throughout the application process as well as in negotiating the final details. This is also a time when a more senior mentor can be especially valuable in determining the questions to ask, the positions to take, the "must haves" and potential "deal breakers" for both personal and departmental needs, and then in rehearsing the discussions. There is the saying that we get what we negotiate, or to paraphrase Ben Franklin, "Agree in haste; repent at leisure." There are no emergencies in negotiation; the prospective chair should view the process as a dance, not a wrestling match, and should seek the win-win and find common ground. Psychiatrists can use their skills at listening "between the lines," remembering that everyone, deans included, has an unconscious that shapes reactions and decisions.
The initial 2- to 6-month "honeymoon" also is pivotal in setting the stage for the future. There is an opportunity for the new leader to express and clarify goals, identify and enlist constituencies, establish priorities, and develop a supportive infrastructure.
The new leader will face a steep learning curve in which she or he will assess the environment and match strategies and tactics to the culture and setting. Communicating the vision, ideally in a way that empowers action and promotes buy-in, can enhance comfort and trust. Personal presence can contribute significantly to this process. While any leadership position is a marathon, the initial stages resemble a one-mile run, so it is important to be balanced and keep the long-term goal in sight while meeting intermediate objectives along the way.
Developing a team is one of the first tasks, especially for the leader joining a department or institution with deeply entrenched views, beliefs, values, and loyalties. A team broadens perspective, helps move in the direction of change, provides moral and concrete support, and also can give feedback (positive and negative) and help in planning and anticipating consequences.
Recruiting is one of the early and important functions of a new leader. Generally, negotiations include at least initial funding for additional faculty/staff. A new leader should recruit carefully; the quality and abilities of new faculty/staff will send a message to the community about the leader’s values and directions. There is a saying that first-class people recruit first-class faculty, while second-class people recruit third-class faculty. Recruit to fit the job to be done, assessing the candidate’s potential for productivity in the new position. Look for personal attitude and loyalty as well as team compatibility. Be open and spell out expectations, limits, and benchmarks of accountability. Do not promise what you cannot deliver as that will lead to disappointment and disillusionment.
Physicians are not economists, and financial management is not a residency core competency; nor is having a master’s in business administration a position requirement. Nonetheless, the leader must learn to follow the money trail in order to manage the department or institution and be responsible for its financial functions (
14). Making sense of a spreadsheet or financial report is critical. Learning the terms and functions is a start, but most chairs will rely on trustworthy and knowledgeable financial administrative staff who can follow and translate budget and finance information.
No matter where leaders are in the hierarchy, they also have a boss (who has a boss) and must deal with both those to whom they are accountable as well as those who are responsible to them. The leader and boss need each other; their relationship often circumscribes the outcome of the leader’s efforts. As psychiatrists, we recognize the importance of a positive working relationship and the ease of "splitting," and we use that awareness by clarifying authority and responsibility, determining what the boss’s values and wishes are, helping the boss look good, and addressing disagreements before they grow or fester. Communication is vital—both through informal interactions and through the formal chain of command, building trust through persuasion, persistence, and performance.
There is always too much to do and too little time. Maintaining a focus on priorities, learning to delegate and teach others to perform these tasks well while protecting time for personal growth as well as for emergencies, all support good time management. The use of time, role strain, and competing priorities leads to a discussion of female leaders.
As the first and/or only female in leadership positions in different institutions, I can empathize with the findings of Dr. Vaidya, who highlights particular issues for women chairs (
15). It is well known that women experience the stereotypes and expectations of colleagues unused to, uncomfortable, or competitive with women leaders, as well as a greater sense of loneliness than their male counterparts (
16). Women’s female colleagues tend to be at lower levels academically or in more administrative roles. There are few women at similar career levels, and those women tend to be in other departments or institutions. Additionally, women are said to have a different leadership style. While such styles fall on a continuum, research in the business community has reported that women are less focused on hierarchy and organizational structure, more apt to share power, and more nurturing than their male colleagues (
17,
18). Women can fall easily into a nurturing, "mothering" role, experiencing difficulty delegating and not putting to use the power or authority of their position. Some women may be uncomfortable with the ambition and competitive in-fighting seen in many academic institutions, may be less experienced at politics or team-playing, and may be less charismatic. Many women leaders are (not always consciously) evaluated as mothers by their male and female colleagues. Faculty may have unrealistically high expectations that the new chair will fix everything and "make it nice." Colleagues may be ambivalent about a strong and powerful "mother," but at the same time may demean a compromising "mother" whom they see as weak or less effective. And of course, a strong and assertive woman can quickly be labeled as aggressive, destructive, or a "bitch." Men, in particular, can feel uncomfortable working for a woman. They may feel that women are weak or unfit, that they do not understand finance, or cannot play the hardball that academic medicine may require. Men also voice fear of tears or accusations of sexual harassment. Further, women do not embody people’s concept of a leader—a concept based on generations of male leadership. Consequently, women need to take particular care to use the power of their positions, to recognize the conflicting and often unconscious expectations of behavior, and to avoid personalizing their responses to what can be a "game."
How should we measure success? Typically, popularity (love/respect) is one measure, but it is insufficient. Meeting goals and fulfilling the mission is the best measure. Is there a modification of the prevailing culture that will ensure that these outcomes can be sustained? The leader’s success reflects the success of the team, and consequently the team’s success will support the success of the leader. Thus, generosity with praise is not simply window dressing, but an acknowledgment of contributions and fact.
When should such measurements begin? Leading a department is analogous to planting a vegetable garden: lettuce is available rapidly, while carrots and asparagus take years to develop. So it is in medical centers. Time has different meanings for institutions and individuals. Bureaucracies do not value timeliness, and in fact, do much to maintain a slow pace, so that institutional time seems almost infinite. Individuals, on the other hand, possess relatively short productive periods, a sense of finiteness and mortality, and, thus, impatience. Another aphorism voiced by deans is that institutional reputations change long after the time of their successes and failures, while individual reputations are affected more rapidly. Consequently, individuals may "take the hit" for institutional problems but also may get the credit for systems’ successes. Leaders also recognize that the last 10% of job accomplishment may take as much time as the first 90% and may not be worth the effort. Perfect is the enemy of good!
In addressing problems, there is the saying that garbage flows uphill: the bigger the problem, the more rapid the rise, and the longer it incubates, the harder it is to sanitize. It is important to act rapidly and decisively. Admission of errors and apologies can be positive and offset the negative consequences brought on by the initial problem. Crises can bring opportunity for new approaches, with clarification of goals, and a chance to refocus, restructure and reprioritize.
In spite of their best efforts, leaders are not always successful. There is a saying that "institutions do not love you back." Leaders recognize that not everyone wants them to succeed and are not surprised that for many the operant principle is, "What’s in it for me?" The political potholes can become big enough to cause a wreck if the chair does not pay sufficient attention to or becomes overwhelmed by the political context and conflicts. Even psychiatrists who can see clearly the dynamic issues in their patients can lose track of the importance of dynamics in shaping or understanding colleagues’ behavior. Inattention to the importance of networking, both within the department and institution, and neglect of time-consuming relationships with those who have authority and influence can also derail good efforts.
Physicians often do not know how to fight, or which political battles to take on. In academia, battles tend to recur and tend to be more about individual power and prestige than mission. If ammunition is limited, leaders need to save their bullets for the big and important battles. An important determination is when to ignore problems and when to go to the mat. Leaders should never engage in a fight if there is absolutely no chance of winning, but also be prepared to deal with the consequences of losing.
In any measure of success, it is important to know when to say goodbye. Clearly, very important irresolvable conflicts, such as ethical issues, can prompt departure, as can a change in mission. Recognizing limits to personal competence (which can be determined through introspection as well as feedback from colleagues, 360-degree evaluations) may prompt a change. For some leaders, the need for change, creativity, and growth occurs regularly, no matter how well a current experience is progressing, leading to exploration of new and challenging (sometimes better) opportunities. The vaudeville expression "Always leave them wanting more" can be translated into "do not overstay." Change can foster fresh ideas, energy, and resources; new leaders can redress mistakes, adapt, clean house, and restructure.
As psychiatrists, we have opportunities to use knowledge and understanding of behavior to identify what is important to the institution and its faculty and staff, and the means to avoid manipulation to focus on goals. We know how to be change agents and recognize the importance of faculty and staff participation and concurrence. Though "what’s in it for me" will never be replaced entirely by "what’s in it for us," the process of team-building to effect mission and vision defines leadership.
At the end of the day, what really counts are pride and pleasure in programs and institutions and their influence on students, trainees, patient care, and the profession. These can be measured in broad programmatic strokes and their impact on the future, but also by each student or trainee, one by one.
Finally, no matter how elevated or important leaders are, they need to remember that life exists outside of work and find fulfillment in family and friends. No one has ever come to the end of a career and said, "Gosh, I wish I had spent more time in the office!"